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Cellular Responses: protective by localizing White Cells / leukocytes Phagocytosis Chemical Responses Histamine, leukotaxin & necrosin – limit amount of exudtae = less swelling Histamine- vasodilation, increase permiability Leukotaxin- margination(line up of WBCs along cell walls Necrosin- phagocytosis Clot formation When area is injured cellularly , collagen fibers exposed The platlets forming a clot stick to these fibers Begins when protein thromboplastin released from damages cell, which causes prothrombin to become thrombin, fibinogen converted to fibrin which is sticky Chronic inflammation replace leukocytes with macrophages and lymphocytes and plasma cells Form very vascular and loose connective tissue structure Common in overuse or overload with micro trauma Resistive to physical and pharmological treatments Inflammation Repair & Healing Phase   Fibroblastic Repair Healing, proliferative and regenerative activity leads to scar formation and repair Fibroplasia – begins w/in hrs, last up to 6 wks Initial signs will subside Patient less point tender pain decreases Granulation tissue growth begins as clot is broken down As wound heals , fibroblast appear in wound site and begin making extracellular matrix (ground substance and nonfibrous proteins) Fibroblasts begin depositing collagen fibers and strength increases (occurs randomly at first) Remodeling and Regeneration of Tissue Long process Ongoing breakdown and building of scar tissue with increasing strength and order Begins within weeks and may take years Healing : Some Comparisons of Tissues Factors Affecting Healing Time Extent of injury Edema Hemorrhage Poor vascular supply Separation of tissue Muscular spasm Atrophy Corticosteroids Keloid and hypertrophic scars Infection Humidity, climate and oxygen Health, age, nutrition Management Concepts Drugs and Medications –   Analgesics –   Anti-inflammatory Physical Modalities –   Heat –   Cold –   Others Exercise Rehabilitation Pain and Injury Pain Types Mechanisms (sources) of Pain Acute vs chronic Referred pain Myofascial pain (trigger pts)- hypersensitive nerve within bound muscle Sclerotomic / dermatomic pain- comes from bone, fascia, or skin origin Treatment of Pain Therapeutic modalities medications Psychological Aspects of Pain Subjective Emotional treatment Pain thresholds Differing with environment Pain is very real to the athlete Psychosocial Intervention for Sports Injuries and Illnesses Chapter 11 Understanding the Psyche of an athlete following serious injury Coach Athletic Trainer Other athletes Characteristics of an athlete’s reaction to injury: emotional control varies physical characteristics psychosocial characteristics Sport as a Stressor Something is telling the brain that tells the athlete that something is happening A psychosomatic phenomenon Negative stress is increased when the athlete loses the “pleasure stress” from the sport Stress is good to have initiates constructive activity or positive change Responses to Stress Physical: autonomic, immunologic, neuroregulatory, and hormonal (“flight or fight response”) Psychological Reactions to Injury: Depends on length of recovery Mood disturbances vs. Depression (can lead to suicide) Characteristics of Suicidal Athlete: high risk group (15 and 24 years of age) injury requires surgery long rehabilitation period being replaced by a teammate The “At Risk” athlete Some athletes seem injury prone May be more prone to injuries if: Anxious, tense, restless or nervous Insecurity (low self esteem and low self confidence) Undisciplined in skill development associated with the sport Lack structure in personal and social life Responses to Stress Sociological Responses: Athlete may feel abandon from the team Provide Social Support: Incorporate athlete’s rehab into team practice Overtraining During Rehabilitation: - can lead to staleness and “burnout” Overtraining Imbalance between athlete’s physical load and coping ability Staleness Training too long and hard w/o rest Anxiety (feeling uncertain or apprehensive) can cause physical responses Symptoms? Emotional stress Burnout: physical and emotional exhaustion; leads to negative concepts Role of the Coach, Athletic Trainer, and Physician Coach: “provide a good talk” might reveal emotional and physical problems Athletic trainer: must have appropriate counseling skills to confront athlete’s fears, frustrations, daily crises and refer to the appropriate medical professional or team physician Reacting to the athlete (dealing with difficult patients) Relationships matter Specific Psychological Factors in the Rehabilitation Process Rehabilitation involves more than an injury; it’s involves the person who is injured Rapport Cooperation ( it’ s not one person’s job) Educating the athlete on the rehabilitation process: In layman’s terms (use charts and