From: Subject: bmj.com Booth et al. 319 (7209): 579a Date: Mon, 30 Jun 2003 12:05:09 +0100 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0000_01C33EFF.DA5E46A0"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V5.50.4133.2400 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://bmj.com/cgi/content/full/319/7209/579/a?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=rostron+c&searchid=1056971048765_3667&stored_search=&FIRSTINDEX=0&resourcetype=1,2,3,4,10&journalcode=bmj =EF=BB=BF bmj.com Booth et al. 319 (7209): 579a 3DBMJ=20 3D"Intended
Home Help Search/Archive Feedback Search=20 Result

3D""=20 Email=20 this article to a friend
3D""=20Respond=20 to this article
3D""=20Related editor= ials=20 in BMJ
3D""=20PubMed=20 citation
3D""=20Related=20 articles in PubMed
3D""=20Download to=20 Citation Manager
3D""=20Search Medline for articles by: =
Booth,=20 A. || Rostron
, C. =
3D""=20Alert me when:
New articles cite this=20 article
BMJ 1999;319:579 = ( 28 August )

Letters

Bilateral cataract extraction can be safely done within = 48 hours

EDITOR3D---=20Gray et=20 al highlighted the benefit of bilateral cataract surgery, particularly = if the=20 second eye is operated on within six weeks of the first.1=20

We agree with their view that surgery should be directed at those = with most=20 need. Nevertheless, Gray et al also recognise that an = increase in the=20 availability of cataract surgery would help to satisfy = increased=20 demand. A step towards achieving this and accomplishing = surgery in=20 both eyes is simultaneous bilateral cataract extraction. = Although=20 this does not greatly reduce operating time, it halves the = number of=20 outpatient visits required. However, simultaneous bilateral=20 extraction is controversial, as shown when the issue was = raised in=20 the Journal of Cataract and Refractive Surgery in = 1997. 2=20 3=20

Most conservative surgeons agree that simultaneous extraction is = appropriate=20 only in unusual circumstances3D---=20for=20 example, when the surgery requires general anaesthesia and = repeated=20 general anaesthesia represents a risk to the patient. The = principal=20 concern which prevents many surgeons adopting simultaneous=20 extraction is the risk of potentially blinding bilateral=20 postoperative infection: endophthalmitis.

A study of 316 cases of simultaneous bilateral extraction = indicated a=20 low incidence of complications, and although endophthalmitis = occurred=20 in one case, it was unilateral.4=20 Despite this, most cataract extractions in the United Kingdom = are=20 performed on one eye at a time with a gap of many weeks or = months=20 until the second eye receives surgery. Endophthalmitis has a = low=20 incidence, estimated as 0.1%, and, although it may occur at = any stage=20 after surgery, serious infection with pathogenic bacteria = usually=20 occurs within 48 hours.5=20

A further concern about simultaneous extraction is the inability to = alter the=20 choice of power of intraocular lens placed in the second eye = based on=20 experience with the first. Our eye department offers patients = presenting with bilateral cataracts surgery on one eye at a = time but=20 on consecutive operating lists 48 hours apart. We feel = that this=20 avoids or reduces the perceived risks and problems of = simultaneous=20 extraction. At the same time it achieves the benefits of = halving=20 outpatient visits and performing surgery on both eyes in = close=20 succession. To date, we have not experienced any cases of=20 endophthalmitis in this group of patients.
Adam Booth, senior = house=20 officer in ophthalmology
Andrew Coombes, = specialist=20 registrar in ophthalmology
andrewcoombes@compuserve.com=

Chad Rostron, = consultant=20 ophthalmologist
Department of=20 Ophthalmology, St Georges Hospital, London SW17 0QT



1.=20 Gray CS, Crabtree HL, O'Connell JE, Allen ED. = Waiting in=20 the dark: cataract surgery in older people. BMJ 1999; 318:=20 1367-1368[Free Full Text].=20 (22 May.)
2.=20 Masket S, ed. Consultation section. J Cataract = Refract=20 Surg 1997; 23: 1437-1441[Medline].=20
3.=20 Responses to Consultation section (letters). J = Cataract=20 Refract Surg 1998; 24: 430-431[Medline].=20
4.=20 Beatty S, Aggarwal RK, David DB, Guarro M, Jones H, = Pearce=20 JL. Bilateral simultaneous cataract surgery in the UK. Br J=20 Ophthalmol 1995; 79: 111-114.
5.=20 Kressloff MS, Castellarin AA, Zarbin MA.=20 Endophthalmitis Surv Ophthalmol 1998; 43: = 193-224[Medline].=20


=C2=A9 = BMJ=20 1999

Related editorials in BMJ:

Waiting in the dark: cataract surgery in older = people.=20
C S Gray, H L Crabtree, J E O'Connell, and E D Allen
BMJ 1999 = 318:=20 1367-1368. [Full=20 text]  =20



3D""=20 Email=20 this article to a friend
3D""=20Respond=20 to this article
3D""=20Related editor= ials=20 in BMJ
3D""=20PubMed=20 citation
3D""=20Related=20 articles in PubMed
3D""=20Download to=20 Citation Manager
3D""=20Search Medline for articles by: =
Booth,=20 A. || Rostron
, C. =
3D""=20Alert me when:
New articles cite this=20 article


