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WzG5+vbNWm6r9z3+adx45/cn/84T2nvv6abV9/+cJFiwsVPTOjsnKI7FEtYpxVfeTI7LfvWfvUF9ZryqG1pcX2AzfvOrHZ33rb0T7VYovvfPaeZ2zvLcb+xc9CXgIAABeQimwZl63EP3nxpT9766H5fL41xBgV2caF7IsLC1vzB4/Pf/O2Y+9YHK/cNdywZ+HKPcurY7bsWz0Pndq88/DsrqObayfmrUVWVPSnXbH6D2/Y8e79p/7ozuNj5GbGa27c/eonDj3GKfpQFa6OlZcAAMAFZohew7hY/dl78s0vuehffuBA9MjIKftF28eff/nF77x77dbPr0+bs2Frfu/h6S8ObrY8GRU9IiqiVcuoyiF71XD5xQvfeu3OvQv5c7cdO3x4LarFUK+/ae9rnxQ9F4fsUa0iI7vJnxdZpewBAIDH3Hw2e+BUfOf3/cbh/Q8M47DrH3z1jTdd/srrtj93d374SLxv/8n9x/u0MUXvp2+gHKtvxLi4kLu2j8+5bOWrnzDOe77rrrVP3Lc+TjGLWN02vvG5u164t7Vh7FXjMBjy+eXsJQAAcC7U0C5b2tw7DMemPhuHsfK+Yxtv/9D8HasLz7l8+dXX7rp6NdfmdXBrOjHPIbK1ftEYe5cWD2xO+w5vvvUjJw4dn0X0qpxn3njV8g/esHPPQkTLqsqYRchLeQkAADwOtMqosVVU5hBxze7xQORQdWJt672f2XjvXW1xaG15vHipbR8iczrVxwe3+sbm8b4571GZrfdqlZdetPg9N+544e7FapFTz4po2fuiCctLAADg8ZGXLWrIcbFNGRXxI0/bXjde/tv3HNt3cFo7NR96zGNqa9N9a5ERPXqLsaJaxVSVkW0pr927/LVXL3/NJUsLLTOzRfVhyIxe0zCkCctLAADgcSIjW2ZkREVMvW7Y2Z/x7L1rvfYdnT56eLb/6Ob+U319o8d8ln0cF9u4NF6yVNfsWrrukqWbd7fdCzlka+3/vO9Ino7KIXWNvAQAAB5PqvdhaFE1ZB363Mn79y5WtKHiiqgrMtu2jJUe1YbVxeUn7V1ssRgxtqyMiJ6VFZUxj3AdrLwEAAAez21ZEdFbZkbEvP/I2943VY5RU8RQEZk9e+sxb/ntr7zxn/34CyKGjIiM6j2y1emTnrlgkvISAAB4XMuoHMZnPv3ij+77XPRYOLHeMnrLiOxx+u0Sc+iVLdrWZkSLltM0DW1oQ8uIiowvXlfrNkt5CQAAPI7N+xQRP/z6Gz5914GP7Lu/V2XEELlQ/a8naLTWa+hVQ0SLVlURka2dPpOpLb+s/wXh9GoBAACcLf/fyuh9qupTjNPaxnweGdl7z9Yq/6oYe0x9XksLsbK6lMMwzefDwpj5iJPyS/gU5CUAAABfFpoRAAAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAMCFbDSCx8LGvH/43iP/zx/n3/qJ+dAfkmfv28s8oy+WZ3UmD7XNM97Ko5rel7DFfHQPLB/dWL6UCZ/V1X/UWzl7y3pWt5hfac+ds/G48stkemd5knmun+x59p6u+RX43HmU39a5md6XtFfn+X6GPtK9Os/BFs/4uZNn73Gdm9XPc7+PPa6P4Ofo0Pyl765DO7svgcjLx8zxzdkvfuCufOhnTz7E7n6Gefk3Pywf6jl2hof5PIOnaz70t5MP+bge5uHnQ3z3D/2QH2J8eaZxno9oRP/XlM7wZ8E8gxGd4brkw7zynsGOdMZTyjPbxx7ym88zqOuHffiPybo83BYf4tPz4b5CPvL97Yx+GshHuMUzXJc8szX+Unaeh1vIfIRbfLQ70mO0LvnoXoUe9uHnmb08/u1bPMN1yS/hCX5Ojg4PO/BHtiOd6dHh7B6PzuxfFc/N0eGRbvFMj9r5qI4Oj/J172E+7DE8OpzF49GZPVvP+9HhzAaej3h/O7NXobN4PHo0R4fVhTH05dnm4lgAAADkJQAAAPISAAAAeQkAAAB/JavKFM66qerwqa1zdKtwnpuN5IXyUM7ZxC6cdbmwJnZOtnIB7coX1sQupH0sjetx+pS8gF6Q4wJafT8mfYX+mOT3xspLAAAAvky5OBYAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkpREAAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeWkEAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4aAWEJp1gAABFGSURBVAAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQD87/bs1QaBIArD6NzdLQCHowM8fWDQVEAFhApoAY2jDTwd4FAUsMvFojYhPLKEc+yYmd99GQCQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8tIEAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF6aAAAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAAAAeQkAAIC8BAAAQF4CAACAvAQAAEBeAgAAIC8BAACQlwAAACAvAQAAkJcAAADISwAAAOQlAAAAyEsAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAACQlwAAAMhLAAAA5CUAAADyEgAAAOQlAAAA8hIAAAB5CQAAgLwEAAAAeQkAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLEwAAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAACAvAQAAAB5CQAAgLwEAABAXgIAACAvAQAAQF4CAAAgLwEAAJCXAAAAyEsAAAB4WmOCT+gy5/ujHQAAYJgOi5kR3s7v5UfUEUYAAAD+SmSmFQAAAHiR30sAAADkJQAAAPISAAAAeQkAAADyEgAAAHkJAACAvAQAAEBeAgAAgLwEAABAXgIAACAvAQAAkJcAAAAgLwEAAJCXAAAAyEsAAADkJQAAAMhLAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAEBeAgAAIC8BAACQlwAAAMhLAAAAkJcAAADISwAAAOQlAAAA8hIAAADkJQAAAPISAAAAeQkAAIC8BAAAAHkJAACAvAQAAEBeAgAAIC8BAABAXgIAACAvAQAAkJcAAADISwAAAJCXAAAAyEsAAADkJQAAAPISAAAA5CUAAADyEgAAAHkJAAAA8hIAAAB5CQAAgLwEAABAXgIAAIC8BAAAQF4CAAAgLwEAAJCXAAAAIC8BAACQlwAAAMhLAAAA5CUAAADISwAAAOQlAAAA8hIAAAB5CQAAAPISAACAL4sIIwDwS6pRc7u2pWTmIO93rmPSZZZdHcttVVZdzz3HTVzah/NTHdN1VTbdQN8GAP3ue0st86E2af4AAAAASUVORK5CYII=)
Full Head Block for headache treatmen
Dias BF, et al.
Headache Medicine, v.10, n.2, p.37-40, 2019
39
third occipital nerve lies medial to great occipital nerve
and have bers communication between both, and is
blocked in the same injection of GON by the intimacy
proximity.
Auriculotemporal nerve (ATN) block
ATN is located at superior to the posterior portion
of the zygomatic bone just anterior to the ear. It follows
supercial temporal artery that can be palpated and
used as a reference for the block
14
.
Supraorbital nerve (SON) block
SON, which runs approximately 2 cm lateral to the
supratrochlear nerve, the injection can be done in this
point, or the needle can be advanced laterally through
the same puncture that was used for the STN
13,14
.
Supratrochlear nerve (STN) block
STN is blocked by inserting the needle just above
the eyebrow over its medial border
13,14
.
