ࡱ> [ Xbjbj UjjPl$4 8 8 8 8,684T:::::;;;SSSSSSS$U WxSi;;;;;Sy<::BTy<y<y<;R::Sy<;Sy<y<sC:G,OH:: 0d43 8'<RG OHd XT0TGR Xy< XOHy<44Revised 10/25/04 Loyola University Health System Womens Health Screening & Counseling Preventive Guidelines 2004 Objectives: To develop recommended standards for screening and counseling for the health maintenance of women throughout the LUHS network in order to improve the quality and consistency of services offered. To enhance the ability to attract payor contracts through high quality and consistent standards of practice. To define screening and counseling standards that will serve as precursors for future womens health initiatives and programs. Process: The 2004 Womens Health Preventive Guidelines Committee members reviewed and compared screening recommendations from numerous sources. In addition, recommendations were reviewed with appropriate disciplines within LUHS. Committee members reached consensus based on recommendations and best-practice evidence from medical literature. The format of the U.S. Preventative Services Taskforce is used to present the guidelines. This guideline is a revision of the document originally developed by the 1999 Loyola Womens Health Task Force. The level of evidence based on the USPSTF is as follows. Strongly recommended - good evidence concludes this will improve health outcomes. Recommended based on fair evidence. Evidence is inconclusive but favor benefit. Good evidence to recommend against screening asymptomatic patients. I. Insufficient evidence evidence is lacking, poor quality or conflicting. 2004 Womens Health Guideline Committee Richard Besinger OB Gyne Pauline Camacho Endocrine Cheyanne Casas Family Medicine Rani Chintam Gastroenterology Nicole Cirino Psychiatry Sheryl Gabram Breast Care Division Mary Jo Liszek Internal Medicine/Pediatrics Shelly Lo Oncology Robert Mittendorf OB Gyne Ronald Potkul Gyneoncology Bridgid Steele Internal Medicine Amy Stoeffler OB Gyne LUHS Womens Health Preventive Guidelines 2004 SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceHeight, Weight, BMIHeight: Measure at least yearly Weight: Measure at least yearly BMI: Assess yearlyHeight: Measure & record at least once in the chart Weight: Measure yearly or as appropriate BMI: Assess yearlySame as 19-39Compare height to baseline.BThe AAFP recommends periodic measurements; ACOG & USPSTF recommend yearly or as appropriate.Blood PressureAt least every 2 yearsMeasure at least annually or at each visit.Same as 1939Same as 40-64AThe AAP recommends screening at every visit or minimally every 2 years; the ACP, AAP & USPSTF recommend screening every 1-2 years.CholesterolHigh risk patients onlyConsider total and HDL cholesterol level or fasting Lipid profile starting at age 20; then every 5 years.Screen every 2 years or more frequently with additional risk factors.Same as 40-64The AAFP, ACP & USPTF recommend periodic screening for ages 45-65. The AAP recommends selective screening of patients at risk. The NCEP recommends FLP starting at age 20; then every 5 years.EKG & Stress TestingNo routine screeningNo routine screeningEKG: In women over 50 with multiple cardiac risk factors, the clinician may order if results may influence treatment. Stress Testing: At the clinician discretion in women over 50 with multiple cardiac risk factors. Same as 40-64D The USPSTF recommends against routine testing of asymptomatic patients at average risk but finds insufficient evidence regarding asymptomatic high risk patients.The ACC/AHA recommend screening with multiple risk factors and informed consent regarding the pros and cons of testing.SCREENING CATEGORYRECOMMENDTIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 yearsAges 19-39 yearsAges 40-64 yearsAges 65 & OlderLevel of EvidenceColorectalNo routine screeningNo