Home Help Search/Archive Feedback Search=20 Result
3DBMJ
=C2=A9 2003 BMJ = Publishing Group=20 Ltd ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://bmj.com/icons/banner/title.gif R0lGODlheAA8APcAAPw2/8Zs/4iq//r9/+75/2bM/2nN/23O/3HQ/3TR/3vT/4DV/4TW/4zZ/5Lb /5fc/57f/6Pg/6fi/6zj/6/k/8Hq/8zu/+H1/+f3/7jo/8Xs/9Hw/9fy/9rz//L7/////8DAwAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAEAACAALAAAAAB4ADwA QAj+AAsIHEiwoMGDCBMqXMiwocOHECNKnEixYsMEDCJMsCiRAwgQGjiKHDnhIwYDEDh4AHEhA4KC CRpU6CBwQQYLHDQ0GIhggoUNGiAYIKjAQQYMGBoioNABA4EBHCIY7NlhwwYMGx4MHWhggYQOOw1E 0MDBAoWXAmX+zKBAYUkQFg52+EhT4EcQCwpa+CihoAOTBCUARvjgbl+EDe46OIjhIweBbzcUXHDX YGMQi0dqFgwiqebPoEOLHk26tOnTqFOrXs269UPOnl3LDv02Nte7FQbehVBww8e4BP9+JFhbIYGP FBSuBHGYoIG7Ugu8JTD5bluCl5sXFPxgZt4CDOb+Dsic1jDBAwMcF6zwccBW6YMLBABAP8BABZcx QFggk8DOgRSAQAADAhmQAUvXCTSXgAcQFOBHBA6UwF0bzbaXB+95dMFsHHbo4YcghijiiCSWaOKJ HHnUGWsXfBQSig7BBiOMnIHwn0AJLFdhARDctUF04N1lwYsFGNAiCBkQpEF8CB1oI0FzeTDQXiAk KJCKERpwWQcdNCiQbyxd8F0BhX2ElkGcSWYQlSDo9tGYAlGZXHCVDSQjQj1+RJ5BeeJ1EJhSFpBm dR+9J1B2CHFWF0GJgTDAmXfBWQCV2hUgnG13ykcfAPYVACYIZ6JJl0GNErDVoARRNlxBl+35Yab+ M5bIWW6xgtiABU9hEFWtvPbq66/ABivssMQWa+yxyCar7LLMCmvAA64Cm0F6TJ52wF0DGFvcagdQ QIGhwsLabGniqmZluB95gAEFDXi13GEMXDZcBhxMMO1HuUWw7gRHYuBlBfLalugAA/xXJnACBUjA dQZ2FuGSFC6AQQYTLDiAAgh0oIG90CXEWaB0fnQdAncReWi6BW0rULkElbnheRJcF8FHajKa7lZO VhkyCEDapWeiH73M6kfU+QxChAOBmeTOgVWb6l0PJNQoZoyNKqh6T5s5NHNAg1AzQZ+66SfYH+0o kHBt2um02j8jNPObB1EZKGcI11Qndnx1/fXJQNTOWUCkveUdMqbxCTBfAAIUMOFvCRmwnN8EdXw1 XISmjTfVB9UYqpEfRS3QtXATpKLZPDKZ6ab04UgtB4YugDCYSF/p6JhO7s3A3QMdh7lBDvy3QAUt erCBBF6CByZSBFwQgQIbeKBuYxjkNtNdAm7QYKaGc5p4yxasBFUE4BagQAZcbnCBTgQBDMLzHnDQ 7VxIEcwBAwxYQK1jPXfI8rihcfYY/59JQAbg9JZoAbAieVpajzCQgAM68IEQjKAEJ0jBClrQNAEB ADs= ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://oas.highwire.org/RealMedia/ads/adstream_lx.ads/www.bmj.com/cgi/content/full/319/7209/579/a/1323647468/Top/bmj/GB-UKNews-ROS-030101/email_friend.gif/64393234643063653366303031393230 R0lGODlh1AE8AMQAAP///9Hu/+68zZDS/0q2/6SbnACZ/weG3WVjcANcl9Yeff8AZsEAQhQtTGgQ NwAAAP4BAgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH/C05F VFNDQVBFMi4wAwEAAAAh+QQECgD/ACwAAAAA1AE8AAAF/6AhjmRpnmiqrmzrvnAsz3Rt33iu73zv /8CgcEgsGo/IpHLJbDqf0Kh0Sq1ar9isdsvter/gsHhMLpvP6LR6zW673/C4fE6v2+/4vH7P7/v/ UwcJCQ0NCQeAiYqLZoQODAsLDA4NiIyXmJlSDQ6RkpMOoYaWmqWmpz0NkJIOD66unQyjMYKDtrak qLq7fKqRra/BnayVLwkFAgXKywiGvM/QdAnDwdWunsSHKwcNAN7f3wUJ0eTla77A1q+r2JTaKMfg 8uLm9fZhB7Hq1cPYv84muAmQB47evYMIrySAlG7fg37+IskaRyIBAoIFKSbcyLGJL4fCIkacaKnB QIzeDP92XMlySD5JIF9BFOlp0qCLKL0JaNCyp08eLxs6nEmzJiUEyFCq/Mm0KYygMWEVLcrgVQME J1MWc8q1awqoUYlOxVb1Fc6dubyq9fqybEx2Y0Wmw7l0rV2uDSJFfRBXJCgEgAsESKnxrmGmH2OK pSqqATIBAgJEBoAg7eHLKxcuEGoNLk0Gkx4gTWmt0FbMqDu2BblY4qQGZgcDCABbneXUuO1p5rzO ryhttR+YBLBz3+3cyMmhUwcRtLsDpBJUK0Dc4fHk2HdxY1htFahZJoK7oo7Aevbz5LZ/Au3cUOGA 1gCDvI6+viZCnH7THyF9r9X99gV4j3/VACjggdH0R6DRKwYi6KAu4hHY4IMUZnLAgsFMWOGGiiiI oYYchtjHVRgyKOKJ911UQIRRgYjii3MMR1wlLBoH441/HIDTjAZ4CNJ7OAZpRzyEGcDNXjwJqaQd MqIlgo8OAbnklGtYlEwzpFyIJJVctpFAMuCNUKNtXZaJhmNJwreXlGa22QUh141ZTZpu1pkGlDba qecZcgbD5p6AcoFnaYEWGkafr/xp6KJTDDono5BioWWLkVZKhaN+WqopFJhatemnTLBo2i0ugmqq DbUcAl2pp7bq6qu6hAAAIfkEBR4AEAAsGgAHAI4BKwAABf8gJI5kaZ5oqq5s675wLM90bd94Tg96 7//AoHBILBqPMoASyWw6n9CodAobKJfUrHbL7Xqh1ut3TC6bz+QrAM1uu9/wmjhOr9vv6TV+z+/7 hQAEf4OEhYZeBImKJIqLIo2HkZJZSgOCfgRqSpdhVwEjAVc8k6SlR5qbfJlzI6sAoyNWsKa0tT2o mol2oVgkoiVWl7bDxDO4x5ZwncIQrp8koULMxdR4x9dX02Sus516IwDPQIHV5XfY6KLaXL+xasyv QZnr5vVsjQQD3unvXrziEALwiveIHJBQ9Owp7NNIH66ETTr5GsALlhUTjljoKsEL4sKPIH0sK5hP ibiLjwb/VipRkoe3S648hZxJswc3ERddgXq26lmYUTEFWhrortLGmkiTxmgnUEQ2p6PCwGQVsB2E p82wKt3KlUSCBNDmEPw1LyUsV8L++VqZNVXXtzXBQjhgQuLVqCYhoDwxUoRacGzRwh0M0oCBAw0e KGaUraxeMXtjqTRYNdxagoIJa66XILHixZcdtsrWdHS4RFr/Og2sdbNrRKiFHOj8uTZHk6VXvyL4 GEvmygDb/X5N3EmifZR/zPZc+zMwNbNUChOeOi9gzK2La/+B+tosIIgRIGje/LnV3r1utqWs+ipr t9vjzzjOj7eQrwgKABBA3jbj1s6Yhh187VEHn3wItlBf1nL3NZCfJ8yRZ4IaLJ03kEPVWXYdLBXl k+CHKqTjkQ7hCYDKeJ810EBnJ7Sn2ywEDBRASUZp8oyNKckE4o7moTIiCj+akIADAohnohIFrJjA AUwaJhdL+miTz3ePMJNRDEfxqOV6B8ZgSZBCLtmZeCoeYNiZZzaw5ZpmdIklgzXMtiSadBrwJJt4 +uHmD3UakOefe6wCJg19+gnooXFkF0ShiDbKRl9FMOropF/EhEShhlKqKSUUXirppqA+EdM3R2Aa 6qlNWNqEqai2asQqrsZKSpZUhAAAIfkEBQoAEAAsWAEHACkAKwAABTKgIY5kaZ5oqq5s675wLM90 bd94ru987//AoHBILBqPyKRyyWw6n9CodEqtWq/YrJYaAgAh+QQFHgAQACxdAAcAJAErAAAF/yAk jmRpnmiqrmzrvnAsz3Rt3+KA73zv/8CgcFgCGInIpHLJbP4GxqNzSq1arzxoFMvter/VKABMLpvP tC16zW6fpe64fN4EEOj4vH7P7/uNA3d+g4R6YlGChYqLZYeOBImMkpNMjpaAkZSamzuXnog4Azqc pIWfp1GBMwCjpa5+kLGiqJeZKVCtr7qksQSzj7eAKbG7xcYQBJYlWqm2x8+SyZiJ0nYiAcLQ2pOp RUaRoNviptk5aiPYrOPrf+UQ6QHL5+z0dN0jUfEkzM71/m/u8sn79q+gl1hjSNwTIXBfOIMQk0Bi 9lChO3gDE0bcyAPSp1wnFkJgViIdSI4oV3BMpKWuhUgIFSumnBmSZb9gAAL4ElRNkEmaQFGguski XU5qFI8GXZrxEFEVmW4SY0p1RDWCNAI9rcpVqLUaybZ2HfsDK9mzRKSJRct2ldm2cEPJjEs3xtW6 eN3Oy8sX6qG+gFWKCUx4GJzCiElAYhECACH5BAUKABAALFgBBwApACsAAAUyoCGOZGmeaKqubOu+ cCzPdG3feK7vfO//wKBwSCwaj8ikcslsOp/QqHRKrVqv2KyWGgIAIfkEBR4AEAAsfAAHACwBKwAA Bf8gJI5kaZ5oqq5s675wLM90DQ92ru987//AoBACKA6PyKRyyWySBkWjc0qtWq9HaBTL7Xq/4CgA TC6bz74tes1uu0fSt3xOrwII9bx+z+/7/yhFA3iAhYZ8YlGEh3kEAwGMdImTBIuRaAFil3KTnYKW m14EmXGha56oiqZdWmOrp6mxn69TrbRslbkDrbKJoLdBtsCAuY68ql25LJUtvyLMKcoq0MLD1lXH OM+PY7zaI44Bg8gQo2Lf24mQJt7V1+9LpNqPIqRRAZX3cPfigiJaOAj423cHgpZ1I0jhM6cGnsMj Aku5MhjlW8SC9VRBgXRxhBZCEb+RU/ik4cOTPR7/PGj1zSI5CCQzAlg3Co88cEUQBkBIZOBFS+5Q CpXRQISBZ2LwlfhZMk5MEhVxliJxcZ5JilOHamVxAIIBAwk8JkLHVGwRQk+R5ty586WjsTIn/ru6 tS6Kr1+Lmo2qFuPcszJ5lru3q/AucDf52isR1O6eXHJ94MXbdamvvkCRpR088ERZxVcbO8b19nKQ yZPDnmCJuenEzT0BoGOck6BVwHtHo8mHavYP1KhJiBNem7NfmMWRz2SXHJwIfc99vhSt20mlY72R AEet+h/Pm8Zd4lYu2LglgdHj8CVPPGv1Jr3GD9kOXO/c2xMvyua9PGHzvYRAESBh50g1UyX2HPce 03yxOAMEfcAdoJJKcXUWXoLoUGICQzll1qF+ru0nhoMLZuEJiSugmAKE3E34AFXQUIVMjDPQuNR5 zsSoYokQmTbDIDvexaIIDSDg4jIv8TiUfDIIFGQLwYmQAAIAFNAAhSkmqeSWgSgIRAMCFCFAA5VN oyWXaHL2ZA0HUCmmfWYymSaXZ/6QQAFRFNBdNCytOadWrfhZA5hvlpnCI2wN9yePICoxpQAFIEDm opSqkAgTCUDaQAKGVuqpce4N0YCVn5YqI11IJDCpqaxGxOqrVth4RQgAIfkEBQoAEAAsWAEHACkA KwAABTKgIY5kaZ5oqq5s675wLM90bd94ru987//AoHBILBqPyKRyyWw6n9CodEqtWq/YrJYaAgAh +QQFHgAQACzTAAcA2gArAAAF/yAkjmRpnmiqrmzrvnB8DnItJk1i73zv/8AWYBhcNQqFxqHIbDqf u8GQCB0dGgJBrsrtepnSqfcqACCU37R6LRR3EWWAVseu29nuamM6PC/vgIFQVFAPCHwIDw90go2O PgAEXA4FAYmKD2iPm5yPDBAOmKKMnaWQAAOSpi6imEoGq7EyfFOqsiitig0rBAMBt7K0wgS2wCK5 KQF8xqvCzkOpzMeGJMUEyoTSm8/ctdoiviVhAN+c3edT0cABvyTj5Z3E8gPj6LTFnFLtI+/w/hDy etXz9ojAkH3g8hBTsfCfwzvY+Kh65yudiXoB8D3cWOXawYYQxvnqRVCEtzAaOf+qZIINYUiLIrDR iAltxMGVOHskIEUTgMt+PdsZHGILW8qcSFdcMdFSXB4ITV9mk5m0aos/TG+6exo1Ijt2U1xaHUuC 54io/LhqjUivLb2jZNPII+fFwK4TaBNOXfs0LhtiAyOpsYsir1S6QfUK9tuFWLeZbAjj1Zp2r08R QxePgMu4BWB7qAAZMGBW70+1lxOTCAC5MwzQmkUbwFoiszzFqylnnnlNrOs23TivGT367kWJEISZ pLWVT+vfLwITtSGcB3HSDKvzAgk9RubpNlJpt3FdcvdS4KnHblIe+3mk6Z+0h/V+5dDxO+bXX1kS iv79D42Dn3XtAfjPd1/8Z2AdOcwlWN6C5XyHWF2jQegPgoNVaCE8Q23o4XamhAAAIfkEBQoAEAAs WAEHACkAKwAABTKgIY5kaZ5oqq5s675wLM90bd94ru987//AoHBILBqPyKRyyWw6n9CodEqtWq/Y rJYaAgAh+QQFLAEQACz+AAAAsQAyAAAF/yAkjmRpnmiqrmzrvnAMH01zyHiu73zvQ4lCIfErGo/I pOiAGCqf0Kh0lEAIGtOsdiurBgCIG3dMLjcEADCxzG5DmWmA003vDbSGvH5PQwMEa3WCMnFZe4d5 CX5gYoOOLANxAFOIh1VCCDaPmyuRhVKVegcPpKSBnKgmkpSho6UPWKmyqmmgra+ws7oltVA2lRC4 D427uwAEUQ0JB3sJwlXF0VILEMrMBs7C0QQDAQF3O2kDyNImytjaAbtf318A4DiSceTlIjXaqATf Ip4j8znyAhKgVy+VvjjgxI3wBC9GwIfiCBZ05OmdiDT0KgKEyBHjREcIRXAjoTFex5MRP/+2CXnC kzodA2MOqIhSnkSVUliacNdQSkxuNP/hLBHTxU2R5HSSIPBpKBR3CmneYQrgJT9544h2GycUwsE0 Aaha3OnRaRR3Vl0unCRSKE9/cbwxbBtRqglPR80eKQlBLT94XSF0hYoskjqx9MT2FHxMr0+3Tcfy FfGWMliRYfteJqHU61jHZxUKdoeMKTm0Jfii5iUa7ueroKfMNR3VatzUkKsS7dy5W+zHtWYyniT8 4ua1ZVePUMz6dV+r+QayFTRvH+nGxnWTzA3dc+vsi/OSGRgUO0VxjRlOh6D8ai/2x1337NxGOsfF jsS+1L/9veXP7f3XXWdfiPcDeTU5l4qFTryVlR09AXr3GXPIdXdEguYVQ9oIGy6VW0MRalaXJA1N hgRKBsrSD3IncCNPZq4Fxg9UYdG43HdIlOdgDCluMRBRBhYFU2Ip9MiDWDvGMI6Rv3GSJI8ZNikl Ck9OaaV3TF5ploxaSllRll1+hGSYV8pD5pRIrndmbGOuiaZ/bjb5YyohAAAh+QQFCgAQACwaAAcA ZwErAAAFoqAhjmRpnmiqrmzrvnAsz3Rt33iu73zv/8CgcEgsGo/IpHLJbDqf0Kh0Sq1ar9isdsvt er/gsHhMLpvP6LR6zW673/C4fE6v2+/4vH7P7/v/gIGCg4SFhoeIiYqLjI2Oj5CRkpOUlZaXmJma m5ydnp+goaKjpKWmp6ipqqusra6vsLGys7S1tre4ubq7vL2+v8DBwsPExcbHyMnKy8zNzs9FIQAh +QQFLAEQACwhAAAAnQE6AAAF/yAkjmRpnmiqrmzrvnAsz3Rt33iu76zhG7ygcEgsGo/IpDJ5+Dmf