HIVNutritionEssentials

ForProgramandAdministrativeGranteesMarcyFenton,M.S.,R.D.ProgramManager,CareServicesDivisionCountyofLosAngelesDepartmentofPublicHealthOfficeofAIDSProgramsandPolicy

August29,2006LosAngelesCountySquareMiles: 4,086Population: 9.9Million

Latino/a 45.7%

White 31.0%

Asian/PI 13.2%

African-American 9.7%

NativeAmerican 0.3%ProportionofCaliforniaPopulation:29%ProportionofCaliforniaAIDSCases: 35%LivingwithHIV/AIDS: 58,000(Estimated)2

SPA6:South

SPA8:SouthBay

SPA5:West

SPA2:SanFernando

SPA4:Metro

SPA3:SanGabriel

SPA1:AntelopeValley

SPA7:East

2HIVNutritionEssentialsOverviewCurrentnutritionissuesandtreatmentsMedicalnutritiontherapy(MNT)programnecessaryingredientsLessonslearnedmonitoringLosAngelesCountymedicaloutpatientservices’MNTprograms3HIVNutritionEssentialsCurrentHIVNutritionIssues5HIVMNTOverallGoalsOptimizenutritionstatus,immunityandqualityoflifePreventnutrientdeficienciesAchieveandmaintainoptimalbodyweightandcompositionManageco-morbiditiesMaximizeeffectivenessofmedications6ViciousCycleofMalnutritionandHIVPoorNutritionresultinginweightloss,musclewasting,weakness,nutrientdeficienciesIncreasedNutritionalneeds,ReducedfoodintakeandincreasedlossofnutrientsIncreasedvulnerabilitytoinfectionse.g.Entericinfections,flu,TBhenceIncreasedHIVreplication,HasteneddiseaseprogressionIncreasedmorbidityImpairedimmunesystemPoorabilitytofightHIVandotherinfections,IncreasedoxidativestressHIVSource:FantaProjectAdaptedfromRCQHCandFANTA20037NutritionIssuesandTreatmentsCommonSideEffectsGIdistressDiarrheaNausea/vomitingGasAnorexiaFatigueTastealterationsMouthpainAnemiaHyperlipidemiaInsulinresistanceHypertensionLivertoxicityRenalimpairmentObesityLipodystrophyPeripheralneuropathyCancer9CausesofWeightLoss1-InadequateIntakeOralanduppergastrointestinalAnorexiaPsychosocial-economicMalabsorptionSource:MangiliAetal.CID2006:42(15March)p836-4210CausesofWeightLoss2-AlteredMetabolismUncontrolledHIVinfectionMetabolicdemandsofHAARTOpportunisticinfectionsormalignancies(AIDS-definingconditions)Hormonaldeficiencies(testosteroneorthyroid)CytokinedysregulationSource:MangiliAetal.CID2006:42(15March)p836-4211ImpactofViralLoadonRestingEnergyExpenditure13HIVWastingDefinitionsCDCNutritionforHealthyLiving(Tufts)Grinspoon,Mulligan&DHHSWorkingGroupPolsky,Kotler&Steinhart14CaloriesNeededandWeightChangeRelationtoViralLoadNotonHAART0.92kgbodyweightdecreasepereachHIVRNAlog10increase22KcalincreaseinREEperincreaseinper1-logcopy/mlStableHAART0.35kgbodyweightdecreasepereach100-cell/mm3CD4celldecrease81kcalhigherREESource:Wankeetal.CID2006:42(15March)15InternationalNutritionFeedingSafelyandAdequatelyAccesstonutritiousfoodAccesstosafewaterMalnutritionLinkedwithHIVinfectionLinkedwithpoorprognosisLinkedwithpoorprognosisdespiteARTBreastfeedingAccesstoHIVmedications17Overweight,ObesityandHIVSources:(1)Amorosaetal.JAIDS2005;Aug15;39(5):557-61.(2)NHANES1999-2000;7/0318WeightClassificationUsingBMIBMI1NoteUnderweight<18.5Malnutrition2<18.5Wasting3<20.0Normal18.5-24.9Overweight25.0-29.9Obesity(I)30.0-34.9Obesity(II)35.9-39.9ExtremeObesity(III)>40.0(1)NationalHeart,LungandBloodInstitute,(2)Magilietal.CID2006March,(3)Amorosa;Grinspoon,Mulligan&DHHSWorkingGroup2003April-SCID19DesirableGirthMeasurementsWaistcircumferenceMen:<40inchesWomen:<35inchesNHANESmethodologyWaisttoHipRatio?LessaccurateNotrecommendedHipcircumferenceokMonitorwaist&hipfrombaseline21Overweight,Obesity&HIVFuelofMetabolicAbnormalitiesBMIpositivecorrelationwithTotalcholesterolTriglyceridesGlucoseObesitynotcorrelatedwithAge,income,employment,educationPast/currentIVDuseHIVtreatment,viralloadSource:Amorosaetal.JAIDS2005;Aug15;39(5):557-61.22TreatmentofObesityTherapeuticLifestyleChangesNutritioncounselingDietaryintakeLimitsaturatedfatsIncreasefiberto35g/dayPortioncontrolReduceexcesscarbohydratesandhighsugardrinksPlentyoffruitsandvegetablesSmallmeals:maximum5hoursapartEatslowly23HIVandDiabetesMellitusAnIncreasingHIVNutritionProblemHIV-positivemenwhoaretakinghighlyactiveantiretroviraltherapy(HAART)aremorethanfourtimesmorelikelytodevelopdiabetesthanHIV-negativemen.