simple graphs to illustrate the injury and healing process) Explain expectations of the athlete (consequences of not following procedures ; overall plan; the how and why of what you are doing) Expect and accept the athlete venting Psychological Approaches in the Phases of Rehabilitation Immediate postinjury period Early postoperative period Advanced postoperative or rehabilitation period Overcompliance of rehabilitation Poor rehabilitation compliance Initial Sports Reentry Period Allowing Athlete to Regain Competitive Confidence Regain performance in small increments Decrease anxiety with systematic desensitization Jacobson progressive relaxation method Mental training techniques Quieting the anxious mind Meditation: maintains a focus and turns away all other stimulus Progressive relaxation:tense muscle group for 5-10 secs, relax for 30sec; progression through muscle groups; then wills tension out of the body part Cognitive restructuring Refuting Irrational Thoughts: internal dialogue focuses on positive Thought stopping: focuses on undesired thought and halts it’s progression; replace with a positive Initial Sports Reentry Period Allowing Athlete to Regain Competitive Confidence Positive Self Talk vs Negative Self Talk Therapeutic Imagery: helps focus on goals Healing Process and Pain Control: Techniques for coping with pain Tension Reduction Attention Diversion: focus attention away from pain by distracting the mind Altering Pain Sensation: example-instead of perceiving pain, perceive the cold of an ice pack Emergency Procedures: On-The-Field Acute Care Chapter 12 The Emergency Plan Have an Emergency Plan & Practice It! Considerations in Development Parent Notification Principles of Emergency Care Primary Assessment The Unconscious Athlete Review of Life-saving Techniques (CPR) Equipment Considerations Obstructed Airway On the Field Assessment Treatment cannot occur until systematic assessment has been made Determines nature of injury Provides direction in the decision making process Primary and Secondary survey Primary: Life threatening (A,B,Cs , bleeding, shock – total body) Secondary: a closer look at the injuries sustained, vital signs, more detail and focused Guidelines for the Unconscious Athlete Note body position Determined level of consciousness / responsiveness ABCs Always consider neck/spine injury Do not remove helmet until.. If not breathing, …. (prone? Supine?) Prone and breathing Monitor life support Once stabilized, begin secondary survey Control of Hemorrhage External bleeding Internal hemorrhage Bleeding with subcutaneous or muscle tissue Bleeding within a cavity Difficult to diagnosis Usually requires hospitalization when suspect May show signs of shock Signs of shock Low blood pressure Systolic pressure usually below 90mm Hg Pulse rapid and weak Drowsy and sluggish Respiration shallow and extremely rapid Skin is pale, cool, and clammy Conscious person may appear disinterested in surroundings, irritability, restlessness, excitement urinary retention and fecal incontinence (severe) Shock :decrease in blood available to circulatory system Types of Shock Hypovolemic: trauma w/ blood loss Respiratory:lungs unable to supply blood to circulating system (pneumothorax) Neurogenic:general dilation of vessels; can not longer deliver blood and supply O2 Psychogenic: fainting; temp. dilation of blood vessels, decrease blood to brain Cardiogenic:in ability of heart to pump enough blood Septic: bacterial infection; toxins cause dilation of vessels Anaphylactic: allergic reaction Metabolic: severe illness untreated (diabetes) or loss of bodily fluid (thru vomiting, diarrhea, urine, etc Shock Management of Shock Psychological reaction to injury Maintain body temp. at normal range Elevate feet/legs 8-12 inches Neck injury: athlete immobilized as found Head injury: head/shoulders elevated Leg fracture: keep level after splinting Significance of Vital Signs Pulse (60-80 bpm)& Respiration (12) Blood Pressure Systolic: heart pumping Diastolic: pressure present in arties between beats Temperature Skin Color Pupils Consciousness Movement Ability Nerve Responses Musculoskeletal Assessment History and Background Information Subjective Info: feelings of patient Previous Injury Mechanism of Injury Anatomy and Biomechanics Observation Palpation Assessment Decisions to be Made Seriousness of Injury: Life-threatening? Type of First Aid Required? Medical Referral Required? Transportation Necessary? RICE REST ICE COMPRESSION ELEVATION TRANSPORTATION REVIEW Emergency Immobilization Techniques Moving the Athlete With Spinal Injury What to do with spinal injuries Use of spine board Ambulatory Aided Transportation Methods commonly employed Fitting and using crutch or cane Crutch Fitting To fit, wear low heeled shoes and use correct posture Length of crutch is determined by placing the tip 6 in from outer margin of shoe