M4J0KjVRCcusdsvter+1Q6PxLM8CgLQaUCKsAQOwfE6v2++qBKKQKDtra1gnAwABeEUDaIVxh42O j1tiAgh9fj40imwoboyQOYoDBIqCnqWmpzR6Ag1NlphqKZyoNYRwIm62s7q7vBB6AAVkrmewm7m9 LmqkhJ3Izs8pzUwIapTDMpmxx9DGaaQQ39ziz8VKB9Rpq61m2OVW2+MkuADh8fa9tWk5Pgf9TSgN BKgJdg1GNmPSblXZVK/FlCAN5SlbEXFhrIj3MvLIp6mGgQQNHIh00KCPiV/AEP88qASlnT6E8jJ5 K8ExAEZ5HOERSNQRHE+c9HAZOjHvzdCdAQyNGiFqTUIINW9qnArIXQyQDBZoXcBARMl1PvSofEAW ArsYB4kemycoQLOJtaQKvTURgswRd8GtSVrrqU81oarIdFtsrt1CJZbGpcqYh1UXCRxsZeCgBIOv TshqfiCszAEI/vz5EZH2XadaQ8GlBjUiTWq1L+nGzkeCtuyXafzqnVkbMFTcvHGdzo03duPjN4y3 OFAZAuUTXSmXDLuZLMsfYhBo154AJIrSbY5lWnab1FIUqEv4/m3ctoj1O1WwpVkuFPue5daz1428 fzKpI4ghQlcsSNdddWSBZUD/AwWQIMCDAnz3GFPHcCSNe4fBQ4J+77kmAoYYcihfXSNgSJqHrc00 34co+udiEQkMCAMDlyHImRPnpBChCeBJ1IxM9BTnWlKZvCYRcSQcBKI7ImrDW4mP7UWkb/kQmdSE L+qSG4BGNKAVDV0hyFICDRqEpV7SANkWYAO06WZFIirpTohIsrAilMpBoIZbbr55X599ZknOG0Fq 0ZwNlFXXhIAxmChRPTmdmOeIdUqqyZLGNdlNoXj21CFi6JEoqDiEvmHRHA+s8JxXHyEgQz4REdJQ UzPBCkOcKGKKX6WUcspinj1SyOuog5ZKqH1CLPhCqgU6QFZJO8Iwj1+gvveN/2933qJCehsiqWu3 Gm4ajqOOktIkl8Q2Yuy6ombBbAuJQiAAGiiscsJ4JjCT5Fu8KWKkW072NI+whRYFLn9H+nrfCRy6 IYiJiaTLC7sUA4YuF6vuIdAblMDm2hQ8XZgLt7vlIoqR+aKYbSZtFlLXtC7kI/KTBDMii5A2sSgx Mle0XHGpF5tA4BCrQsBgNQ1sa2xCtDaZE8K3AMl0kVIEUtSkCTtl6bBNL5Ky1jsjR4XPpg5xqA0P GKKOnX3KdaoVbzsUtzzfBF3E3HTbHfbeIwytgt8uaJUoZ2Xay/fhiHPzLgzOggtMjIlHLvksZ6Mg uEjyFrDd5tpN7vnnjyxuwv/lY3zqKeiop75E0itULgJXBvYDOQKKOIK36nK0iXsRzGkluggPbCU4 ZSQlsA7rIqCD/B3h7v5FX84PERlXJkh2efH9rOBqtHcAjEc9SOn9wk4WO8SFKMNV+4j4c0xxOgrT izCSAzSK9BUMht/hxiGL3afwDn0h3/+OBLUdNK0ThnkEGlCmPwEGIgZiGAnx7ieD5Zngd1mAXh1g 9heaGbBFZ7oP+2Ygs8QU8Hma6kLV1nXCFPjDeJ+5h6O+wMGSjVBpa1Hf1wZYBA4RwhMl3IIUcsJC XUDufC2iQ/9sOIQUdqOFOtCPw0qxQC78zIOoOCIX2nRDIoQjWztwYiy2IMX/LmbBjDSoGBrBoMUG uiBuN3mIQ9rFkIuJUVtvvJjbPgXFvF3kjRDZIwmNxb418qCN7ZOJNJBiCI5g4YBtkFobEpEaMEby DQhbl0J+qMG/jGsvX5RV03IWkz3V8I1qoo8p6cZJb2FSUjbTV29WWco7egyLLwgMHhAJBugJJ0V7 CgXLbFJDw2iwKJWko7CG0kmiTOshNbkSPWRyrVrxxkJuodVrnmkhadXFe5/CQv+ieZ4gvicO3SwP e5ZBnF/GAJfj46EceOmFgf2KnUgy2K9S0z97SiqZ8FznbVggoirtRpwkYk2HABqcctzplCwgmSiE 1IkWGRQX5qrTFEtW0Sfl/7M+ASVCSNloB4Xuhp9MqpN70Ecw87TIkkwBJ0wPFp5r2uxlCfWoRutC Mj6a6Uk3fdJ5VqS7TpXoNetZ0ppyqEMjYBR1UgRpplR6Jlv9s6W5VCZNEwY+nrrDpFHljYhsOUte YUihM10ROPWEJH+lIKzva+JIi2AADF4whnKYh5XwtTBgpu90PHngVdW5gsBq1a81/Z9a9zQlEO5U RWMd1gpSaSkr7YmwDGunr9ZzWY/t9bA6sCro9AqoovbVp78S2Mfu5FbMwoaYoGWrTui42NyUNqNM DRJEyZqYsmUIDrd1rSrZELGtdvYdriltH2Ogz9RBdLhbPa1tWPvSw043tv8ismRt44pYde5WshF9 g6V6hRG2rFW2jDhuYpdrA/HuTox0qlB+PirU6gYUPtjllXa9GlK4CiKyzbMTvkSLXHlmCA3hWE+w UIuEq0Wvp3g8LXqNylHMtpaJHguqgSfM1QILAozVzO1SjcRba9EUxFiNhnpRS+BZosyQWYsehulC YQZfl76cunBa8TvS7NI2pzoEp39vg8AS24VfhbowaTQslSbpx4dHEdX+hoCLXtBzC1aVVadw+9el AlewB+6UbljmyF4ZyZxirlnUGFpkqm4pnTEbmX1NlpQ047DAbYaDFOi1ZRbBuA1/zoIFaTgY3Crj akop2ygdGApCda15i0Zxs+M6m5PXAOk1T+uUZsEGFaoVaXySHK6bVxyeMxMqppxGNS0R9wC80uF2 NjiVHHEga1jfzdZ5ZEqsYT1rGojP1riWsbCHTexiG/vYyE62spfN7GYf29UpaLWzp01tX9joWWOg YLW3rewxdKc7/jBBCAAAIfkEBQoAEAAsIQABAJ0BOQAABcugIY5kaZ5oqq5s675wLM90bd94ru98 7//AoHBILBqPyKRyyWw6n9CodEqtWq/YrHbL7Xq/4LB4TC6bz+i0es1uu9/wuHxOr9vv+Lx+z+/7 /4CBgoOEhYaHiImKi4yNjo+QkZKTlJWWl5iZmpucnZ6foKGio6SlpqeoqaqrrK2ur7CxsrO0tba3 uLm6u7y9vr/AwcLDxMXGx8jJysvMzc7P0NHS09TV1tfY2drb3N3e3+Dh4uPk5ebn6Onq6+zt7u/w 8fLz9PX29/iJIQAh+QQFyAAQACwsAA0AkQElAAAF/yAkigQxnmiqrmzrvnAsz3Rt33iu73zv34TB AAAY/GwD03HJbDqf0Kh0yiJai1SVNZDter/gsPg7CFyN4KFVOW673/B4mHAOm61ouX7P7/tZdHhh akRsf4eIiYpRgUR5X1uLkpOUlTKNWGJJlpydnouYj5+jpKWmM6EQQQEBmy55q0Ioq62vhjG0rbco Qqy6MLBlsie0oqfHyD+hhFu7q0Sqd1cmBNJrs2WOM8zSxhCErHUpzwDRV4Xm57vJlevsOpiOJdZs zI5FQVcBdEnxI/GZgEUSMZDEtBHgTtgrgo8bvxLnFAVyd0zNO2XqTuj7tzCPPVjivlnzpoKZwmsE Bf+dkMaFREeE50CqPHSn5bFbMy/CCymCmSFuxDZqzJkKBk8IKE3OOgizoCqhI472UUPyEwBDdyjq RHW0aE+mBnMideq1hc9ZtVISsTlUW1N0/45CPTSs4lVidcccQKBAwYK/gAMLHky4sGHAfRGMkxrx 7d24YueWZXEWkNSxVk6iDOs2qtOteybyQXC4tOnThxVD7jzCmma4nAOqBcB28grXLWxDwP1189PI n3lko/1oeNpovtCU2efyUbUSapgrvJNEyK7lrKj5mr7W2HNix3ltka4qb5l0ys2QR0hdawq/fxUI mE+/vv37+PPrtw9/gerfrIlAj2OGTCbZZSk0Rtn/ZQP2BhuAsmFG2xFZ5aOEevlMKCBK/HwzEEtX EQLZPtG5At5aMCkRSD9ZbQgXISTBuEk36RBXjSO6+IahGu6NQNoCCpwj5JBEFmlkkfAdEJsxDXro