HIV-positivewomentakingproteaseinhibitorsarethreetimesmorelikelytodevelopdiabetesthanHIV-positivewomenonnon-proteaseinhibitorcombinationsorHIV-negativewomenSources:BrownTTetal.AntiretroviraltherapyandtheprevalenceandincidenceofdiabetesmellitusintheMulticenterAIDSCohortStudy.ArchInternMed165:1179-1184,2005.JustmanJEetal.ProteaseinhibitoruseandtheincidenceofdiabetesmellitusinalargecohortofHIV-infectedwomen.JournalofAcquiredImmuneDeficiencySyndromes,32:298–302,200325DiabetesMajorRiskFactorsGeneralPopulationOverweight,obesityEspeciallyVATParentorsiblingEthnicityAlaskaNative,AmericanIndian,AfricanAmerican,LatinoAmerican,AsianAmericaInactivityExercise<3x/wkHistoryofimpairedglucosetoleranceorimpairedfastingglucoseHypertensionCardio-vasculardiseasePolycysticovariansyndrome26HeartDiseaseMajorRiskFactorsGeneralPopulationIncreasingageGenderHeredity,familyhistoryofprematureheartdiseaseOverweight/obesityHighbloodpressureTobaccouseHyper-ordyslipidemiaEspeciallyhighLDL&lowHDLDiabetesMetabolicsyndromePhysicalinactivityPoornutritionAnatherogenicdietSource:Preventingchronicdiseases:Investingwiselyinhealthpreventingheartdiseaseandstroke.July2005.CDC.February6,2006.29HeartDiseaseRiskFactorsHIVPopulationInflammationduetoHIVLipidabnormalitiesduetoHAARTOtherdrugeffects:InsulinresistanceMorphologicalchangesMetabolicsyndrome30HeartDiseasePrevention&TreatmentTherapeuticLifestyleChange(TLC)DietPhysicalexerciseManagementofconcomitantdiseasesDiabetes,hypertension,obesity,etc.SmokingcessationStressreduction31LiverDiseaseFueledbyOverweight&ObesityWaist>hip,insulinresistance&diabetesPredictsadvancedformsofchronichepatitisCComplicatesnonalcoholicsteatohepatitis(NASH)FitnessinverselyrelatedTx:Healthydiet,exercise,weightlossSources:CharltonMRetal.HepatologyJune2006;46(6)1177-1186;ChurchTSetal.Gastroenterology.2006Jun;130(7):2023-2030.32RenalDiseaseandHIVAGrowingNutritionProblemDialysisHIV:1.5%,AIDS:0.4%DialysiscenterstreatingPLWH/A1985:11%2000:37%Numberinitiatedsince1995:stableAbnormalkidneyfunction

