SCREENING FOR AND MANAGEMENT OF by pengxiang

VIEWS: 8 PAGES: 18

									Sexually
Transmitted
Diseases




    Royal Adelaide Hospital
    Department of Health
                                                                  STD Services: Medical Student Handbook




           2005 Handbook:
           STD Seminars
           for Medical Students




           STD Services / Clinic 275
           First Floor
           275 North Terrace
           Adelaide SA 5000

           Telephone:                       (08) 8222 5075
           Fax:                             (08) 8232 3504
           Email:                           STDServices@health.sa.gov.au
           Web site:                        stdservices.on.net




w:\st_nonum\upstairs\educate\med students\handouts\2005book.doc




                                                                                   -2-
                                STD Services: Medical Student Handbook




Introduction to the Sexually Transmitted Diseases Seminar
Students are rostered to spend two half-day sessions at Clinic 275. The Clinic is located opposite
the Royal Adelaide Hospital at:

       First Floor
       275 North Terrace
       Adelaide

Aim
To provide an understanding of the scope of a public health sexually transmitted diseases (STD)
program and an appreciation of the skills and training necessary to work as a sexual health
physician or to manage STD related problems in other areas of medical practice.

More specific aims of the attachment are to provide:

      An overview of the role and function of STD Services and how the service can be utilised
       by medical practitioners.

      An understanding of the roles of contact tracing, counselling and health education in STD
       management.

      An outline of the reporting (notification) system for sexually transmitted infections (STI) and
       the responsibilities of the medical practitioner.

      A clinical framework for managing and screening for STD, focussing on sexual history
       taking, risk assessment and STD signs and symptoms.



Duration of Attachment
  Two, half-day sessions in 5th Year during the Obstetrics and Gynaecology term



Resources Available
      Web site: http://www. stdservices.on.net

      STD Services Resource room which has self learning video packages, reprints of recent
       relevant journal articles and patient education material available for student use.

      Publications of STD Services, including Diagnosis and Management Guidelines, Patient
       Education Handouts, Quarterly Surveillance Reports and Annual Epidemiologic Reports
       are available on-line at the STD Services website.

      Student information handouts.

      SHine SA video library (telephone 8431 5177).

      The CDC Atlanta website: http://www2a.cdc.gov/stdtraining/self-study/default.asp




                                                 -3-
                             STD Services: Medical Student Handbook




Outcomes
 At the end of this introduction to STD, the student should:
   understand the nature of the service provided to patients at Clinic 275
   be aware of the support provided to medical practitioners by STD Services
   be able to undertake a risk assessment for STIs.


Course Coordinators
 Students are welcome at Clinic 275; those who wish to arrange electives or selectives,
 require assistance with STD related projects, or attend clinic sessions as observers, please
 contact the Clinic Manager:
 Dr Russell Waddell        Telephone:  8222 5075
             Email:        Rwaddell@mail.rah.sa.gov.au


Examination
 For students from the University of Adelaide, there may be one question incorporated into
 the OSCE examination at the end of the term. This question will be taken directly from
 material covered during the day‘s seminar. Adequate information to satisfactorily answer
 the question is provided in this handout, in the case discussions and in the material
 covered by the course presenters.


Program
 Two half-day seminars held on Thursday mornings. The sessions begin promptly at the
 indicated times, so please arrive punctually. Tea & coffee are provided.