m4FkIYiCgisw402TlS05ZXA5rNiaCTy6qCKH5ZSHIoQXwtUiZgtC01NLgbCVGYAqUlcFbDdmkhCd veVxR1MwHOBXkEQ+8AAAhg6ZqJCLHnnkoFqigCVYEIpyoFgrUFkSg2BlWemWZ/ZAiIoX+tmZnSI1 ZROqu2nTSGsBtqVEJqy2mslmtYKKVWdkuukknKF66cKPRjaq6KGMIuuokQL8paRtvDn5IJShfvpC /5Mq6Batp9RqeEkJ7kiZp0dnHhcdrAHZ+aqLVVH1lGeP9dYSrrHCu2tAvZb5q7wjvjDoOYYim+ii ARNBsLIBN5owogUvfAWkts3FrVxRYrqpb1pYTOXEwFX7glIp2FPgEOHINqe++7KLLhpz2krRq+fx +ZZabOQq60q8wrVuytYI6e8CAlwx8KFDM2x00VYcbDTDSi9NBMRd8cRxgJcGSJoCSq4WYQosLZbT 1BHO9UIQQlQVjxLu1kpdzPyq7HaYY7GlQlZpNfLTybDZbC/O+Orc8rm27gMuuD8HnbSyRxONuMOH G6x4wgczDgDUYoHsYLzWwutt5hD8+JekVyyGdv/o4vkGtqVc8tC1u7Y6t1Z4gLe+8sprtmnGzarS PHumD7Kab+4p0/Bv440j7XjBxBu/tLEPAwlhvJOdDurmZfW3QNax1bY5jXxHKH1bm+9googq5Uo6 8LK7TUcsVYHKltpu0bv13rtjNqavgO88A7HFK574/8ZSWuQERsAr/EUxjWhPWTLUDBL0DA0MlEek RGA97GWvF+HLUyY06Bx7SEeDbokgPkQlEy6UL0Cxa1v60he+GLAuLHJS06nqpbv6/U6FT5KbCg7w F8Mdz3HLa5rCCsg0/x0PcYN61ghBiMIhtaRnblrIBnnCw/hkC4oxgiJtbiHFJw7pchZDwmPCJCP/ sYhGM6uaIRZWVDYT5eZBTlIObEbFwTYZIU1T9Bv+gpUUzLEAPj5cliAHWaRm+QcQZeuRDyazl/+s gGw9go51JGEN8nQjgaADXehiYittaNGPc9NhjbaoyS3uaRw0Osc+1OEPoDhQH4qkYHwCSchaLksA 8FGAHnQDGly4o0DOiKVRiOSe+f1DK8I8JhRKYAProeaZ0CSMLndJqV5O4ox9emMyLyIoZ0bzm6XB Gh8wYU1OmMEYNHxTOdfZg86ckp2LCFAgtPDE9sHznpbZYzrxuYcXYnMo+eCnQHFxQl8NlC4PzCco D8rQtwxnoQ0dJzPHFtGKovIM27SoRjcKioxyB/SjIFVBCAAAIfkEBRQAEAAsYgExAAsACwAABSEg AI1kCYil+aApBDxr68Jx+tLseOMqDbM7HyoonAlPpxAAIfkEBRQAEAAsYgEaACYAIgAABWogJI5k aZ4QgK4sC6htHAMPLN8mXeP8qD+93g8YvA2JxdZxl1wtmc3cY0qdRk/Hl+3qs0633O7oGy69xsiy CGxVY8nuHDhOr9vv+LwhLzLs9X6AgXd+hYSFg3SIhoqLiWqOjJCRj1yUklwhACH5BAUUABAALH8B FAAeABcAAAV0ICSOZFkCZqqqALq+7OPCtAg8cl3f+KzHuNzI8CPxgjMDsQg5IkUGxILpfCoW2GIV iVX4asHeaOFtFcVCyKLF/uV4o3L7QZvxXAK2C776kvJzZj8odBByhEw2LmsoiIkkCwIjjo9qU4qV cSd+mVhZmSWflSEAIfkEBRQAEAAsfwEUADsAHAAABeUgJI5kWRpmqq5smxqoK8+0CMd1ro83vv+y ng9IfAmLSJMQlmxCFtAo1ImUWqkphXbL7Xq/4HA3VSibz+i0es1mk9yQgkj9eJzjcnx7n2/P2XV3 cX98e3plI4iDeHV2BYGPIg8mZm+WiWcKgn1znXGBnnJ1AHiheX+oh5qVh6GEj42IjQCKpyWKb5Wb rJyHjaB1iaa1fWqti73Jrr+Tprmpd6u4taml1hDMD6S4yNyCENKFftmT4mgKJeHmaNjkh4VYIwDM APX18Trz2qP4QPOk+kj1yycw4MB8JAwe/KFw4Y57QEIAACH5BAUUABAALH8BHQA7AB8AAAXqICSK QmmeaKquLDq+QCzPdG3fOA7fItDXP1owRxwCITljTEm0CZCz0RL5k/qg0lcQxrXKBFGq+ErumaGx x2NKvlaxaABYNjy3p0Y1W2vlR8OAdnQ7eGVxbzyBY3aMh2JjbnBsdHOFhpZvkgB6kXeEbpVNoqNN Ty+hpKmkpnytrq8LsbKzC6+2t7h8tLG5tga/wMHCw8TFxJG3xsrLzAZ4yc3R0pvIvda5xptr19y9 v35q293j19p65Oi45ufp7eDh7O7y6+HV8uP09fft9EL75NoC/nNHDUm8gfjIHETIrdNChvgeQuz2 7EUIACH5BAXIABAALKoBKwALABEAAAUQoCGOZGmeaKqubOu+cCzDIQA7 ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://bmj.com/icons/toc/rarrowsm.gif R0lGODdhCQALAKIAAP///2PO/973/7Xn/+///wAAAAAAAAAAACwAAAAACQALAEADGTiwvBGiuRcU e7ZR2KJ0mYZJW0Bcj3epTQIAOw== ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://bmj.com/icons/spacer.gif R0lGODlhAQABAIAAAP///wAAACH5BAEAAAAALAAAAAABAAEAQAICRAEAOw== ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://bmj.com/math/12pt/normal/mdash.gif R0lGODlhEAAGAKEAAEVFRWxsbP///wAAACH5BAEAAAIALAAAAAAQAAYAAAIOVI6ZIuAPIZu02ouz 3gUAOw== ------=_NextPart_000_0000_01C33EFF.DA5E46A0 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://oas.highwire.org/RealMedia/ads/Creatives/bmj/BMJ-CE-Bottom-030107/BMJ4formats1.gif R0lGODlh1AE8APcAAP/////37/b3//f39+/39+/v9//m3ubm9+bm797m8//ezv/vAN7e79be7//W vf/mANbW7s7W787W5v/Frc7O5v/WAMXO5v+9nP/MAMXF5r3F5v/FAP+1lL2+3v+9ALW93rW13v+1 AK213v+lhK2t3q2t1qWt1v+cc6Wl1pylzpyl1v+ZAP+ZAP+MY5yc1pmZzJmZzP+MAPeEUoyUzpCU xfd7QoyMzoyMxYSMxfd7AISExfdzAHuExfdrMXt7xf9mAHt7vXN7vvdjIfdjAHNzvWtzvGtrtvdS EPdSAGNrtfdKAGNjtVpjteZKCFpatVpard5CEFJarc5CGVJSrUpSrb06Ia06KUpKrUpKpUJKpUJC pZkzMzpCpIwxOjo6pTg6nDE6pXspQjMzmSkxnGshSikpnCkqlFohUiEpnCEplEohYyEhlEIZaxkh lDEZcxkZlBkZjBAZlBAZjCEQexAQlBAQjAgQjBAJhAgIjAgIhAAIhAAIjAAAjAAAhAAAewAAc/4B AgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH/C05FVFNDQVBFMi4wAwEA AAAh+QQENgH/ACwAAAAA1AE8AAAI/wABCBxIsKDBgwgTKlzIsKHDhxAjSpxIsaLFixgzatzIsaPH jyBDihxJsqTJkyhTqhypp6XLlzBjypxJs6bNmzhz6tyJU6CSn0CDCh1KtKjRo0iTKl3KtKnTp1Cj Sp1KtapSgjH3aN3KtavXr2DDih1LtqzZs2hl+rTKtq3bt3Djyp1L1ylWmGjz6t3Lt6/frWoB1B1M