ࡱ>  `lbjbjcTcT 4>>.d1+++++???8wt?^tX^Z^Z^Z^Z^Z^Z^)`bfZ^+eeeZ^++o^e++X^eX^jXUZt?eW2D^^0^FWJ1cj1cdZ1c+Z"Z^Z^gj^eeee1c :  9/11/07 -start learning normal x-ray anatomy on plain film -osteopenia - loss of bone (a descriptive word for osteoporosis) -generalized, regionalized, localized -localized is the most serious -osteomyelitis (infection), lytic metastasis (tumor) -radiolucent absorb little amount of x-rays -an object that allows most x-rays to pass through (black on the film) -contrast shades of gray (high contrast = less shades of gray) -bone want high contrast -chest - want low contrast (need to see rather subtle changes in attenuation) -what controls image contrast? kVp = Kontrast (never solve a contrast pblm with mAs -oral contrast - (barium) to provide a separate in anatomy we normally wouldnt discern -contrast introduced in GI tract allowing us to separate tissues -contrast also sometimes introduced into veins (venogram), arteries (arteriogram), lymph (lymph angiogram), lungs (bronchogram), CSF (mylogram outline cord or cauda equina), and disc (discogram) -differential absorption most absorption is thickest portion of long bone is cortical bone, and interior portion is trabecular/medullary, next soft tissue (water density), then fat, then air -metastasis starts in one spot and migrated to another spot (usually cancer) -bone infections often start in another tissue (like lung), and migrate to bone -infective metastasis starts in lungs and metastasizes to bone -Hounsfield units CT image made of voxels a single hounsfield is unit to represent a single voxel -hematopoiesis formation of blood cells by marrow (driven by hormone erythropoietin) -red marrow in young people, and yellow marrow (fatty) in older people -marrow is production site (factory where RBC production takes place) -every hollow chamber of bone has red marrow, in adolescents -yellow marrow is degradation of red marrow factories (use it, or lose it) -attenuating technologies (image reflects attenuation/absorption values) - x-ray, tomogram (blurrogram blurred around the edges), fluoroscopy, CT 9/13/07 -emission technology -patient is emitter (MRI, and NMR ie bone scan) -MRI releases proton, NMR releases photon -image based upon mapping protons (MRI) -image based upon osteoblastic bone activity (bone scan) -two types of bone production (1). enchondral (cartilage precursor being formed) -long bones (enchondral growth adds length to long bone by working through a growth plate) (2). intramembranous (direct application of new bone on old bone) -most of skull -happens throughout life 9/18/07 -finding 1st rib is KEY to getting reference in lower cervical region (its very unusual to be able to count down from C1/2 on AP view) -cervical TPs are small, often not seen -black space=IVD -C1 not perfectly inline with spinolaminar line -obliques could be either ant or post -LPO=left post oblique position (looking up right IVF) -LPO should always be marked on rt side of film place marker over the anatomy -LAO=left ant oblique position looking down left IVF -LAO placed on rt side of film -generally IVFs orientated down and forward -if left IVF, left-sided structures bound the hole, but some rt sided structures are visible 9/18/07[2] -on oblique C views, the opposite side pedicle appears round (and is superimposed over the vert body) -oblique lumbar is to see posterior elements -scotty dog: eye=pedicle; ear=superior articular process; leg=inf art process; neck=pars interarticularis (bone b/n joint); body of dog=lamina -in oblique lumbar images, one ilium is perpendicular and the other is parallel to film -flat ilium always the same as the Scotty dogs -if LPO: left ilium visible -if LAO: rt ilium visible -RAO: see left ilium and left pedicles -top of iliac crest usually intersects somewhere in the body of L4 -anterior listhesis (percentage method) -measure distance b/n ant/post sacral promontory -draw line down back of vert body to sacrum line -calculate % anterior translation on the sacrum -active growth plate; ZPC (zone of provisional calcification); primary growth center; cortex, trabecular, periosteum -ZPC most mature layer of the growth plate -least mature layer of the metaphysis -between the growth plate and the metaphysis 9/20/07 Where does imaging fit in the chiropractic practice? -OPPQRST (history/identify chief complaint) -review of systems -exam: orthopedic, neurologic, chiropractic -assemble info into differential dx (listed in order of probability) -decide what further studies are required (rule-in, rule-out, monitor known conditions) Differential accuracy depends on history and physical exam Quality Control -to be able to diagnose -to not overradiate the patient -there is more risk to patient to not get a diagnostic film then to overdose them with x-ray 9/25/07 Quality Control -Anatomy: is the entire region depicted on the radiograph? -Bone: search for signs of patient motion and evaluate technique -can you see the big white lines and small white lines? -Cartilage: look into the various joint spaces which may become obscured by positioning errors -Soft tissues: helps evaluate technique and signs of injury or pathology Interpretation -Anatomy: sub-inventory -TP, endplate, SP, lamina, vert, etc -Bone: cortical and trabecular destruction or pathology -Cartilage: joint spaces, search for signs of arthritis, injury, and anomaly -Soft tissues: target approach to the regional inspection of the presented soft tissues Diagnostic Imperatives in Radiology -radiographs are usually only taken of the area involved, unless there is significant clinical indication to warrant full spine exposure -imaging is for documentation not education/discovery (ie dont take x-rays specifically for anomalies) -in a perfect world these two items would not be mutually exclusive; however, we are required to deal with realities of cost versus benefit -there are segments of our profession that continue to search for loopholes (beat the system) -in the context of billing and documentation there are some appropriate uses of patient education; none of which involves the use of radiology -improper use of billing codes or failure to document necessity for certain radiologic procedures should impede reimbursement; the worst outcome is that the behavior could be considered fraud -a minimum of two views, at right angles to each other, must be taken for adequate initial diagnostic interpretation (helps depict a 3D object in 2D) -single axis radiograph is not that useful and typically denied reimbursement as a diagnostic study (except AP pelvis and frontal view of the chest) -often the oblique view of the ankle shows the fracture most clearly -each view has its own abilities to reveal pathologies -decisions concerning the use of dx imaging should not be based on reimbursement -studies obtained are based on clinical need: Rule In, Rule Out, and/or Monitor -any film worth taking must be interpreted to reach a diagnostic conclusion -dont let third party payers tell you who reads the film -no third party payer can force you to interpret the film -the practicing chiro has control over who reads the films -checklists limit your thinking process and are not appropriate for professional interpretation 9/25/07[2] Liability -individuals/institutions are held responsible based on the types, and level of service they provide -malpractice responsibilities comparable to that of a reasonable and prudent general practitioner 2 levels of liability: general practice and Specialist -the responsibility for proper radiologic diagnosis falls to either the general practitioner or radiologist -the burden is placed upon whomever performs the services -federal law: all studies must be interpreted to reach a diagnostic conclusion (Public Law 97-35 sec.978) -it is up to the general practitioner to decide who is to provide the professional component of the imaging studies -successful transfer of liability only occurs if it is the office policy to have all imaging studies read by a certified radiologist -3 behaviors possible in the diagnostic imaging arena: -general practitioner could read them all (refer none) -could refer them all to radiologist (refer all) -send some and read some (refer some) -if refers all: maintain general practice level of liability -if refer none: you will have a specialist level of liability -if refer some: specialist level of liability -the locality rule in some counties: level of training is a limit of liability -cant rely on locality rule anymore -we have 315 hours radiology training vs radiologist who has 7-9000 hours training -chiro radiologists are about equal with skeletal radiologists and fellows at reading x-rays -GP chiro physicians are about equal with GP medical doctors at reading films 10/2/07 The Radiology Report (if the x-ray is taken, it must be interpreted) What is the role of the report? -verbal rendition of the film study -medico legal communication -insurance company -workmans compensation boards -attorneys (patients attorney) -provides a standard for comparison -part of the