tag:blogger.com,1999:blog-12507944122282118362024-02-20T07:19:06.713-08:00ALDHABAANفهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.comBlogger23125tag:blogger.com,1999:blog-1250794412228211836.post-22128409461877892772012-04-18T03:20:00.002-07:002012-04-18T03:21:06.497-07:00<div dir="rtl" style="text-align: right;" trbidi="on">
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt; mso-fareast-font-family: DFKai-SB;">Comparison of the extraction efficiencies of different leaching
agents for reliable assessment of bio-accessible trace metal fractions in airborne
particulate matter <o:p></o:p></span></b></div>
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<u><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">A. Mukhtar<sup>1</sup></span></u><sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">, 2</span></sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;"> and A.Limbeck<sup>1</sup><o:p></o:p></span></div>
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<sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">1</span></sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;"> Institute of
Chemical Technologies and Analytics, Vienna University of Technology, Vienna,
Austria, <o:p></o:p></span></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">alimbeck@mail.zserv.tuwien.ac.at<i style="mso-bidi-font-style: normal;"><a href="mailto:soilchen@ntu.edu.tw"></a><o:p></o:p></i></span></div>
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<sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">2</span></sup><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Division of Science and Technology, University of Education, Lahore,
Pakistan<o:p></o:p></span></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">ch_mazam@hotmail.com<o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Abstract<o:p></o:p></span></b></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">In present study, an in-vitro physiologically
based extraction test has been applied for extraction of bio-accessible trace
metal fractions in airborne particulate matter (APM) samples collected from different
urban sites in Austria and Pakistan using the leaching agents H<sub>2</sub>O, sodium
chloride, ammonium acetate, ammonium citrate, synthetic gastric juice and
artificial lung fluids. Obtained extracts were then measured using an ETV-ICP-OES
procedure which allowed highly sensitive measurement of dissolved analytes even
in the presence of leaching agents. Derived results indicated that the
investigated leaching agents extract different amounts of trace metals. In
general, leaching agents with organic nature yielded comparatively greater extractable
and thus bio-accessible trace metal fractions to that of simple solvents like H<sub>2</sub>O
or aqueous NaCl solution. With water, only 26.3±4.0% of Cd was found to be
bio-accessible whereas </span><span style="font-size: 10pt;">88.4±24.8 </span><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">of Cd was obtained as
bio-accessible fraction with the use of synthetic gastric juice. The
concentrations of bio-accessible metal fractions varied from 0.4 ng m<sup>-3</sup>
(Cd) to 714 ng m<sup>-3</sup> (Zn) and 0.3 ng m<sup>-3</sup> (Cd) to 190 ng m<sup>-3</sup>
(Zn) for PM10 samples collected from Karachi (Pakistan) and Graz (Austria)
respectively. <o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Key words</span></i></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">:</span></b><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;"> Bio-accessibility;
trace metals; airborne particulate matter; synthetic body fluids <o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Introduction<o:p></o:p></span></b></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">In recent years, many toxicological studies
have implicated metal contents as a possible harmful component of APM
(Prieditis and Adamson, 2002) since they can be absorbed into human tissues during
breathing especially particles with an aerodynamic diameter less than 10
microns (PM10). The toxicity of metal depends upon its species that are
present. Thus, for risk assessment of metal toxicity, it is important to
determine bio-accessible concentrations instead of total metal contents
(Michelozzi et al., 1998).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Particles
in the 2.5- to 10-μm size fraction are in most cases deposited in the tracheal
and the bronchial region after inhalation, from where they are transported
within hours by the so-called mucociliary clearance adoral and are mainly
swallowed. This fraction reaches the gastrointestinal tract (GIT), where it
comes into contact with gastric juice (Hamel et al., 1998). On the other hand
particles less than 1 µm can enter into the alveolar region of lungs where they
interact with the lung fluid (Jianjum et al., 2010 and Song et al., 2011). For
risk assessment of metal toxicity the determination of bio-accessible fractions
is recommended. For this purpose extraction procedures with different leaching
agents such as water, buffer solutions or synthetic body fluids were reported
in literature. Since the chemical composition of these leaching agents is
different it is expected that inconsistent amount of bio-accessible metal
fractions is obtained via the use of applied leaching agents. Therefore, it is
highly needed to evaluate the extraction efficiencies of various commonly used
leaching agents for true estimation of bio-accessible trace metal fractions in
APM. <o:p></o:p></span></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">In
present study, an in-vitro physiologically based extraction test (PBET) was
employed for extraction of APM samples from Graz (Austria) and Karachi
(Pakistan) with the leaching agents water, sodium chloride, ammonium acetate,
ammonium citrate, synthetic gastric juice, artificial lysosomal fluid and
Gamble solution, followed by measurement of resulting extracts using
electrothermal vaporization inductively-coupled plasma atomic emission
spectrometry (ETV-ICP-OES). Derived results were discussed in order to gain
more detailed information about the extraction behavior of the investigated
leaching agents. <o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Materials
and Methods<o:p></o:p></span></b></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Reagents and materials<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10pt; mso-fareast-font-family: DFKai-SB;">High purity water was obtained by purifying de-ionized water (reverse
osmosis/ion exchange combination Euro 20 plus, SG Water Systems, Germany) with
an Easypure 2 system (Thermo Barnstead, USA). All used chemicals and reagents
were of analytical reagent grade and were procured from Merck (Darmstadt,
Germany). Pepsin from porcine stomach mucosa (456 units mg−1 solid) was
purchased from Sigma Aldrich (Chemie GmbH, Steinheim, Germany). Certified
multielement standard solutions of In, As, Ba, Cd, Co, Cu, Mn, Ni, Pb and Zn
(1000 mg/L) were purchased from Merck (Darmstadt, Germany) and diluted with 1%
HNO<sub>3</sub> (v/v) in order to prepare various working standard solutions. A
1 mol l<sup>-1</sup> solution of ammonium acetate was prepared by dissolving
77.0825 g weight in one litre of bi-distilled water and pH of the solution was
maintained at 7. Similarly, 0.1 mol l<sup>-1</sup> ammonium citrate solution
was prepared by dissolving 22.619 g in one litre of high purity water and pH of
the solution was maintained at 4.4 with the use of HCl. The synthetic gastric
juice was prepared according to a US Pharmacopeia methodology by dissolving 2 g
NaCl in 50 ml of high purity water followed by addition of 7 ml of conc. HCl in
order to maintain pH of resulting solution at 2-2.5. To this solution, 3.2 g of
pepsin were added, dissolved well and finally the volume was make up to 1 litre
using bi-distilled water. Artificial lysosomal fluid and Gamble solution were
prepared according to Colombo et al., 2008. Indium at level of 1 ppm was also
added to the prepared leaching agents as an internal standard in order to
overcome non-spectral interferences as well as errors related to manual sample
handling steps. The prepared leaching agents were stored in refrigerator at 4°C
until further use.</span><span style="color: red; font-family: "Times New Roman","serif"; font-size: 10pt;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 10pt; mso-fareast-font-family: DFKai-SB;"><o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 10pt;">Instrumentation<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10pt;">An iCAP 6500
series ICP-OES spectrometer (Thermo Scientific, USA) has been used for
simultaneous multielement analysis of As, Ba, Cd, Co, Cu, Mn, Ni, Pb, Zn. For
sample introduction by electrothermal vaporization, an ETV system model 4000A
ETV (Spectral Systems, Fürstenfeldbruck, Germany) was used corresponding in
essence to a longitudinally heated graphite tube furnace. A detailed
description of instrumentation and optimized method parameters can be found in Mukhtar
and Limbeck, 2011.<o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 10pt;">Collection
of PM10 samples<o:p></o:p></span></i></div>
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<span style="font-size: 10pt; mso-bidi-font-size: 12.0pt;">Sampling of size
segregated APM samples (PM10) was performed at an urban site in Karachi, during
March-April 2009 (20 * 25 cm) using high volume sampler, with an intake volume
of approximately 1223 m<sup>3</sup>. Whereas sampling at Graz was done during July-August,
2006 (147 * 147 mm) with the help of an automated sampling device (Leckel,
Germany) containing a PM10 pre-separation head, with an intake volume of Graz
samples was 650 m<sup>3</sup>. <span style="mso-spacerun: yes;"> </span>Quartz
fiber filters (PALL Life-sciences, Michigan, USA) were used as sampling
substrates. <o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 10pt;">In-Vitro
physiological based extraction test (PBET) and determination of residual/total
metal contents<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10pt;">For determining
the bio-accessible trace metal fraction present in APM, an in-vitro
physiological based extraction test was performed. For this purpose, aliquots
with a diameter of 10 mm were punched out from each collected PM10 sample. Six
punches from each PM10 sample were taken into pre-cleaned polypropylene tubes
followed by addition of 700 mg of leaching agent. From each sample three
replicates have been prepared with each type of leaching agent. Closed tubes
were treated in an ultrasonic bath (Sonorex TK30, Bandelin, Germany) at 37°C
for 1 h in order to extract soluble trace metal fractions. After cooling down
the sample solutions to room temperature, the derived extracts were centrifuged
(Hettich, Zentrifugen-EBA 20) at 5000 rpm for 10 min for separation of undissolved
material and remaining filter substrate . The supernatant clear sample
solutions were transferred to new 3 ml polypropylene tubes and stored until
further analysis.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10pt;">The remaining
eight aerosol filter punches (diameter 12 mm) were used for determination of
total trace metal contents. For sample digestion the filter punches were
transferred into pre-cleaned Bernas type Teflon lined bombs followed by
addition of 1 ml conc. HNO<sub>3</sub>, 1 ml HCl and 50 µl of HClO<sub>4</sub>.<span style="mso-spacerun: yes;"> </span>The Teflon lined bombs were then placed in
indigenously developed refractory oven and treated at 130 °C for 1 h in order
to dissolve total metal contents. Finally, the temperature of the refractory
oven was increased to 150 °C and maintained for other 30 min for evaporation of
excessive amount of HNO<sub>3</sub> and HCl. After cooling the insoluble filter
material including the small droplet of HClO<sub>4</sub> remaining in the
Teflon lined bombs were transferred in new PP tubes and . diluted to a final
mass of approximately 2 g with 1% (v/v) HCl. Simultaneously a defined amount of
In as internal standard was added. After centrifugation the supernatant
solutions were removed and stored in new PP tube at 4°C until ananlysis.<o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 10pt;">ETV-ICP-OES
Analysis of standard solutions and PM10 samples<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10pt;">Measurement of
standard solution and prepared PM10 extracts was carried out according to Mukhtar
and Limbeck, 2011. Briefly, 40 µl of the prepared extracts/digests were
pipetted into precleaned graphite boats and dried using an IR-lamp. For
analysis, the graphite boats were inserted into the graphite furnace tube of
the ETV system and the furnace program was started by the ICP-OES software and
the emission spectra of the vapor introduced into plasma was measured.<o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Results
and Discussion<o:p></o:p></span></b></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Total metal concentrations in PM10 samples from
Karachi ranged from few ng m<sup>-3</sup> to some hundred ng m<sup>-3</sup>.
The highest concentrations among the measured elements were observed for Zn ranging
from 361 ng m<sup>-3</sup> to 918 ng m<sup>-3</sup> whereas lowest
concentrations were observed for trace element Cd varying from 1.9 ng m<sup>-3</sup>
to 4.2 ng m<sup>-3</sup>. As and Co revealed results below their detection
limits i.e., less than 0.5 ng m<sup>-3</sup>. These results were found in
accordance to literature findings as reported by Venkataraman et al., 2002, and
Salam et al., 2003 for mega south Asian cities Mumbai and Dhaka respectively. Similar
observations were found for PM 10 samples collected from Graz, with
concentrations of Zn varying from 71 ng m<sup>-3</sup> to 300 ng m<sup>-3 </sup>and
Cd concentrations ranging from 0.9 to 1.5 ng m<sup>-3</sup>. These findings were
in agreement with the results reported in literature from various sites in
central Europe. For example, Limbeck et al., 2009 have reported concentrations
of Cd and Zn in the order of 0.1 ng m<sup>-3 </sup>and 200 ng m<sup>-3 </sup>respectively
in PM10 samples collected from various urban sites in Vienna. The results
indicated clearly that atmosphere of Karachi is significantly more contaminated
with toxic trace elements as compared to Graz. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Bio-accessible fractions were found to be
lower than the corresponding total metal concentrations, indicating that only a
fraction of metal is soluble in various leaching agents. Since
bio-accessibility test has been performed with different leaching agents,
variable amounts of bio-accessible trace metal fractions have been released
which reflect differences in their ionic strength and composition. Therefore a
question arises about the trueness of bio-accessible fractions. It was found
that lowest bio-accessible trace metal fractions were obtained with the use of
water and NaCl as compared to leaching agents with organic composition like
synthetic gastric juice and artificial lysosomal fluid (Figure 1a and 1b).
However, the Gamble solution released comparable quantities of bio-accessible
trace metal fractions to that of water and NaCl. Furthermore, the low leaching
ability of Gamble solution as compared to </span><span style="font-size: 9pt; mso-fareast-font-family: DFKai-SB;"><o:p></o:p></span></div>
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<span style="font-size: 9pt; mso-fareast-font-family: DFKai-SB; mso-fareast-language: ZH-TW;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt; tab-stops: 36.3pt;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Fig. 1 Trace metal
fractions extractable with different leaching agents (%), results are average
of twenty investigated PM10 samples.<o:p></o:p></span></div>
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<br /></div>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 9pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: DFKai-SB; mso-fareast-language: ZH-TW; mso-font-kerning: 1.0pt;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" />
</span>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">synthetic gastric juice and artificial
lysosomal fluid could be explained on the basis that it is neutral (pH<sub>˜</sub>7),
thus the interaction of Gamble solution with PM10 metal particles is not so aggressive.
In contrast, synthetic gastric juice and artificial lysosomal fluid being having
complex organic nature and acidic pH causes the metals to release easily,
thereby posing serious health risks when trace fractions become part of body
fluid. It can also be deduced from above figure that the metal extracting
behavior of applied leaching agents is quite similar for PM10 samples collected
from two entirely different sites i.e., Graz (Central Europe) and Karachi
(South Asia), indicating that bio-accessibility is element as well as leaching
agent dependent. <o:p></o:p></span></div>
<br />
<div class="MsoBodyTextIndent2" style="layout-grid-mode: char; line-height: normal; margin: 0cm 0cm 0pt; mso-char-indent-count: 2.0; mso-para-margin-bottom: .0001pt; mso-para-margin-left: 0gd; mso-para-margin-right: 0cm; mso-para-margin-top: 0cm; text-align: justify; text-indent: 20pt; text-justify: inter-ideograph;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Using
synthetic gastric juice for assessment of bio-accessible trace metal fractions concentrations
in PM10 ranging from 0.4 ng m<sup>-3</sup> (Cd) to 714 ng m<sup>-3</sup> (Zn) were
found in aerosol samples collected in Karachi, whereas<span style="mso-spacerun: yes;"> </span>bio-accessible trace metal concentrations in PM10
samples from Graz varied from 0.3 ng m<sup>-3</sup> (Cd) to 190 ng m<sup>-3</sup>
(Zn). Comparison of bio-accessible fraction in PM10 samples reported in present
study with literature data is not possible, since current study is carried out
for the first time where an attempt has been made to provide a guideline for
estimation of actual bio-accessible trace metal fractions in APM. <span style="color: red;"><o:p></o:p></span></span></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<br /></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Conclusion<o:p></o:p></span></b></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<br /></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">In this study an attempt has been made for
the first time in order to propose a model for the estimation of true
bio-accessible trace metal fractions in APM which could be used as a guideline
for future studies. In present study, an in-vitro PBET was applied for
extraction of bio-accessible metal fractions present in APM using various
leaching agents followed by subsequent measurement of gastric extracts using a
recently developed ETV-ICP-OES procedure. The obtained results indicated severe
differences in the extraction efficiencies of the investigated leaching agents.