and 2 in in front of shoe Underarm brace should be 1 in below fold of axilla Hand brace should be even with athlete’s hand when elbow is flexed 30 degrees Summary Most important aspect of Emergency Care of the injured athlete is to have an Emergency Plan, and the second most important is to practice it. Expect the unexpected and always be prepared for breathing emergencies. Be prepared to provide emergency transportation. OFF-THE-FIELD INJURY EVALUATION Chapter 13 Introduction Evaluation of Sports Injuries Definition: Evaluation vs Diagnosis By law, athletic trainers cannot make a diagnosis as can physicians, however debating the difference between diagnosis and evaluation serves no useful purpose. Basic Knowledge Requirements Normal anatomy and biomechanics Understand hazards of sports participation Basic Knowledge Requirements for Making an Evaluation Human Anatomy anatomical landmarks body planes abdominopelvic quadrants medical terminology Biomechanics Pathobiomechanics Understanding the sport Body Planes Transverse Plane divides top from bottom (does not have to be equal division) Midsagittal Divides into right and left Coronal Divides front and back (anterior and posterior) Abdominal Quadrants Upper Right Liver, gallbladder, portion of pancreas, colon Upper left Spleen, colon , portion of pancreas Lower right Appendix, colon Lower left colon Medical Terminology Distal Proximal Anterior Posterior Medial Lateral Inferior Superior Midline Abduction Adduction Eversion Extension External rotation Flexion Internal rotation Inversion Pronation Supination Valgus Varus Biomechanics Application of mechanical forces that may be from within or outside the body Pathomechanics: mechanical forces applied to body that result in injury or structural deviation Understanding the sport Knowing patterns performed Understanding kinesiological and biomechanical principles can assist you in focusing on the tissues involved Terms Etiology: cause of injury or disease Pathology: structural and functional changes that result from illness / injury Symptom: changes that indicate illness or disease; subjective Sign: indicator of disease/injury; objective Diagnosis: names specific condition Prognosis: predicts outcome of injury / illness Sequela: condition following/resulting from disease or injury; additional development as complication of what already exists Syndrome: group of symptoms indicating disease HOPS History Observation Palpation Special tests Movement Assessment: AROM, RROM, PROM Goniometric Manual Muscle testing Neurologic Examination Sensory Reflex Referred pain SOAP Notes Definition - a system to effectively document and record subjective, objective findings, and develop a treatment plan for the athlete. Subjective Component Objective Component Assessment of the Injury Plan of Treatment Progress Notes Additional Diagnostic Tests Progress notes should be routinely recorded Additional Diagnostic Tests Imaging Techniques Plain Films (x-rays)(one angle of an injury; skeletal) Arthrography visual joint study using dye or air-dye combo; shows soft tissue or loose body) Arthroscopy: fiber-optic arthroscope to view the inside of a joint CT (computed tomography; pentrates with thin, fan shaped x-ray beam to produce cross sections; allows injury to be viewed from different angles) Progress Notes Additional Diagnostic Tests Bone Scan (intravenous radioactive tracer; images skeleton and bony lesions) MRI (Electromagnetic imaging; field excites ions within tissue and that emits energy detected and recorded by a computer Ultrasonography (ultrasoound used to view, locate, measure by reflectining high frequency sound waves) Echocardiography (ultrasound record of cardiac structures Other Diagnostic Tests ECG (elctrical activity of heart) EEG (eletrcical activity of brain) EMG (graphic recording of muscle contarction) NCV (Nerve Conduction Velocity; measures speed of muscle action) Synovial Fluid Analysis (detects infection) Blood Tests Urinalysis Summary Athletic Trainers Make Evaluations Certain Fundamental Knowledge Necessary A Systematic Approach Best (HOPS) Soap Notes and Progress are Needed Physician Will Use Additional Tests BLOODBORNE PATHOGENS Chapter 14 INTRODUCTION The Athletic Trainer must be knowledgeable and concerned about Bloodborne Pathogens in the athletic training room or on-the-field. OSHA(Occupational Safety and Health Administration) in 1991 established guidelines for the handling of BBP Definition of BBP How a Virus Works The virus acts as a parasite, living off the nutrients of the host cell. Shell of proteins that contains either the RNA or DNA strand Causes “illness” in the host cell, redirecting it’s cellular activity level to create more viruses Bloodborne Pathogens Hepatitis B Virus Signs/Symptoms: flu-like (fatigue, weakness, nausea, headache, fever, possibly jaundice) May show no signs; 2-6weeks