permanent patient record -**an x-ray report is capable of replacing the lost film -professional communication b/n physicians, attorneys, employers, workmans comp boards, etc -expedite treatment by highlighting indications and contraindication for treatment Apposition=what percent of fractured surfaces are touching Report Format I. Stationary (template, includes who is interpreting: name of business with address & phone#) II. Patient information - name or ID #, and Date of Birth (or age) III. Radiology info (the series and the date the series was performed) IV. Technique (optional) kvp and mas, etc V. Body (findings) generic description of what the image contains VI. Impressions (Conclusion) summarize most to least important (short phrase, ie DJD in hip) VII. Recommendations (when needed) used only when we want you to read them 10/2/07[2] Imaging Tools -plain film -myelography -CT & helical computerized tomography -MRI -SPECT -PET Scan (MRI, SPECT, and PET are all sources of patient emission) PLAIN film -not used to look at bone density -will not see change in density unless change is greater than 30-50% -3-5% change (bone scan), 1-3% change to see on MR or CT -Panorex view: bones of face (maxilla, mandible, teeth) -panorex became affordable right after CT came along Strengths of Plain film -availability -relatively low cost -well known usages -entry level diagnostic tool -search for contraindications to further imaging -quick assessment of gross osseous and soft tissue integrity Weaknesses of Plain film -ionizing radiation -relatively poor case resolution/outcome (not talking about line-pair performance) -not as capable as CT/MRI at revealing pathology -poor spatial localization -3D in 2D -soft tissues generally not seen -soft tissues seen best in MR -frequently fail to document fractures, even under ideal conditions Plain film limited by: -poor patient positioning -patient motion (esp. if kvp or mA is too low) -incomplete series -trauma patients, the elderly may not be able to cooperate during the exam -C1-C2 & C6-C7 regions tough to evaluate Plain film proper use -introductory study -can evaluate intervertebral foramen well -use to rule out contraindications for advanced imaging -not good for central canal stenosis Tomography -precursor to CT Classic head patterns: Linear Circular Elliptical Hypocycloidal Trispiral -both tube and film move creating a pivot point, which can be adjusted -tomogram=laminagram=blurrogram -edges of image are blurred, but center of image is in focus Myelography -air was the 1st contrast agent used -air was hard to control (ie air embolus headaches could arise) -other materials include poppy seed oil, pantopaque (neither are water soluble) -in the 1940s water soluble products (but they were very toxic arachnoiditis, etc) -in 1970, metrizamide: non-ionic, water soluble, in use today Complications -arachnoidits (less than 1%) -infections (needle) -arterial bleeding (large caliber needles, blind stick can slice aa or vv epidural hematoma) -headache is most frequent complication 10/9/07[1] Proper use of myelography -if CT or MR is not available -people who cannot undergo MRI b/c of time, size, claustrophobia, or embedded metal -Maybe used in conjunction with CT Arachnoiditis -blunting of nrv root sleeves -maybe a complication of myelography -intradural-intramedullary lesions -headache (most people get a headache: 8/10) -contrast isnt the problem, but the puncturing of the dural sleeve, and the release of a drop of blood into the CSF (CSF is highly filtered blood with all proteins taken out) -it is believed that the proteins (from a drop of blood) entering the CSF are the causative agent -(bring a friend with that can drive patient home in case of severe headache) Myelography Strengths -relatively good availability -good cost benefit ratio -well known utilization Myelography Weakness -ionizing radiation -relatively poor resolution -if cant displace contrast, then pathology is hidden from us -soft tissues not well seen (system is designed to highlight suspended metal) -high rate of false negatives -potential complications from contrast agent (headaches &/or anaphylactic shock) Radionuclide Imaging Group(ie bone scan, PET scan) & MR are both emission based technology -energy that is mapped out come from the patient Bone Scan -dose of radioactive material injected into vein -takes several hours for radioactive material to get into the skeleton -children, puppies, kittens are the most metabolically active, and therefore the most radiosensitive -patient emits radiation in the x-ray band -gamma camera (aka scintilloscope) maps out the radiation -emission pattern is isotropic (emits in 360 deg and in 3-D) -hot spot = area of increased uptake (of technetium) -bone scan is hooked up to phosphanated compounds PET scan: linked with glucose Computerized Tomography (CT) -an attenuating technology that provides true 3-D imaging -16 shades of gray -beam passes through patient as machine rotates 360 deg -measuring throughput (attenuated remnant beam) -pixilated image: occurs when lost some of sensory array (in modern machines) -helical format of imaging can be done in 5 minutes -CT is only imaging option when patient is on life support (equipment doesnt work in presence of high magnetic field) -CORTEX IS WHITE CT Strengths -widely available -Improved visualization of soft tissues (but not as good as MR) -can provide 3-dimensional imaging * -accurately measure a variety of structures -image manipulation possible (benefit of CT over MR) -can shift interest toward bone end or shift toward air end (digitally) -may be combined with myelography -normally, CSF is fluid-density and therefore should be colored similar to other soft tissues -if CSF is white (much whiter than other ST), assume something was added to it: CT myelography CT weaknesses -higher cost than plain film -ionizing radiation -intracranial artifacts (star artifact) -artifacts secondary to metallic implants -dose is a consideration 10/9/07[2] -understand how the image is produced, why info is needed, and know which tool is most appropriate based on patient presentation CT proper use -very good axial images -excellent bone detail -some application in the neurology work-up Helical CT -although MR is fast becoming the dominant modality for cross-sectional musculoskeletal imaging, the availability, speed, and versatility of CT continue to make it a mainstay in emergency NMS imaging - helical CT is faster (maybe 7 min as opposed to 20-25 min for an MR study) -greater diagnostic yield with helical CT image -ability to reformat the image *This modality has several advantages: -EXTREMELY rapid data acquisition -optimization of contrast delivery -reduced respiratory misregistration (only have to hold breath once) -much more sensitive than PF in fracture identification -multiplanar reconstruction (MPR) in 2-D and 3-D possible -reformatted image SPECT & PET scan emission technologies (as opposed to attenuation-based) -SPECT: single photon emission computerized tomography (dont confuse with CT) -its relationship to bone scan is similar to tomographys relationship to plain film -PET: positron emitted tomography -more tightly linked to brain activity -even though were only looking at the brain, it is a whole body dose MRI best tool to image CNS (ie cord) Common problems -spinal fracture (the more edema, the more recent the fracture) -soft tissue injury -skeletal survey for signs of metastasis -post-traumatic complications (DJD, syrinx) -peripheral entrapment -central canal stenosis (better than CT in that MR can tell whether cord is injured) -intracranial abnormalities -T1: FOR FAT, ANATOMY ( SPIN-LATTICE, LONGITUDINAL RELAXATION -CSF IS BLACK; TR<800 ms, TE<30 ms -T2: FOR WATER ( SPIN-SPIN, TRANSVERSE RELAXATION -CSF (&NP) IS WHITE; TR>1800 ms, TE > 75 ms -radiofrequency (RF) coils greatly improved the image -both the sender and antennae -placed on or near area of interest -used to excite target tissue (sender) -also received info regarding hydrogen nuclei relaxation Image production -hydrogen is a charged particle representing 80% of all the atoms in the body -hydrogen behaves like a small bar magnet -they are randomly oriented and the sum of their charges cancel out -the MR scanner can spatially locate Hydrogen as it emits energy within the body -in the strong magnetic field of the MR unit, the hydrogen molecules ten to align with the (or less often against) field -the hydrogen molecules are not held static, but are induced to demonstrate precession (Wobble) -they are aligned, but they precess or spin out of phase 10/11/07 -hydrogen is a charged particle representing 80% of all the atoms in the body -hydrogen behaves like a small bar magnet -they are randomly oriented and their charges cancel out -the MR scanner can spatially locate hydrogen within the body -energy must come from the patient in order to capture the mapable pattern -in the strong magnetic field of the MR unit, the hydrogen molecules tend to align with (or against) the field -the hydrogen