30%PLWH/AHIVandCKDnutritionguidelinesNotsetyetIndividualize33HIVNutritionEssentialsMedicalNutritionTherapy(MNT)ProgramNecessaryIngredients34ContinuumofCareCountyofLosAngeles.ContinuumofCare,OfficeofAIDSProgramsandPolicy.35HIVRegisteredDietitianStandardsofProfessionalPracticeProvidesqualityservicebasedonclientexpectationsandneedsEffectivelyapplies,participatesinorgeneratesresearchtoenhancepracticeEffectivelyappliesknowledgeandcommunicateswithothers36HIVRegisteredDietitianStandardsofProfessionalPracticeUsesresourceseffectivelyandefficientlyinpracticeSystematicallyevaluatesthequalityandeffectivenessofpracticeandrevisespracticeasneededtoincorporatetheresultsofevaluationEngagesinlifelongself-developmenttoimproveknowledgeandenhanceprofessionalcompetence37HIVRegisteredDietitianCareResponsibilityCreatescreeningtoolsformedicalproviderstoidentifyclientsatriskMonitornutrition-relatedabnormallaboratoryvaluesAssessclientsregularly,consistentlyEnsureadequatenutrient&caloricintake38HIVRegisteredDietitianCareResponsibilityWithmedicalteam,identifyandcorrectcausesofcachexia,weightloss/gain,othernutritionproblemsandbarriersRefertoprovidersandotherdisciplinesCommunicate:document,speak,shareParticipateinteamcaseconferencesPromotecontinuityofcare39

Relationship

Between

Patient/Client/Group&

Dietetics

Professional

-

NutritionDiagnosis

?

Identifyandlabelproblem

?

Determinecause/contributingriskfactors

?

Clustersignsandsymptoms/definingcharacteristics

NutritionAssessment

?

Obtain/collecttimelyand

appropriatedata

?

Analyze/interpretwith

evidence-basedstandards

?

?

Identifyriskfactors

?

Useappropriatetoolsandmethods

?

Involveinterdisciplinarycollaboration

Screening

&Referral

System

Outcomes

ManagementSystem

?

MonitorthesuccessoftheNutritionCareProcessimplementation

?

Evaluatetheimpactwithaggregatedata

?

Identifyandanalyzecausesoflessthanoptimalperformanceandoutcomes

?

RefinetheuseoftheNutritionCareProcess

ADANUTRITIONCAREPROCESS

ANDMODEL

?

Document

NutritionMonitoringandEvaluation

?

Monitorprogress

?

Measureoutcomeindicators

?

Evaluateoutcomes

?

Document

NutritionIntervention

?

Plannutritionintervention

·

Formulategoalsanddetermineaplanofaction

?

Implementthenutritionintervention

·

Careisdeliveredandactionsarecarriedout

?