before infected person will test positive for antigen Note: the virus can survive for at least 1 week in dried blood or contaminated surfaces Vaccine is available; 3 doses over 6 months Transmission: Minimal chance in sports participation Less than 1 per 1 million games Bloodborne Pathogens Human Immunodeficiency Virus Retrovirus: enters the host cell and changes the RNA to proviral DNA replication Signs/Symptoms: fatigue, weight loss, muscle/joint pain, painful or swollen glands, night sweats, fever Infected person may go 8 to 10 years before developing signs 1 out of every 100 adult males between 20 & 49 is HIV positive Most who have HIV will develop AIDS Acquired Immunodeficiency Syndrome No protection against infection No vaccine available / no cure Prevention: Greatest risk through unprotected intimate sexual contact Transmission through sports participation has not been documented at this time 3 drug regime current treatment: blocks action of virus to make new virus cells Blocks copying of viral genes (reverse transcription) = disables reproduction of new virus Protects T-cells and slows production of HIV Bloodborne Pathogens in Athletics Policy Regulation HIV and Athletic Participation Theoretical higher risk sports: boxing, wrestling. martial arts Right to participate (ADA 1991) Testing Athletes for HIV Cannot be required (ADA of 1991) Confidential verses anonymous Encourage testing but EDUCATE In HS environment this means parents Universal Precautions Preparing the Athletic Trainer Personally Preparing the Athlete Open wounds and skin lesions must be covered and not allowed to return until managed and uniform no longer contaminated When Bleeding Occurs Availability of Supplies & Equipment Sharps Protecting the Coach & Athletic Trainer PPE: gloves, gowns, masks, breathing barriers Disinfectant solutions: commercial, 10% bleach(FDA) Laundry: 159.8 degrees F Protecting the Athlete from Exposure Summary Definition of BBP Prevention and Protection Post exposure Documentation ID of source Testing Counseling Evaluation of reports Post exposure medications Limiting the Risks For more information, CDC: 1-800-342-2437 Using Therapeutic Modalities Chapter 15 What are Modalities? External therapeutic means that serves as an adjunct to various techniques of rehabilitative exercise. Legal Concerns: Vary from state to state Appropriate selection is paramount Types of Modalities Electrical stimulating currents Shortwave and microwave diathermy Infrared modalities (hot packs and cold packs) Ultrasound (classified as acoustic) Thermal Cryotherapy: cold Transmission of Energy Human tissue must absorb energy for change to occur Transmission Conduction- heat transferred from warmer to cooler object (cold pack) Convection- heat through movement of fluid or gas (whirlpool) Radiation- heat transferred through space (diathermy) Conversion- heat generated form another energy source (ultrasound) Effects of Cryotherapy Electromagnetic; classified as infrared The longer the application the deeper the cooling of tissues Delivered through cold packs or ice, immersion in cold water, ice massage vapocoolant sprays, and cryokinetics Vasconstrictor of blood vessels hunting response (incr. Temp) Decreases metabolic rate (decrease hypoxic injury; decrease waste products in muscle spasms) Decreases nerve-ending excitability Application time: 20 minutes Raynaud’s Phenomenon Cyrotherapy Special Considerations Raynaud’s phenomenon Vasospasm of arteries may last minutes to hours; causes tissue death Signs: intermittent skin blanching or cyanosis to fingers and toes, followed by redness and return to normal color; pain not normally present but tingling, numbness, and burning may occur Frostbite with extended time or temperature Allergic reaction (hives, swelling, joint pain) Nerve palsy (uncommon) Paroxysmal cold hemoglobinuria (rare disease) Post exposure; possible renal failure, hypertension, and coma; early symptoms are severe back/leg pain, headaches, vomiting, diarrhea, dark brown urine Thermotherapy Methods: moist, dry, superficial and deep (paraffin), shortwave and microwave diathermy Physiological effects: increase molecular activity, extensibility of collagen tissues, ( joint stiffness, pain, muscle spasm, inflammation, edema and ( blood flow. Application Procedures: never apply: when loss of sensation, immediately after an injury, to eyes or genitals, abdomen during pregnancy, and acute inflammation Special Consideration Never Apply Heat.. Loss of sensation Acute injury Decreased arterial circulation To eyes or genitals To abdomen during pregnancy To a body part showing signs of acute inflammation Ultrasound “most widely used” A deep-heating modality # of oscillations = frequency of a sound wave # Hz = 1 cycle/sec, 1kHz = 1000 cycles/sec, and 1 MHz = 1 million/sec. Human ear cannot detect sound greater than 20,000 Hz= ultrasound