 First Session:

     09:15         Welcome and clinic tour
     09:30         Role and function of STD Services and notification of STD
     10:30         Break
     10:45         Taking a sexual history & screening for STDs
     12:15         Close


 Second Session:

     09:15         Clinical case discussions
     10:45         Break
     11:00         Slide presentation
     12:15         Close




                                               -4-
                                      STD Services: Medical Student Handbook




Role and Function of STD Services
   STD Services aims to provide effective clinical care, teaching and STD control measures.
Clinical Services: Clinic 275 is the clinical arm of STD Services.
          Free and confidential advice, testing, treatment for all STDs (including HIV infection) is
          offered at Clinic 275, (1st Floor) 275 North Terrace, Adelaide 5000.
          Clinic Hours Monday, Thursday, Friday              10.00 a.m. - 4.30 p.m.
                           Tuesday, Wednesday                11.30 a.m. - 6.30 p.m.
          No appointment is necessary and patients may self-refer.
          Members of the public or health professionals may phone 8222 5075 for telephone advice
          on STDs & related issues.
          A toll free number is available for country callers: 1800 806 490

Training and Education
      Publications
       Annual Epidemiologic and Quarterly Surveillance Reports. These describe the patterns
       and dynamics of STDs in South Australia.
      Clinical training is offered to undergraduate and postgraduate health care workers
       from a range of disciplines.
      Web site: stdservices.on.net provides up to date information about STDs for the
       general public, students and health workers.

Consultant Services
      Advice and support with all aspects of individual client management
      Epidemiologic and statistical information
      Health promotion and other STD control activities
        For further information, contact Dr Gavin Hart, telephone 8222 5075, email
        Gavin.Hart@health.sa.gov.au

STD Surveillance
    The Surveillance Unit of STD Services responsible for the collection and analysis of
     epidemiological data and operation of the STD notification systems in South Australia.
    Epidemiological analysis of surveillance data forms the basis of control strategies, guidelines
     for medical practitioners and informs policy decision making in relation to STDs.


Organisation of STD Services
    STD Services combines clinical and public health roles.
    Its functions are to:
        provide a clinical care service
        evaluate and improve laboratory diagnosis of STD
        provide effective training programs for health care workers
        participate in research, such as vaccine and pharmaceutical trials
        implement STD control strategies, such as contact tracing, screening and health promotion
        conduct state-wide surveillance of STD
        analyse and publish epidemiological data related to STD in South Australia
        provide state-wide consultation to clinicians on diagnosis and management of STD.

                                                         -5-
                                STD Services: Medical Student Handbook




Assessing Patients:
Taking a Sexual History & Screening Patients for STDs
Presentation of Patients
  Assessment of patients for the presence of STDs may occur in several scenarios:
     The patient has symptoms suggestive of STD,
     the patient requests screening for STD, because of perceived risk behaviours,
     the doctor determines that patients presenting for other reasons are at risk of STD.
  For many infections (notably chlamydia) most patients will be asymptomatic. The clinician‘s
  role, therefore, is not only to diagnose and treat symptomatic patients, but also to determine
  which asymptomatic patients may be at risk and to offer screening if appropriate.
  In many cases the patient will request screening because of a history of perceived risk
  (which may in reality be either high or low risk). However, in some instances, the clinician
  may become aware of a potential for STD risk because of other risk factors such as injecting
  drug use, new sexual partner etc, which may be revealed during the consultation.

History Taking
  The STD interview determines whom to test, which sites to test, and what tests to
  perform. Commence by telling the patient that you would like to ask some questions so that
  you can understand better how they may be at risk of STDs.
  Begin with the least sensitive questions, such as an open question about their reason for
  attendance, their medication history, allergy history etc. Patients requesting STD screening
  should be asked "How do you feel you are at risk?" to elicit any circumstances or events of
  particular concern.

  These questions, together with the explanation that you need to investigate STD risks, help
  prepare for the discussion of more specific and sensitive issues as listed below.

Reason for consultation
     Asymptomatic — for check up, or concerns about potential exposure to STD,
     presence of symptoms.