molecules are not held static, but are induced to demonstrate precession (wobble) -they are aligned, but they precess or spin out of phase -a strict linear relationship exists b/n the frequency of precession and the MR magnetic field -the Larmor equation forms the foundation for MR imaging -frequency of precession = (gyro magnetic ratio) x (strength of the External field) -*we can make hydrogen not just line up, but work together Resonance -Energy must be added to the system. RF identical to the Larmor frequency is pulsed into the patient. This is the concept of resonance. This causes the aligned hydrogen atoms to precess in phase. The RF pulse is turned off and the excited hydrogen atoms undergo relaxation (when the mapping takes place). This release of excess energy is in the form of RF and specialized antenna (surface coils) receive the input. Tremendous computer power is now brought to bear and an image is reconstructed. Imaging Techniques -the MR image appearance is controlled by altering the timing of RF pulses sent into the patient and the returning echo -the appearance of the image reflects the intensity of the emitted signal. -High signal intensity appears bright and dark areas represent areas of low signal intensity -brightness = lots of hydrogen atoms emitting energy -intensity of the signal is determined by the quantity of mobile hydrogens emitting at the time we listen and two magnetic relaxation times (T1 and T2) -manipulating the repetition of administered RF pulses (repetition time, TR) -collection of the time emitted RF signal (Echo Time, TE) -TR and TE influence the image characteristics. Images may be described as proton density in which the image is based on the population of hydrogen T1-weighted or T2-weighted where the specific relaxation characteristics of the various tissues will be highlighted or suppressed. MR Pulsing sequences: Weighting TR TE Proton long short T1 short short T2 long long T1 protocols utilized: TR<600 and TE <25 -TRs of 200-600 milliseconds approximately -TEs lasting about 25 ms T2 images are very time consuming protocols and have long TRs and long TEs -T2 is on the order of thousands of milliseconds -hybrid images have been developed to take advantage of T2 type images with greater economy of time -hybrid images make the time of the study shorter, and are used when chasing a specific diagnosis MRI strengths -superior resolution -superior tissue contrast -images soft tissue very well (MR soft tissue image is much superior to CT) -non-contrast enhancement in the spinal canal -axial images OK (somewhat comparable to CT) -coronal, sagittal, etc. images are far superior to CT -MRA (Magnetic Resonance Angiography) can produce non-contrast visualization of major and minor vessels -use MRA if you have a question about the vasculature of the neck and/or brain -measurements may be accomplished -MR reports on the physiology as well as anatomy -not reliant on attenuation of ionizing radiation -no known harmful effects T1: fat is always white, fluid (CSF, cysts, edema) is always dark (signal void) -there is not enough mobile hydrogen in cortex to signal (always a signal void) -bone that is down (dark) on T1 and up on T2 should be thought an aggressive tumor until proven otherwise 10/16/07 1)Atlantoaxial instability a) Inflammatory arthritis -seropositive/seronegative arthropathies -pos rheumatoid factors b) trisomy 21 c) trauma 2) Spinolaminar line (aka post. Cervical line) used more than Georges line DDx: atlantoaxial sublux, ant/post, dislocation, odontoid fx. 3) Teardrop distance DDx: septic arthritis, hemarthrosis -difference of >2mm from side to side is a positive sign (Waldenstroms sign) -ie 2 yr old refuses to bear weight -must rule out infection (ie septic arthritis) 4) Meyerdings grading method -4 grades; - percentile method is preferered over Meyerdings method -spondylosis vs spondylolisthesis vs spondylolysis -spondylosis: degenerative change of vert body -spondylolisthesis: anterior translation of vert body -spondylolysis: defect in pars interarticularis -Spondylolytic spondylolisthesis: pars fracture with anterolisthesis -no pain unless unstable or hot on a bone scan -compare traction/compression or flex/extension radiographs to see if unstable 5) Acromiohumeral joint space -acromion process to humeral head Normal: 7-11 mm <7mm: consider rotator cuff tear >11mm: shoulder dislocation, or paralysis due to stroke 6) Glenohumeral joint space -average sup, middle, and inf joint spaces -osteoarthritis (narrowing of joint