is inaudible by humans High frequency generator ( coax cable (transducer (crystal) conversion to a sound = PIEZOELECTRIC EFFECT Ultrasound “most widely used” Intensity of US beam expressed by # of watts per square centimeter (W/cm2) Pulsed Versus Continous Ultrasound Indications Application Procedures Direct skin . Dosage and tx time Underwater . Special considerations Bladder Technique Ultrasound “most widely used” US in Combination with other modalities hot packs cold packs electrical stimulation currents Phonophoresis medium: 10% hydrocortisone ointment Electrotherapy Produces magnetic, chemical, mechanical, and thermal effects Flow of electrons between two points Key Terms of electrotherapy amperes . Voltage . TENS coulomb . Watts . NMES ohms . AC vs DC . EMS Ampere: volume/amount of electrical energy Ohm: resistance Voltage: force Watt: Power Coulomb: unit of electrical charge; defined as a quantity of electrical charge that can be transferred by an ampere in one second TENS (transcutaneous –for peripheral nerves) NEMS (neuromuscular electrical stimulator) Electrotherapy Indications Gate Control Theory Descending Pain Control Opiate Pain Control Theory Parameters of Electrotherapy: Muscle Contraction . Retardation of Atrophy Muscle Pumping . Muscle Reeducation Muscle Strengthening . Iontophoresis Biofeedback Provides athlete with a chance to make correct small changes in performance. EMG most widely used Biofeedback information is displayed using lights, meters, auditory tones and beeps Low-Power Laser Massage Systematic manipulation of soft tissue Mechanical responses Physiological responses Psychological responses Types of Message Strokes: Effleurage . Hacking . Accupressure Stroke variations . Pincing Pacetrissage . Vibration Friction/Deep . Tapotement Guidelines for Giving Massage Traction Physiological Effects Indications Application Procedures Manual Traction Mechanical Traction Positional Traction Wall-mounted traction Intermittent Compression Units Indications: controlling or reducing swelling after acute injury. Equipment Treatment Parameters Therapeutic Exercise Ch 16 Rehabilitation of athletic injuries through programs utilizing progressive therapeutic exercises is a major responsibility of the athletic trainer. Today athletic trainers must perform rehabilitation programs on athletes in the traditional setting, as well as in the clinical setting on the non-traditional athlete. Therapeutic Exercise Versus Conditioning Exercise Programs General preparation vs restoring normal body function General Effects Inactivity Loss of fitness, strength, coordination, and endurance Effects of Immobilization on the Body Effects on Muscle Within 24 hrs Loss of muscle mass; with greatest atrophy due to slow twitch developing fast twitch characteristics Immobilizing muscle in lengthened or neutral position will atrophy less than one immobilized short Muscle becomes less efficient ( neuromuscular recruitment, return in about one week after immobilization ceases Effects on Joints Loses compression = loss of lubrication; leads to degeneration (articular cartilage deprived of nutrients) This is why we do early motion Effects of Immobilization on the Body Effects on Ligament and bone These adapt to stress placed on them with ADL- this is how they get their strength Full repair may take as long as 12 months Effects on Cardiorespiratory System Resting HR increase approx. ½ beat per day of immobilization As this increases, stroke volume, maximum oxygen uptake and vital capacity decrease Major Components of a Rehabilitation Program Minimizing Swelling Controlling Pain Restoring Range of Motion Restoring Muscular Strength, Endurance and Power Maintaining CV endurance Incorporating functional progressions Physiological versus Accessory Movements When restoring ROM, consider the difference Physiological Result from active muscle contraction and results in extremity motion Accessory Hoe articulating surfaces move with respect to each other Accompany physiological movements If the capsule or ligaments are the limiting factor in ROM, chances are this is the problem Types of Exercise Isometric Exercises Isotonic Exercises Progressive Resistive Exercises Concentric and Eccentric Exercises Isokinetic Exercises Testing Strength, Endurance & Power Reestablishing Proprioception continued Proprioception: ability to determine position of a joint in space Kinesthesia: ability to detect movement With injury, the CNS forgets how to put information together and react In athletics, you want responses to be automatic 4 elements for re-establishing neuromuscular control Proprioceptive and kinesthetic awareness Dynamic stability preparatory and reactive muscle characteristic Conscious and unconscious functional motor patterns Developing a Rehab Plan Exercise Phases (management and progression) Acute Inflammatory response Focus on control