Highest bio-accessible trace metal fractions are obtained with the use of synthetic
body fluids, lowest results were observed for water and sodium chloride
solution. Generally it was found that the presence of organic complexing agent
as well as acidic conditions improve the solubility of trace metals
significantly. Therefore, for future studies it is highly recommended to use
synthetic body fluids for estimation of bio-accessible trace metal fractions in
APM, since they enable a more reliable assessment of bio-accessible trace metal
fractions in PM10 than pure inorganic solutions. <o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;"><span style="mso-tab-count: 1;"> </span><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Acknowledgements<o:p></o:p></span></b></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<br /></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt; mso-char-indent-count: 2.0; text-indent: 20pt;">
<span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">Azam Mukhtar acknowledges the Higher Education Commission (HEC),
Pakistan and the Austrian Exchange Service (ÖAD) for providing a Ph.D.
scholarship for the period 2007-2011.</span><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB; mso-fareast-language: ZH-TW;"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt; mso-char-indent-count: 2.0; text-indent: 20pt;">
<br /></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 10pt; mso-fareast-font-family: DFKai-SB;">References<o:p></o:p></span></b></div>
<br />
<div class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt;">
<br /></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Limbeck A, Handler M, Puls C, Zibral J, Bauer H and Puxbaum H. Impact of
mineral components and selected trace metals on ambient PM10 concentrations.
Atmos Environ 2009; 43: 530-538.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Mukhtar A and Limbeck A. Development of an ETV-ICP-OES procedure for
assessment of bio-accessible trace metal fractions in airborne particulate
matter, J Anal At Spectrom 2011; 26: 2081-2088.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Colombo C, Monhemius A J and Plant JA. Platinum, palladium and rhodium
release from vehicle exhaust catalysts and road dust exposed to simulated lung
fluids,<span style="mso-spacerun: yes;"> </span>Ecotoxicology and Environmental
Safety 2008; 71: 722–730.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Prieditis H and Adamson IYR. Comparative pulmonary toxicity of various
soluble metals found in urban particulate dusts, Exp Lung Res 2002; 28: 563-572.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Jianjun N, Rasmussen P E, Hassan NM and Vincent R. Concentration
Distribution and Bioaccessibility of Trace Elements in Nano and Fine Urban
Airborne Particulate Matter: Influence of Particle Size, Water Air Soil Pollut
2010; 213: 211–225. <o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Michelozzi P, Forastiere F, Fusco D, Perucci CA, Ostro B, Ancona C and
Palloti G. Air Pollution and Daily Mortality in Rome, Italy, Occup Environ Med
1998; 55: 605-610.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Hamel SC, Buckley B and Lioy PJ. Bioaccessibility of metals in soils for different
liquid to solid ratios in synthetic gastric fluid, Environ Sci Technol 1998; 32:
358–362.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Song S, Lee K, Lee Y M, Lee JH, Lee S, Yu SD and Paek D. Acute health
effects of urban fine and ultrafine particles on children with atopic
dermatitis, Environ. Res., 3 (2011), pp. 394-399.<o:p></o:p></span></div>
<br />
<div align="left" class="MsoNormal" style="layout-grid-mode: char; margin: 0cm 0cm 0pt 20pt; mso-char-indent-count: -2.0; text-align: left; text-indent: -20pt;">
<span style="font-size: 10pt; mso-bidi-font-weight: bold; mso-fareast-font-family: DFKai-SB;">Salam A, Bauer H, Kassin K., Mohammad US, and Puxbaum H. Aerosol chemical
characteristics of a mega-city in southeast Asia (Dhaka-Bangladesh), Atmos
Environ 2003; 37: 2517-2528.<o:p></o:p></span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 10pt; mso-ansi-language: EN-US; mso-bidi-font-weight: bold; mso-bidi-language: AR-SA; mso-fareast-font-family: DFKai-SB; mso-fareast-language: ZH-CN; mso-font-kerning: 1.0pt;">Venkataraman C, Reddy
CK, Josson S, and Reddy M S. Aerosol size and chemical characteristics at
mumbai, india, during the indoex-ifp (1999), Atmos Environ, 2002; 36: 1979</span></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-17961907324485028432012-02-03T13:43:00.001-08:002012-02-03T13:43:04.465-08:00<div dir="rtl" style="text-align: right;" trbidi="on">
<b><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"> <div align="left">
Management of male urethral discharge</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Patient complains of urethral discharge or dysuria</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><div align="left">
If history of receptive oral or anal</div>
<div align="left">
sex take 2 swabs of throat or anus</div>
<div align="left">
1. NAAT Chlamydia</div>
<div align="left">
2. MC&S</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Take history, examine patient</div>
<div align="left">
YES Visible urethral discharge present? NO</div>
<div align="left">
Immediate treatment for Gonorrhoea and Chlamydia</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: xx-small;"><div align="left">
Azithromycin 1g and amoxycillin* 3g, and probenecid* 1g orally</div>
<div align="left">
(*use ceftriaxone 250mg IMI instead if partner from outside Top End or Central Australia)</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Education and counselling. Promote / provide condoms</div>
<div align="left">
Arrange full check-up and same treatment for sex partner/s</div>
<div align="left">
Follow up test results</div>
<div align="left">
Review in one week to give results of tests and ensure symptoms have resolved and contact tracing done</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
If symptoms not better re-examine, re-test. Consult with Medical Officer at local Sexual Health Unit</div>
</span></span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
33</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Management of epididymo-orchitis</div>
<div align="left">
(swollen painful testes)</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Causes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The causes of epididymo-orchitis vary with age.</div>
<div align="left">
Among younger sexually active men gonorrhoea and chlamydia are common (usually <35</div>
<div align="left">
years but can be <45 years in Indigenous men in remote communities).</div>
<div align="left">
Among older men, organisms associated with urinary tract infections (</div>
</span></span><i><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">E. coli</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">, </span></span><i><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">Pseudomonas</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">,</span></span><i><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Klebsiella </div>
<div align="left">
the cause.</div>
<div align="left">
Many references use age 35 years as a cut off point to guide treatment. However, for men</div>
<div align="left">
living in remote NT communities or whose sexual networks relate to remote communities</div>
<div align="left">
with high rates of gonorrhoea and chlamydia, 45 years may be more appropriate.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">species) occur. It is not possible to tell by clinical examination which organism is</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
History, examination and tests</div>
</span></span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Ask about:</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
suddenly, or whether there was any trauma preceding the pain;</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">how long the pain and swelling have been present, whether it started slowly or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">any nausea or vomiting;</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">recent symptoms of urethral discharge or dysuria;</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">other possible STI symptoms (eg. sores, warts or lumps, rash, sore throat);</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">sexual partners and if any of them are from outside the NT.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Examination</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Look for urethral discharge and fever especially (see Male examination, p 10).</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
In all men with epididymo-orchitis</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
trichomonas; and</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Take a first void urine for gonorrhoea culture and NAAT for chlamydia and</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">a midstream urine for MC&S.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
For men in whom a urethral discharge is present regardless of age</div>
<div align="left">
Take 2 swabs of the discharge:</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
media); and</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">First swab for MC&S (roll onto glass slide and let dry in air and put swab in transport</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
pathology company instructions (dry tube for PCR, transport media tube for TMA, see</div>
<div align="left">
p 13).</div>
<div align="left">
Torsion of the testis can be very similar to epididymo-orchitis and is an emergency.</div>
<div align="left">
If there is any doubt about the diagnosis, the patient should be referred immediately to</div>
<div align="left">
hospital. Nurses and Aboriginal health workers should always consult with a doctor.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Second swab for NAAT for gonorrhoea, chlamydia and trichomonas according to</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
34</div>
</span></span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
For all men under 35 (under 45 if remote community connection</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">)</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
HbcAb)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Take a blood test for syphilis serology, HIV +/- Hepatitis B (HBsAg, HBsAb, and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
See hepatitis B, p 14.</div>
</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Treatment</div>
</span></span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
If there is any doubt about the diagnosis, consult with a specialist and consider</div>
<div align="left">
referring immediately to hospital to rule out torsion of the testis.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
For men of any age in whom a urethral discharge is present or for men under 35 years of</div>
<div align="left">
age (under 45 years in remote communities) gonorrhoea or chlamydia are likely causes.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">ceftriaxone 250mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">IMI stat; and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
azithromycin 1g </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">orally stat; and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
doxycycline 100mg </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">bd for 14 days.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
For men over 35 years of age (over 45 years in remote communities) in whom a urethral</div>
<div align="left">
discharge is not present a urinary tract infection is the likely cause.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Repeat the azithromycin on day 8 if any doubt about ability to take the doxycycline.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">cephalexin 1g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">bd for 14 days, or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">amoxycillin+clavulinate 875/125mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">bd for 14 days, or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">norfloxacin 400mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">bd for 14 days, or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">ciprofloxacin 500mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">bd for 14 days.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
If allergic to the medication, consult the local SHU.</div>
<div align="left">
For all men</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Paracetamol for the pain and advise rest in bed.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Wearing firm underpants can support the scrotum and help reduce the pain.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
infections found.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Check the results of the tests for other infections and the antibiotic sensitivity of any</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
consider sending to hospital.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">See him on days 3 and 8 - if he is not improving, consult with the local SHU and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
For men treated for an STI</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
given single dose treatment for gonorrhoea and chlamydia.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ensure that all sexual partner/s from the last 3 months are checked for STIs and</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
to reduce their risk of pelvic infection and infertility.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Explain that all partner/s need to be treated as well so he doesn’t get re-infected and</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
treatment.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Advise him not to have sex until 1 week after both his treatment and his partner/s</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Discuss condoms and safe sex.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
give </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">On day 8 if there is any doubt about whether he is able to take all the doxycycline,</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">azithromycin 1g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">by mouth once again.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
For men treated for a urinary tract infection</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Check the organism found on culture and its antibiotic sensitivity.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">When the infection is resolved, arrange renal investigations (eg. ultrasound).</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
35</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Differential diagnosis: Scrotal swelling: epididymo-orchitis</div>
<div align="left">
or torsion of the testis?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Scrotal swelling may be due to either epididymo-orchitis or torsion of the testis. It can be very</div>
<div align="left">
difficult to tell the difference between the two on clinical grounds. Torsion of the testis</div>
<div align="left">
requires surgery and, if there is a delay of more than several hours, can lead to loss of the</div>
<div align="left">
testis. Therefore a quick decision is needed.</div>
<div align="left">
Nurses and Aboriginal Health Workers should always consult with a doctor. Doctors should</div>
<div align="left">
consider consulting a specialist.</div>
</span></span><b><span style="font-family: Arial;"><div align="left">
If there is any doubt about the diagnosis refer immediately to hospital.</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The table below provides an outline to assist in making a diagnosis.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Torsion</div>
<div align="left">
Epididymo-orchitis</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Age</div>
<div align="left">
Can be any age but more</div>
<div align="left">
usually under 1 year or</div>
<div align="left">
between 10-25 years.</div>
<div align="left">
Rare in boys before puberty.</div>
<div align="left">
Usually young sexually active</div>
<div align="left">
men or older men.</div>
<div align="left">
Onset</div>
<div align="left">
Usually sudden but can</div>
<div align="left">
be gradual. Sometimes</div>
<div align="left">
related to recent trauma.</div>
<div align="left">
Gradual.</div>
<div align="left">
Pain</div>
<div align="left">
Always present usually</div>
<div align="left">
moderately strong or severe.</div>
<div align="left">
Usually mild to moderate.</div>
<div align="left">
Other symptoms</div>
<div align="left">
May have abdominal pain,</div>
<div align="left">
and vomiting.</div>
<div align="left">
May have abdominal pain,</div>
<div align="left">
dysuria or urethral discharge.</div>
<div align="left">
Fever</div>
<div align="left">
Either no fever or less than</div>
<div align="left">
37.5</div>
<div align="left">
Usually more than 37.5</div>
<div align="left">
but may be absent.</div>
<div align="left">
On examination</div>
<div align="left">
Scrotum often swollen,</div>
<div align="left">
red and warm. Testicle within</div>
<div align="left">
the scrotum also swollen and</div>
<div align="left">
tender. Affected testicle may</div>
<div align="left">
be sitting higher than the</div>
<div align="left">
other and/or lying sideways.</div>
<div align="left">
Scrotum often swollen, red</div>
<div align="left">
and warm. Testicle within</div>
<div align="left">
the scrotum also swollen</div>
<div align="left">
and tender. Urethral discharge</div>
<div align="left">
may be present. May be nitrites</div>
<div align="left">
on urinalysis.</div>
<div align="left">
Effect of lifting the scrotum</div>
<div align="left">
Either no change in pain</div>
<div align="left">
or worsens the pain.</div>
<div align="left">
May relieve the pain.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">o</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">C.</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">o</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">C</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
36</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Take 2 swabs of discharge if present:</div>
<div align="left">
MC&S and NAAT Gono/Chlamydia/Trichomonas</div>
<div align="left">
Take separate urines:</div>
<div align="left">
First-Void Urine MC&S and NAAT</div>
<div align="left">
Gono/Chlamydia/Trichomonas and</div>
<div align="left">
Mid-Stream Urine for MC&S</div>
<div align="left">
Take blood for HIV, syphilis serology, +/-Hep B</div>
<div align="left">
(if not immune and can do follow up see p 14)</div>
<div align="left">
Take separate urines:</div>
<div align="left">
First-Void Urine for MC&S and</div>
<div align="left">
NAAT Gono/Chlamydia/ Trichomonas and</div>
<div align="left">
Mid-Stream Urine for MC&S</div>
<div align="left">
Cephalexin 1g bd for 14 days, OR</div>
<div align="left">
amoxycillin+clavulinate 875/125mg</div>
<div align="left">
bd for 14 days, OR norfloxacin</div>
<div align="left">
400mg bd for 14 days, OR</div>
<div align="left">
ciprofloxacin 500mg bd for 14 days</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Review on Days 3 and 7. Check test results.</div>
<div align="left">
If not improving consider sending to hospital</div>
</span></span></span><b><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"><div align="left">
Management of epididymo-orchitis</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><div align="left">
Nurses and Aboriginal health workers</div>
<div align="left">
should always consult with a doctor</div>
<div align="left">
Paracetamol</div>
<div align="left">
Rest in bed</div>
<div align="left">
Scrotal support</div>
<div align="left">
(eg firm underpants)</div>
<div align="left">
Consider torsion of testis: if any doubt,</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Take history, examine patient </div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;">send immediately to hospital</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Visible urethral discharge present</div>
<div align="left">
or patient under 35 years ?</div>
<div align="left">
(under 45 in remote community)</div>
<div align="left">
YES</div>
<div align="left">
Probable STI</div>
<div align="left">
NO</div>
<div align="left">
Probable urinary</div>
<div align="left">
tract infection</div>
<div align="left">
Azithromycin 1g orally and ceftriaxone 250mg IMI</div>
<div align="left">
and doxycycline 100mg bd for 14 days</div>
<div align="left">
Review on Day 3: if no improvement consult with</div>
<div align="left">
local Sexual Health Unit and consider sending to</div>
<div align="left">
hospital. Check test results</div>
<div align="left">
Review on Day 7. If no improvement send to</div>
<div align="left">
hospital. If improving, give azithromycin 1g if any</div>
<div align="left">
doubt about compliance with doxycycline</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Education and counselling</div>
<div align="left">
Promote / provide condoms</div>
<div align="left">
Arrange full check-up and treatment</div>
<div align="left">
for gonorrhoea and chlamydia for sex partner/s</div>
<div align="left">
When infection resolved, arrange renal</div>
<div align="left">
investigations</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Patient with swollen, red, painful scrotum</div>
</span></span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
37</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Management of genital ulcers</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Causes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The common causes will vary with the population group.</div>
<div align="left">
Among non-Aboriginal people the commonest cause is herpes although syphilis does occur.</div>
<div align="left">
Among Aboriginal people syphilis is relatively common especially in remote communities</div>
<div align="left">
although herpes also occurs. Donovanosis is mainly found in remote communities and while</div>
<div align="left">
increasingly rare, still occurs.</div>
<div align="left">
The possibility of malignancy as a cause of genital ulceration should not be overlooked</div>
<div align="left">
especially if there is poor response to treatment. Increased rates of vulval carcinoma have</div>
<div align="left">
been observed in the East Arnhem region in recent years.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
History and examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">How long the ulcers have been present and have they had them before?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
discharge, dysuria, rash, sore throat)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ask about other possible STI symptoms (eg. warts or lumps, urethral or vaginal</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
Central Australia.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ask about sexual partner/s and if any of them are from outside the Top End or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">See Sexual history p 5.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Examination </div>
<div align="left">
It is important to look inside the vagina with a speculum in women, under the foreskin and</div>
<div align="left">
scrotum in men and in the peri-anal region in both sexes.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(see Male examination, p 10; Female examination, p 11).</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Genital Herpes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
May present as multiple, painful or itchy small blisters, which become ulcers, then scabs and</div>
<div align="left">
then heal. There may be tender lymph nodes in the groin. The first or primary episode is</div>
<div align="left">
always the most severe episode and can last 2-3 weeks. It is often associated with flu like</div>
<div align="left">
symptoms and headache and there can be severe localised genital swelling, pain and</div>
<div align="left">
retention of urine, requiring hospitalisation. Herpes can recur. If so, the ulcers are not usually</div>
<div align="left">
as severe and heal within a week.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Syphilis</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Usually presents as a single (occasionally 2) </div>
<div align="left">
rolled edge and the base of the ulcer is firm (‘indurated’) although they can often be atypical</div>
<div align="left">
in appearance. Without treatment the sore will go away in 4-6 weeks but the person will still</div>
<div align="left">
have syphilis.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">painless </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">ulcer/s which are red, round with a</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Donovanosis</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Usually presents as a red, beefy, raised, raw, painless lesion. Can be painful if secondary</div>
<div align="left">
infection is present. Without treatment the ulcer will not heal, and can spread slowly outwards</div>
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and become very large, eroding normal tissue. Ulcer/s may be present for months or years. It</div>
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can be difficult to tell syphilis and donovanosis apart.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
These infections can vary greatly in the way they look. It is frequently not possible to</div>
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tell by looking which organism is the cause.</div>
</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
38</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Investigations</div>
</span></span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Do a full STI check</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
herpes, syphilis and donovanosis.</div>
<div align="left">
(For herpes like sores: if blisters are present gently burst with a sterile needle and</div>
<div align="left">
swab the fluid, for other sores just swab the sore or scab).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Using a dry swab, swab the base of the ulcer. REQUEST: genital ulcer NAAT for</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
REQUEST: MC&S and NAAT chlamydia, gonorrhoea and (in women only)</div>
<div align="left">
trichomonas. (If doing a speculum examination in a woman taking endocervical and</div>
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high vaginal swabs is better).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Take 2 self collected vaginal swabs or a urine test in women and a urine test in men.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