Problem description
        Symptom(s): onset, character, duration, and relationship to sexual intercourse and urination
        discharge (urethral, vaginal, cervical, rectal)
        dysuria
        menstrual irregularity
        dyspareunia
        lower abdominal pain
        genital ulcers or lumps
        rashes
        itching
        pelvic tenderness
        similarity to previous problems
        medical problems of sexual partner(s)


                                                 -6-
                                 STD Services: Medical Student Handbook




Sexual activity
      regular sexual partner(s)
      date of most recent sexual exposure and other exposures in the preceding 3 months;
       exposures since last tested
      gender of partner(s), any history of male to male sex ever
      specific exposure sites: oral, vaginal, anal
      use of condoms – sometimes, always or never?
      symptoms among recent partner(s)
      known risk factor(s) of partners
      location of sexual activity and travel history e.g. America, Asia, Africa
      history of injecting drug use
      tattoos — particularly if applied in prison or ―backyard‖ tattoos
      history of blood or blood product transfusion — pre-1985 associated with HIV risk,
       pre-1990 associated with hepatitis C
      needlestick injury or occupational exposure
      body piercing — if not performed professionally.

Other Factors
        Past STDs
        Current and past serious illnesses
        Current medication: prescribed, over-the-counter, illicit
        All patients must be asked about allergy to antibiotics, especially penicillin
        Hepatitis B or hepatitis A vaccination status.


Examination
  Is performed as follows:
      inspection of pubic hair for lice and nits, lumps and skin disease
      palpation of inguinal lymph nodes
      men: inspection of penis & meatus, retraction of foreskin, expression of any discharge
       from the urethra; palpation of the scrotum
      men who have sex with men: inspection of oral cavity and pharynx, inspection of
       perianal area and proctoscopic examination of rectum & anal canal
      women: inspection of external genitalia, perineum, anus; speculum examination of
       vagina and cervix; bimanual pelvic examination

  Examination may also include inspection of the skin of face, trunk, forearms, palms and oral
  mucosa. The perianal area should be routinely inspected.




                                                  -7-
                                STD Services: Medical Student Handbook




Guidelines for STD Specimen Collection in Primary care
  Patients should never be treated for presumed genital infections without first testing.
 Treatment ―on spec‖ frequently leads to misdiagnosis and inappropriate management. In
 addition, contact tracing of notifiable infections cannot be instituted unless a definitive
 diagnosis is made by microbiological testing.
 Ideally, urethral swabs or first void urine specimens should be taken at least 3 hours after
 last void.
Males
 Urethral swabs for Gram stain, gonorrhoea culture and/or chlamydia PCR should be taken
 on men who have urethral symptoms, or who are known to be contacts of people with
 chlamydia or gonorrhoea.
 All other men should have a first void urine sample collected for chlamydia PCR testing.
 Men who have sex with men, people who have had sex overseas or interstate and those who
 have had sex with Aboriginal people may be at higher risk of gonorrhoea and should be
 offered testing with first void urine gonococcal PCR if asymptomatic, or swab for
 microbiology culture & sensitivity (MC&S) if symptomatic.
 Pharyngeal & rectal swabs for MC&S (gonorrhoea) and chlamydia PCR are offered to men
 who have sex with men.
Females
 Swabs from the vagina and cervix should be taken as follows:
    Lateral vaginal wall swabs for Gram stain and culture – to test for candida and bacterial
     vaginosis.
    Posterior fornix swab for assessment of vaginal pH, and wet mount for trichomonads.
    A Pap smear may be performed if indicated, but note that it is not ideal to perform
     screening cytology for cancer of the cervix in the presence of acute inflammation or
     significant discharge.
    Endocervical swab for Gram stain and culture for gonorrhoea.
    Endocervical swab for chlamydia PCR. Women who have had a hysterectomy should
     have urine or urethral swabs collected for gonorrhoea and chlamydia testing.
 Pharyngeal and rectal swabs for gonorrhoea and chlamydia testing should be performed if
 appropriate, depending on sexual history. For example, in sex workers, the pharynx may
 be the only exposed site and in such cases, throat swabs for MC&S and chlamydia PCR
 should be offered.