uLDhw4gTC7378q/jx5Ajjw2suLLly5gzH2bsUrLnz6D1UtZMurTp06iBcm4ZurXr11pHp55Nu7Zt tqv1wN7N9Q4bNm72zPk9p+xvNo6HsyneVfbt59CjS8/Nuzqbn1X2hPkZpixQx9uVdP9vHnOt9PPo 02umXn33dSXZw48f+/2vfK/O1evfzz8u+/avvZcdG2GEgRxZBc7X133kwWSeURw4IOGEFErYQw8S cuBWCxK20J9SE/7EoQMeKoWhAxpCaGFlJ6ZY1IglPvcfgK0JSONWDHKVH1EOMFRDDQI54NYIAo1Q V4iXDfQTkQAYqRSQAAhpVI8A1FAZlFIWxaSTMg6U1Y2O3UGGFVVsocZWNhJooHZhnLEHG1tUEcYd OBbI1RlxWnEGnVyp0UUVZbqpVY6AlScYUlQq9GOQQxZZl5KXIbnlUlgeRaWVirV41KTQzQjmXm40 IVQVdNp4H3ZkBNUEc/XdIYVQUAT/t4erQ0lBJ6GxGZpUDz8uKtAFvdZwRKVtcToXpKQZixSxRV1a m7K2efopWneIqgQUVQBlxZvYacfdHj9ZG1QXWtWXrRJNVGEtFHRu8RMUYXRhbXe47rEjUgNx+VOl R5wwQgtHDHWEDCOMgKlRk/ZQcA9F1VCwDAELJQTB/zK8L5RVCmvUsAUbDJQQP1r8E8g1iMxxwQdf jKmyJ3sMVKVC+CuDUM4G5fAIECs1MMo2/xixykcMW7JQNzPMMsUpK0FywArjTNTOOP8cVA/+tiAE U9JOa1YXP227R6g/DdftqT/Zuoe7SkhR7k97qPEunbQq4SZQfLoNn7fi4adrU/kS/x1kCwEMFIDI SgBOkAFJB8VkhAQ5IHUPBhAUwAlBcWCQ40oclPiSgUs+cw8D/XyBQJQrMULngs/8E6TGnl5QAKpj aflABohcsxKQS166UYbTjukEArkohEABKMFsDwo0PjuXvQuEOFBMygD8QApI7brguytxRKLBS21U 1q314Ucff1nL3Nk/nWHqt0DJOkd931mR/lZn/LSFb8BtZXd83zb40oNXcZTNiHc5oJxgIA5IHgAG pyWCKECBUQIK6ASigESVqAXOK5gChSQhBDqAcEDB4AI5MAIqBSBgkQNAjFJ4NREGgIQmjBjrBOhC GBIvYBgDgAESdcKf1GyCAKjgQP9iNJQDBkmBDBShAUL4K+MxSnspjBIEm/QTI0qReBZj0hQFaDoE QtBJR0jhDjt3gQAK5Eu76cMYqFAH8pHFD3CMo27elzawrC9v9VmbEvS4Byj8hE9g8Q0ZtmAt/uXN fy4BYFL6NsBfBcyKARteECMmwiwJhUkq/EkPOmexyDEQd4Hr4e1YuDpFBkWBqlOCAq00uzLijoI/ QSVQVlnKQ3FKlrEUiJUw5sojKLB0NfOkxTa5QO+NjIKUZNQRBnI1JUxvZsQyogKaKUIqSrJ6Inoi Jil3hNEF8ZgLtJgLf+LNEvlSl4v0El7SeIUCAIAEbRRLH+QABB3U8wY+qAO37vb/lTt2J4/gYltA 9wjQrrjhXKPCm4Jy5aBDYY2L+yJeUFJopehNVCAgXJJAJlA5R0HJRUrwJuWmp4CcDQVZROkVUMKI zgkWTwmzK51Kf8LSKtVSo1Q03o9WSlEnLjAoMniisz4aFJESxaJASSHDpsdNifpUSlRKpTMdhdSf KLWLAOAoOA9lRJBOYEWwZGJW03nGdb5GD30wwUC84Eaw9KEOUXhCBgayhn1mp59jY59A+TjQvn6l Wtgx0P4UqreG2gWiTw2Ks7hnECJCD6KVwuRByhjUw3GAcCht2AgihDpMpXBmpHzZZh3Q2ZtiVV8O 4+xAdvlE1azFWZI1iCtpphAP/4lQAYVrYmIzB8BJMbYgHlIWpKa3OZ8iZIn4Umdj0kgEgRygDW0N i/hmIBAC1PUO4boToNTgT7/y9TuvUoKsvgaoNnUNTXk9pI729tCcvqy1SlisQvT1WPcmNrYFkVIN pkcQLmVWKLmjXU+VYMQLXFOCUdThgGeY0wA7r6fMMi1sFWJJoPy2vz/pnBC8GbsnZta38z1tUCB1 O78phKwAQONZ8ZAEHIghuvJ8gUAKgAathFdQeziXG7oLUPixjWtK2AKOfkKGHKXqbvW611EY+d4I Whid3izuUSFaWY6KkL6ajWIz/xuUzk1AYzWTpAGMuDsvgxmdvLWlAM0csKHCd/+ZP40vOq/MlCgf pZyhbLKUQotTI9m5gfYdrkCkyithSbLC7U2xWWHDhz442ixolTEAaKyV+qFLffK7ll0J22OBfoeO 4iEQUOZgaSkUhw2FJCwiW2LKJSM2ws4SIUgpZkys4hYoRj2wBBemqVmimcsR/aavbZrLBQokYlC6 dbExxWAjJfuU6MTYz0SoVWfpWpMLI4qsgVqwiFW2cy4i1vT0pUAjbRsotBaxa7mq2wxjVAkp/NkR HoZiFWsNP32QNKW1gjZVBYfHe/VrfSwtFDcBVlXpXai92LsUJgfbks46QudKZERE4xQAF3gkM33Y PeOFMmCcpGm8a3kCjZnYAMn/RDOBCaJVn6I8m79ey6Sg9PLcRpt6V6vBxDlObCpxAIcff9rOV+5k dw9EZMTCmIeOMDsqSlwgFNcmRCH1dABw05tSYpIDriYEWia3rMu991ciPeMa40hcVZAVwPe4FR+z vW1+fNeZtOKGuMPHDdlNMsPNSF9Yo7myr8soTrcIAOGhjiAlwqQQg5dUgmwuhQFIoOM/hviLLlDy qzUtpyCP+ZsH0SDKDvPhh2gUwEuOcN7UYSOzlHrqCdD0gsvi1M1TzdMPuyCzdTXYOyP2see77F4h jmt2PF6u7BiQZVHy914N39vVgHsfRNigUx8A+m74cFKVQYKrb7PSDsXB1VcW/wQfF8XwC7DZmix/ wTxapOth/Ge3uz7tpJpS6IMQ8CCNMAdQd4HKcun5jSMywvUgADgQE9BMNOV+3GdGihZ2vacjvzdp ZveAe6F8dCE0tXYUO2UUP4KAQiE0HtgzJkcUICN4S1GCUoGCuzKCSdGBTIGBbOEzRwGDKbiBRcEr JlgU4LMVfcAH7cEHumEvEUhjMKYVj5YWfRCEZNFoRdgcTbhqetBqHzKFVFiFRAE+aNUHeLAHjqaE jvaFX+iF4wOGZKiEgAGG48OF+oYGMOZoeJCFXoiGbiQ+X5iG0kU+b9BGSegV4sMHeECHYWGBVjiI hKgfWaOFRqACL4ACJvAEaP+1B3gwBUkwBVRABVOwBEsQB7qhB1lgBEtABVGAiUvwBJZIBXJghn1g B0YAAh0gAi/wBXDkAmXXVo6WBIqIAiWwBH/IhWKQBEswBU5wA0XgaGVwAyCgARZAAy9mhkbYB1NA AzNwAzbgAkuQB7ToB2LwAi7gAiRwA2ZwhFAohYU4juTYJbvHGl3RB2VAARGgBXHwBkRAABkAiyx2 AwLgXEAABG9APn3wBDTQAZP2Avk4VwIBBm3lB1kAAQcABFzABUBgATjgB2s4h2WQARCQBXTQBkVA ABQAi32QBTpgjwKBAn9gBBSgA1ogBjcgEECwh1vhB2bQARIwBXVQk1/QABn/sAb82Ac6IAD6SAdc QAEA0JJFKIjleJRISRqe0gdicAAF0AZ+wIV/AASTxgXj4weyOGlj8Adc0Qd/AAcFMAVw9Ac8MBAv phV+4AQCcABrMIZ+UAcfQAQ6MItcaAYHIABtyYV+YASTlgWO5gd4cAACoQNLkJNuCQICMQUHqQUH AAF1EJV1CQEAQAF1QHYRyY91IJgvUJR7l5Se+ZmYMSNvJZQo4Ac+yIVj4E4JAAeOJgYDoQIuiZZL 8AFzuJIAIABn6QdcwJKQaYR5AAIMMIt9kAdzBQK0uAbuxJaO9gaCCQAQIAKP+ZK2aQFzKAbuZJU8 WAIDEQUlKRBlcJApIBBF/9CbDPU/DtWCF7AiiVED6Rl9xtOeOVgVMCIX8zkXvdYsEgKaVjEjflAE