HbcAb). </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Take a blood test for syphilis serology, HIV +/- Hepatitis B (HBsAg, HBsAb, and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">See hepatitis B, p14.</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Treatment</div>
</span></span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Treatment should be given straight away - do not wait for test results to come back.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
below).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If the sores are completely typical of herpes, then manage as for herpes only (see</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
p 39).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If not completely typical of herpes, then manage as for syphilis and donovanosis (see</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Talk to your local SHU about any pregnant woman with genital ulcers.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Herpes management</div>
</span></span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Primary herpes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Primary herpes is the person’s first episode of genital herpes.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
daily for 5 days.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Give </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">valaciclovir 500 mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">twice daily for 5 - 10 days, or </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">famciclovir 125 mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">3 times</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
them (or any drying agent).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Keep the sores clean with salt water washes and/or put betadine on the sores to dry</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Give paracetamol 2 tablets by mouth every 4 hours as needed for pain.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
prior to passing urine.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Lignocaine gel may be helpful during the first few days to reduce pain particularly</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
Note: Both valaciclovir and famciclovir require authority prescriptions and are approved for</div>
<div align="left">
recurrent herpes. Both are effective in primary herpes but the PBS will only authorise</div>
<div align="left">
valaciclovir for primary episodes.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Talk to your SHU if the woman is pregnant or can’t pass urine.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Recurrent herpes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Recurrent episodes are usually less severe and heal within a week. Usually only keeping</div>
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them clean and mild pain relief is needed. If the episodes are more severe or frequent,</div>
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specific treatment may be needed. For maximum benefit, treatment should be commenced</div>
<div align="left">
within 24 hours of the onset of symptoms.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
5 days</div>
<div align="left">
If the person is getting 6 or more recurrent episodes per year, they may benefit from taking</div>
<div align="left">
long term daily medication to prevent or reduce the recurrences. Seek advice from your local</div>
<div align="left">
SHU.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Give </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">valaciclovir 500 mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">twice daily for 3 days or </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">famciclovir 125 mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">twice daily for</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
39</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Follow up at 1 week</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">A positive test confirms genital herpes.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
if the sores come back).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">A negative test does not exclude genital herpes (ask them to return for another swab</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Provide herpes information and advice about safe sexual behaviour.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Offer sexual partners information on herpes and a full STI screen.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Any woman who has herpes or whose partner has herpes should be advised to tell</div>
<div align="left">
their doctor of this if they get pregnant in the future (risk of neonatal herpes).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Blood tests for antibodies to herpes are available. However, their interpretation and</div>
<div align="left">
application to the clinical situation is complex. Practitioners are advised to seek advice from</div>
<div align="left">
the local Sexual Health Unit medical officer before considering their use.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Syphilis and donovanosis management</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Give </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">benzathine penicillin </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">IMI 1.8gm or 2.4 million units.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">Azithromycin 1gm </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">orally.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
the same treatment.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Contact trace all sexual partners in the last 3 months and offer a full STI screen and</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Syphilis and donovanosis are notifiable diseases. Contact your local SHU if treating</div>
<div align="left">
for syphilis or donovanosis.</div>
</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Follow up at 1 week</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Check test results.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If the ulcer is still present or the donovanosis test is positive keep giving</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
azithromycin 1g </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">orally once a week until the sore has healed. An alternative is</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
azithromycin 500mg </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">per day for 7 days (there is less evidence for this treatment).</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If possible examine the ulcer each week until it is fully healed.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
biopsy to investigate other causes.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">The ulcer </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">must </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">be examined at 4 weeks. If no response to treatment consider a</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
for a recurrence.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Examine the person at 3 months and 6 months after treatment is completed to look</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
for RPRs on both specimens to be ‘run in parallel’.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If syphilis was diagnosed, repeat syphilis serology 6 months after treatment and ask</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Safe sex advice</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
condoms do not always cover the ulcer. Advise the person not to have sex until the</div>
sores have healed.</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Advise the person about safer sexual practices and condom use. Remember</span></span></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></i></i></i></b></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-36796989433188932692012-02-03T13:41:00.000-08:002012-02-03T13:41:05.851-08:00Management of lower abdominal<div dir="rtl" style="text-align: right;" trbidi="on">
<b><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: large;"> <div align="left">
Management of lower abdominal</div>
<div align="left">
pain / pelvic inflammatory disease</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Woman complains of lower abdominal pain</div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><span style="color: white; font-family: Myriad-Roman; font-size: xx-small;"><div align="left">
Education and counselling</div>
<div align="left">
Promote / provide condoms</div>
<div align="left">
Arrange full check-up and</div>
<div align="left">
treatment for gonorrhoea,</div>
<div align="left">
chlamydia and trichomonas</div>
<div align="left">
for sex partner/s</div>
<div align="left">
If no VE and no history of discharge,</div>
<div align="left">
consider treatment if age < 35 and</div>
<div align="left">
other risk indicators present : deep</div>
<div align="left">
dyspareunia, intermenstrual</div>
<div align="left">
bleeding, STI or PID in past</div>
<div align="left">
12 months</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Take history, examine patient</div>
<div align="left">
Take 2 endocervical swabs: MC&S, NAAT Gono/Chlamydia/Trichomonas</div>
<div align="left">
Take 1 high vaginal swab: MC&S</div>
<div align="left">
Take blood for HIV, syphilis serology, +/-Hep B (if not immune and can do follow up see p 14)</div>
<div align="left">
If dysuria or urinary frequency present take a mid-stream urine for MC&S</div>
<div align="left">
YES</div>
<div align="left">
YES</div>
<div align="left">
NO</div>
<div align="left">
NO </div>
</span></span></span><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;"><span style="color: white; font-family: Myriad-Roman; font-size: x-small;">Manage for other conditions</span></span></span><b><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><div align="left">
Are any of the following present?</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Missed, overdue or delayed period</div>
<div align="left">
Recent delivery, miscarriage or abortion</div>
<div align="left">
Abdominal guarding, rigidity or rebound tenderness</div>
<div align="left">
Abdominal mass or swelling</div>
<div align="left">
Active vaginal bleeding</div>
<div align="left">
Patient is pregnant</div>
<div align="left">
Patient is very unwell or Temp >38°C</div>
</span></span></span><b><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-small;"><div align="left">
Day 1: ceftriaxone 250mg IV/IM and azithromycin 1g oral</div>
<div align="left">
Day 2: start doxycycline 100mg bd and metronidazole 400mg bd for 14 days</div>
<div align="left">
(daily roxithromycin 300mg if breastfeeding instead of doxycycline; see p 27 re doxycycline)</div>
</span></span></span><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><div align="left">
Immediate transfer to hospital</div>
</span></span></span><span style="color: #020303; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #020303; font-family: Myriad-Bold; font-size: x-small;"><span style="color: #020303; font-family: Myriad-Bold; font-size: x-small;"><div align="left">
Review on day 3: if no improvement, send to hospital</div>
<div align="left">
Review on day 8: if no improvement send to hospital</div>
<div align="left">
Repeat azithromycin 1g</div>
<div align="left">
Continue medications to day 14</div>
</span></span></span><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><span style="color: white; font-family: Myriad-Bold; font-size: x-small;"><div align="left">
Review on day 14 with full examination. Consult</div>
<div align="left">
local SHU or gynaecologist if not fully improved</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
*</div>
<div align="left">
*</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
30</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Management of male urethral discharge or</div>
<div align="left">
dysuria</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Causes</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Usually caused by gonorrhoea or chlamydia but is sometimes caused by trichomonas or</div>
<div align="left">
other organisms.</div>
<div align="left">
It is not possible to tell by clinical examination which organism is the cause</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">.</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
History, examination and tests</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
sore throat, see p 5).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ask the man about other possible STI symptoms (eg. sores, warts or lumps, rash,</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
outside the Top End or Central Australia (see p 14).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ask about his sexual partners in the past 3 months and whether any of them are from</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Examination </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(see Male examination, p10)</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Investigations </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(see Investigations-males, p 15)</span></span><b><span style="font-family: Arial;"><div align="left">
Do a full STI check</div>
</span><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
If discharge is present</div>
<div align="left">
Take 2 swabs (no need to swab inside the penis):</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
swab in transport media);</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">First swab for MC&S for gonorrhoea (roll onto glass slide and let dry in air and put</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
pathology company instructions (dry tube for PCR, transport media tube for TMA, see</div>
<div align="left">
p 13);</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Second swab for NAAT for gonorrhoea, chlamydia and trichomonas according to</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
for gonorrhoea, chlamydia and trichomonas.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If discharge is not present, send a first void urine for gonorrhoea culture and NAAT</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
If history of receptive oral or anal sex</div>
<div align="left">
Take 2 swabs of throat or anus:</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">First swab for MC&S for gonorrhoea,</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Second swab for NAAT for chlamydia.</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
For men over 40 years of age who have dysuria and no discharge</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Collect midstream urine MC&S to check for a urine infection (UTI);</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Blood test for syphilis serology, HIV +/- hepatitis B (HBsAg, HBsAb, and HbcAb)</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
See hepatitis B, p 14.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
31</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Treatment</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Treat immediately for gonorrhoea and chlamydia even if no discharge is present.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Give oral </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">amoxycillin 3g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">and </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">probenecid 1g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">and </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">azithromycin 1g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">once only.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If allergic to penicillin contact the local Sexual Health Unit.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
Australia (see p 14) - then give </div>
<div align="left">
instead.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If he has had a recent sexual partner who is from outside the Top End or Central</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">ceftriaxone 250mg </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">IMI and </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">azithromycin 1g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">orally</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
given the same treatment.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Make sure that sexual partner/s from the last 3 months are checked for STIs and</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Explain that all partner/s need to be treated as well so he doesn’t get re-infected.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
treatment.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Advise him not to have sex until 1 week after both his treatment and his partner/s</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Discuss safe sex and condom use.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Follow up</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
test results for other infections and discuss safe sex and condom use again.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If resources permit, ask him to come back in 1 week to be sure he is better, check the</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If no improvement, discuss with the local SHU.</span></span><b><span style="font-family: Arial; font-size: medium;"><span style="font-family: Arial; font-size: medium;"><div align="left">
If he has symptoms 1 week after treatment</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
It may be re-infection, resistant infection, trichomonas or another organism.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
- if trichomonas is present then treat him and his partner/s with 1 dose of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Check the results of the tests taken initially:</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
metronidazole 2g </div>
<div align="left">
- if culture for gonorrhoea was positive, check the antibiotic sensitivity.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">or </span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">tinidazole 2g </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">orally (don’t give tinidazole to pregnant women),</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
back or never got better in the first place.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If he did not have trichomonas, ask whether his symptoms got better and then came</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Check the original treatment was taken properly. Repeat if it was not.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Make sure all sexual partners were tested and treated.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If re-infection is likely, repeat the STI check-up and treatment.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
(see p 14).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ask if he had sex with someone from outside the Top End or Central Australia</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
necessary to do an intra-urethral swab to confirm a diagnosis of urethritis and</div>
<div align="left">
maximise the chance of culturing gonorrhoea (see technique below).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Talk with the local SHU about what further tests or treatment are needed. It may be</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Doing a urethral swab (ie. from inside the penis)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
If an antibiotic resistant gonorrhoea is suspected then another specimen for MC&S is</div>
<div align="left">
needed.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If discharge is present take a swab of it for MC&S for gonorrhoea.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
- moisten the tip of a thin urethral swab with sterile saline (ie. the wire stem swab not</div>
<div align="left">
the wooden stem swab);</div>
<div align="left">
- gently insert the tip of the swab 1-2cm into the urethra, leave it in place for a few</div>
<div align="left">
seconds and then withdraw it.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If there is no discharge then:</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Gently roll the swab on a glass slide and let dry in the air.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Put the swab in transport medium (charcoal is best but Stuarts medium can be used).</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Keep the swab at room temperature: do not refrigerate or let it get too hot.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Write ‘MC&S for gonorrhoea’ on the form and get it to the lab as soon as possible.</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
32</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><div align="left">
Take blood for HIV, syphilis serology, +/-Hep B</div>
<div align="left">
(if not immune and can do follow up see p 14)</div>
<div align="left">
Take 2 swabs of discharge for:</div>
<div align="left">
MC&S, NAAT Gono/Chlamydia/Trichomonas</div>
<div align="left">
Take first void urine for:</div>
<div align="left">
MC&S, NAAT Gono/Chlamydia/Trichomonas</div>
</span></span></span><b><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"><span style="color: #231f20; font-family: Myriad-Bold; font-size: x-large;"><div align="left">
Management of male urethral discharge</div>
</span></span></span><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;"><span style="color: #231f20; font-family: Myriad-Roman; font-size: x-small;">Patient complains of urethral discharge or dysuria</span></span></span></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-20074654737682981832012-02-03T13:16:00.000-08:002012-02-03T13:16:40.596-08:00Acknowledgements<div dir="rtl" style="text-align: right;" trbidi="on">
<span style="font-size: x-small;"><span style="color: white; font-family: Arial;"><span style="color: white; font-family: Arial;"> <div align="left">
DEPARTMENT O F </div>
</span></span><b><span style="color: white; font-family: Arial;"><span style="color: white; font-family: Arial;">HEALT H A N D FA M I L I E S</span></span><span style="color: white; font-family: Arial; font-size: large;"><span style="color: white; font-family: Arial; font-size: large;"><span style="color: white; font-family: Arial; font-size: large;"><div align="left">
NT Guidelines for the Management of</div>
<div align="left">
Sexually Transmitted Infections in the</div>
<div align="left">
Primary Health Care setting</div>
</span></span></span><span style="color: white; font-family: Arial;"><span style="color: white; font-family: Arial;"><div align="left">
Sexual Health and Blood Borne Virus Unit</div>
<div align="left">
Centre for Disease Control</div>
</span></span><span style="color: grey; font-family: Arial; font-size: x-large;"><span style="color: grey; font-family: Arial; font-size: x-large;"><span style="color: grey; font-family: Arial; font-size: x-large;"><div align="left">
Acknowledgements</div>
</span></span></span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;"><div align="left">
The authors are grateful to the many people who have assisted in the production of this guideline, including:</div>
<div align="left">
- Steven Skov, Maggie Richardson & Anne Davis, Sexual Health & Blood Bourne Virus Unit NT</div>
<div align="left">
- Kerrie Gell & Raelin Huang, Nganampa Health Council</div>
<div align="left">
- Kirsty Smith, Tri State STI/HIV Project</div>
<div align="left">
- Annie Tangey, Ngaanyatjarra Health Service</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
Updated May 2008 - Guidelines are for review May 2009</div>
<div align="left">
Further copies of the guidelines are available at:</div>
</span><span style="color: #3366ff; font-family: Arial; font-size: small;"><span style="color: #3366ff; font-family: Arial; font-size: small;"><span style="color: #3366ff; font-family: Arial; font-size: small;"><div align="left">
http://www.nt.gov.au/health/cdc/protocols.shtml</div>
</span></span></span><span style="font-family: TimesNewRoman;"><div align="left">
General enquiries about this publication should be directed to:</div>
<div align="left">
Sexual Health and Blood Borne Virus Unit (SHBBVU)</div>
<div align="left">
Department of Health and Community Services</div>
<div align="left">
PO Box 40596</div>
<div align="left">
Casuarina NT 0811</div>
<div align="left">
Phone: (08) 89228874</div>
<div align="left">
Facsimile: (08) 89228809</div>
</span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;"><div align="left">
Cover painting: Better Health</div>
<div align="left">
Story: People are calling out for help. They have sickness caused by bacteria, and blood borne viruses. Some sickness</div>
<div align="left">
causes discharge. When treatment happens and information is shared, people feel better and can tell others.</div>
<div align="left">
Artist: Nola Jimarin of Nauiyu Community</div>
</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
3</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Contents</div>
</span></span></span><span style="font-family: ArialMT; font-size: medium;"><span style="font-family: ArialMT; font-size: medium;"><div align="left">
Sexual history......................................................................................... 5</div>
<div align="left">
Sexual risk assessment.......................................................................... 8</div>
<div align="left">
Male examination ................................................................................. 10</div>
<div align="left">
Female examination ............................................................................. 11</div>
<div align="left">
Important points – lab tests for STIs..................................................... 13</div>
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Antibiotic Resistance of </div>
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Hepatitis B ............................................................................................ 14</div>
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Investigations – males.......................................................................... 15</div>
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Investigations – females....................................................................... 17</div>
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pH testing of vaginal secretions ........................................................... 19</div>
</span></span><i><span style="font-family: Arial; font-size: medium;"><span style="font-family: Arial; font-size: medium;">Neisseria gonorrhoeae</span></span><span style="font-family: ArialMT; font-size: medium;"><span style="font-family: ArialMT; font-size: medium;">................................... 14</span></span><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><div align="left">