Notes on Urine Testing for Chlamydia
 Urine samples collected for PCR chlamydia testing should be a first pass specimen, ideally
 taken at least 3 hours after voiding.
 A test of cure for chlamydia is not routinely performed as the PCR test may remain positive
 for several weeks after successful eradication of the live organism. This is because the test
 detects chlamydial DNA fragments from dead organisms.
 Because of the prevalence of chlamydia in the young female population, screening by first
 void urine chlamydia PCR testing should be offered to all women presenting for post coital
 contraception if a complete STD screen is not performed.
 First void urine gonococcal PCR screening is not reliable as a definitive diagnostic test for N.
 gonorrhoeae. All positive urine screens should be confirmed with a standard culture &
 sensitivity test performed on a genital swab.
                                                 -8-
                                STD Services: Medical Student Handbook




 In most cases, first void urine testing for chlamydia and/or gonorrhoea is not appropriate for
 symptomatic patients or contacts – these patients require swab tests.

Serology
 Routine serology performed at Clinic 275 includes: syphilis testing (EIA); HIV antibody; hepatitis
 B surface antigen, and hepatitis C antibody. Hepatitis A total antibody is performed before
 immunisation of those at high risk, such as men who have sex with men, sex workers and
 injecting drug users.

 Serology for herpes simplex type 2 infection is not recommended as part of the STD screen.
 Herpes simplex is best detected on swabs taken from the base of a new lesion (ie within 72
 hours). All laboratories in South Australia use PCR techniques to diagnose genital herpes.

 While type specific serology for Herpes simplex virus is available, it should only be performed
 after full discussion of the implications of the test result.




                                                 -9-
                                     STD Services: Medical Student Handbook




A Brief Guide to Sexual History Taking for Primary Care Providers
Adapted from “The Clinical Approach to the STD Patient‖
National Network of STD/HIV Prevention Training Centers, June 2004
http://depts.washington.edu/nnptc/core_training/clinical/PDF/Clinical%20Approach%202004.pdf

Setting the Stage: Introductory Statements and Questions
Teens
   Care needs to be taken when introducing sensitive topics such as sexuality with teenagers.
   It is important to interview the teen alone and reinforce confidentiality. Start with asking
   about neutral topics like school, sports, or other activities.
   Discussions should be appropriate for the teen‘s developmental level and you should be
   explicit. If you identify that the teen is sexually active, you will want to clarify the kind of sex
   he/she has engaged in.
   “Now I am going to take a few minutes to ask you some sensitive questions that are
   important for me to help you be healthy. Anything we discuss will be completely confidential.
   I won‟t discuss this with anyone, not even your parents, without your permission. ”
   “Some of my patients your age have started having sex. Have you had sex?”

Adults
   “Now I am going to take a few minutes to ask you some direct questions about your sexual
   practices. These questions are very personal, but it is important for me to know so I can help
   you be healthy. I ask these questions of all of my patients regardless of age or marital status.
   Like the rest of this visit, this information is strictly confidential.”

The 5 “P”s: Partners, Pregnancy prevention, Protection, Practices, Past STDs

1. Partners

   It is important to determine the number and gender of a patient‘s sexual partners.
   You should make no assumptions about partner gender in the initial history taking.
          “Do you have sex with men, women, or both?”

          

          

          

2. Prevention of pregnancy

   Based on partner information from the prior section, you may determine that the patient is at
   risk of pregnancy. If so, determine first if a pregnancy is desired.

              “Are you or your partner trying to get pregnant?”

              If no, “What are you doing to prevent pregnancy?”




                                                      - 10 -
                               STD Services: Medical Student Handbook




3. Protection from STDs

  With this open-ended question, you allow different avenues of discussion: condom use,
  monogamy, the patient‘s self-perception of risk. If you have determined that the patient
  has had only one partner in the past 12 months, infrequent or no condom use may not
  warrant risk-reduction counseling.

           “What do you do to protect yourself from STDs and HIV?”