of swelling and pain RICE, active rest As initial reaction resolves, begin active mobility Fibroblastic repair phase Control pain and focus on maintaining CV, restore full ROM, regain strength, and re-establish neuromuscular control Maturation-remodeling phase Pain and swelling gone; focus on realigning fibers Regain sport specific strength and ability Controlling Mobility During Rehabilitation Adhering to a Rehabilitation Program Criteria for Full Return to Activity Pain, swelling, ROM, strength, neuromuscular control all resolve Risk of re-injury down Functionally able Athlete psyche Additional Considerations Open versus Closed Kinetic Chain Exercise Aquatic Exercise PNF Techniques and Patterns Joint Mobilization and Traction Mobilization Techniques Summary Athletic Trainers use of Rehabilitation Effects of Inactivity & Immobilization Major Components of a Rehab Program Developing a Rehabilitation Plan Additional/Unusual Approaches to Rehabilitation and Uses of Therapeutic Exercises Pharmacology, Drugs and Sport Chapter 17 What is Pharmacology? The branch of science that deals with the actions of drugs on biological systems, especially drugs that are used in medicine for diagnostic and therapeutic purposes. DRUGS CAN BE ABUSED BY ATHLETES What is a Drug? A chemical used in the prevention, treatment or diagnosis of disease. Administration of drugs can be internally or externally. Internally: inhalation, intradermally, intranasally, intraspinally, intramuscularly, intravenously, orally, rectally, and sublingually. Drug Administration Externally: Methods: inuctions (massage ointment), ointments, pastes, plasters, solutions, & transdermal patches. Drug Vehicle: the inactive substance that transports the drug (may be solid or liquid vehicle) Distribution: to reach therapeutic level of concentration, the volume of distribution must be reached Efficacy: drug’s ability top produce specific effect Potency: dose of drug required to produce effect Biotransformation: changing drug so it can be metabolized (usually in liver, can be in kidneys or blood) Drug Administration Drug Absorption: determined by chemical characteristics, dosage form, gastric emptying time Drug Half life: rate at which a drug disappears from the body through metabolism, usually measured in hours; determines dosage interval (when / how often it is administered Drugs and Physical Activity Decreases absorption after oral administration Increases absorption of intramuscular or subcutaneous administration (due to blood flow to area) Exercise does affect amount of drug which reaches receptor site, which significantly affects activity of the drug Legal Concerns in Administering versus Dispensing Drugs Drug Administration is defined as providing a single dose of medication for immediate use by patient; dispensing refers to providing multiple doses At no time can any one person licensed by law legally prescribe or dispense prescription drugs. Administration of Over-the-Counter Drugs: AT College not as restrictive (fewer minors) High School very restrictive (depends on the philosophy of the school district and team physician) Note: OTC includes all drugs (antibiotic creams, acetaminophen, etc) Legal Concerns in Administering versus Dispensing Drugs Record Keeping: all medication given/prescribed to an athlete must be documented. Be Aware of State Regulations of ordering, prescribing, distributing, storing, dispensing, medications. Labeling Requirements of Over the Counter Drugs The name of the product Name and address of manufacturer Net contents Name of all active and inactive ingredients Name of habit forming drug contained in the preparation Cautions and warnings to consumer Directions for safe and effective use Cannot be repackaged without re-labeling; Liability for adverse patient outcomes is transferred to the dispenser of improperly labeled OTCs…WHY? Selected Drugs Used to Treat Athletes Physician Desk Reference and Drug Facts and Comparisons: Types: Analgesic, Antifungal, Antibiotics, Respiratory, anti-inflammatory (NSAIDS), Gastrointestinal, Nasal decongestants and antihistamines, and cough medicines. Local antiseptics and disinfectants Kill bacteria or inhibit growth Alcohol, phenol, halogens, oxidizing aganets Antifungal Agents Epidermophyton, Trichophyton, Candida Albicans- most common fungi Antibiotics Asthmatics Inhibit pain and Inflammation Counterirritants and Local Aesthetics (sprays, local injections (lydocaine) Narcotic Analgesics (opium derived: coedine, morphine) Non narcotic analgesics and Antipyretics (acetominiphen) Reduce inflammation Acetylsalicyclic acid (aspirin) NSAIDs Corticosteroids: cortisone; prolonged use will result in complications Protocol For Using Over the Counter Medications Stay current with governmental regulations Check package insert of the medication for contraindications, indications, dosage