AhGRPNgGzYkD5KMHiDlpaRBdefABTwCZfWCbuNmDeCCUAvAFMIaN9yiBtSgQN0CLcBCcAGAD48Oc MzYG5MmTAiEA0DWcGuCc8WSE2ikQWpCZAIAAcUCLOOBc+7hehqUUpidlc/GjSiCkVlGf6gYX0PIW zIIkpqWfU/EfoymeYyg+cNCcDGAH4hMFAxEEvdkHXJAB1miEEPpifaClk7ajXZlWs6gHQgkAOjCl bymZAMAActAHJAoAKUCeXOgDKUqmTyAQtEmLFXkAPNCfAgEB1liHcykQSf9AnkZZbBMwAiFIGAoU qVdTqZLKFsZipG+RpG7BLCgFbE6aaGjUB2AwEC/ABZVIBViwBATBBY6WBxEgEFcahFj5pjw4po4W oweApc0hkWWHoQJRAlmwqlmwBBkKAFrgB3f6AnraB2V5m2QaoyIAjlxoBzfaBwd6AFFwBauKBQcK ACYQm4+aZhk4GKGzbucKFZ4qF+0ag60VquI4qvVmVn3ABAPRAT5wA/yKAzigAzrwr2NAPn7QXALB BFHZB3FAAdCVq30KmA3gXC96hmvoB/gqEBkQkv36rwBrAwPbrM8arbjpB3HQnMYJY0xYBxIwYzaA A/x6A/4KsDPABGZolLz/slojCDUm9TJDM6QjcK5QkzI3q0u9grM/IwQtMAInYIJIyzMjw56/MjQk k3MyyLM5izRIMSlCQG9D0bRLS4IU87V6plNGm2YiorSTSoJJ6zIAtrZWExRLozQnkEpBSxtQyqeM +gdkGEd2OE/NmQE96AdBgALR9aApCgZ+IKASC2NkJ4EFOxA+oLdoGEeNBrLpKLJi4AdjMBAn+xV9 kAYJcKh0OLl2WCg9aikGsTKHNzkjFiVdp3JC0Tw6hCkXlro/0XRB4oHdVBDPg19CMinTIzxOVTiH 9zyAtlkOJDW467or1XoUZDGVojlp5mCZtDHOa7y481sTEDFMUgMVJyLF/wuklgGliwoARKCnYOEH ELqsxOmXXQmhiLsGzXkAExsbQ4gGjzuY6NuVltuVmOsHXsC51sqDdkmr9SsWRsk4QRJ9mNR5/hUl UbQ5VoR5DKTAUTIhHrRUxOMAKYRNPBd5EcwhYoQiIqZEYuVKE4xEJsgko+de0wPCyEROGTQCKaRf jNJBC8wwgvM652pCHJx58BYkm9U5TsIkqSckKYxFqAGl/ikQ5wsWj2iEYzAAAuECf0AFHZAHpymm D1sHoQsA9Mu497uXA0GgYVG5zemsl/uwpyoQncuHH2rAW5yO4Xieukd54aRJGlZLOlQwk3pNKZcl 8upQIjRb3uQktxUx3v+kVa3jKHAGAM30TEoTwzZncVhlddrjTbdWyLjmyOmqPZACqg+Ccx43aC9C yYs8pGGlyk4mWRfwL4AMc5acJMrFe1yYBQPxxF9hB21whmo1aXDgAkbwrLraBwQZxk5Ysbj8n02o B7xsp2kcsg/bBu4EANX6hG8AkHNaB3MMGG1gBzxqng1nHovTUTllgJtiyo0HABYzyE8GAEfrVJI8 MpLCRZzCVKAcZ1UVxOw8ZWO1VTwXzz8lNCIDRA+3bq3bzzJsX0Exz0oTIlNrQFL3bjglVVdlGlB6 p1zquUaAq2iJBRlqAh/Amumoq+q7uL9KXRpaByCqA03oBy3GrNG8xtL/Opza/MZdGQVBYLAMwM1w TAI6abribEbvnDLEcnSomxAl4s58fBBX0znp7F6ccls250q1C3X+rC+QshDNtDPpSRAH3aRmW19Y ZnRI0bQTAEFZt1GKVVunwZ828J/7q60WChjECbnoa7g1rUYzFtRpKgLCuag0kNd5QALL2r88iLmO xpeTecB7oL5JAAf3eAA36hV+sASbGc6JZMfL51AldtTzetXnPMrmsRBWIqpHaiwaxmE8hxBlPYCH YtrE2zihHK+kfZ7titrLSyVrbV+iXda0fI6o2AbBaQKm2RV7mQIX6qoAMAB+/b6Hy4/UJQBYoKd+ QAUDQYRvFZy0adlL/zCu0CwQauy/fepodUChmZuOdtABULmoA5uOdaABZynUmz3ODuXQrKxVqB1S sHtSt73OR9E5UjNTjexeeBZn/E1sSgHbViWFQOQytV10TN1nRSHgIkh0AdACDEMsyvJn0VLL6MiD WiAABZAGXYqQFvDcWsEHdhCcys2HfrCoAlAGfoBWdTBXLlC62JgBHzBjUNloXlAAAmAGvakHumkB 3/hW0XyNVHmbNN5oTQkAJVC64pMCPtCDvwkAN1DjPJgHIrDRms1qnK2D5lFgRUU6Yq1tjIdu3SbW yMLaBqS0PzE9MeJSFH7nrAxuYjVrbT4UDJ7gUuUvlFPONBXhgvzfZP9dFHQuQRIVVeg20fpybj+R bhgN4sz42IzJAF+QB3qQB2+gAxQw38jNp7DaFXgwBmKAAgPBBGLQy2+lnUDA6c68BBDwBXgLAFMg BnWlmwyg6ZyeB/TUkYkrBiAtEB0gBmOwFWMwBqouEE6g61xYke+UBnmQB3bwBSXwApzOhXUgiz7w hs6sBR/QoYU11GS1Up1TOkbUQ2O9MUP3vW5uHjRnJbubU1ASAFbyujmlRUOjLIdnMu8OX4oze4cy 75lMVWy90AVv21anMSjVrvee7+UmZ5isPRuE59oT8EVXGlnDrC9AAR+gAiXQATOApnwoBiBQv2/l AzPQ8i1/Ay9wBTv/+QQdAAIv8AIfYAImOgUucPMwTwUEWwc3QAEdgIsd8AIregXR6PIzYAM+YAcs HgQ2YAMufwMzAPRciAdLQAEQ0Iod8AFGAI6ONgUZkAEmgAIfIAJiyZmn+3VAhRCptN+sHHgIXfe3 exAenOAF4cG197sQlXrI9egG8Ul+TvBAsbwxLEk69MOGvs7o9PCIdeagFzDVVEGo09v0BXtK/NaW 7laAyQVToAV1+oRbsYWeS4ZfmKZpgAVYkKD8OKViD5heEPqPOYeoL/a331ZZ2AZcgAUD24SOZgaV +PtQ3JlkbscFGCQpI/fGY38J/fxB0QIJlnGxW34/19AIdKRzD1L7/+L8xwv9IjL904Y6BiADblZ0 Opd5kM/Q1S8413/3CORSAZOkyR8l8Tm+nX+HY1gWpG8WYHgWANGnjx+BewweRJhQ4cKDAgXqYWjQ YZ+Ie/RcxKgHAAAlHT1+BBnS45EaNY6IRJmSpMmULT8KKdmyR40eKGHSdOly5cmcPTveRDlTiM+O JVkSDYpTZEmeSJXsdBpVqseNGzNerJhV61auXb1+BVvx6sWNU82eRZtW7Vq2bd2+hSuyKoCxYe3e xZtX78KxGjnGBRxY8GDChQ23ndtX8WLGjR0/hhxZ8uTJZQ9fxpxZ82bOLhNTBh1a9GjSpf12Rp1a 9WrWSD+bhh1b9mJsx5Zb38adW/fg17R9/wYe2vZu4sWNH2/ZO/hy5s0xDkceXfr01cqdX8ceGzp1 7t29B54bXvx48uXNn0efXv169u3dv4cfX/58+vXt38efX/9+/v39/wcwQAEHJLBAAwsMCAAh+QQF PACAACylAAsAIQEnAAAIqwCVCBxIsKDBgwgTKlzIsKHDhxAjSpxIsaLFixgzatzIsaPHjyBDihxJ sqTJkyhTqlzJsqXLlzBjypxJs6bNmzhz6tzJs6fPn0CDCh1KtKjRo0iTKl3KtKnTp1CjSp1KtarV q1izat3KtavXr2DDih1LtqzZs2jTql3Ltq3bt3Djyp1Lt67du3jz6t3Lt6/fv4ADCx5MuLDhw4gT K17MuLHjx5AjS55MuTLYgAAh+QQFvgCAACy1AAkAcwAUAAAI/wABCRxIcOCQGCt2FBTIwYHDhxB7 LJwI6KHAHg45UNzIcWALhy06iuy4YcGCB0MmOgDAsqXLGiMBtRRYg6WDmDgBjWA5IqfFkRhMLkip 0qVRADBHzgRUE8DNnCM/OgiJc2nHEEJjbFwJQEGNr2BrHIm5tOlTqGiVshSZQ2gIjlzPLgRLUMhX IQLL2qRoVywgGSNGSCT4dTDgI33xAurxVSBgwQO/tvw6luIDkxg6xt1oVSfPvGuZ7p24E4AMBS4V