Zygomatic nerve (ZN) block
ZN is blocked by placing the index nger on ventral
rim of the orbit at the lateral canthus of the eye, and rmly
press against the supraorbital portion of the zygomatic
arch
12,14
.
POSSIBLE INDICATIONS
Full head block can be performed together with
botulinum toxin, as a bridge therapy, while waiting to
the toxin starting to work
15-17
. Refractory headache,
primary headache in pregnancy and the presence of
contraindications for other treatment’s options.
Peripheral nerve block has already been tested for
primary headache disorders like migraine prevention,
migraine acute treatment, cluster, neuralgia and tension-
type, as well as to secondary headache disorders such
posttraumatic headache, post-surgical headache
and scar related pain. It can also be considered as a
transitional treatment in chronic headaches.
LIMITATIONS
The major side effects occur due to local injection.
There are related cases of local infection, nerve damage
with later neuroma formation, hematoma, local injury to
adjacent structures and, rarely, systemic manifestations
due to absorption of local anesthetics (seizure, alteration
in consciousness and cardiac conduction effects when
high doses are used). Using small needles and aiming for
perineural sites are helpful in avoiding these side effects.
When patient has anatomic abnormalities, such as skull
defects, local infection or previous surgical scars, the
procedure is not indicated.
Assistant’s training about the location of structures,
technique and aseptic environment is necessary for
a great performance of the procedure. Studies must
be designed to identify the efcient amount of local
anesthetic, necessity of ultrasound guided
18
and
addition of corticosteroid (methylprednisolone or
betamethasone).
FUTURE DIRECTIONS
Thereby, clinical trials are important to assess the
role of the full head block for headache treatment. It
represents the combination of several well tolerated and
effective therapy, with a lack of side effects.
DISCUSSION
There are many examples of peripheral targeted
treatments, such as low-level laser therapy, topical
lidocaine, dry needling, electrical stimulation and
massaging
19
. There are other forms of inducing anesthesia
with nerve blocks, e.g., lidocaine transdermal patch
20
.
It has already been discussed through literature
about the role of peripheral nerve block on headache
management
21,22
. Peripheral nerve block can result in
rapid relief of pain and allodynia, reduce the number of
headache days and medication consumption
23
and its
effects may last for several weeks. Thereby, nerve block
is a viable and safe treatment option for selected groups
of headache patients, particularly those with intractable
headache.
Although there are many studies about effectiveness
of a specic nerve block
24-26
, especially greater occipital
nerve block
27
, there is no case report that apply full
head block for treatment of primary headache. Why
should we do a full head block? Due to: (1) distribution
nerve pain - headaches are not limited to one nerve; (2)
necessity of a complete peripheral detachment to arouse
neuromodulation; (3) acute response in headache attack;
and (4) refractory headaches to others procedures.
CONCLUSION
Considering this rational, structured scientic
evidence with blinded and sham-controlled studies is
needed to understand the action mechanism, validate
doses of the anesthetics, train professionals and establish
the efcacy of full nerve block in headache disorders.
REFERENCES
1. Feigin VL, Abajobir AA, Abate KH, Abd-Allah F, Abdulle AM,
Abera SF et al (2017) Global, regional, and national burden
of neurological disorders during 1990–2015: a systematic
analysis for the global burden of disease study 2015. Lancet
Neurol, 16:877–897.
2. Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z (2018)
Migraine is rst cause of disability in under 50s: will health
politicians now take notice? J Headache Pain, 19:17.
3. Queiroz LP, Peres MFP, Piovesan EJ, Kowacs F, Ciciarelli
MC, Souza JA et al (2009) A nationwide population-based
study of migraine in Brazil. Cephalalgia, 29:642–649.
4. Queiroz LP, Peres MFP, Piovesan EJ, Kowacs F, Ciciarelli MC,
Souza JA et al (2009) A nationwide population-based study
of tension-type headache in Brazil. Headache, 49:71–78.
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