directions. Substance Abuse Among Athletes Performance-enhancing drugs Ergogenic aid: legal or illegal used to enhance athletic performance: anabolic steroids Blood reinjection (doping, packing, boosting): increasing # RBCs to meet increased aerobic demands; remove 900ml of blood and reinfuse after 6 weeks Stimulants: Psychomotor-stimulant (amphetamines and non amphetamines, caffeine (>12mgs USOC) Adrenergic (epinephrenine); sympathomimetic (commonly found in cold remedies); Anabolic steroids Anabolic (desired) verses androgenic (NOT) Commonly used: Anavar, Dianabol Anadrol, Finajet Androstenedione Dietary supplement thought to increase testosterone; effects last a few hours Pre-cursor to anabolic steroid Human Growth Hormone Lack of results in dwarfism Increase muscle mass and connective muscle tissue, lax muscles and ligaments during growth, decreases fat % More difficult to detect in urine Causes pre-mature growth plate closure; diabetes, CV problems, decreases sexual desire / impotence Understand the occurrence of substance abuse among the athletic population. Recognizing symptoms of a substance abuser Recreational substance abuse Smokeless tobacco, alcohol, crack, cocaine, marijuana Common Terms Diuretic: increase kidney excretion by decreasing absorption (to eliminate fluids) Analgesic:inhibit pain Anti-inflammatory: inhibit inflammation Antipyretic: reduces fever Drug Testing in Athletes Mandated by the NCAA and USOC protect athlete’s health and ensure fair competition Is drug testing legal? 1968 - 1st drug testing Olympic Games 1986 - mandatory drug testing NCAA Method of the testing Sanction for positive tests Banned Substances Performance-enhancing drugs Street or recreational drugs NCAA and USOC 4600 banned drugs How can this impact you in your profession?  è ò [ ú “—Èäåæèî÷ÓÙßéÔåKYms{|}¼Z68´¶i"$#%#'#U#`#s#f$~$Æ%í%ï&'Î'Ý')$)W)f)q)ˆ)“)Ö)à))*4*y*„*¯*µ*í*ù* ++z+€+p,öïöïëïöïäïäïëïëïäïäïäïäïöïäïäïàÜïÒïÒïÒïÒïÜöïöïöïöïöïöïÇöï¿ï¿ï¿ï¿ï¿ï¿ï¿ï¿ïöïh4>—h4>—>*h4>—h4>—6>*]h4>—h4>—5\h4>—hh0 h4>—hb‘hb‘ h4>—h4>—h4>—h4>—6]K'(.?Xl’“ 3 z ª è    I b o p „ Ï úúÀ!¬úÀ!¬òÀ!\êúÀ!¬êÀ!*}êÀ!*}êÀ!*}êÀ!*}úÀ!¬úÀ!¬úÀ!¬úÀ!¬êÀ!*}êÀ!*}êÀ!*}êúÀ!¬úÀ!¬úÀ!¬âÀ!÷âÀ!÷úÀ!¬úÀ!¬âÀ!÷ & Fgd4>— & Fgd4>— & Fgd4>—gd4>—^„ýÏ þ 7 N O P _ ™ Ë e z ¿ ø ( [ — ì 7`˜yŸ¬÷À!¬÷À!¬÷À!¬òÀ!¬òÀ!¬òÀ!¬êÀ!÷êÀ!÷÷À!¬òÀ!¬êÀ!÷êÀ!÷êÀ!÷êÀ!÷òÀ!¬òÀ!¬âÀ!¬âÚÀ!¬ÚÀ!¬ÚÚÚÀ!¬òÀ!¬âÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—¬ý$JKk|‚¢·ÆÎÞü#:OetŠž§°»ÓÔ÷÷À!¬òÀ!¬òÀ!¬òÀ!¬êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}êÀ!*}òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬ & Fgd4>—gd4>— & Fgd4>—Ôåð ,t»Íäðñ/?Z{|}¹Ä *úÀ!¬úÀ!¬òÀ!÷òÀ!÷òÀ!÷êêÀ!¬úÀ!¬òÀ!÷òÀ!÷úÀ!¬úÀ!¬âÀ!\êâÀ!\êâÀ!\êâÀ!\êâÀ!\êàÀ!¬àÀ!¬úÀ!¬úÀ!¬úÀ!¬ØÀ!¬ØÀ!¬ØÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>—*^w­Á.‡ŸÒæ'Dg…¼á "=Zp÷À!¬ïÀ!¬ïÀ!¬ïÀ!¬êÀ!¬÷À!¬÷À!¬÷À!¬÷À!¬ïÀ!¬êÀ!¬âÀ!¬ÚÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÒÀ!¬ÊÀ!¬ÊÀ!¬ÊÀ!¬ÊÀ!¬êÀ!¬÷À!¬ & F gd4>— & F gd4>— & F gd4>— & F gd4>—gd4>— & Fgd4>— & Fgd4>—²Ö Hs‡ŸÆÞ 3\i¦°Ô'8€´ÿ¶÷À!¬ïÀ!¬ïÀ!¬ïÀ!¬ïÀ!¬êÀ!¬÷À!¬ïÀ!¬÷À!¬ïÀ!¬÷À!¬êÀ!¬êÀ!¬âÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬âÀ!¬âÀ!¬êÀ!¬êÀ!¬ÒÀ!¬ÒÀ!¬ & F gd4>— & F gd4>— & F gd4>—gd4>— & Fgd4>— & Fgd4>—¶ðB—ŸÉþ\áB^y©Ëê:a“ºÕï÷À!¬÷À!¬òÀ!¬êÀ!¬âÀ!¬âÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬òÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬òÀ!¬êÀ!¬êÀ!¬âÀ!¬âÀ!¬ÊÀ!¬ & F gd4>— & Fgd4>— & F gd4>— & F gd4>— & F gd4>—gd4>— & Fgd4>—ï/ Ä Ý !!„!Ô!ý!'"I"i"{"Ç"%#&#'#U#`#s#™#·#Ë#è#÷À!¬÷À!¬ïÀ!¬çÀ!¬çÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÒÀ!¬ÊÀ!¬ÊÀ!¬ÊÀ!¬ÈÀ!¬ÈÀ!¬âÀ!¬âÀ!¬âÀ!¬ÀÀ!ÞÚÀÀ!ÞÚÀÀ!ÞÚÀÀ!ÞÚ & Fgd4>— & F gd4>— & Fgd4>— & Fgd4>—gd4>— & F gd4>— & F gd4>— & F gd4>—è#û#$:$S$e$f$~$¿$Ü$%+%m%Æ%í%&3&8&Z&w&&±&Æ&î&ï&'÷À!. ïÀ!¬ïÀ!¬ïÀ!¬ïÀ!¬êÀ!¬êÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬ïÀ!¬ïÀ!¬êÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬êÀ!¬êÀ!¬ & Fgd4>—gd4>— & Fgd4>— & Fgd4>—''+'W'p'ˆ'¶'Î'Ý'ð'(-(A(i(ˆ(ê())W)f)ˆ)Ö))*y*¯*í*÷À!ÞÚ÷À!ÞÚïÀ!. ïÀ!. çÀ!¬çÀ!¬çÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬âÀ!¬âÀ!¬âÀ!¬çÀ!¬çÀ!¬çÀ!¬çÀ!¬çÀ!¬çÀ!¬ & Fgd4>—gd4>— & Fgd4>— & Fgd4>— & Fgd4>—í* +y+z+€+”+µ+Ù+÷+!,F,p,,²,Á,Ù, --$-+-9-J-Z-u-˜-¾-÷À!¬÷À!¬òÀ!¬òÀ!¬êÀ!ÞÚâÀ!. âÀ!. âÀ!. ÷À!¬÷À!¬÷À!¬òÀ!¬ÚÀ!¬ÚÀ!¬÷À!¬÷À!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬òÀ!¬êÀ!ÞÚâÀ!.  & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—p,,Z-u-.1.¬.±.Ð.æ.¾/Í/ï0÷0ÿ12Ñ:ç: ;;;);4;=;H;R;a;f;Ã@Å@áCñCLL T!T_T`TöV÷VWW¯W°W__nn1nùnoo*oYqpqOrcrnsŠsòtýtHuQuXu¸uöïöïöïöïöïöïöïëïáïáïáïáïáïáïëïáïëï×ïÍïÃïÃï»ïëïëáï®ïöïöïöïöï£ï£ïöh4>—h4>—5>*\h4>—h4>—56\]h4>—h4>—H* j®ðh4>—h4>— j­ðh4>—h4>— j¯ðh4>—h4>—h4>—h4>—5\h4>— h4>—h4>—h4>—h4>—6]@¾-Î-â-û-..1.Z.v.‘.«.¬.±.¶.º.Æ.Ð.æ. /0/P/c/ƒ//¾/Í/0÷À!. ïÀ!ÞÚ÷À!. ïÀ!ÞÚïÀ!ÞÚêÀ!¬ïÀ!ÞÚïÀ!ÞÚïÀ!ÞÚïÀ!ÞÚêÀ!¬êÀ!¬ïÀ!ÞÚïÀ!ÞÚïÀ!ÞÚïÀ!ÞÚêÀ!¬ïÀ!ÞÚïÀ!ÞÚ÷À!. ÷À!. ïÀ!ÞÚ÷À!. ÷À!. êÀ!¬âÀ!¬ & Fgd4>—gd4>— & Fgd4>— & Fgd4>—0n0¡0ï0÷0†1Î1ÿ122"2#2.2;2Y2Z223<3\3‡3½3Ë3à3÷À!¬÷À!¬÷À!¬òÀ!¬êÿÀ!k‡êÀ!