KJbpVAhqpKV7VmTZ4zXLC6CNJl3owSRKzSy9hvXLGgDB2Llpjl5YOkBXrl0H2jQwGfnsrkdhOmzp cHDBtia1Av8/yjJpZ+t6nVIsDYCqEOoATuQGYCCwEOtcA8B0zVJj8o2XLeDBSNBl959A6IVm1nos TUBQC6O15OBA+LEkn0AQqnegQAgJ1NsCFcTEVX2BlajYeZ8Vp5yGzKUo0BEsBZCbd54BIBtXuy24 YVALxADeAgoRuNxCKNr4n44tGknQUp3VeGN5kS1n1Q5CYRDggCIOWVCRsqUn13EuAgIjADKqCKaS OEbJYmdCCfWAT1ouSdtAr3WpYJwIBvdggxs6KVCaK57V2YdZwcniQlwpIEMNE7Rkp3GiHXomABeM JYNz7fVZIVJqCmqhXzG0uQFUm1GUoUuNKuklg2Qe5SmkFKZTCGikZ8EHJSABDkUqngNx0FIAJzT1 aKCsBoYpABxUZmasaN5Ka2THJpXDCivkkFZMRzR27ZmyabvtSGAp++24aVlH7rnopktamOq26+61 5r7LUUAAIfkEBb4AgAAsswAgAGwAEQAACP8AAQkcSHDgkBgrdhQseGSEAwAADFyosbCixYsYCXJw 4KBHxo8gAW1YsODBkIstAkBcCXHCkZAwQT4EQDGmTYEYSC44afEEy58AHNwcWnBjR6IwQ+iMcbHG SgMyBPaYCaAF0qtYQebQGQLjzAAvCc4USlBIixEjag48UqOGEEBCToxoEbZgDbQt3g7s0bYuoBpy 0/oVeEQGWrUYH5DEgPHIyhELZXAkC+jIhZ8G1DoFgJZlAI8DZRj4ySHszJo9Rnu2OjAly8wYPZA0 iXEzANAZvzpQTVPgZgVAKdtWQJXsaYGqL4y4oLI3IJ8QHQAH8NniVpJMMY5YCbIFRAVhvUf/9L3y wkvoAMKqZt2jucfjmymLvwD3e/joFhUv8PBxO0SZEEU10HQUbRYAQapR1MN3BDnkgFXHLQjRCLgN 5J+AyEEEGkICybZABd2tNFhlbdXwEncNTvgXfgMdBx1kFh0HyHQrTXBCi0CxZFVOC8Rw3QIKfSRh VZGhiKKFKsYnFkQU+QdjRTI2xBtEBrxFVY4j7KATBvrxF5JqCiw0U5iANOcXBxDdqCSOvUHHQVlt WclkQWZdBhF9diJWkE46PRCTeAC4hCRErE1AKIIarhjUkr1JaABBhgJw43FG4SYDfuK9GRpaL3m4 lE2RRudAcwCQqWgAFFnG4poCyTiTec9BbgQWIC62NJCblTXHGnRkxcDnBjepmiN4GuUYgF6s0jon IO3lyNpxRzQXwG6y6nUpUNUJpN9ORNVAY0QjjNjClBfopShlyjoHl53fqRUlu9FVWMOVRw2Uwwor 5JBVXxkJ0RZWbJkYEl96EhSwXwEBACH5BAW+AIAALDUBCQBaABEAAAj/AAEJHEhw4JAYK3YULHhk hAMAAAxMqLGw4kIHGAX2wMjBosePIAFtWLDgwRCPLQJAXAnRwZGQBVcKrNESpk2QGEguOGnxBMuf EV/elAloo4OON5MWDKEzhkeaEA3IECiEw0oHSYkq3Vowh84QHx8CCCB0oFWIFAHVqNED0JEWI04I IUj0yNq2gISsfdljxIipC4XAPYEX5AOSGD4eWTli4RGVAJC2lAEZYouBRKFiBTQCoowJLBWUBXT2 6lyPHkia/AgVQGGCoAFsjloZIlmBmWtyhqgAaGOBsQM4MMB7NEGvJJ1+7AzRInMAuHnPrQEZcG7Z Ap+fcHuBt8AWEC8M+uwO4PfCwws8hHzunOjKwuR/X9/MfMJAIUTFlsU/diBCgaktUAFM4EFknEDk GRAddAMxJ19zaunmIF0QAvXTXDktEANyCygUUg8rXbYQcQDYB4hWu5W34EwSQmTeiRVauFINO+iE AXrq2USiAgsVCICIKE4II4OaZecihQyS+JFOOj2QlI8TlEVZVJhBaKSKQ7KIXYovEkUeYAKdEBeA TGqoVGwtDcdSYUEemWWEWwq5IpwGUHREfALFwOQGW90pYwBpzXnlg0S2iKWgpYVWFno7caVWbysF wIFxbWI536BIEtQCieGNlsMKK+TgKEFrnTbqqQTpFahAAQEAIfkEBSwBgAAsBwAEAKgBMQAACP8A AQkcSLCgwYMIEypcyLChw4cQI0qcSLGixYsYM2rcyLGjx48gQ4ocSbKkyZMoU6pcybKly5cwY8qc SbOmzZs4c+rcybOnz59AgwodSrSo0aNIkypdyrSp06dQo0qdSrWq1atYs2rdyrWr169gw4odS7as 2bNo06pdy7at27dw48qdS7eu3bt48+rdy7ev37+AAwseTLiw4cOIEytezLix48eQI0ueTLmy5cuY M2veHHZIjBU7DnJw4ICDQdIOWpBELXC0gx4WWSfsQdo059sbFix4MOSgAwAAHBgEDmAESeICfwOo YRF5whrAhd/ejEH3gt6+ow8Hbnykc+XMKzr/Rwg9+HTNIazHSKhcOkHi3UV+Bx6e4viD5d2fr5zD egiF7W1XHEFH1DDCgfUJVEMNsB3RwggnCGGQEA+2cAQg8y0HiIEjwDbhgyd4ONB9gPRwwggybKjd fpY9oBsGCwVYEHwDjRAAccAFkKJA0clwI3Gq1YhjAC1kKINywF1QEAc4Bichj8ANdMQEOBpwwoos TuaBbrzFmCNqqNEISJEABMDBCMoFcCGGABjwI3FqCnQlcAY48CYAyeXYpIYCUVmmAwYAp8Ca4/kJ gAJImpelZP3ptp6XezbZnQLA7QgIpXwSp4CENfy4448nCHQEpngCkiZzQmBqG5lKCnQBd1CW/9pD juH18KN+izrm4gIeNJRopANuuKCUgWYKnIivDlieAgTNGqWpwIUqEJnSKbcmIELkGKtAIwBnm5xY 5prYZwJtuUAFDimnwILslhesgiOM9mZ493U7oL3xbQstnyoqCixxEmaYYH7iKlbdAjE0ukBovoYb a3c9FEtnsfQ+yy2s+M74LHgDEczmv8wJTJDHBRu2g3UY7Nprug5/3N2PE9RwIccfE5QxqxqXSnO/ 0hWrkHPJBqlgyyULZp11D0Ak43uwLksQphWXevGAzsYpkAwiD61ospYCcqK0zs2pH5OKFl2Yueop 3TKN5RmwJpnGSg1Ixvs6wKnEefLrcdvMHYCRbHfOHfEjBxfCjavZgcVw9AYRLT0irIAUG4ADpMZt M+S2NhmAz/vWRzLZTQ6q75h7Yno44oDtel3ja2MucQAHQl4v5CWSasCRG9PXcbgtSAzABdfe1ztx rxGNul85rLBCDiQJwSBGzotYkfMJLtRDDU8er/323Hfv/ffghz9XQAAh+QQFPACAACwHAAQAqAEx AAAI/wABCRxIsKDBgwgTKlzIsKHDhxAjSpxIsaLFixgzatzIsaPHjyBDihxJsqTJkyhTqlzJsqXL lzBjypxJs6bNmzhz6tzJs6fPn0CDCh3aUYnRo0iTKl3KtKnTp1CjSp1KtarVq1izKiXKNabWr2DD ih1LtqxZpF3TsjzLtq3bt3DjKlFL96Tcu3jz6sVbt6/IvYADCx5M1W9XwogTK15M1rDjjYwjS54M 9vFQypgzawZsWejmz6BDN+5MmqHo06gTl16NMLXr13pZyx4Iu7Ztt7N33t7Nm3Funb2DC+f8G+fw 48jfFjeevLnzsMtvPp9OvWr068yNYt/OvbtJtN7Di44fXxE8+fPo06tfz769+/fw48uf77e6/ftM 6RPFz1+yfs/9BajYf0AJaCBiBPp04IKCJagRgxD25qBuEVYo14Q5WaghXBhetOGHonUoE4gktiUi TCWmaNaJLqno4lgsTvTijAjGGBGNOAZm44059sjXjg/5KGRcQAY55JFsFankkkw26eSTUEYp5ZRU uhQQADs= ------=_NextPart_000_0000_01C33EFF.DA5E46A0--