routine screening unlessFOBT: Annually in women over 50.and/or Flexible Sigmoidoscopy: Offered every 5 years starting at age 50 -or- Colonoscopy every 10 years -or- Double Contrast Barium Enema every 5 years. Same as 40-64A The AGA recommends colonoscopy as the preferred strategy. The AAFP, NCI, ACP & USPSTF recommend choosing any of the strategies listed.Bone DensityNo routine screeningNo routine screeningSelectively screen women with the following risk factors: - Women with e" 1 risk factor other than menopause - All postmenopausal women with fracturesAll women e" 65 should be screened then tested every 2 years. BUSPSTF & the Nat l Osteoporosis Fdn recommend routine screening in all women > 65 years. Testing in women < 65 is recommended if one or more risk factors are identified.Pap SmearRoutine screening should begin at age 21 or within 3 years for patients with a positive history of sexual activity, whichever comes first. For women with at least 3 normal smears, the screening interval may be extended, at the discretion of the clinician & client, but should not exceed three years.Same as 11-18Same as 19-39Women over 65 with no previous screening should have three annual normal smears prior to discontinuing screening. Screening may be discontinued at 65 years if the woman was regularly screened, has had 3 normal pap smears and has had no abnormal smears in the previous 9 years.A More frequent screening should be considered for women with risk factors: Age of first sexual intercourse is < 18 yrs; multiple sexual partners: smoking, or low SES; Pap smear is not recommended in women with hysterectomy for reasons other than precancerous or cancerous conditions. The AAFP, ACP & USPSTF recommend screening for all sexually active women at least every 3 years. The ACOG, ACPM & NCI recommend at least 2-3 normal screenings at one-year intervals prior to moving to the three-year screening interval.SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceOvarian CancerNo routine screeningAnnual pelvic exam with palpation of the adnexae should be performed. A careful family history for ovarian cancer should be obtained. Same as 19-39Same as 40-64IACOG, AMA & NCI recommend annual pelvic exam with palpation of the adnexa; the ACS recommends every 1-3 years until the age of 40; then annually.Breast Examination & MammographyNo routine screeningClinical breast exam: In patients <35 years, clinical exam should be performed every 1-3 years depending on the risk profile. Mammography: May start earlier than 40 if high risk. High risk includes extensive family history of breast or ovarian cancer at a young age; chest wall radiation; family history of BRCA gene 1 or 2. Mammography: Between 40-49 yrs, mammogram screening should be performed at 1-2 year intervals. After age 50, annual mammography is recommended. Clinical breast exam: Recommended annually in all patients over 40.Mammography: Annual mammograms after age 70 should continue unless there are co-morbid diseases that are expected to significantly shorten life expectancy. Clinical breast exam: Recommended annually in patients over 40.BThe ACOG, NCI, AAFP, & USPSTF recommend mammograms every 1-2 years after age 40. The ACS, AMA & ACR recommend annual mammograms after age 40.Thyroid Disease & CancersNo routine screeningExam by palpation is performed in all patients 19 years and older.Same as 19-39. In postmenopausal women, assess subtle signs and symptoms of hypothyroidism and test as necessary. Same as 40-64IThe ACP, USPSTF, and the ACS recommend yearly thyroid palpation only.Skin CancerNo routine screeningBaseline exam during routine physical. Same as 19-39Same as 40-64IThe ACS recommends at least (1) baseline exam..SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceDiabetes Mellitus No routine screening