ÞÚêÀ!ÞÚèÀ!¬èÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬àÀ!. ØÀ!¬àÀ!. ØÀ!¬ØÀ!¬òÀ!¬ÐÀ!ÐeÈÀ!.  & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—à3ì344&484P4Q4]4n4¬4¸4Õ4Ý4 5!5-5\5g5‹5—5§5²5¸5¹5Í5Ô5÷À!. ÷À!. ÷À!. ïÀ!ÐeïÀ!ÐeïÀ!ÐeêÀ!¬êÀ!¬ïÀ!Ðe÷À!. ïÀ!Ðe÷À!. ïÀ!Ðe÷À!. êÀ!¬ïÀ!Ðe÷À!. ïÀ!Ðe÷À!. ïÀ!Ðe÷À!. ïÀ!Ðe÷À!. êÀ!¬êÀ!¬âÀ!.  & Fgd4>—gd4>— & Fgd4>— & Fgd4>—Ô5Ý5æ5ð5ø56 66666'616:6D6V6^6p6z6„66–6œ66ª6÷6X7p7÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. òÀ!¬òÀ!¬÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. ÷À!. òÀ!¬÷À!. êÀ!¬êÀ!¬÷À!.  & Fgd4>—gd4>— & Fgd4>—p7Œ7ù7ÿ7$8s8±8Þ8929¯9Þ9ã9ë9÷9::5:A:W:n:v:}:‹:Œ:˜:;÷À!¬÷À!¬òÀ!¬êÀ!. êÀ!. êÀ!. êÀ!. êÀ!. êÀ!. êÿÀ!¼µêÀ!. òÀ!¬êÀ!. êÀ!. êÀ!. êÀ!. ÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬òÀ!¬òÀ!¬âÿÀ!] & Fgd4>— & Fgd4>—gd4>— & Fgd4>—;4;H;a;s;Ÿ;Ë;ç;û;2<<Ò<c=d==Ý=V>½>÷>ø>?1?T?‚?Ã?ï?÷À!Ðe÷À!Ðe÷À!Ðe÷À!ÐeòÀ!¬êÀ!. êÀ!. âÀ!¬ÚÀ!¬ÚÀ!¬âÀ!¬âÀ!¬òÀ!¬òÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬òÀ!¬òÀ!¬êÀ!. êÀ!. êÀ!. êÀ!. êÀ!.  & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—ï?ü?@@2@Z@|@Ÿ@Ã@Ä@Å@Ú@Û@æ@ç@ô@wAâAôABOBŒBïBCC÷À!. ÷À!. òÀ!¬êÀ!ÐeêÀ!ÐeêÀ!ÐeêÀ!ÐeêÀ!ÐeèÀ!¬èÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬àÿÀ!äÌàÿÀ!äÌàÀ!W òÀ!¬àÀ!W àÀ!W àÿÀ!äÌòÀ!¬ØÀ!µÃ & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—CoCÁCDEDSDzDšD¯DÌDE…EÂEF%F&FIFiFˆF”FÎFG?GnGÉGöG÷G÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬ïÀ!¬ïÀ!¬êÀ!¬âÀ!µÃ÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬êÀ!¬âÀ!µÃ÷À!¬÷À!¬÷À!¬ïÀ!¬ïÀ!¬÷À!¬ïÀ!¬ïÀ!¬ïÀ!¬êÀ!¬ & Fgd4>—gd4>— & Fgd4>— & Fgd4>—÷GøGùGúGH.HMHH­HÆHçHI#IIIJIKILIbIŒI¢IJ0JUJ\J„JúÀ!¬úÀ!¬úÀ!¬òÀ!µÃêÀ!¬êÀ!¬âÀ!¬âÀ!¬êÀ!¬âÀ!¬âÀ!¬âÀ!¬ÚÀ!¬úÀ!¬úÀ!¬úÀ!¬úÀ!¬ÒÀ!¬ÒÀ!¬êÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬ & Fgd4>— & F gd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>—„J²JæJÿJ$K,K>KXKfKtKK‰K”KªKÄK×KLLL L+L@L§L·LÐL÷À!¬÷À!¬÷À!¬ïÀ!¬êÀ!¬âÀ!µÃâÀ!µÃâÀ!µÃ÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬÷À!¬âÀ!µÃâÀ!µÃàÀ!¬àÀ!¬êÀ!¬êÀ!¬êÀ!¬ØÀ!¬ØÀ!¬ÐÀ!*} & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>— & Fgd4>—ÐLóLM'MIMxMœM¤M·M¸MÏMNNVN”NÊN O%OMOŠOúOP8P•P¹P×P÷À!*}òÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬òÀ!¬òÀ!¬êÀ!¬êÀ!¬âÀ!÷âÀ!÷âÀ!÷âÀ!÷òÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬âÀ!÷ÚÀ!¬ÚÀ!¬ÚÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—×PìPQ$QiQ%RQRR˜RÆR_S`SnSoSÈSmTU%U8UJUWUvUŠU¦UÙU÷À!¬òÀ!¬êÀ!¬âÀ!¬âÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬âÀ!¬òÀ!¬òÀ!¬òÀ!¬÷À!¬÷À!QÙ÷À!¬òÀ!¬ÚÀ!¬ÒÀ!*}ÒÀ!*}ÒÀ!*}ÒÀ!*}ÒÀ!*}ÒÀ!*} & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—ÙU÷UV=VÝVGWeW²WÕWáWøWXAXSXqX™X£X®XÎXÜXYYMYrYŽYúÀ!¬òÀ!¬òÀ!¬òÀ!¬òÿÀ!Þ…úÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬âÀ!¬âÀ!¬âÀ!¬úÀ!¬òÀ!¬âÀ!¬âÀ!¬âÀ!¬òÀ!¬âÀ!¬úÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>—ŽY¬YÈYãYäYZZ.Z:Z¼ZéZ[#[/[C[[[v[”[Ä[ì[\\l\\Õ\å\÷À!÷÷À!÷÷À!÷òÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬òÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬òÀ!¬âÀ!¬âÀ!¬âÀ!¬âÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—å\í\])]A]Y]s]š]·]Ò]î] ^^+^7^N^^^r^†^œ^»^þ^____úÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬òÀ!¬êÀ!¬êÀ!¬êÀ!¬êÀ!¬âÀ!¬úÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬úÀ!¬ÚÀ!¬ÚÀ!¬ÚÀ!¬úÀ!¬ØÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>—_4_:_;_Ï_w`x`y`´`ê`û`a>a?a@aAahazaˆaíaPbÀbÒb=c\cúÀ!¬úÀ!¬úÀ!¬òÿÀ!ê–òÿÀ!ê–úÀ!¬úÀ!¬òÀ!\êêÀ!*}òÀ!\êêÀ!*}âÀ!÷úÀ!¬úÀ!¬úÀ!¬úÀ!¬ÚÀ!÷ÒÀ!¬ÒÀ!¬ÒÀ!¬ÒÀ!¬ÚÀ!÷ÒÀ!¬ÒÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>— & Fgd4>—gd4>—\c]cƒc cócdAd~dÒdÓdee&eAere‹e±e²eÜeff\fff fÂfg0gúÀ!¬úÀ!¬òÀ!*}êÀ!÷êÀ!÷òÀ!*}êÀ!÷êÀ!÷úÀ!¬úÀ!¬âÀ!\êâÀ!\êâÀ!\êâÀ!\êâÀ!\êâÀ!\êúÀ!¬úÀ!¬òÀ!*}òÀ!*}êÀ!÷òÀ!*}êÀ!÷êÀ!÷êÿÀ!„¼úÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>—gd4>—0gDgWgwgšg¯gÓgñgògügýg?hgh®hßhi=iPii³iÌiùij;jMjj÷À!\ê÷À!\ê÷À!\ê÷À!\ê÷À!\ê÷À!\ê÷À!\êòÀ!¬òÀ!¬òÀ!¬êÀ!÷êÀ!÷âÀ!*}âÀ!*}âÀ!*}êÀ!÷êÀ!÷êÀ!÷êÀ!÷òÀ!¬âÀ!*}êÀ!÷ÚÀ!¬ÚÀ!¬ÚÀ!¬ & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—j›jk+k^k‰kŠk‹kŒk·kÜklBlYlklzl”l¾lÏlël m#m$m,mTm÷À!÷ïÀ!¬÷À!÷ïÀ!¬ïÀ!¬êÀ!¬êÀ!¬êÀ!¬âÀ!\êâÀ!\êâÀ!\êÚÀ!*}ÚÀ!*}ÚÀ!*}ÚÀ!*}êÀ!¬âÀ!\êâÀ!\êâÀ!\êâÀ!\êâÀ!\êêÀ!¬êÀ!¬ÒÀ!*} & Fgd4>— & Fgd4>— & Fgd4>—gd4>— & Fgd4>— & Fgd4>—Tm{mŸmÀmnn1n— & Fgd4>— & Fgd4>—gd4>— & Fgd4>—¿rmsnsŠs¹stŒtÄtXu¸uâuvrv·vïvBw«w¬wÜwôwx"xNx†x¨xÎx_y÷ÿÀ!ê¾òÀ!¬òÀ!¬÷À!Ðe÷ÿÀ!]÷ÿÀ!]òÀ!¬êÿÀ!¼µêÿÀ!¼µêÀ!. âÀ!¬âÀ!¬âÀ!¬òÀ!¬÷À!Ðe÷ÿÀ!]òÀ!¬òÀ!¬êÀ!. êÀ!. êÀ!. êÀ!. êÀ!. êÀ!. êÀ!. òÀ!¬ & F gd4>— & Fgd4>—gd4>— & Fgd4>—¸uÎx_ydzezèz*{B{C{||¥}µ}12?@Ô ‚ ‚‚]„^„ùïùïùïùïùïùïùïùïùåùïùáh4>—h4>—h4>—5\h4>—h4>—6] h4>—h4>—_y…y¾yÆydzez‰z©zÖzèz*{6{A{B{C{a{­{ä{||2|R|Y| |Ð|û|ü|Z}úÀ!¬òÀ!ÐeòÀ!ÐeêÿÀ!¼µúÀ!¬òÀ!ÐeêÀ!. êÀ!. òÀ!ÐeêÀ!. òÀ!ÐeòÀ!ÐeúÀ!¬úÀ!¬òÀ!ÐeêÀ!. êÀ!. êÀ!. úÀ!¬òÀ!ÐeêÀ!. êÀ!. êÀ!. úÀ!¬òÀ!ÐeúÀ!¬òÿÀ!] & Fgd4>— & Fgd4>—gd4>—Z}y}•}ï}„~~á~12Do °þ€2€N€º€Ü€?@Œ·Ô ‚úÀ!¬òÀ!. êÀ!¬êÀ!¬òÀ!. êÀ!¬êÀ!¬úÀ!¬òÀ!. êÀ!¬êÀ!¬òÀ!. êÀ!¬êÀ!¬òÀ!. êÀ!¬êÀ!¬êÀ!¬êÀ!¬úÀ!¬âÀ!ÐeÚÀ!. 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