Syndromic presentations and management</div>
</span></span></span><span style="font-family: ArialMT;"><div align="left">
Management of abnormal vaginal discharge.........................................................20</div>
</span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;"><div align="left">
Flow chart – Vaginal and speculum examination not possible .........................................................23</div>
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Flow chart – Vaginal and speculum examination possible ...............................................................24</div>
</span></span><span style="font-family: ArialMT;"><div align="left">
Management of Pelvic Inflammatory Disease........................................................25</div>
</span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;"><div align="left">
Flow chart – PID............................................................................................................................... 29</div>
</span></span><span style="font-family: ArialMT;"><div align="left">
Management of male urethral discharge or dysuria...............................................30</div>
</span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;"><div align="left">
Flow chart – male urethral discharge ................................................................................................ 32</div>
</span></span><span style="font-family: ArialMT;"><div align="left">
Management of epididymo-orchitis ........................................................................33</div>
</span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;"><div align="left">
Flow chart – epididymo-orchitis......................................................................................................... 36</div>
</span></span><span style="font-family: ArialMT;"><div align="left">
Management of genital ulcers................................................................................37</div>
</span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;"><div align="left">
Flow chart – genital ulcers................................................................................................................. 40</div>
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Flow chart – genital herpes ............................................................................................................... 41</div>
</span></span><span style="font-family: ArialMT;"><div align="left">
Management of genital warts.................................................................................42</div>
</span><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><span style="color: #4d4d4d; font-family: ArialMT; font-size: medium;"><div align="left">
Disease Specific Treatment</div>
</span></span></span><span style="font-family: ArialMT;"><div align="left">
Gonorrhoea ...........................................................................................................45</div>
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Chlamydia..............................................................................................................47</div>
</span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
4</div>
</span></span></span><span style="font-family: ArialMT;"><div align="left">
Trichomonasis .......................................................................................................48</div>
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Donovanosis..........................................................................................................49</div>
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Syphilis ..................................................................................................................50</div>
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Genital Herpes.......................................................................................................51</div>
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Bacterial vaginosis.................................................................................................52</div>
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Candidiasis ............................................................................................................53</div>
</span><span style="font-family: ArialMT; font-size: medium;"><span style="font-family: ArialMT; font-size: medium;"><div align="left">
Standard treatment protocols for sexually transmitted infections ...... 54</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
5</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Sexual history</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
At all times, ensure patient privacy, confidentiality and comfort. Be friendly and nonjudgemental</div>
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and ask open ended questions. The following checklist will help you cover all</div>
<div align="left">
the questions you should ask.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Presenting complaints</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Listen to the patient’s reason for attending. Follow-up with questions about their symptoms.</div>
<div align="left">
SYMPTOMS - ask about onset, duration and change over time.</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Urethral/vaginal/anal discharge - amount, colour, odour?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Abnormal vaginal or rectal bleeding?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Dysuria/urinary frequency?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
better or worse?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Lower abdominal pain - genital/anal, pain type, site of pain, what makes the pain</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Itch/discomfort in perineum, peri-anal, pubic region?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Genital lumps, sores?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Pain with defecation?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Dyspareunia?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Fever, enlarged lymph nodes?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Rashes - genital and elsewhere?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Sore throat?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any other symptoms?</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Sexual history</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Do they have a current regular sexual partner (or partners)?</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Is the partner male or female?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">How long have they been together?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Type of sexual contact - oral/vaginal/anal?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Do they use condoms - always/sometimes/never?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
likely to have had other partners recently, a man who has sex with other men, a sex</div>
<div align="left">
worker, an injecting drug user)?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Are they concerned about their current partner’s past or current risk (eg. is the partner</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
partner?</div>
<div align="left">
Have they had sexual intercourse with any casual partners in the past 3 months?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">When was the last unprotected (without a condom) sexual intercourse with this</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Type of sexual contact – oral/vaginal/anal?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Were condoms used?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Were any of these partners from outside the Top End or Central Australia (see p 14)?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
Have they had more than 1 sexual partner in the past 6 months?</div>
<div align="left">
Have they ever accepted money/favours for sex?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Were any of these partners injecting drug users or sex workers?</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
6</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Social history</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Do they drink alcohol? How much and how often?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Do they smoke?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any history of tattoos/piercing?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
ever shared equipment?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any history of current or past IV drug use, if so - when did they last inject, have they</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any blood transfusions - if so when (pre 1985 for HIV and pre 1990 for HCV)?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any needle stick injuries?</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Past medical history</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any previous sexually transmitted infections (STI) or similar symptoms?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any medical or surgical conditions?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
vaccinating all Aboriginal children against Hepatitis B at birth since 1988 and all</div>
<div align="left">
children since 1990)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Have they been vaccinated for Hepatitis B or A? (The NT has had a program of</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Medications/allergies</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Current medications prescribed - particularly antibiotics or creams?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any medications they have taken without prescription?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any known allergies?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Current contraception - any problems?</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Gynaecological history</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Date of last menstrual period?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Usual menstrual cycle - has this changed?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Pregnancies including terminations/miscarriages?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Complications in pregnancy?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Gynaecological procedures - past history?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Contraceptive history - any problems?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Abnormal vaginal bleeding?</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Pap smears - date of most recent pap, any abnormal pap smears?</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Pre-test information if testing for blood borne viruses</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Explain the nature of the test, and how confidentiality of test results will be assured.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Ensure client understands the concept of a ‘window period’.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Advise client that they should return in person for test results.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
what might it mean?</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Discuss social and cultural implications of a positive test - who they would tell and</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
7</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Education as part of a sexual health consultation</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
miscarriages in women.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Discuss how STIs are spread and the importance of treatment to prevent infertility and</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Discuss safe sex and the use of condoms.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Advise that if they have an STI, recent partners will need to be checked and treated.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Contact tracing</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
infection and miscarriages and infertility in women).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Explain the reasons partners need a check-up and treatment (to prevent repeat</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
know:</div>
<div align="left">
1. ask them to tell their partner/s to come to the clinic for a check-up and treatment;</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Explain how confidentiality will be maintained and methods of letting their partner/s</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
or</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
2. ask for the names of their partner/s and the clinic staff can follow them up, names of</div>
<div align="left">
contacts will never be recorded in the index case’s medical record and contacts </div>
<div align="left">
not </div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">are</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">told who named them.</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
8</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Sexual risk assessment</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
These guidelines are for all regions of the Northern Territory (NT). The prevalence of STIs</div>
<div align="left">
varies greatly within the NT and this will affect the likelihood that a person who has had</div>
<div align="left">
unprotected intercourse may have been exposed to an STI. Practitioners can seek advice</div>
<div align="left">
from their local Centre for Disease Control (CDC) about the prevalence of STIs in their area.</div>
<div align="left">
While these guidelines generally recommend a syndromic management approach, different</div>
<div align="left">
approaches are appropriate for people or groups with different risk status. As a result,</div>
<div align="left">
recommendations for treatment will vary. Some of the protocols in this publication suggest</div>
<div align="left">
making a risk assessment, identify criteria to do so and recommend treatment accordingly.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Remote Communities</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
People who live in and are sexually active in remote communities are at increased risk of</div>
<div align="left">
syphilis, gonorrhoea, chlamydia and trichomonas because of the very high rates of infection</div>
<div align="left">
in those communities. In general terms, communities in the western regions of Central</div>
<div align="left">
Australia have higher rates than other regions. However, there are also remote communities</div>
<div align="left">
where rates are lower.</div>
<div align="left">
People who live in urban settings but who have a sexual network connection to remote</div>
<div align="left">
communities are also at an increased risk of infection. That is, those people whose sexual</div>
<div align="left">
partners are connected to remote communities.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Age</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
There is international evidence that people in their mid to late teens and early adulthood</div>
<div align="left">
have higher rates of STIs than older people. As a generalisation, people will have a higher</div>
<div align="left">
STI risk if they are:</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">under 25 years with no sexual network connection to remote communities; or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">under 35 years with a sexual network connection to remote communities.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Sexual Partners</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The greater the number of sexual partners a person has, the higher their risk of contracting</div>
<div align="left">
an STI. People with higher numbers of sexual partners pose an increased risk of infecting</div>
<div align="left">
others. This is especially true if they have concurrent sexual partners: ie. they are having sex</div>
<div align="left">
with more than one person during the same time period.</div>
<div align="left">
There is evidence from international studies that for chlamydia infection in women, there is</div>
<div align="left">
an increased risk of infection if a woman has:</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">a new sexual partner in the past 3 months; or</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
This evidence suggests that there is a similarly increased level of risk for other STIs and for</div>
<div align="left">
people in the NT.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">more than 1 sexual partner in the past 6 months.</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
9</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Recent STI</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Evidence tells us that people who contract an STI are at greater risk of doing so again.</div>
<div align="left">
Various studies have measured this over periods of 3, 6 and 12 months. A person who has</div>
<div align="left">
had an STI in the past 12 months may be at increased risk of re-infection.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Alcohol and other substance use</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
There is a perception that excessive use of alcohol and other substances increases the risk</div>
<div align="left">
of STIs. There is evidence from Central Australia to support this. However, it is not the</div>
<div align="left">
substance use on its own that increases risk, but that people who are intoxicated become</div>
<div align="left">
disinhibited and are more likely to have sex (especially with someone who is not their usual</div>
<div align="left">
partner) and less likely to have safe sex, and therefore more likely to contract an STI.</div>
</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Regular partner’s behaviour</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
When assessing a person’s risk of an STI, their regular partner’s behaviour may be more</div>
<div align="left">
important than their own. This is particularly the case for women. It is relatively common for</div>
<div align="left">
women to be monogamous but for their husbands or boyfriends to have other sexual</div>
<div align="left">
partners. This would increase the woman’s risk of STI. Similarly, a sexual partner’s alcohol or</div>
<div align="left">
drug use may suggest an increased risk for the person.</div>
</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
10</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Male examination</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Ensure privacy and patient comfort throughout the examination.</div>
<div align="left">
Ensure good lighting and have underwear removed to allow adequate examination.</div>
<div align="left">
A sheet to cover the genital area should be used before and after examination for client</div>
<div align="left">
comfort. It is important the patient is informed about what the examination involves and</div>
<div align="left">
consents to the examination.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Start with a general examination of skin, abdomen, inguinal region then genital area.</div>
</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
General examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Skin - rashes, tattoos, fungal infections in flexures, skin creases.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Hands and feet - fungal infections, rashes.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
development.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Nails on hands and feet - candida or fungal infections or changes in nail</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Hair and eyebrows - hair loss, lice.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Lymph nodes - cervical, axilla, inguinal.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Mouth, teeth and throat - inflammation, ulcers, plaques, oral candida.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Temperature and pulse if febrile.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Abdominal examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
(always palpate gently).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Look for tenderness, masses, guarding, rebound tenderness, scars, bowel sounds</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Inguinal region</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Examine for lymph nodes - enlarged, tender, bilateral or unilateral, fluctuant.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Rashes - folliculitis, fungal infections.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Genital examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Pubic hair area - any skin lesions or signs of pubic lice.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
odour and consistency.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Penis and under the foreskin - note any discharge from the meatus and its colour,</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any lumps, rashes or ulcers eg. warts, molluscum, genital herpes, candida.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
(epididymitis).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Scrotum and testicles - any swelling, heat, tenderness - unilateral or bilateral</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
symptoms).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Examine the anal area for rashes, ulcers, lumps, discharge (+/-proctoscopy if anal</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Offer prostate examination in males over 45 years.</span></span><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><span style="color: #333333; font-family: ArialMT; font-size: small;"><div align="left">
SHBBVU Guidelines May 2008</div>
</span></span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
11</div>
</span></span></span><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><span style="color: grey; font-family: ArialMT; font-size: x-large;"><div align="left">
Female examination</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Ensure privacy and patient comfort throughout the examination.</div>
<div align="left">
Ensure good lighting and have underwear removed to allow adequate examination.</div>
<div align="left">
A sheet to cover the genital area should be used before and after examination for client</div>
<div align="left">
comfort. It is important the patient is informed about what the examination involves and</div>
<div align="left">
consents to the examination.</div>
</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Start with a general examination of skin, abdomen, inguinal region then genital area.</div>
</span></span><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
General examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Skin - rashes, tattoos, fungal infections in flexures/skin creases.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Hands and feet - fungal infections, rashes.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
development.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Nails on hands and feet - candida or fungal infections or changes in nail</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Hair and eyebrows - hair loss, lice.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Lymph nodes - cervical, axilla, inguinal.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Mouth, teeth and throat - inflammation, ulcers, plaques, oral candida</span></span><i><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;">.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Temperature and pulse if febrile.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Abdominal examination</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
(always palpate gently).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Look for tenderness, masses, guarding, rebound tenderness, scars, bowel sounds</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Inguinal region</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Examine for lymph nodes - enlarged, tender, bilateral or unilateral, fluctuant.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Rashes - folliculitis, fungal infections.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Breast examination - as required</div>
<div align="left">
External genital examination - vulva</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Pubic hair area - any skin lesions, warts, molluscum, scabies, pubic lice.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
redness, swelling, signs of itching, excoriation or scratch marks.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Gently open the labia and examine the labia majora and minora. Look for any vulval</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any signs of discharge - note its colour, odour and consistency.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Look for ulceration or splits in the skin - herpes, donovanosis, syphilis or trauma.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
plaques.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any lesions eg. warts, cysts, molluscum contagiosum, pigmented lesions, white</span></span><b><span style="font-family: Arial; font-size: small;"><span style="font-family: Arial; font-size: small;"><div align="left">
Higher rates of carcinoma of the vulva have been observed in the East Arnhem region</div>
<div align="left">
among Aboriginal women in recent years.</div>
</span></span><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><span style="color: #9a9a9a; font-family: ArialMT; font-size: x-large;"><div align="left">
12</div>
</span></span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Internal genital examination - vaginal speculum</div>
</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Insert speculum gently - usually best lubricated with warm water.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
smell, colour and consistency. Any warts, cysts, ulcers or signs of trauma.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Note the vaginal walls and check for inflammation, discharge - increased quantity,</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Note the cervix - shape, size, ectropion, inflammation, discharge, bleeding.</span></span><span style="font-family: SymbolMT; font-size: small;"><span style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Are there any warts, ulcers, polyps or cysts on the cervix.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Bimanual examination</div>