unless high risk.No routine screening unless high risk. In women > 40, fasting glucose is recommended every 5 years, more often if high risk.Same as 40-64B Risk factors are: Positive family history in parents or siblings, obesity HTN, hyper-lipidemia, history of glucose intolerance. Gestational diabetes or infant weight > 4000 gm., American Indian, Hispanic, or African American races, PCOS.The ACP, ACOG and USPSTF recommend universal testing for gestational diabetes testing in pregnancy. The USPSTF recommends plasma glucose levels in women over 40 with strong family history of disease, American Indian, Hispanic, or African American heritage. A compilation of several groups recommend using USPSFs age of 40 to begin screening.Iron Deficiency AnemiaNo routine screeningNo routine screeningNo routine screeningNo routine screeningThe ACP, ACOG and USPSTF offer no recommendation for routine screening. ACOG recommends Hct & Hgb during pregnancy and in women with history of excessive menstrual flow.Vision & HearingVision: Assessed annually using the Snellen chart Hearing: No routine screeningVision: Same as 11-18 Hearing: No routine screeningVision: Same as 19-39. Glaucoma screening should be performed every 2 years in all patients >40 with the following risk factors: - African American race - Diabetes - Severe myopia - Family history of glaucoma Hearing: No routine screeningVision: Same as 40-64. Glaucoma screening should be offered annually in all women 65 & older. Hearing: Should be assessed in all women 65 & older using single question about hearing or the whispered voice technique outside the patients view. Otoscopic exam & audiometry should be performed in patients with an identified loss.The AAFP, ACOG recommend annual vision screening; the AAO & USPSTF recommend glaucoma screening in populations at risk & age 65+. The AAFP, ACOG & USPSTF recommend questioning older adults about hearing; the CTEPHE recommends questioning and/or the whispered voice technique.SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderSubstance Use Alcohol, Drugs & TobaccoAlcohol: The CAGE questions should be asked at least annually. Drugs: A history should be elicited at least annually. Tobacco: Ask about tobacco use at every visit, including type, current use, past use, and calculated packs per year. If positive for current smoking, offer counseling. Screening questions for drug and alcohol use are strongly recommended. Clinicians should be alerted to signs and symptoms of physiologic dependence or withdrawal, such as craving, compulsive alcohol or drug-seeking behavior, tremulousness, agitation, weight loss, headaches, and changes in mental status.Same a 11-18 Screening questions to detect problem drinking or drug use is recommended. Pregnant women should avoid drinking alcohol or using drugs during the pregnancy. Avoid alcohol use while driving, boating, swimming, etc.Same as 19-39Same as 40-64Questions about the physical signs of substance use may provide insight into dependent behaviors, include questions about frequent headaches, absences from work based on vague somatic complaints, insomnia, unexplained mood changes, GI disorders, uncontrolled HTN, impotence and/or other sexual disorders and neuropathies. CAGE questions: 1. During the past month have you thought you should cut down on your drinking of alcohol? 2. Has Anyone complained about your drinking during the past month? 3. During the past month have you felt Guilty or upset about your drinking? 