4. Practices

  If the patient has had more than one partner in the past year, you may want to explore
  sexual practices and condom use to guide risk reduction strategies. Different types of sex,
  and whether the patient is insertive or receptive, will depend on the gender of partners.

  “To understand your risks for STDs, I need to be explicit about the kind of sex you have
  had over the last year.”
           “Have you had vaginal sex, meaning „penis in vagina sex‟ ”?

           If answer is yes, “Do you use condoms: never, sometimes, or always?”

                     “Have you had anal sex, meaning „penis in rectum/anus sex‟ ”?

           If answer is yes, “Do you use condoms: never, sometimes, or always?”

                     “Have you had oral sex, meaning „mouth on penis/vagina‟ ”?

  For condom answers:

  If answer is “never‖: “Why don‟t you use condoms?”

  If answer is “sometimes”: “In what situations, or with whom, do you not use condoms?”

5. Past history of STDs

  A history of STDs increases the risk of repeat infection. Affirmative answers should be
  followed up with specific questions about the type of infection and dates of treatment.
  Immunization history for hepatitis B also can be asked.

           “Have you ever had an STD?”

           “Have any of your partners had an STD?”



Additional Questions to Identify HIV and Hepatitis Risk

           “Have you or any of your partners injected drugs?

           “Have any of your partners exchanged money or drugs for sex?”




                                               - 11 -
                                STD Services: Medical Student Handbook



Notes on Management of STD
  STD Services publishes guidelines: ―Diagnosis and Management of Sexually Transmitted
  Infections‖. Students may download a (PDF) copy from the STD Services website:
  www.stdservices.on.net/management/. These guidelines are regularly updated and
  students are encouraged to consult them for detail about current management practices.
  Medical practitioners may contact STD Services for telephone advice about the management
  of STDs. A consultant Sexual Health Physician is available on call through the RAH
  Switchboard for urgent enquiries after hours.
  The proper management of a sexually transmitted disease has three components:
        treatment
        counselling/contact tracing
        follow up

1. Treatment
   Antibiotic therapy or other treatment is provided at Clinic 275 in accordance with our
   published treatment guidelines. Students are encouraged to make themselves familiar with
   the treatment recommendations for the following STIs:
     Chlamydia:                     ........................................................................................
     Gonorrhoea:                    ........................................................................................
     Non Specific Urethritis:       ........................................................................................
     Trichomoniasis:                ........................................................................................
     Bacterial Vaginosis:           ........................................................................................
     Genital Warts:                 ........................................................................................
     Molluscum Contagiosum:         ........................................................................................
     Herpes:                        1 episode                      episodic Rx                     suppressive Rx
                 valaciclovir       ........................................................................................
                 famciclovir        ........................................................................................
     Pubic Lice:                    ........................................................................................
     Scabies:                       ........................................................................................

2. Counselling and Contact Tracing
  The clinician is responsible for counselling the patient about the natural history of the
  disease, its sequelae and method of spread; about the therapy and its possible side effects;
  and about the necessity of follow-up and investigation of sex partners. Condom use should
  be discussed with the patient so that the risk of reinfection will be minimised. Hepatitis B and
  A vaccination should be offered to those at risk.
  Mandatory reporting and contact tracing is required for all cases of gonorrhoea, chlamydia,
  syphilis and HIV infection and all incident cases of hepatitis infection. See below for discussion.
3. Follow-up
  At least one follow-up visit is essential to:
        assess clinical response to therapy
        assess side effects of therapy
        ensure adherence with treatment recommendations
        perform investigations to demonstrate cure – gonorrhoea, trichomonas
        confirm that all current sex partners have been investigated and treated and check
          whether there have been new sexual partners since the initial visit.
                                                    - 12 -
                                STD Services: Medical Student Handbook




Notification and Contact Tracing

Notification
The Surveillance Unit of STD Services is responsible for state-wide surveillance of the following
diseases:
      Chlamydia
      Gonorrhoea
      Syphilis
      Donovanosis
      Human Immunodeficiency Virus (HIV) infection
      Acquired Immune Deficiency Syndrome (AIDS)
      Hepatitis B (HBV) infection
      Hepatitis C (HCV) infection

Reporting Mechanism
In South Australia, under the Public and Environmental Health Act 1987, it is mandatory for both
medical practitioners and diagnostic laboratories to notify cases of these diseases to the
Surveillance Unit of STD Services.