</span></span><span style="font-family: ArialMT;"><span style="font-family: ArialMT;"><div align="left">
<span style="font-size: small;">With one hand on the abdomen and 2 or 3 fingers of the other hand in the vagina, note any</span></div>
<div align="left">
<span style="font-size: small;">tenderness or pain when moving the cervix, feel the size and orientation of the uterus, for</span></div>
<div align="left">
<span style="font-size: small;">any masses in the adnexa (if any of these signs are present see PID protocol, p 25</span></div>
</span></span><i><span style="font-family: Arial;"><span style="font-family: Arial;"><span style="font-size: small;">)</span></span></span><span style="font-family: Times New Roman;"><span style="font-size: small;">.</span></span><b><span style="font-family: Arial; font-size: large;"><span style="font-family: Arial; font-size: large;"><div align="left">
Anal examination</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Examine the anal area for warts, lesions, ulcers, discharge or rashes (+/- proctoscopy if anal</div>
symptoms).</span></span></b></i></b></b></b></b></b></b></i></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></i></b></span></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-68698552944478120552012-02-03T13:11:00.000-08:002012-02-03T13:11:17.630-08:00CDC Fact Sheet: Meningitis<div dir="rtl" style="text-align: right;" trbidi="on">
<b><span style="font-family: TimesNewRoman,Bold; font-size: large;"><span style="font-family: TimesNewRoman,Bold; font-size: large;"> <div align="left">
CDC Fact Sheet: Meningitis</div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
What is meningitis?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Meningitis is an infection of the fluid of a person's spinal cord and the fluid that</div>
<div align="left">
surrounds the brain. People sometimes refer to it as spinal meningitis. Meningitis is</div>
<div align="left">
usually caused by a viral or bacterial infection. Knowing whether meningitis is caused by</div>
<div align="left">
a virus or bacterium is important because the severity of illness and the treatment differ.</div>
<div align="left">
Viral meningitis is generally less severe and resolves without specific treatment, while</div>
<div align="left">
bacterial meningitis can be quite severe and may result in brain damage, hearing loss, or</div>
<div align="left">
learning disability.</div>
<div align="left">
For bacterial meningitis, it is also important to know which type of bacteria is causing the</div>
<div align="left">
meningitis because antibiotics can prevent some types from spreading and infecting other</div>
<div align="left">
people. Before the 1990s, </div>
<div align="left">
bacterial meningitis, but new vaccines being given to all children as part of their routine</div>
<div align="left">
immunizations have reduced the occurrence of invasive disease due to </div>
<div align="left">
Today, </div>
<div align="left">
bacterial meningitis.</div>
</span><i><span style="font-family: TimesNewRoman,Italic;">Haemophilus influenzae </span><span style="font-family: TimesNewRoman;">type b (Hib) was the leading cause of</span><i><span style="font-family: TimesNewRoman,Italic;">H. influenzae</span><span style="font-family: TimesNewRoman;">.</span><i><span style="font-family: TimesNewRoman,Italic;">Streptococcus pneumoniae </span><span style="font-family: TimesNewRoman;">and </span><i><span style="font-family: TimesNewRoman,Italic;">Neisseria meningitidis </span><span style="font-family: TimesNewRoman;">are the leading causes of</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
What are the signs and symptoms of meningitis?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
High fever, headache, and stiff neck are common symptoms of meningitis in anyone over</div>
<div align="left">
the age of 2 years. These symptoms can develop over several hours, or they may take 1</div>
<div align="left">
to 2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright</div>
<div align="left">
lights, confusion, and sleepiness.</div>
<div align="left">
In newborns and small infants, the classic symptoms of fever, headache, and neck</div>
<div align="left">
stiffness may be absent or difficult to detect, and the infant may only appear slow or</div>
<div align="left">
inactive, or be irritable, have vomiting, or be feeding poorly. As the disease progresses,</div>
<div align="left">
patients of any age may have seizures.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
How is meningitis diagnosed?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Early diagnosis and treatment are very important. If symptoms occur, the patient should</div>
<div align="left">
see a doctor immediately. The diagnosis is usually made by growing bacteria from a</div>
<div align="left">
sample of spinal fluid. The spinal fluid is obtained by performing a spinal tap, in which a</div>
<div align="left">
needle is inserted into an area in the lower back where fluid in the spinal canal is readily</div>
<div align="left">
accessible.</div>
<div align="left">
Identification of the type of bacteria responsible is important for selection of correct</div>
<div align="left">
antibiotics.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
Can meningitis be treated?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Bacterial meningitis can be treated with a number of effective antibiotics. It is important,</div>
<div align="left">
however, that treatment be started early in the course of the disease. Appropriate</div>
</span><b><span style="font-family: TimesNewRoman,Bold; font-size: large;"><span style="font-family: TimesNewRoman,Bold; font-size: large;"><div align="left">
CDC Fact Sheet: Meningitis</div>
</span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
Page 2</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
antibiotic treatment of most common types of bacterial meningitis should reduce the risk</div>
<div align="left">
of dying from meningitis to below 15%, although the risk is higher among the elderly.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
Is meningitis contagious?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Yes, some forms are bacterial meningitis are contagious. The bacteria are spread through</div>
<div align="left">
the exchange of respiratory and throat secretions (i.e., coughing, kissing).</div>
<div align="left">
Fortunately, none of the bacteria that cause meningitis are as contagious as things like the</div>
<div align="left">
common cold or the flu, and they are not spread by casual contact or by simply breathing</div>
<div align="left">
the air where a person with meningitis has been.</div>
<div align="left">
However, sometimes the bacteria that cause meningitis have spread to other people who</div>
<div align="left">
have had close or prolonged contact with a patient with meningitis caused by </div>
<div align="left">
meningitidis </div>
<div align="left">
People in the same household or day-care center, or anyone with direct contact with a</div>
<div align="left">
patient's oral secretions (such as a boyfriend or girlfriend) would be considered at</div>
<div align="left">
increased risk of acquiring the infection. People who qualify as close contacts of a</div>
<div align="left">
person with meningitis caused by </div>
<div align="left">
them from getting the disease. Antibiotics for contacts of a person with Hib meningitis</div>
<div align="left">
disease are no longer recommended if all contacts 4 years of age or younger are fully</div>
<div align="left">
vaccinated against Hib disease (see below).</div>
</span><i><span style="font-family: TimesNewRoman,Italic;">Neisseria</span><span style="font-family: TimesNewRoman;">(also called meningococcal meningitis) or Hib.</span><i><span style="font-family: TimesNewRoman,Italic;">N. meningitidis </span><span style="font-family: TimesNewRoman;">should receive antibiotics to prevent</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
Are there vaccines against meningitis?</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Yes, there are vaccines against Hib and against some strains of </div>
<div align="left">
types of </div>
<div align="left">
effective.</div>
<div align="left">
There is also a vaccine that protects against four strains of </div>
<div align="left">
routinely used in the United States and is not effective in children under 18 months of</div>
<div align="left">
age. The vaccine against </div>
<div align="left">
types of meningococcal meningitis in the United States.</div>
<div align="left">
Meningitis cases should be reported to state or local health departments to assure followup</div>
<div align="left">
of close contacts and recognize outbreaks. Although large epidemics of</div>
<div align="left">
meningococcal meningitis do not occur in the United States, some countries experience</div>
<div align="left">
large, periodic epidemics.</div>
<div align="left">
Overseas travelers should check to see if meningococcal vaccine is recommended for</div>
<div align="left">
their destination. Travelers should receive the vaccine at least 1 week before departure, if</div>
<div align="left">
possible. Information on areas for which meningococcal vaccine is recommended can be</div>
<div align="left">
obtained by calling the Centers for Disease Control and Prevention at (404)-332-4565.</div>
<div align="left">
A vaccine to prevent meningitis due to </div>
<div align="left">
meningitis) can also prevent other forms of infection due to </div>
<div align="left">
pneumococcal vaccine is not effective in children under 2 years of age but is</div>
</span><i><span style="font-family: TimesNewRoman,Italic;">N. meningitidis </span><span style="font-family: TimesNewRoman;">and many</span><i><span style="font-family: TimesNewRoman,Italic;">Streptococcus pneumoniae</span><span style="font-family: TimesNewRoman;">. The vaccines against Hib are very safe and highly</span><i><span style="font-family: TimesNewRoman,Italic;">N. meningitidis</span><span style="font-family: TimesNewRoman;">, but it is not</span><i><span style="font-family: TimesNewRoman,Italic;">N. meningitidis </span><span style="font-family: TimesNewRoman;">is sometimes used to control outbreaks of some</span><i><span style="font-family: TimesNewRoman,Italic;">S. pneumoniae </span><span style="font-family: TimesNewRoman;">(also called pneumococcal</span><i><span style="font-family: TimesNewRoman,Italic;">S. pneumoniae</span><span style="font-family: TimesNewRoman;">. The</span><b><span style="font-family: TimesNewRoman,Bold; font-size: large;"><span style="font-family: TimesNewRoman,Bold; font-size: large;"><div align="left">
CDC Fact Sheet: Meningitis</div>
</span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
Page 3</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
recommended for all persons over 65 years of age and younger persons with certain</div>
<div align="left">
chronic medical problems.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
Update from October 20, 1999 Press Release:</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
The Advisory Committee on Immunization Practices (ACIP) has modified its guidelines</div>
<div align="left">
for use of the polysaccharide meningococcal vaccine to prevent bacterial meningitis,</div>
<div align="left">
particularly for college freshmen who live in dormitories, a group found to be at a</div>
<div align="left">
modestly increased risk of meningococcal disease relative to other persons their age.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
ACIP Modifies Recommendations for Meningitis Vaccination</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
The Advisory Committee on Immunization Practices (ACIP) has modified its guidelines</div>
<div align="left">
for use of the polysaccharide meningococcal vaccine to prevent bacterial meningitis,</div>
<div align="left">
particularly for college freshmen who live in dormitories, a group found to be at a</div>
<div align="left">
modestly increased risk of meningococcal disease relative to other persons their age.</div>
<div align="left">
At its October 20 meeting, the ACIP, citing results of two CDC studies done in 1998</div>
<div align="left">
which identified the slightly higher risk among freshman dormitory residents,</div>
<div align="left">
recommended that those who provide medical care to this group give information to</div>
<div align="left">
students and their parents about meningococcal disease and the benefits of vaccination.</div>
<div align="left">
Vaccination should be provided or made easily available to those freshmen who wish to</div>
<div align="left">
reduce their risk of disease. Other undergraduate students wishing to reduce their risk of</div>
<div align="left">
meningococcal disease can also choose to be vaccinated.</div>
<div align="left">
The currently available vaccine protects against some types (serogroups) of the bacterium</div>
</span><i><span style="font-family: TimesNewRoman,Italic;"><div align="left">
Neisseria meningitidis </div>
<div align="left">
meningitis and sepsis in children and young adults in the United States. A single dose of</div>
<div align="left">
the vaccine is recommended, and vaccination will decrease the risk of disease caused by</div>
</span><span style="font-family: TimesNewRoman;">(also called meningococcus), an important cause of bacterial</span><i><span style="font-family: TimesNewRoman,Italic;"><div align="left">
N. meningitidis </div>
<div align="left">
eliminate risk of the disease because the vaccine does not protect against serogroup B and</div>
<div align="left">
because, although it is highly effective against serogroups C and Y, it still does not confer</div>
<div align="left">
100% protection against these serogroups. In 1998-1999, serogroups C and Y caused</div>
<div align="left">
about 70% of cases among college students.</div>
<div align="left">
Approximately 3,000 cases of meningococcal disease occur each year in the United</div>
<div align="left">
States, and 10%-13% of patients die despite receiving antibiotics early in the illness. Of</div>
<div align="left">
those who survive, an additional 10% have severe aftereffects of the disease, including</div>
<div align="left">
mental retardation, hearing loss and loss of limbs.</div>
<div align="left">
On September 30, 1997, the American College Health Association (ACHA), which</div>
<div align="left">
represents about one-half of colleges with student health services in the United States,</div>
<div align="left">
released a statement recommending that "college health services [take] a more proactive</div>
<div align="left">
role in alerting students and their parents about the dangers of meningococcal disease"</div>
<div align="left">
and that "college students consider vaccination against potentially fatal meningococcal</div>
<div align="left">
disease.” In early 1998, CDC, in collaboration with the Council of State and Territorial</div>
<div align="left">
Epidemiologists (CSTE) and ACHA’s Vaccine Preventable Disease Task Force, initiated</div>
<div align="left">
two studies to better define the risk of meningococcal disease associated with college</div>
<div align="left">
campuses. Both studies indicated that freshmen college students, particularly those who</div>
</span><span style="font-family: TimesNewRoman;">serogroups A, C, Y, and W-135. However, vaccination will not totally</span><b><span style="font-family: TimesNewRoman,Bold; font-size: large;"><span style="font-family: TimesNewRoman,Bold; font-size: large;"><div align="left">
CDC Fact Sheet: Meningitis</div>
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Page 4</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
live in dormitories, constitute a group at a modestly increased risk for meningococcal</div>
<div align="left">
disease.</div>
<div align="left">
More information on meningococcal disease, its symptoms, and the vaccine is available</div>
<div align="left">
on the CDC website, </div>
College Health Association. </span><span style="color: blue; font-family: TimesNewRoman;"><span style="color: blue; font-family: TimesNewRoman;">http://www.cdc.gov/ncidod/dbmd/diseaseinfo </span></span><span style="font-family: TimesNewRoman;">and the American</span><span style="color: blue; font-family: TimesNewRoman;"><span style="color: blue; font-family: TimesNewRoman;">http://www.acha.org/special-prj/men/faq.htm</span></span></b></i></i></b></b></b></i></i></i></i></i></i></b></i></i></b></b></b></b></b></i></i></i></i></b></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com1tag:blogger.com,1999:blog-1250794412228211836.post-57880587265362424352012-02-03T13:09:00.001-08:002012-02-03T13:09:20.435-08:00Diagnosis is confirmed by microscopic examination of skin scrapings<div dir="rtl" style="text-align: right;" trbidi="on">
<span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"> <div align="left">
Diagnosis is confirmed by microscopic examination of skin scrapings.</div>
</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
8. Tinea circinata </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">presents with round fungal lesions on the face and leg with normal sensation.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
9. Pityriasis rosea </div>
<div align="left">
oval shaped lesions generally only on the trunk. Lesions are normally not itchy and sensation,</div>
<div align="left">
sweating and peripheral nerves are all normal.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">presents with an initial ‘herald lesion’ followed several weeks later by numerous</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
10. Seborrhoeic dermatitis </div>
<div align="left">
is normal and lesions are common on the trunk and may coalesce into larger patches.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">lesions are yellow coloured, itchy and show coarse scaling. Sensation</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
11. Annular psoriasis </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">is characterized by the presence of grey scaly figurate lesions that usually</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
exhibit a symmetrical distribution. There may be pustules or pitting of the nails.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
12. Lichen planus </div>
<div align="left">
lesions.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">presents with skin papules that may coalesce into larger patches or annular</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
13. Granuloma annulare </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">presents with round ring-like symptomless papules or nodules.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
14. Pityriasis alba </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">is a mild eczematous condition which leaves slightly scaling hypopigmented</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
macules with an ill-defined border. It can be difficult to distinguish from early leprosy disease.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
15. Discoid eczema </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">presents as discrete well-defined coin shaped patches of eczema on the skin.</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Usually the pattern of the lesions is symmetrical and they are very itchy.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
16. Fixed drug eruptions </div>
<div align="left">
are more erythematous and infiltrated. Lesions subside after the withdrawal of the causative</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">show well defined violaceous macules. In the active stage the lesions</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
drug and reappear rapidly at the same site with re-administration of the drug.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Less commonly occurring conditions</div>
</span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
1. Systemic lupus erythematosus (SLE) </div>
<div align="left">
lesions of lupus erythematosus discoides, necrobiosis lipoidica (check for hyperglycaemia) and</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">may be taken for leprosy. Ring-like skin and mucosal</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
of porphyria cutanea tarda (lesions chiefly on the hands and face, where exposed to the light)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
may pose diagnostic problems.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
2. Sarcoidosis </div>
<div align="left">
tuberculoid leprosy. They can be differentiated by absence of loss of sensation.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">may show annular lesions, some times polycyclic, which may closely resemble</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3. Neurofibromatosis (Von Recklinghausen’s disease) </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">has numerous café au lait patches that</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
may be confused with leprosy. In neurofibromatosis Type 1 all children have these patches</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
before 2 years old and 70% have freckles in the axillae. Nearly all also have hamartomas in the</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
iris (Lisch’s nodules) and develop neurofibromas. In Type 2 caféau lait patches rarely occur</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
and freckles are absent.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
4. Kaposi’s sarcoma lesions </div>
<div align="left">
and nodular. They can be found particularly in Aboriginal and African patients and mimic</div>
<div align="left">
lepromatous leprosy.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">are often found on the foot or leg. Lesions are shiny, violaceous</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
5. Lupus vulgaris </div>
<div align="left">
plaques. Typically lupus vulgaris lesions are accompanied with ulceration and scarring.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(skin tuberculosis) shows brown-yellowish nodules that may coalesce into</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
6. Syphilis </div>
<div align="left">
often have a false positive VDRL screening test for syphilis.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">infection may lead to a residual light coloured skin lesion. People with leprosy may</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
7. Diffuse cutaneous leishmaniasis </div>
<div align="left">
considered in immigrants from or travelers to regions with endemic leishmaniasis. In dermal</div>
<div align="left">
leishmaniasis however, eyebrows are not affected.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">may closely mimic lepromatous leprosy and should be</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
8. Lymphoma </div>
<div align="left">
Causes of neuropathy should also be considered in those patients presenting with a peripheral</div>
<div align="left">
neuropathy. If assessment demonstrates diminished temperature and pain sensation, while sparing</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">may present with shiny nodular skin lesions. It occurs more commonly in males.</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">24</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
vibration, position sense and deep tendon reflexes, which is very unusual, </div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">primary amyloidosis</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
and </div>
<div align="left">
muscle wasting of the hand should also warrant the exclusion of leprosy as a diagnosis.</div>
<div align="left">
Of note, 2 conditions may co-exist, especially in tropical climates such as the NT. In particular</div>
<div align="left">
leprosy and fungal lesions may have a similar appearance, and can often occur together, especially</div>
<div align="left">
in tropical climates. If there is any doubt about the diagnosis a trial of antifungal treatment such</div>
<div align="left">
as selenium sulphide (Selsun) for tinea versicolor or miconazole for tinea corporis should be</div>
<div align="left">
commenced. The patient can be reviewed after 2 months of therapy to assess the response.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">syringomyelia </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">should be considered. Cases of peripheral neuropathy such as foot drop or</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Treatment</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
MDT is the standard for the treatment of leprosy worldwide and was first introduced in 1982.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Research demonstrates that it is the key to achieving cure in the individual, reducing the rates of</div>
<div align="left">
drug resistance and breaking the cycle of transmission. Recommended regimens for treatment have</div>
<div align="left">
been based on those recommended in the WHO </div>
<div align="left">
the Disease Burden Due to Leprosy </div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">Enhanced Global Strategy for further Reducing</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(2011-2015)</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">5 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">but have included a 24 month treatment option</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
for cases with a high bacillary index. Consideration should be taken of the drug profiles (Appendix</div>
<div align="left">
4). It is recommended that if the classification of a case is in doubt, or the skin smear is positive,</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
that the patient be treated as having MB leprosy.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
NT CDC leprosy treatment recommendations</div>
</span><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Paucibacillary leprosy (PB)</div>
</span><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;"><div align="left">
NT CDC recommended treatment for those 15 years and above (Table 10)</div>
<div align="left">
1. Dapsone 100mg daily (self administered) plus rifampicin 600mg monthly for 6 months for all</div>
<div align="left">
types of paucibacillary (PB) leprosy including single lesion paucibacillary (SLPB) leprosy.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">:</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Single dose rifampicin, ofloxacin and minocycline (ROM) has been used in India, Bangladesh and</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Brasil for PB leprosy, however a recent WHO sponsored Indian study</div>
<div align="left">
similar success rates in the complete clearance of PB leprosy, relapse rates over a 54 month</div>
<div align="left">
period were more than 2 times higher among patients treated with ROM as compared to WHO</div>
<div align="left">