4. In the past month was there Ever a single day in which you had 5 or more drinks of beer, wine, or liquor? Note: Any yes answer should be considered a positive screening result. The CAGE tool is used to assess alcohol use; in addition, the AAFP, ACOG & USPSTF recommend annual assessment of drug and tobacco use.SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceSTDsAll adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy & STDs, including HIV. Sexually active adolescents should be screened annually for GC & chlamydia. In addition, high-risk adolescents should be offered screening for syphilis, HIV, Hepatitis B & C.Women should be assessed for sexual behaviors that might result in STD s, including HIV. All women d" 25 should be screened for GC and chlamydia. All women at risk should be counseled and offered an opportunity to receive screening for syphilis, HIV, Hepatitis B & C. Same as 19-39Same as 40-64AThe AAP, AAFP, AMA & USPSTF recommend annual counseling about sexual practices & risks for sexually transmitted diseases. Patients at risk should receive information about transmission, prevention, and safe reproductive health.PregnancyFirst Trimester Hgb or Hct U/A incl. Micro urine C&S ABO & Rh typing Antibody screening Rubella titre Syphilis screen Pap smear HSAg HIV counseling & testing.Same as 11-18Same as 19-39N/AAThe ACOG recommendations for prenatal assessment are suggested.Domestic ViolenceThe patient is asked the following series of questions annually: 1. Have you ever been pushed, slapped, hit, kicked, or otherwise hurt by your partner or someone important to you? 2. Have you ever been insulted or Same as 11-18Same as 19-39Same as 40-64Children - B Adults - IRecommendations are excerpts from the HITS Domestic Violence Screening tool and the Abuse Assessment Screen by the Nursing Research Consortium on Violence & Abuse.SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceDomestic Violence (continued)talked down to by your partner or someone important to you? 3. Has our partner or anyone important to you ever forced you to have sexual activities? (incl. intercourse, fondling, or touching)? 4. Has your partner or anyone important to you screamed or cursed at you? DepressionSee attached checklist PHQ-9.Same as 11-18Same as 19-39Same as 40-64B Positive responses will require further follow up and confidential discussion.Prime MD (Primary Care Evaluation of Mental Disorders)Anxiety & PanicThe patient is asked the following series of questions annually: 1. During the past month, have you been bothered a lot by nerves or feeling anxious or on edge? 2. During the last month, have you been worrying about a lot of different things? 3. During the past month, have you had an anxiety attack (suddenly feeling fear or panic)?Same as 11-18Same as 19-39Same as 40-64Positive responses will require further follow up and confidential discussion.PRIME-M tool; (Primary Care Evaluation of Mental Disorders).SCREENING CATEGORYRECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceEating DisordersThe patient is asked the following series of 4 questions annually: ESP 4 1. Are you satisfied with your eating patterns? 2. Do you ever eat in secret? 3. Does your weight affect the way you feel about yourself? 4. Do you currently suffer with or have you ever suffered in the past with an eating disorder? Same as 11-18Same as 19-39Same as 40-64ESP 4 (Eating Disorder Screen for Primary Eating Disorders) J GEN INT MED 2003; 18:5356.ImmunizationsdT q 10 years; Hepatitis B for adult women with risk factors of IVDA, blood transfusion, health related job, multiple sexual partners, and household or sexual contact with Hepatitis B carriers. Verify Varicella & MMR at ages 11-12. Rubella at childbearing age if no evidence of immunity.Same as 11-18 Consider Influenza and Pneumococcal if high risk.dT q 10 years; Influenza yearly over 50 and/or high risk comordities (Diabetes, CHF, renal or liver disease, resident of chronic care facilities, chronic lung disease).dT q 10 years; Influenza yearly; Pneumococcal vaccine at least once.ARecommendations are taken from the