space) 7) Prevertebral soft tissues -rule of thumb: -at C3: <7mm -at C7: <20mm -positive sign: hematoma (blood), abscess (pus), neoplasm 8) Kleins line (along lateral margin of femoral neck) -line should be medial to the epiphysis -SCFE (slipped capitofemoral epiphysis) -Can be drawn on both AP and frog-leg projections 10/23/07 Principles of X-ray interpretation Table 7.2 the 7 categories of bone disease (VICTANE) -vascular (hematologic), infection, congenital, trauma, arthritis, neoplasm/tumor, endocrine/nutritional/metabolic (dont study the rare features, but the most common for now) Table 7.3 radiological predictor variables ANALYSIS OF THE LESION: skeletal location, position within bone, site of origin, shape (the more round the lesion is, the more aggressive it tends to be), size, margination, cortical integrity, behavior of the lesion, matrix, periosteal response, soft tissue changes, joint changes PRELIMINARY ANALYSIS: clinical data (age, sex, race, history), number of lesions, symmetry of lesions, systems involved SUPPLEMENTARY ANALYSIS: other radiologic procedures, lab exam, biopsy Table 7.4? -bone infections often start as: upper respiratory, skin, or GU infection -benign lesions can be seen in first 3 decades -no benign process is capable of cortical destruction -benign has sharp margins, and destruction is more geographic -aggressive primary tumor: starts in bone -soft tissue mass -aggressive secondary tumor (metastasis): starts elsewhere and spreads to bone -cannot be found before the 4th decade -best example of polyostotic presentation -moth-eaten destruction is characteristic of aggressive (primary and secondary) -imperceptible margins Radiological features of lesion behavior OSTEOLYTIC BEHAVIOR -geographic lesion (destroys bone slowly) -motheaten lesion (destroys quickly) OSTEOBLASTIC BEHAVIOR -sclerosis MIXED BEHAVIOR Table 7.11 laboratory values -HLA-B27: ankylosing spondylitis -digastric line was originally described off a tomogram -spondolytic anterolisthesis -Meyerding works, but will not help document progression of spondylos ------------------------------------------------------- 10/30/07 -on emission technologies cortex is black -on attenuating technologies, cortex is white -very difficult to find the edges of the foramen magnum on film -McGregors works better than Chamberlains line -phosphate is the carrier molecule for bone scan -if center edge angle is reduced, likely congenital -enchondral process forms the greater trochanter -when missing bone in one area, bone is enlarged in another area     the guy with the bow tie <=GH} s t |  u T U V ~ ⿳ʨ{{{pppppphh9hr!ZCJaJhh9hFFCJaJhh9hhmCJaJhh9hhm>*CJaJhh9h3CJaJhh9hCJaJhh9h@rN>*CJaJhh9h@rNCJaJhh9h>*CJaJhh9h{=>*CJaJhh9h{=CJaJhh9hHCJaJhGFCJaJ) <}+ s  u  ;  < W V^V`gdhm$V^V`a$gdhm W w{}kv@Ƚyynychh9h~CJaJhh9hzHCJaJhh9h$XCJaJhh9hf3;CJH*aJhh9hf3;CJaJhh9hCJaJhh9hyO>*CJaJhh9h4IgCJaJhh9hyOCJaJhh9h`RJCJaJhh9hr!Z>*CJaJhh9h{=CJaJhh9hr!ZCJaJhh9hfuCJaJ&W ;fwx V^V`gdf3;$V^V`a$gdf3; V^V`gdyO V^V`gd`RJ$V^V`a$gd`RJ V^V`gdhm@yz{|}3Pk0 V^V`gdA\$V^V`a$gdA\V^VgdzH V^V`gdf3;xy}?BFLVk/0Yzti^i^ihh9hb+(CJaJhh9h}=iCJaJhh9hA7<CJaJhh9hCJaJhh9h/k1CJaJhh9h4IgCJaJhh9h%CJaJhh9h CJaJhh9hIHCJaJhh9hCJaJhh9hA\CJaJhGFCJaJhh9h~CJaJhh9hzHCJaJhh9h$XCJaJ#0b5\5{8Y$V^V`a$gdTHQ V^V`gdyO V^V`gd}=i V^V`gd/k1$V^V`a$gd/k1 V^V`gdA\!78Y*+,;VW{kl!""K$U$V$`$4'?''''( (ԽyynybnbnWnWnhh9hKCJaJhh9h_y5CJaJhh9h_yCJaJhh9hVCJaJhh9hLCJaJhh9h./z5CJaJhh9h3HCJaJhh9h3H5CJaJhh9h./zCJaJhh9hfuCJaJhh9hTHQ5CJaJhh9hTHQCJaJhh9h2XCJaJhh9hCJaJhh9hvc:CJaJ" J+,;SyVW{lV ;!!!"M" V^V`gdhm V^V`gdTHQM""":#t###K$V$`$$'%^%%&o&&h''' (0(m((( V^V`gd_y$V^V`a$gd_y V^V`gdhm (/(0(I(Y(l(m((((((')())))L*S*T*h*i***+,+-+7+8+M++++.,,,ȽӽӦxmmmbmhh9h+gCJaJhh9hzCJaJhh9hnCJaJhh9hi 5CJaJhh9hi CJaJhh9h|Y>*CJaJhh9hi >*CJaJhh9h|YCJaJhh9hCJaJhh9hZCJaJhh9hVCJaJhh9hK5CJaJhh9h_yCJaJhh9hKCJaJ#(()N)))L*T*i***** +-+N+r+++/,,,,,.- V^V`gd|Y$V^V`a$gd|Y V^V`gdZ V^V`gdhm,,,,--H-s-t-z-{-------.3.8.:.S......../E/K/L////0>000-1>11ܾܾܾܳܳܫƔ~r~j~h9ECJaJhh9hUt5CJ aJ hh9hh'CJaJhh9hUtCJaJhh9hU5CJaJhh9hUCJaJhGFCJaJhh9hi~CJaJh'NCJaJhh9h./zCJaJhh9hu!CJaJhh9h+gCJaJhh9h./z5CJaJhh9h+g5CJaJ).-t---4....../ //@/E/L/V/////0>0v00 V^V`gdU$V^V`a$gdU V^V`gdhm000001R11112G2c2o2222 3(3X3l3333 484q44gdh' V^V`gdU133344F5G5[5f5g55555556666666666777777777ȽȽtii^hh9h%$CJaJhh9hWCJaJhh9hVCJaJhVCJaJhh9h"`CJaJhh9h`CJH*aJhh9h`5CJ aJ hh9hGFCJaJh`CJaJhh9h`CJaJhh9h/CJaJhh9h/5CJ aJ hh9hUtCJaJhh9h_XCJaJhh9hh'CJaJ#4444444444G5g5555556l66777727H777 & Fgd/ V^V`gdU777788999:::::;?<@<g<q<<<<<<]>>>>?? 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