PB standard MDT for those with 2 to 5 lesions. Therefore 6 months of PB treatment should be</div>
<div align="left">
given for all PB leprosy (Table 10).</div>
<div align="left">
Even for SLPB it is recommended that 6 months PB treatment be given as this is felt to be more</div>
<div align="left">
likely to achieve the highest and sustained cure rate.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">21 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">demonstrated that despite</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">22</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Single once-off treatment with ROM for SLPB would be considered in the NT only in very isolated</div>
<div align="left">
locations where follow-up is deemed absolutely not possible or a patient is defaulting such that</div>
<div align="left">
continued follow-up and treatment became impossible.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">25</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 10. NT first line MDT regimen with adult (≥15 years old) doses</div>
</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
PB including SLPB MB – Low BI <4+ </div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;">MB – High BI ≥4+</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Duration </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">6 months 12 months 24 months</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Dapsone </div>
<div align="left">
100mg daily selfadministered</div>
<div align="left">
100mg daily selfadministered</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">100mg daily selfadministered</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Rifampicin </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">600mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">600mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">600mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Clofazimine </div>
<div align="left">
50mg daily selfadministered</div>
<div align="left">
plus</div>
<div align="left">
300mg monthly* DOT</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">-</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
50mg daily self-administered</div>
<div align="left">
plus</div>
<div align="left">
300mg monthly* DOT</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
* </div>
<div align="left">
remember (on the same day of the week throughout the course)</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">In practice, 4-weekly dosing and review may be easier to implement for the health service and easier for the patient to</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
# </div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">DOT, directly observed treatment, means dose ingestion is observed and recorded by a health worker</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Multibacillary leprosy (MB)</div>
</span><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;"><div align="left">
NT CDC recommended treatment for those 15 years and above (Table 10):</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
1. Those with high BI should be treated for 24 months or until smear negative.</div>
<div align="left">
2. Low BI (<4+) MB leprosy patients should be adequately treated with 12 months treatment but</div>
<div align="left">
still require vigilant follow-up.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
3. High BI (≥4+) MB leprosy patients should have treatment for at least 24 months until there is</div>
<div align="left">
more conclusive evidence of efficacy with the 12 month regimen.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Although the WHO currently recommends 12 months of treatment for all MB leprosy, the NT</div>
<div align="left">
recommendation for the present includes continuation for 24 months treatment for MB patients</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
with a BI of ≥4+. This is due to 90% of relapses being in MB patients with a BI of 4+ or greater</div>
<div align="left">
there being no long term relapse data available to support limiting MDT treatment to 12 months.</div>
<div align="left">
It should be noted also that patients with smears that remain positive following recommended</div>
<div align="left">
treatment have a higher leprosy relapse rate.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">23 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">and</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Ongoing leprosy treatment studies</div>
</span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
A study in Brazil of the initial and the final BI of MB patients receiving either 12 or 24 months of</div>
<div align="left">
WHO MDT followed patients for 2 years and showed no significant difference in decline in the BI in</div>
<div align="left">
high and low BI groups and no significant difference in the frequency of reactions. The study was</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
however unable to evaluate the relapse occurrence and is due to continue follow-up for a further 5</div>
<div align="left">
years.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">24</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
There are well-documented reports of persistence of disease or relapses even after 24 months of</div>
<div align="left">
treatment. Although most MB patients become smear negative after 24 months of treatment, some</div>
<div align="left">
high BI cases can take 5 to 6 years to become smear negative. Due to most relapses occurring 5</div>
<div align="left">
years post-treatment cessation, intensive surveillance, including of nerve impairment, is probably</div>
<div align="left">
required for 8 to 10 years to detect relapses in high bacterial load cases.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">23</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">26</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Special case considerations</div>
</span><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Treatment of children with leprosy</div>
</span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
The WHO recommends fixed doses for children from 10-14 years. These doses are also</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
recommended for use in the NT in consultation with appropriate specialists (Table 11).</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 11. WHO and NT recommended doses for 10-14 year old children</div>
<div align="left">
PB including SLPB MB - Low BI <4+ </div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;">MB - High BI ≥4+</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Duration </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">6 months 12 months 24 months</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Dapsone </div>
<div align="left">
50mg daily selfadministered</div>
<div align="left">
50mg daily selfadministered</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">50mg daily selfadministered</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Rifampicin </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">450mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">450mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">450mg monthly* DOT</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Clofazimine </div>
<div align="left">
50mg daily selfadministered</div>
<div align="left">
150mg monthly* DOT</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">-</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
50mg daily selfadministered</div>
<div align="left">
150mg monthly* DOT</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* In practice, 4-weekly dosing and review may be easier to implement for the health service and easier for the patient to</div>
<div align="left">
remember (on the same day of the week throughout the course)</div>
</span></span><span style="font-family: LucidaSansUnicode; font-size: xx-small;"><span style="font-family: LucidaSansUnicode; font-size: xx-small;"><div align="left">
# </div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">DOT, directly observed treatment, means dose ingestion is observed and recorded by a health worker</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Children, especially those under the age of 10 years, should with the assistance of expert specialist</div>
<div align="left">
advice, receive proportionately reduced doses of the above drugs to minimize adverse drug</div>
<div align="left">
reactions. Clofazimine is available only in a 50mg capsule formulation and smaller calculated daily</div>
<div align="left">
doses may be given for example as 50mg on alternate days, or 50mg twice a week.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Pregnancy</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Leprosy is exacerbated during pregnancy and therefore continuation of patients on standard MDT is</div>
<div align="left">
essential. Precaution should be taken with regard to breast-feeding as the medications are excreted</div>
<div align="left">
in breast milk. There are however, no reports of any adverse effects except for mild-discoloration</div>
<div align="left">
of the infant due to clofazimine.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Co-existent leprosy with active TB disease</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Screening for leprosy should be considered in all cases of active TB infection. Patients diagnosed</div>
<div align="left">
with both leprosy and TB require both full TB and leprosy treatment (see </div>
<div align="left">
of Tuberculosis in the Northern Territory</div>
<div align="left">
regimens and should be given in the dose required to treat TB. Second-line regimens for leprosy</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">Guidelines for the Control</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">, 2008).</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">25 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Currently only rifampicin is common to both</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
that contain minocycline or ofloxacin may be necessary if there are severe side-effects caused by</div>
<div align="left">
a drug in the first-line regimens. Information about all drugs used is provided in Appendix 4.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Co-existent leprosy with latent tuberculosis infection (LTBI)</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Leprosy treatment should be the priority however if LTBI is present and active TB is excluded then</div>
<div align="left">
LTBI can be opportunistically treated. Treatment completed with a MDT leprosy regimen containing</div>
<div align="left">
rifampicin daily for at least 4 months will prophylactically treat LTBI avoiding the requirement for</div>
<div align="left">
isoniazid treatment.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">27</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Co-existent infection with human immunodeficiency virus (HIV)</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The concern that HIV infection would increase susceptibility to leprosy has not been realised and</div>
<div align="left">
evidence suggests it does not alter the clinical features of leprosy. Patients may have co-infection</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
with leprosy and HIV and current evidence suggests that no modification is required of the standard</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
MDT for leprosy or the antiretroviral regimen for HIV management. Care of the patient should be by</div>
<div align="left">
specialists familiar with both diseases.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Unable or refusal to take rifampicin (adult)</div>
</span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
PB leprosy: </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">a 6 month regimen consisting of daily administration of:</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• 50mg clofazimine; together with 2 of the following drugs –</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">400mg ofloxacin, 100mg minocycline OR 500mg clarithromycin.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
MB leprosy: </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">the above regimen followed by daily administration of</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• 50mg clofazimine; together with</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">100mg minocycline OR 400mg ofloxacin.</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
All taken for an additional 18 months or until smear negative.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Unable or refusal to take clofazimine (adult)</div>
</span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
MB leprosy: </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">clofazimine can be replaced by ofloxacin 400mg daily or by minocycline 100mg</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
daily.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Unable or refusal to take dapsone (adult)</div>
</span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
PB leprosy: </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">clofazimine 50mg daily should be substituted for dapsone.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
MB leprosy: </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">No further modification of the regimen is required.</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Defaulters</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Leprosy treatment defaulters represent a challenge to manage due to the requirement for many</div>
<div align="left">
months of treatment and for extended time period follow-up. Usage of the above treatment regimens</div>
<div align="left">
can be considered where refusal is of certain regimen medications.</div>
<div align="left">
Single dose ROM treatment in SLPB cases may be considered in persistent defaulters.</div>
<div align="left">
defaulter PB cases (non SLPB) single dose ROM treatment may be considered but is not ideal. For</div>
<div align="left">
MB cases every effort should be made to treat and follow-up the patient according to the treatment</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">21 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">In extreme</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
guidelines due to significant concerns regarding long-term relapses.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Treatment plan considerations</div>
</span><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Pre-treatment investigations</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
1. FBE, UEC, LFT, hepatitis B and C and HIV serology</div>
<div align="left">
2. G6PD</div>
<div align="left">
3. Mantoux and CXR to exclude co-existent TB or LTBI (see p26).</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">28</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Follow-up consultations</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
1. Ophthalmology review</div>
<div align="left">
2. Photography of skin lesions (with consent)</div>
<div align="left">
3. Document BI of skin smears/biopsies</div>
<div align="left">
4. Discuss importance of medication adherence and the planned regimen</div>
<div align="left">
5. Discuss drug side-effects and when to report to medical staff</div>
<div align="left">
6. Discuss the need to seek medical advice about deteriorating nerve function</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Case Holding</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Medication should initially be dispensed weekly until full adherence with and understanding of the</div>
<div align="left">
regimen is assured, and then a 4-weekly cycle of DOT and examination is established. Failure</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
to attend a single 4-weekly DOT requires an immediate effort to trace the patient and find an</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
explanation.</div>
<div align="left">
Sometimes this situation arises because the patient is ill at home with a leprosy reaction, a drug</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
side effect, or intercurrent illness. The patient who suffers a leprosy reaction may lose confidence</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
in the treatment regimen unless it is carefully explained beforehand that this might occur, and does</div>
<div align="left">
not imply bacteriological worsening of the illness or failure of treatment.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
For each case a local member of the health staff should be identified to accept responsibility for</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
providing medication, assessing adherence, monitoring nerve function, and tracing absentees - all</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
on a 4-weekly basis. Review should occur 3-monthly by a local medical officer, and 6-monthly by</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
TB/leprosy unit staff.</div>
<div align="left">
Adherence should be documented on the leprosy treatment card (see Appendix 5).</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Completed Treatment</div>
</span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Completed treatment for a cure is defined as:</div>
<div align="left">
•</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">• </span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;">MB leprosy (BI ≥4+) </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">- 24 months of doses (or 24 x 4-weekly cycles) within 36 months.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">• </span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;">MB leprosy (BI <4+) </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">- 12 months of doses (or 12 x 4-weekly cycles) within 18 months.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
<div align="left">
Those who do not adequately complete treatment need to be fully re-evaluated. Re-treatment</div>
<div align="left">
regimens will depend on clinical and bacteriological examination.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">• PB leprosy </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">– 6 months of doses (or 6 x 4-weekly cycles) within 9 months.</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Prevention</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The 2003 WHO ‘Final Push’ strategy for leprosy aimed to eliminate the disease as a condition of</div>
<div align="left">
public health importance worldwide. Prevention is also an essential aspect in the NT in particular in</div>
<div align="left">
moving towards disease elimination.</div>
<div align="left">
The strategy aims at preventing exposure to the disease. It can be approached through improving</div>
<div align="left">
education of health staff, environmental factors and by immunoprophylaxis of babies with BCG.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">29</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Health education</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Health staff need to be aware of the population of people who are at greatest risk of leprosy. This</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
includes the Aboriginal and migrant populations and specifically family and household contacts of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
active cases of leprosy.</div>
<div align="left">
In addition, ongoing provision and updating of knowledge to health staff is needed to enable them</div>
<div align="left">
to diagnose patients with leprosy, provide ongoing care and management of patients and to form a</div>
<div align="left">
working relationship with the TB/Leprosy Unit.</div>
<div align="left">
This should be achieved through:</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• The health worker curriculum</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Orientation of health and allied health staff</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Ongoing education sessions for health staff in the NT</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Environmental factors</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Leprosy has long been considered a ‘disease of poverty’ however there is little evidence confirming</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
the precise mechanisms through which poverty exerts its effects. One study from Malawi, showed</div>
<div align="left">
persons living in the worst standard of housing had double the risk of leprosy compared to those</div>
<div align="left">
living in the best category of dwelling.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">14</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Other diseases with respiratory transmission such as TB are associated with overcrowding and</div>
<div align="left">
overcrowding probably also increases the risk of acquiring leprosy. Advocacy to improve housing</div>
<div align="left">
quality, ventilation, water supply, and nutrition and to alleviate overcrowding, particularly in pockets</div>
<div align="left">
of relatively high incidence is considered vital for leprosy control.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Immunoprophylaxis</div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT;"><div align="left">
Bacille Calmette-Guérin (BCG) vaccine at birth</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
BCG vaccine has been widely used in the NT since 1960 and more than 90% of Aboriginal people</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
have been vaccinated. International trials have demonstrated a protective efficacy of BCG of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
between 20% and 80%,</div>
<div align="left">
for TB) control strategy in the NT. The entire </div>
<div align="left">
vaccine trials have shown promise.</div>
<div align="left">
While a recent meta-analysis of 26 studies using BCG for control of leprosy</div>
<div align="left">
vaccination may enhance protection against leprosy, repeat BCG is not recommended in the NT.</div>
<div align="left">
The protection conferred by BCG appears greatest if the vaccine is administered before 15 years</div>
<div align="left">
of age. BCG offers greater protection against MB than PB leprosy.</div>
<div align="left">
The current policy in the NT is that BCG is recommended at birth for:</div>
<div align="left">
1. All Aboriginal neonates.</div>
<div align="left">
2. Non-Aboriginal neonates who will live in Aboriginal communities or in countries for more than 3</div>
<div align="left">
months with a high prevalence of tuberculosis.</div>
<div align="left">
3. Non-Aboriginal neonates born to mothers who have been treated for leprosy.</div>
<div align="left">
No booster is currently recommended.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">26,27 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">and it is a recommended leprosy (and in certain population age groups</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">M. leprae </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">genome has been sequenced and new</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">28 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">supports that repeated</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">30</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
High risk group screening</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Opportunistic screening for leprosy by primary health care staff should be undertaken whenever</div>
<div align="left">
those people in high-risk groups present for medical care or examination.</div>
<div align="left">
The main high risk groups are Aboriginal and migrant populations. These populations are also the</div>
<div align="left">
high-risk groups for TB, so leprosy screening should be considered whenever screening for TB.</div>
<div align="left">
This includes:</div>
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1. TB school screening of 10 year olds (which targets migrant and Aboriginal children);</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
2. review of asylum seekers, newly resettled humanitarian migrants and detained fisherman;</div>
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3. review of patients on Immigration Department TB Health Undertakings (TBUs); and</div>
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4. community TB screening programmes.</div>
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Screening should include a full examination of the skin, including eyebrows, nerve examination</div>
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including an abnormalities in extremities due to denervation.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Contact tracing</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Of all new leprosy cases in highly or moderately endemic areas, only around 30% have a history of</div>
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having been a household contact of a previous case.</div>
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where leprosy is now rare and there is a delay in presentation, as in the NT. One study has shown</div>
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that 95% of secondary cases occurred within 6 years of the diagnosis of the primary cases.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">14 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">This percentage is likely to be much higher</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">14</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
There are few health staff who have much experience with leprosy, so most need to be trained in</div>
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detecting the early signs and symptoms of leprosy. Patients who are suspected of having leprosy</div>
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should be reviewed by the most experienced local staff who will in turn liaise with the CDC TB/</div>
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Leprosy Unit.</div>
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How to go about leprosy screening</div>
</span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">Household, family, and close social contacts should be identified and examined for signs of</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
leprosy. Those at highest risk of disease are shared-bedroom contacts, and children who share</div>
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the household with the index case.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Results should be documented in the local records, and the central leprosy database.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• New cases should be referred to the TB/leprosy Unit.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