CDC, ACOG & USPSTF.SCREENING CATEGORY RECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceDental & Oral HygieneDaily brushing with a fluoride-containing toothpaste and flossing. Encourage to see an oral health provider annually for preventative care.Same as 11-18Same as 19-39Same as 40-64ARecommendations are taken from the ADA, ACOG, CTF & USPSTF.Injury PreventionAge-specific safety counseling should be provided as part of routine care. The following are recommended in order to prevent unintentional injuries: Lap/shoulder belts, bicycle/motorcycle helmets, smoke & CO detectors, safe storage/removal of firearms, infant care seats, back-to-sleep infant positioning, poison control numbers, traffic, sports, and water safety. Same as 11-18 Women should be screened and counseled on domestic violence as part of the periodic evaluation.Same as 19-39Same as 40-64 Elderly women should be counseled on measure to reduce the risk of falls. The physical exam should include observations that my indicate signs of elder abuse. Encourage setting hot water tank at less than 120-130 degrees Fahrenheit. Encourage CPR training for household members.AAFP, ACOG, USPSTF, AMA.Sexual BehaviorClinicians should routinely counsel adolescents in the prevention of unintended pregnancies, responsible sexual behavior, abstinence, and education on high-risk behaviors, and STDs.Counsel on STD prevention and avoiding high-risk sexual behaviors. Counsel on responsible reproductive health.Same as 19-39Counsel on sexuality and effects of normal aging. Counsel on STD prevention.SCREENING CATEGORY RECOMMENDATIONS BY AGE GROUPCOMMENTSREFERENCESAges 11-18 YearsAges 19-39 YearsAges 40-64 YearsAges 65 & OlderLevel of EvidenceChemo PreventionMultivitamins with folic acid should be taken by women planning pregnancy.Same as 11-18 Preventive therapy Tamoxifen should be discussed with women at increased risk* of breast cancer ages e" 35.Counsel about the benefits/risks of HRT and calcium supplements, otherwise same as 19-39.Same as 40-64 B * For Gail Scoring, see www..bcra.ncinih.gov/brcACOG; WHI; ASCO indicate that the potential risks of HRT may outweigh benefits for asymptomatic women. *Breast cancer risk assessment; high risk Gail Score e" 1.66%.Food & NutritionClinicians should routinely provide nutritional assessment and counseling. Counsel on the need for a balanced diet that includes a wide variety of foods. Adolescents should be encouraged to follow a diet that will provide adequate calcium and folic acid intake. Adequate dietary intake and nutritional consideration should be discussed for lactating women. Same as 11- 18Same as 19-39Same as 40-64USPSTF, ACOG, AAFP.ExerciseAdolescents should receive annual counseling about the benefits of exercise and should be encouraged in safe exercise on a regular basis.Providers should routinely assess activity practices and counsel in engaging in a program of regular exercise that is tailored to their health status and lifestyle.Same as 19-39 Women should receive counseling re: weight-bearing exercise to help prevent post-menopausal osteoporosis.Same as 40-64 Abbreviations for Recommending Organizations AAFP American Academy of Family Physicians AAO American Academy of Ophthalmologists AAP American Academy of Pediatrics ACC American College of Cardiology ACOG American College of Obstetricians & Gynecologists ACP American College of Physicians ACPM American College of Preventive Medicine ACR American College of Radiologists ACS American Cancer Society ADA American Dental Association AGA American Gastroenterological Association AHA American Hospital Association AMA American Medical Association ASCO American Society of Clinical Oncology CDC Centers for Disease Control & Prevention CTEPHE Canadian Task Force on the Pediatric Health Examination CTF Canadian Task Force NCEP National Cholesterol Education Program NCI National Cancer Institute USPSTF U.S. Preventative Services Taskforce {|~N;@IJ  o p ; < = Q W q w   78Mwz{|#TX{CJ>*CJ 5CJ\CJ 5CJ\5\CJ$EHCJCJ$ 5CJ$\ 5CJH\CJ M9Rv{}~MN;<>?