This dual notification system operates as follows:
   Laboratory    A copy of all positive test results is sent to the STD Services by the laboratory.
   Medical       The Medical Practitioner who has ordered the positive diagnostic test is
                 required to notify STD Services on the appropriate form, or by telephone.
                 On receipt of a positive laboratory result diagnostic of a notifiable STD, the
                 Surveillance Unit will send notification forms and reply paid envelopes to the
                 medical practitioner who ordered the test.


Purpose of notification of STDs
The aims of the surveillance system are:
      To facilitate accurate epidemiological data collection, allowing observation of disease
       trends and dynamics of STD transmission in the community.
      To monitor the level of testing in the community.
      To facilitate contact tracing and treatment.
      To reduce the prevalence of disease in the community, to decrease reinfection rates and
       to reduce the morbidity resulting from delayed or missed diagnosis.




                                                - 13 -
                                STD Services: Medical Student Handbook




Contact Tracing
Definition
  Contact tracing is the process of contacting the sexual partners of an individual with a
  notifiable disease to advise that they may have been exposed to the infection, and to
  encourage them to attend for testing and treatment.

  The objectives of contact tracing are to:
         interrupt the transmission of disease
         minimise the risk of complications arising from infection
         encourage behaviour change toward safer sex practices.


  Doctors may undertake contact tracing or may refer cases to STD Services for contact
  tracing.
  Be aware:
        contact tracing is labour intensive and time consuming
        all partners within the relevant time period must be contacted - any partner could
         be the source of the infection
        the relevant time period varies with each disease - the disease incubation period
         and the patient's symptoms determine the time period.
        there may be language / cultural barriers to communication.
        there may be conflict with ‗family doctor‘ role.



  Many medical practitioners choose to delegate contact tracing of cases to STD Services,
  where it is a confidential process performed by health professionals trained in the skills of
  contact tracing.



Further Information
  Further information about STD notification and contact tracing is available on the STD
  Services web site at www.stdservices.on.net/notification/




                                                - 14 -
                                STD Services: Medical Student Handbook




Case Discussions
1. An 18 year old woman presents complaining of a vaginal discharge and painful urination.
      What is the differential diagnosis?
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________

      What further history should be elicited?
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________

      What signs should you look for on examination?
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________

      What investigations should you perform?
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________




                                                  - 15 -
                                  STD Services: Medical Student Handbook




2.   A 35 year old Aboriginal man presents with a urethral discharge.
        What is the differential diagnosis?
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________

        What investigations should you perform to establish the diagnosis?
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________



        Your investigations confirm a diagnosis of gonorrhoea. What are the main aspects of
         management?
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________
         ________________________________________________________________________




                                                  - 16 -
                                STD Services: Medical Student Handbook




3. You are seeing a monogamous married couple, returning for results of swabs taken from
   perineal ulcers on the wife. Rapid antigen detection on the swab confirms the presence of
   herpes simplex virus. How do you counsel the couple in relation to:
      Natural history and prognosis of the condition
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________

      Treatment
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________

      Transmission (Where did the infection come from? How/when can it be passed on?) Are
       there any other investigations or history that might help with counselling here?
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________
       _________________________________________________________

                                                - 17 -
                            STD Services: Medical Student Handbook




   Implications for future pregnancies

    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________


   Implications for the husband
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________




                                            - 18 -

								
To top