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(Table 12).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Contacts of MB cases need to be reviewed annually with a clinical examination for 6 years</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
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to exclude disease, provided advice about symptoms and signs and a search for a source of</div>
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infection for the diagnosed PB case should be carried out.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Contacts of PB cases are at lower risk of developing disease. They should be examined once</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">31</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 12. Follow-up of contacts of leprosy cases</div>
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Classification of the index </div>
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Years of annual CDC followup</div>
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after index diagnosis </div>
</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">PB – Including SLPB MB</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">0* 6</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Type of follow-up </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Skin and nerve examination</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Skin and nerve examination</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* Discharge if initial examination is negative</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
# </div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">Perform VMT-ST or skin smear only if indicated by skin and nerve examination</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Future prevention considerations</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;"><div align="left">
M. leprae </div>
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leprosy patients of developing disease varies according to the ‘closeness’ of the contact (bedroom,</div>
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household, neighbour, social), the type of index case (MB/PB) and the contact age.</div>
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In Malawi, being a household contact with a recent or past </div>
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increased risk of developing leprosy when compared with the general population.</div>
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48% slept in the same room, and their risk was 8-fold that of the non-contact individuals. However,</div>
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children aged between 5 and 9 years who shared a bedroom with an MB case had 37 times the</div>
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risk compared with children of the same age without contact with a MB case. For household and</div>
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bedroom contacts of </div>
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household contacts of MB cases, particularly children and those who have shared a bedroom with</div>
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the index case are the highest priority for followup and future consideration of prophylaxis.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">transmission is considered to be via nasal secretions or skin. The risk to contacts of</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">MB </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">case was associated with a 5-fold</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">14 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Of these contacts</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">PB </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">cases, the risk was 2 times as high as the non-contact group. Thus</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Chemoprophylaxis</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Medication given before the onset of disease to persons exposed to </div>
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A meta-analysis of 14 historic trials demonstrated that preventive treatment (using dapsone in 13</div>
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and rifampicin in 1) provided 60% protection against leprosy.</div>
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2 more recent studies using rifampicin as chemoprophylaxis.</div>
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The epidemiological study on contact transmission and chemoprophylaxis in leprosy (COLEP) has</div>
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looked at 21,000 contacts of 1037 newly diagnosed leprosy patients in Bangladesh between 2001</div>
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and 2007.</div>
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either a single dose of rifampicin or placebo.</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">M. leprae </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">may prevent disease.</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">29 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Variable results have been shown in</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">30 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Contacts were divided into groups ie. close and distant contacts and were each given</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
The most recent findings show that the reduction in incidence after 2 years by a single dose of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
rifampicin was 57%, and the protection was strongest among less high-risk contacts. The number</div>
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needed to treat to prevent a single case of leprosy among contacts was 265.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">31</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The Koninklijk Instituut voor de Tropen/Royal Tropical Institute (KIT) study</div>
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study carried out on 5 Indonesian islands with endemic leprosy between 2000 and 2003. There</div>
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were 3 distinct groups:</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">32 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">was an intervention</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
1. Control group </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">– no treatment</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
2. Contact group </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">– rifampicin given to contacts of leprosy patients</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3. Blanket group </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">– rifampicin given to all persons.</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">32</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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In total there were 3965 patients in the study and the yearly control incidence rate overall was 39</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
per 10,000. The cumulative incidence at 3 years was significantly lower in the blanket group where</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
everyone was given rifampicin. There was however no difference in incidence between the group</div>
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who had no treatment and the contact group who were given rifampicin. At 3 years further follow-up</div>
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(2003-2006), there was no difference between the 3 groups in terms of incidence.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">32</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Further studies need to the carried out with longer follow-up periods to ascertain the overall benefit</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
of rifampicin chemprophylaxis, but the evidence at this stage is not strong enough to recommend</div>
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rifampicin as chemoprophylaxis for leprosy contacts.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">33</span></span><b><span style="font-family: Arial-BoldMT; font-size: large;"><span style="font-family: Arial-BoldMT; font-size: large;"><div align="left">
Part 2. Nerve function impairment and lepra reactions</div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: medium;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Classification of nerve function impairment (NFI)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Nerve function impairment (</div>
</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;">NFI) is a clinically detectable loss of motor, sensory, or autonomic</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
peripheral nerve function. </div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">Mycobacterium leprae </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">is the only bacterial agent known to specifically</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
infect peripheral nerves. It is the resulting nerve function impairment (NFI) and associated deformities</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
and disability that has made leprosy such a feared disease. In field cohort studies 33-56% of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
newly diagnosed patients have nerve damage</div>
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developed nerve damage during treatment.</div>
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silent neuropathy and Type 1 and Type 2 reactions.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">33,34,35 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">and in a Bangladeshi study 25% of MB patients</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">36,37 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">The main processes associated with NFI include</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Silent neuropathy</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
NFI may occur in association with symptoms of neuritis (point pain and tenderness in nerve trunks,</div>
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or distal pain, hyperaesthesia and tingling in the sensory areas supplied by the nerve) or it may</div>
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occur insidiously without symptoms (termed ‘silent’ neuropathy). </div>
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of nerve function without any nerve pain, nerve tenderness, or symptoms of reaction. </div>
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to 86% of all NFI occurs silently,</div>
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by voluntary muscle testing - sensory testing (VMT-ST) whether or not the patient complains of</div>
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symptoms. When the directly observed component of MDT is administered monthly (or 4-weekly)</div>
<div align="left">
by a health worker, such an assessment should be performed.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">Silent neuropathy is impairment</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Up</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">37,38 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">which mandates regular testing of motor and sensory function</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Lepra reactions</div>
</span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Lepra reactions are immunologically mediated episodes of acute or subacute inflammation and</div>
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are classified as either Type 1 (reversal) reactions or Type 2 (erythema nodosum leprosum (ENL))</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
reactions (Table 11). They occur more commonly in MB leprosy than PB leprosy patients and in</div>
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patients who present initially with NFI.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">39</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Type 1 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(reversal or upgrading) reactions are a delayed hypersensitivity response to </span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">M. leprae</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
antigens occurring in borderline lepromatous (BL), borderline (BB) or borderline tuberculoid (BT)</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
cases. They are characterised by acute neuritis and/or acutely inflamed skin lesions. Usually with</div>
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onset there is an associated change in Ridley-Jopling classification towards the tuberculoid end of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
the spectrum. There is nerve tenderness with loss of sensory and motor functions. Redness and</div>
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swelling in pre-existing skin lesions occurs, and lesions which have not been visible may appear.</div>
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Fever, malaise and peripheral oedema are additional features if the reaction is severe. Onset may</div>
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be spontaneous though it is commonest after starting treatment.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Type 2 </div>
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that develops due to an imbalance of the humoral immune system. They are the most serious</div>
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complication of leprosy and occur in about 15% of patients with multibacillary disease (LL and</div>
<div align="left">
BL).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(erythema nodosum leprosum or ENL) reactions are an immune complex response</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">39 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Reactions may occur spontaneously or while on treatment. There is a sudden appearance</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
of superficial or deep crops of new, tender, subcutaneous nodules on the back, the dorsum of the</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
hands or the extensor aspects of the forearms and thighs that generally last for about 3 days. The</div>
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whole episode usually lasts 2 weeks though may be prolonged or recurrent over several years.</div>
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ENL is commonly associated with systemic systems including:</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• High fever peaking in the evenings</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Neuritis</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Leucocytosis</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">34</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Orchitis</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Nephritis</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
<div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">Periostitis including joint inflammation</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">Iridocyclitis (eye inflammation)</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Type 1 and Type 2 reactions may coexist in a case of BL. The introduction of WHO-MB-MDT has</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
seen a reduction in the frequency and severity of ENL due to the anti-inflammatory effect of the</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
clofazimine component.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 13. Comparison of the features of Type 1 and Type 2 reactions</div>
<div align="left">
Type 1 Type 2</div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Classification </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">BT, BB, BL LL (occasionally BL, BB)</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Immunology </div>
<div align="left">
immunity</div>
<div align="left">
Immune-complex deposition, elevated</div>
<div align="left">
TNF-alpha levels, dysfunctional cell</div>
<div align="left">
mediated immunity</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Changing cell mediated</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Classification change </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Upgrading (usually) toward TT No change</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Timing </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">First months of MDT May be years after treatment</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Recurrent </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Usually not Often</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Duration </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Several months 2 weeks</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Sites of inflammation </div>
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soles, lymph nodes</div>
<div align="left">
The differential diagnosis of the skin lesions of Type 1 or Type 2 reactions is active leprosy (Table</div>
<div align="left">
14). In the context of drug resistance, leprosy may progress with the appearance of new lesions</div>
<div align="left">
despite MDT. Also, following the completion of treatment and apparent cure, new leprosy lesions</div>
<div align="left">
can be associated with a relapse (see p 46).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Nerves, skin lesions Skin nodules, iris, testes, joints, nerves,</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">35</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 14. Comparison of the features of new leprosy nodules and Type 2 reactions</div>
<div align="left">
New leprosy nodules Type 2 reaction</div>
<div align="left">
Onset </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Gradual Sudden</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Number </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1 at a time Nodules appear in crops</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Tenderness </div>
</span></span><span style="font-family: ArialMT; font-size: medium;"><span style="font-family: ArialMT; font-size: medium;">- +</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Bacterial Index </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">High in the nodule High or low</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
SFG reading* </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Often solids Mainly granules</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Resolution </div>
<div align="left">
weeks, with or without treatment</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">After months of MDT Successive waves of nodules subside after 2</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* SFG, Solid-Fragmented-Granular reading - the proportions of solid, fragmented or granular appearing AFB in a skin smear. ‘Solids’ are</div>
<div align="left">
presumed to be viable bacilli; ‘Fragmented’ and ‘Granular’ are recently and remotely dead, respectively.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Disability grading</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
NFI and its secondary consequences are described in a ‘disability grading’ (0, 1, or 2) for the</div>
<div align="left">
purposes of reporting to WHO, and for monitoring program objectives. The highest value for any</div>
<div align="left">
body part is taken as the overall disability grading for the patient; eg. if hands, feet, and left eye are</div>
<div align="left">
graded 0, but the right eye is graded 2, then the overall grading for the patient is 2. It is sometimes</div>
<div align="left">
expressed as an Eye-Hand-Foot (EHF) score where each hand, foot, and eye is graded 0, 1 or 2,</div>
<div align="left">
and these grades are summed bilaterally for a maximum score of 12.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 15. WHO grading of leprosy related disability</div>
</span></span><span style="font-family: Arial-BoldMT; font-size: xx-small;"><span style="font-family: Arial-BoldMT; font-size: xx-small;">1</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Grading* </div>
<div align="left">
0 </div>
<div align="left">
deformity or damage</div>
<div align="left">
No eye problems due to leprosy; no evidence of</div>
<div align="left">
visual loss</div>
</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">Hands and Feet Eyes</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">No anaesthesia, no visible</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
1 </div>
<div align="left">
visible deformity or damage</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Anaesthesia present, but no</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
2 </div>
<div align="left">
present</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Visible deformity or damage</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Severe visual impairment (visual acuity worse</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
than 6/60; unable to count fingers at 6 metres)</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
or lagophthalmos or iridocyclitis or corneal</div>
<div align="left">
opacities</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* The highest value of the leprosy disability grade for any part is taken as the overall disability grading of the patient</div>
<div align="left">
# Includes muscle weakness</div>
<div align="left">
† Includes ulceration, shortening, disorganisation, stiffness, loss of part or all of the hand or foot</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">36</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
However, disability grades or hand, foot, eye (HFE) scores are not sensitive enough to be useful</div>
<div align="left">
in monitoring the progress of subtle impairment in an </div>
<div align="left">
is required (Appendices 1 and 2), and together with the indications for prednisolone and other</div>
<div align="left">
therapies, decisions about the requirement for prednisolone therapy can be made.</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">individual </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">patient. For this purpose the VMTST</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Detection of neuropathy</div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT;"><div align="left">
Nerve conduction studies (NCS)</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Advanced neuropathy is already present before signs and symptoms of NFI appear. Nerve</div>
<div align="left">
conduction studies are able to detect this neuropathy before it is clinically apparent. This is a time</div>
<div align="left">
consuming and uncomfortable procedure and should only be requested in consultation with the TB/</div>
<div align="left">
Leprosy Unit.</div>
<div align="left">
The indications are:</div>
<div align="left">
1. To assist (where necessary) in the diagnosis of a suspected leprosy case.</div>
<div align="left">
2. As soon as possible after diagnosis to establish a baseline assessment of the extent and</div>
<div align="left">
severity of nerve damage.</div>
<div align="left">
3. Ideally at yearly intervals while taking MDT.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
4. When new symptoms of neuritis, or findings of NFI - appear after MDT completion.</div>
</span></span><b><span lang="JA" style="font-family: Arial-BoldMT;"><div align="left">
Voluntary muscle test-sensory test (VMT-ST)</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
In between the sensitive assessments that NCS provide, a VMT-ST should be performed to detect</div>
<div align="left">
NFI as a baseline at diagnosis, monthly while on MDT, and at each review after release from</div>
<div align="left">
treatment for the prescribed durations of follow-up (see Table 18, p44). With practice (for both</div>
<div align="left">
health worker and the patient), this should take around 10 minutes to complete thoroughly. See</div>
<div align="left">
Appendix 1 for the method.</div>
<div align="left">
The advantage of a standardised form of documentation is that an examiner can make a direct</div>
<div align="left">
comparison with an earlier examination (even if performed by another person) in trying to assess</div>
<div align="left">
whether new NFI has occurred or not. Use of a ballpoint pen for sensory testing is not as sensitive</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
for protective light-touch thresholds as nylon monofilaments, but they are universally available when</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
the latter are not. With appropriate training, their use produces reliable results between different</div>
<div align="left">
observers.</div>
</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: medium;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Treatment of nerve function impairment (NFI) and lepra reactions</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Nerve damage occurs before diagnosis, during and after drug treatment and may also occur as</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
silent neuropathy without signs of inflammation. Treatment of reactions is aimed at controlling</div>
<div align="left">
acute inflammation, reducing pain and reversing eye and nerve damage. During treatment for lepra</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
reactions MDT should be continued.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Clinical suspicion of reactional states should lead to urgent specialist review and advice</div>
</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
should be sought regarding anti-inflammatory and immunomodulating drugs due to the</div>
</span></span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
potential for permanent disabilities. </div>
<div align="left">
decreased peripheral nerve function because of motor and sensory loss.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Disabilities are a consequence of neural damage with</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">37</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Many studies have reported beneficial responses of NFI in reactions and silent neuropathy with</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
prednisolone. Studies show that improvement occurs in 60-80% of patients with neuropathy, mostly</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
within the first 3 months of a course, especially within the first few days, but further gains can be</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