Document

Document

NCP40ScreeningandReferralScreenforReferralCriteriaNew/re-entryintocare,MNT>6monthsMedicaldiagnosis,nutritionstatuschangePhysicalchanges,weightconcernsOral,GIsymptomsMetabolic,othermedicalconditionsBarrierstonutrition,livingenvironment,functionalstatusBehavioralconcerns,unusualbehaviorsSource:ADAMNTEvidenceBasedGuidesforPractice,March200541ScreeningandReferralReferralDocumentationPhysician’sorderforMNTSignatureanddateofphysicianorauthorizedpersontoreferforMNTMedicaldiagnosesandinformationCurrentlabsandmeasurementsConsenttoreleasemedicalinformationProofofresidency,income,diagnosisSource:ADAMNTEvidenceBasedGuidesforPractice,March200542NutritionCareProcessADIMENutritionAssessmentNutritionDiagnosisNutritionInterventionNutritionMonitoringNutritionEvaluationDocumentation:clearandexplicit43NutritionCareProcessNutritionAssessmentReasonforreferralAssessdata(ABCD)AnthropometricBiochemistryClinicalDietaryClientinput44NutritionCareProcessNutritionDiagnosisProblemDiagnosticlabelIntake,clinical,orbehavioral/environmentalEtiologyCauseorcontributingriskfactorsSigns/SymptomsDefiningcharacteristicsPESstatement45NutritionCareProcessNutritionDiagnosisPESStatement(P)Increasednutrientneeds(E)asrelatedtoinadequateintakeoffoodsandmalabsorptionduetoAIDSenteropathy(S)asevidencedby25poundweightlossin6monthsandnow91%IBW46NutritionCareProcessNutritionInterventionInterventionsFoodand/orNutrientDeliveryNutritionEducationNutritionCounselingCoordinationofNutritionCareReceptivityandadherencepotentialPlanandfollow-update47NutritionCareProcessNutritionMonitoringReviewandmeasurestatusofinterventionatscheduledtimeTrackoutcomeswithtoolsADAHIVMNTProtocolProgressNoteWeightandnutritionflowsheetElectronichealthrecorddatafieldsFormatTerminology:diagnosis,interventions,etcOthertools48NutritionCareProcessNutritionEvaluationSystematiccomparisonsReferencestandardsEvaluatechangesSignsandsymptomsPreviousstatusandinterventiongoalsProgresstowardgoal49HIVMNTToolsBasicsHIVMNTProtocols(ADA,1998)Adult(18years-adult)Children(under18years)HealthCareandHIV:NutritionalGuideforProvidersandClients(HRSA/HAB,2002)IntegratingNutritionintoMedicalManagementofHIV,(CID-SApril12003)Nutritioninterventioninthecareofpersonswithhumanimmunodeficiencyvirus.(ADA&DietitiansofCanadaJointPosition,2004)50HIVMNTToolsNew:ADAEvidenceAnalysisLibrarySystematicreviewofscientificresearchSelecttopicandexpertworkinggroupDefinequestions,analyticalframework,inclusionandexclusioncriteriaConductliteraturereviewperquestionAnalyzearticlesCompleteevidencesummariesandtablesDraftproposedconclusionstatementsReachconsensusonconclusionstatementsandgrades(strengthandqualityoftheevidence)Publishtoonlinelibrary(EAL)51HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditionsAdultweightmanagementDeterminantsofpediatricoverweightChronickidneydisease(revision)ChronicobstructivepulmonarydiseaseCriticalillnessDisordersoflipidmetabolism(hyperlipidemiarevision)52HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditions(cont.)GestationaldiabetesGlutenintolerance/CeliacHeartfailureHIV/AIDSHydrationHypertension53HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditions(cont.)NutritioninathleticperformanceNutritioncareinbariatricsurgeryOncologyPediatricweightmanagementSpinalcordinjury&nutritionUnintendedweightloss54HIVMNTToolsNew:ADAEALCurrentProjectsAssessmentEstimatingenergyexpenditureFoodsNon-nutritivesweetener55HIVMNTToolsEmerging:HIVNutritionEvidenceAnalysisQuestionsWhat

arethecaloricneeds

ofpeoplewithHIV/AIDS?WhatistheevidencetosupportaparticularmacronutrientcompositionofadietforpeoplewithHIV/AIDS?

FocusBothchildrenandadultsPeoplewithHIV/AIDSPast10yearsofresearch56HIVMNTToolsNewandEmergingNutritionCareManualWebbasedUses