@dh^d$da$$a$X@IJ C  7 X x  3 V n o  ^`  & Fd`dh^o p d$If $$Ifa$$^a$d   ) ; < g`^U^^^^^ d$If $$Ifa$$$Ifl4\%/9$  094 lal< = Q q /)))$If$$Ifl֞%/9 T$  094 lal   " > @ $$Ifa$$If /& $If d$If$$Ifl֞%/9 T$  094 lal  $$Ifa$$If/& $If d$If$$Ifl֞%/9 T$  094 lal!guv7$If78Mbw/ )))$If$$Ifl֞%/9 T$  094 lalwNOP^`a{ $$Ifa$$If {|/& $If d$If$$Ifl֞%/9 T$  094 lalX`LCC d$If $d$Ifa$$$Ifl4\%/9$  094 lal$If d$If $$Ifa$ d$If#8/H& $If d$If$$Ifl֞%/9p$  094 lal8T{ !$If $$Ifa$$If /& $If d$If$$Ifl֞%/9p$  094 lalJ"< $$Ifa$$If^`$If<=G]a PQRado/ : !!!!u"v""###N$O$Y$$$$$$$$$%'(())*)0)])d){))))))****++---A-L-M-N-_- 5CJ\ 5CJ\>*CJCJ$CJPJ CJPJo(CJCJOJPJQJ^Jo(S<=Gt/& $If d$If$$Ifl֞%/9p$  094 lalt $$Ifa$$If /& d$If $$Ifa$$$Ifl֞%/9p$  094 lal .U`L d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$If.>PQR&t$$Ifl֞4%/9p$  094 lal $$Ifa$Rav  $$Ifa$$If d$If d/)))$If$$Ifl֞4%/9p$  094 laldq, - . / !!!!u" $$Ifa$$If u"v""""/)))$If$$Ifl֞4%/9p$  094 lal"[#\#]#^#l#n## $$Ifa$$If#####/h)))$If$$Ifl֞4%/9p$  094 lal###$$$$N$ $$Ifa$$IfN$O$Y$b$/& d$If $$Ifa$$$Ifl֞4%/9p$  094 lalb$$$$$$$$$U`L d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$If$$$$$&P $$Ifl$֞4%/9p$  094 lal $$Ifa$$$$%%%)%Q%%%%&' $$Ifa$$If '((,(/d& $If d$If$$Ifl֞4%/9p$  094 lal,(A(V(k(l()$If))*)\)])/)))$If$$Ifl֞4%/9p$  094 lal]){)))))2*E*M*X*h*|****++++t,u,-$If----/& d$If $$Ifa$$$Ifl֞4%/9p$  094 lal-8-A-L-M-N-_-p--UL d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$If-----&$$Ifl֞4%/9p$  094 lal $$Ifa$_-------.3.:.d222222(333r3344444444/50515756 899999:::j<k<u<<<<<<====c==:>;>F>??)?j?2A3A=AlAwAxAyAAAAAA-BCCCC*CJCJ$CJ 5CJ\Z----2.3...000h0i000011S2T2d223R333$If^`$If^`$If3 4 4 44$If4444/& d$If $$Ifa$$$Ifl֞4%/9p$  094 lal44444444 5U`L d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$If 55/50515&` $$Ifl֞4%/9p$  094 lal $$Ifa$15756 8 888889 $$Ifa$$If$If 9999/0&  $If d$If$$Ifl֞4%/9p$  094 lal9999 :::2:@:N:R:T:: $$Ifa$$If$If ::::/X))$If$$Ifl֞4%/9p$  094 lal:\;;;;;;;j<$If$If^`j<k<u<~</& d$If $$Ifa$$$Ifl֞4%/9p$  094 lal~<<<<<<<<<U`L d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$If<<===&$$Ifl֞4%/9p$  094 lal $$Ifa$==='=c==5>6>7>8>9>:>$If^`$If $If^$If :>;>F>d>/x& $If d$If$$Ifl֞4%/9p$  094 lald>r>>>>>? $$Ifa$$If??)?j?/h)#$If$If$$Ifl֞4%/9p$  094 lalj?? @|@@@@@2A$If$If^`2A3A=AFA/& d$If $$Ifa$$$Ifl֞4%/9p$  094 lalFAcAlAwAxAyAAAAU`L d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$IfAAAAA&P$$Ifl֞4%/9p$  094 lal $$Ifa$AA-B^B}BBCC)C7CECFCNCCCC$If$IfCCCCtD/d )))$If$$Ifl֞4%/9p$  094 laltDuDDDDDDEEEEFF*CJ>* CJ 5>*CJ\CJCJPJ CJPJo(>*B*CJphCJPJ CJPJo(CJ 5CJ\CJCJ$CJJ4G5G~GGGGGG $$Ifa$$IfGGGDH/ & $If d$If$$Ifl֞4%/9p$  094 lalDHEHHhIvIwIIIIIJJJJKK(K$If(K)K9KK/X& $If d$If$$Ifl֞4%/9p$  094 lalK`LnLLLL$IfLLLL/#$If $d$Ifa$$$Ifl֞4%/9p$  094 lalLLLMMMMU`LC d$If d$If$$Ifl4\%/9$  094 lal $$Ifa$ d$IfM(M9MIM[M\M$If $$Ifa$\M]MnMM/l& $If d$If$$Ifl֞4%/9p$  094 lalMMMfNO6O8OOOpPrPPH$If^H` $$Ifa$$If PPQQ/& $If d$If$$Ifl֞4%/9p$  094 lalQQ$R%RRRRRRSSSS3S$If 3S4S=SS/& $If d$If$$Ifl֞4%/9p$  094 lalSlTzT{TTTTTT$IfTTTT%U/&&&$^a$$$Ifl֞4%/9p$  094 lal%U&U'U(U[UUUU VKVVVVV-WWWWWW-XMXXXX ^`^$^a$0X8X9XQXZXXXXXXCJ>*CJ>* CJ '&P1h0= /!"#$%* 0&P1h0= /!"@#$% i8@8 NormalCJ_HaJmH sH tH D@D Heading 1$dh@&^ 5CJ$\>@> Heading 2$dh@&^CJ$D@D Heading 3$$dh@&^a$CJ$6@6 Heading 4$dh@&CJ$B@B Heading 5$$dh@&a$ 5CJ\B@B Heading 6$$dh@&a$ 5CJ\<@< Heading 7$dh@& 5CJ\6@6 Heading 8$@& 5CJ\4 @4 Heading 9 $@&>*CJ<A@< Default Paragraph FontFC@F Body Text Indentdh^CJ JR@J Body Text Indent 2dh^CJ$*B@* Body TextCJ2P@"2 Body Text 2>*CJLS@2L Body Text Indent 3^`CJpP)9Rv{}~MN;<>?@IJC7Xx3Vnop);<=Qq  " > @  ! 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