ADAEvidenceAnalysisLibraryEvidence-basedMNTprotocolsEvidence-basedguidelinesADApositionpapers57ReimbursementMNT,SupplementsMedicareMedicaidManagedCareHMOs,KaiserPermanenteRWCA58PersonalProfessionalCompetenceDieteticsProfessionals’EthicalObligationCodeofEthicsfortheProfessionofDietetics,(6)StandardsofProfessionalPractice,(7)GuidedbythenutritioncareprocessProfessionalDevelopmentPortfolio(8)75creditseveryfiveyears59RyanWhiteCAREActandMNTCurrentStatusMNTbyRDDefinedbyHRSAguidanceRequiredinTitleIIIservicesRWCAreauthorizationExpectedafterLaborDay2006ADAandothersworkingtogetMNTascoremedicalserviceAIDSEducationTrainingHIVnutritiontrainingforproviders60CurrentProceduralTerminologyMNTCPTCodes97802Initialassessmentandintervention,individual,face-to-facewiththepatient,each15minutes97803Re-assessmentandintervention,individual,fact-to-facewiththepatient,each15minutes97804Group(2ormoreindividuals),each30minutes61HIVNutritionEssentialsLessonsLearnedMonitoringLosAngelesCountyMedicalOutpatientServices’MNTPrograms62MonitoringHIVMNTServicesMNTProgramEvaluationItemsScreeningfornutritionrelatedproblemsReferralforbaselineMNT(06-07)AppropriatereferralforMNTMNTprovidedbyanRDMNTdocumentation(05-06)Outcome:maintainor5%towardsgoalweightafter3monthsofcare(07-08)RDqualifications6329(.8,0-10)2(.1,0-1)Screened77(2.1,0-8)38(1,0-4)ReferraltoMNT66(1.8,0-6)32(.9,0-5)MNTProvided62n/aMNTQuality244(6.8,4-10)154(4.3,2-8)ChartsReviewed(average,range)3636Sites(of37)16,48716,143Clients(>1visit)Yr152005-2006Yr142004-2005MonitoringMNTPrograms64RDAvailability2004-20052005-2006Clinics,number3737Onsite>?day/month2832Referraloffsite45Noneavailable50AccesstoMNT65ChangingPracticesandAttitudesEstablishingtheFrameworkforMNTWheelsofchangemoveslowlyDevelopinfrastructureStandardsofcare,guidelines,contractsIndicators,monitoringtools,reportsMNTservices:disparityinclinicsProviders,programmanagers,fundingAwareness,interpretationandabilitiesExpectations,goalsetting,reporting,access66ChangingPracticesandAttitudesTechnicalAssistance:ProvidersandRDsProvidermeetings,calls,emailsProviderandstaffpresentationsAteachyear’sprogrammonitoringDifferentandevolvingTAfocusAlwaysprovidematerialsEx:HRSANutritionManualCD,screening&referralforms,articles,standardsofcare,BMIchart,nutrition&weightflowchart67ChangingPracticesandAttitudesTechnicalAssistance:RDSDietitiansinAIDSCare(DIAC)DIAClistserveQuarterlymeetingssinceApril2005Networking–long-lastingrelationshipsTrainingandproblemsolvingNutritioncareprocessWhentoprovide/discontinue:nutritionalsupplements,food/mealservicesHyperlipidemia,insulinresistance,

renaldisease68PersonalGrowthLessonsLearnedMoremedicalrecordsreviewedMonitoringtools-streamlinedand

tally/commentssheetsIncreasetimespentmonitoringEvaluationreportofMNTprogramsEstablishongoingdatabaseBaselineknowledgeofprograms69ScreeningforNutritionProblemsLessonsLearnedNewton’slawsofmotionProviders’resistanceProblems?Don’tlookandyouwon’tfindScreeningvs.referringDefining“atrisk”Makeiteasytolook,think,documentSimplequestionswork70HeightandWeightMeasurementsLessonsLearnedRoutinemeasurementsneededHeightnotalwaysmeasuredWeightusuallymeasuredAccuracyquestionableonbothWhomeasures?Howtrained?Shoes?Calibrationofscales?Stadiometer?MonitoringweightAdding/subtractingusuallynotdoneBMInotusuallydoneGraphingnotdone71ReducingBarrierstoMNTLessonsLearnedReducingbrokenappointmentsSetappointmentswithclientCoordinatewithprimarycarevisitRemindersandfollow-upcallsandlettersDocumentinmedicalrecordSupportMNTinclinicInclude,discussandreferralfromstartIncentivesandrewardsforMNTvisitAsk/respondtoclientrequestforMNT72Needed:ProactiveHealthyClinic

LessonsLearnedTakeresponsibilityandpowerEducate&supportstaff:promote:NutritionandhealthknowledgeClients’food,nutrientandsafetyneedsChangethemenuandfood/watersafetypracticesforclientandnon-clienteventsMeetings,parties,fundraisers,vendingmachines,vouchers,boardmeetings,holidays,etc.73HIVNutritionEssentialsWhathasbeenyourexperience?Whathasworkedwell?Whathasbeenachallenge?74AcknowledgmentsArcyMartinezRDAltaMedHealthServicesCorporationAudraGustafsonRDNortheastValleyHealthCorporationTammyDarkeMSRDStMaryMedicalCAREProgramJillStrejcMSRDSRDUCLACarenOngjocoRDCNSDLosAngelesCountyHarbor-UCLAMedicalCenterJanBKingMDMPHOAPPMedicalDirector75MarcyFenton,M.S.,R.D.ProgramManager,CareServicesDivisionOfficeofAIDSProgramsandPolicy600SouthCommonwealthAvenue2ndFloorLosAngeles,California90005-4001Phone:213/351-8368Fax:213/738-6566E-mail:mfenton@ThispresentationisavailableatForAdditionalInformationoWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0zr#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A