made at a slower rate for several more months.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">40,41</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Acute primary NFI (first attack and those less than 6 months in duration) have a better prognosis</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
with treatment than chronic or recurrent forms, but improvement may still be seen in up to 50% of</div>
<div align="left">
the latter episodes.</div>
<div align="left">
duration of NFI.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">40,42 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Variablility in response to corticosteroid treatment relates to severity and</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">40,41</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
The major modes of action of corticosteroids are:</div>
<div align="left">
1. Reduction of oedema in nerves and skin (improvement may be seen within days because of</div>
<div align="left">
alleviation of raised intra-neural pressure and ischaemia).</div>
<div align="left">
2. Suppression of </div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">M leprae</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">-specific T-cell inflammation. In Type 1 reactions, serial skin biopsies</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
have shown a slow decrease in Th1*cytokines (interferon-gamma, interleukin-12, and inducible</div>
<div align="left">
nitric oxide synthase) and cellularity in lesions. BL patients however may still have considerable</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
inflammation in lesions at 180 days, despite a course of treatment.</div>
<div align="left">
3. Reduction of post-inflammatory scarring within lesions.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Indications for prednisolone</div>
</span><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 16. Indications for prednisolone</div>
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1 Recent NFI at</div>
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diagnosis</div>
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At the time of diagnosis of leprosy, NFI is detected that the patient tells</div>
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you is <12 months old.</div>
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2 New NFI during</div>
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or after MDT</div>
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NFI with or without symptoms of neuritis or reaction, detected on a</div>
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monthly VMT-ST during treatment or on annual VMT-ST after MDT</div>
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completion that had not been recorded on the previous assessment.</div>
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This includes:</div>
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•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• new loss of sensation in 2 or more points on the sensory chart; and</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• new weakness, paralysis or increasing lid gap on the motor record.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3 Type 1 reaction </div>
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diagnosis, start prednisolone with MDT.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Any degree of severity, with or without neuritis or new NFI. If present at</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
4 Type 2 reaction </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Moderate or severe ENL (not mild), or, ENL with neuritis or new NFI.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
5</div>
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Progressive</div>
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subclinical</div>
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neuropathy</div>
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Deteriorating nerve conduction studies where worsening NFI has not</div>
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been detected on VMT-ST.</div>
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NB. </div>
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digital shortening, or deteriorating vision are </div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: xx-small;"><span style="font-family: Arial-BoldMT; font-size: xx-small;">Advancing secondary consequences of NFI</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">, e.g. enlarging ulcer, worsening contracture, increased clawing,</span></span><b><span style="font-family: Arial-BoldMT; font-size: xx-small;"><span style="font-family: Arial-BoldMT; font-size: xx-small;">not alone </span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">an indication of worsening NFI or an indication for prednisolone</span></span><span lang="JA" style="font-family: ArialMT; font-size: xx-small;"><span lang="JA" style="font-family: ArialMT; font-size: xx-small;"><div align="left">
treatment. They may instead reflect old irreversible NFI that is being inadequately managed in terms of appropriate</div>
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footwear and self-care. However, coexisting new NFI should be excluded.</div>
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* </div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">See page 8.</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">38</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Prednisolone regimens</div>
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There is no firm consensus about the optimum regimen of corticosteroids and no randomised</div>
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controlled trials have been reported comparing regimens of differing dose and duration. The WHO</div>
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recommends a standardised 12-week course for outpatient use for Type 1 reactions where therapy</div>
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is generally initiated by experienced leprosy field staff who are not doctors or nurses (prednisolone</div>
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40mg, 30mg, 20mg, 15mg, 10mg, and 5mg daily, in this order, each dose for 2 weeks). Some</div>
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have expressed concern that the doses may be insufficient to be maximally beneficial, and the</div>
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relatively short duration could allow recurrences of NFI. </div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">Whenever prednisolone is being used</span></span><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
precautions (see p39) and prior screening for opportunistic infections must be carried out.</div>
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There is consensus about the general principles of treatment with prednisolone, which should</div>
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ideally be tailored to the response of the individual.</div>
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1. The starting dose should be 1mg/kg (60mg for adults) for a severe reaction with symptoms of</div>
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neuritis. For silent neuropathy or mild reactions, a dose of 40mg may be sufficient since rapid</div>
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symptom amelioration is not required. The initial dose in either situation can be increased if</div>
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symptoms or NFI fail to improve after 2 weeks.</div>
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2. When the symptoms are controlled and NFI improves, tapering can commence.</div>
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3. Dose reduction can occur at a rate equivalent to 5mg every 1 to 2 weeks. This may need to be</div>
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slowed or the dose increased again if symptoms recur or NFI deteriorates.</div>
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4. Generally, in Type 1 reactions, BL cases will require longer treatment than BT.</div>
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5. Change to alternate daily dosing will minimise the cushingoid effects of therapy, particularly</div>
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where prolonged courses are anticipated. This is appropriate when a daily dose of 20mg has</div>
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been attained.</div>
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6. Morning dosing is less suppressive of adrenal function than evening doses.</div>
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7. Once physiological values of corticosteroid have been reached (the equivalent of 7.5mg</div>
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prednisolone per day), tapering should occur slowly to allow recovery of the hypothalamicpituitary-</div>
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adrenal axis.</div>
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8. During and after cessation of a prolonged course of prednisolone, supplementary doses may</div>
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be required for up to 12 months in the event of serious injury, infection or operation. The patient</div>
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should be advised to specifically mention the course of prednisolone to future medical care</div>
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9. During reactions, </div>
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10. Adjuncts to prednisolone for neuritis symptoms are rest of the affected part (bed rest, sling, splint,</div>
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crutches) and local warmth and protection around the nerve with a cotton wool bandage.</div>
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11. A regimen that uses multiples of prednisolone 25mg tablets for as long as possible (rather than</div>
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5mg tablets) will reduce the overall number of tablets per dose and improve patient acceptability</div>
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(Table 17).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">givers.</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">continue MDT without interruption </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">along with prednisolone.</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Department of Health and Families is a smoke free workplace </div>
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Table 17. Example of 9 month tapering course of prednisolone for Type 1 reaction in BL</div>
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leprosy</div>
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Week No. Number of prednisolone tablets Equivalent daily dose</div>
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25mg tablets 5mg tablets</div>
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1-2 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">2 OD* 50mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3-4 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1.5 OD 1 OD 42.5mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
5-6 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1.5 OD 37.5mg</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
7-8 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1 OD 1 OD 30mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
9-10 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1 OD 25mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
11-14 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1.5 AD# 18.75mg</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
15-18 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1 AD 12.5mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
19-22 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">4 AD 10mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
23-26 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">3 AD 7.5mg</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
27-30 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">2 AD 5mg</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
31-34 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">1 AD 2.5mg</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
35-38 </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">0.5 AD 1.25mg</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* OD, once daily</div>
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# AD, alternate days. Transition to AD dosing may be done by gradually increasing to the dose shown on 1 day, and</div>
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tapering the dose on the alternate days to zero.</div>
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Precautions with prednisolone usage</div>
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1. Nerve abscess (requires surgery and appropriate referral prior to prednisolone use).</div>
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2. Untreated infections (TB, strongyloidiasis, amoebiasis, osteomyelitis, infected ulcers, scabies)</div>
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need to be referred to a specialist and treated prior to prednisolone use.*</div>
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Screening prior to the commencement of prednisolone</div>
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1. Mantoux test and chest x-ray for LTBI and active TB.</div>
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2. Stool microscopy and culture (1 specimen), and serology for </div>
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serology and stool are negative, no further action is required. If serology and/or stool are</div>
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positive, give a single dose of ivermectin 200mcg/kg, and recheck serology for a fall in titre and</div>
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stool for clearance of parasite.</div>
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3. Blood glucose, electrolytes, urea and creatinine, FBE, LFT, HIV antibody, hepatitis B and</div>
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melioidosis serology. Where tests are abnormal refer to physician, infectious diseases physician</div>
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or liver clinic doctors as appropriate.</div>
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4. Visual acuities and check history of glaucoma.</div>
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5. Pregnancy test in reproductive age females.</div>
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6. Bone density assessment in postmenopausal women and elderly men.</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">Strongyloides stercoralis. </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">If</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
*Refer to </div>
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Territory.</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: xx-small;"><span style="font-family: Arial-ItalicMT; font-size: xx-small;">Prevention of opportunistic infections in immunosuppressed patients in the tropical top end of the Northern</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">43</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
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Guidelines for the Control of Leprosy in the Northern Territory</div>
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7. History or risk factors for peptic ulceration.</div>
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8. History of psychiatric disorders.</div>
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9. Blood pressure and cardiac examination.</div>
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10. Weight.</div>
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Precautions during prolonged treatment</div>
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1. Avoid live vaccines during and for 3 months after therapy.</div>
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2. Increase dose during acute stress (intercurrent illness, surgery), eg double maintenance</div>
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dose.</div>
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3. High calcium intake (1200mg/day); restrict sodium intake; add potassium supplements if</div>
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necessary.</div>
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Therapy complications and their management</div>
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Type 2 reactions (ENL) are less frequently complicated by neuritis and NFI than Type 1 reactions. In</div>
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LL, NFI may be largely secondary to bacillary infiltration rather than inflammation, and commencing</div>
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MDT alone may produce improvement. If ENL is mild and not accompanied by neuritis or new NFI,</div>
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bed rest and aspirin are recommended.</div>
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Moderate and severe attacks of ENL or ENL with neuritis should be treated with prednisolone.</div>
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The tendency for ENL to recur means the duration of treatment should be as short as possible to</div>
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avoid steroid-dependence (eg 2 to 8 weeks). Recurrent ENL requires an increase of the daily MDT</div>
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clofazimine dose to 300mg (not for longer than 3 months – see drug information in Appendix 4) to</div>
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allow prednisolone to be withdrawn. The clofazimine dose is then tapered over several months by</div>
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100mg increments to 100mg daily, which is maintained until the completion of MDT.</div>
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Iridocyclitis complicating ENL should be treated with corticosteroid eye-drops and a mydriatic and</div>
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reviewed by an ophthalmologist.</div>
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Thalidomide usage</div>
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Thalidomide (400mg daily) reduces TNF-alpha levels and increases CD8 T cell numbers in ENL</div>
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and is rapidly effective in severe and recurrent forms. It controls and prevents neuritis, relieves</div>
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pain and improves nerve function effectively. Thalidomide use allows a reduction in prednisolone</div>
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requirements to avoid steroid dependency and furthermore, studies have shown thalidomide to be</div>
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very effective as a monotherapy.</div>
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The WHO Expert Committee on Leprosy (1997) advised that thalidomide is the drug of choice for</div>
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steroid unresponsive ENL in males and for females of non-reproductive age under expert supervision</div>
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and with extreme caution due to the risk of teratogenicity in the first trimester of pregnancy.</div>
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In the United States of America and Brazil it is licensed for steroid dependant leprosy or when</div>
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steroids are contraindicated in men and women. It is licensed by the Australian Therapeutic Goods</div>
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Administration for the treatment of ENL</div>
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care only. Women should use double contraception and report immediately if there is a delay in</div>
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menstruation.</div>
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In the future, pentoxifylline (a xanthine derivative), may be considered as it has also demonstrated</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">44 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">though treatment should be under specialist hospital</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
efficacy in treating symptoms in a double blind RCT where its usage was compared to thalidomide.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
It was effective in reducing limb oedema and systemic symptoms in 62% of patients,</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">45 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">however</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">41</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
data and evaluation of pentoxifylline are still limited and therefore its use is not recommended.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Prevention of NFI, deformity and handicap</div>
</span><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Early case detection of leprosy</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
An important indicator in assessing the quality of a leprosy control program is the proportion of</div>
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newly diagnosed cases who have Grade 2 disability. Programs with effective education strategies</div>
<div align="left">
to raise the awareness of leprosy among health workers and those at-risk in the community will</div>
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have a new case disability Grade 2 proportion of around 5%. Programs with late case detection</div>
<div align="left">
may have proportions in excess of 50%.</div>
<div align="left">
Having NFI at the time of diagnosis is a risk factor for a poor ultimate disability outcome (measured</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
by the HFE score 5 years after completion of MDT). Those who first develop impairment after</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
treatment commences have a better prognosis. Furthermore, patients who have longstanding NFI</div>
<div align="left">
at the time of diagnosis (NFI for longer than 6 months) have a 15-fold higher incidence of </div>
<div align="left">
episodes </div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;">further</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">of acute NFI than those who do not.</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">37</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Early case detection of leprosy and treatment with MDT rapidly stops multiplication of </div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">M. leprae.</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Combined, these are the most important steps to prevent NFI.</div>
</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Early detection and treatment of NFI</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Effective and rapid management of lepra reactions is essential. It is imperative therefore that:</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
<div align="left">
for treatment.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Patients be taught to recognize early signs and symptoms of reactions and to report promptly</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Health workers are able to diagnose and treat reactions and refer patients when necessary.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
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determined by a central pharmacy.</div>
<div align="left">
The fact that the likelihood of full recovery of nerve function with prednisolone is much higher in</div>
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acute or recent NFI (<6 months duration) than in older NFI, coupled with the fact that up to 80% of</div>
<div align="left">
all NFI occurs imperceptibly (silent neuropathy), mandates a system of regular clinical screening</div>
<div align="left">
for NFI even though a patient is asymptomatic.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• Adequate stocks of prednisolone are available and means of accessing thalidomide quickly is</span></span><b><i><span style="font-family: Arial-BoldItalicMT;"><div align="left">
Self-care of established complications</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Impairments such as anaesthesia, weakness, and loss of sweating may have been present for too</div>
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long to be reversible with prednisolone or other therapies when discovered. In 20 to 30% of acute</div>
<div align="left">
cases the impairments may simply be refractory to therapy. Self-care routines when supported</div>
<div align="left">
by access to appropriate medical, surgical and rehabilitation services can prevent the secondary</div>
<div align="left">
consequences of these impairments.</div>
</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;"><div align="left">
Management of complications</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
1. Dry skin </div>
<div align="left">
rubbing with emulsifying ointment or an oil based topical preparation.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">due to lack of sensation and should be treated by soaking in water, followed by</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
2. Ulceration and fissures </div>
<div align="left">
osteomyelitis if not managed early, and loss of digits or limbs can result. These should be</div>
<div align="left">
covered to allow them to heal.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">(due to loss of protective sensation) lead to deep infection and</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">42</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3. Callus formation </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">(due to decrease in sweating) promotes fissuring and ulceration. Callus</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
formations should be rubbed with pumice stone or an abrasive nylon pad.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
4. Joint contractures </div>
<div align="left">
should be taught to prevent this result. Involvement of specialist physiotherapy and orthopaedic</div>
<div align="left">
care may be required.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">can occur when muscles are paralysed and active and passive exercises</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
5. Eye damage occurs </div>
<div align="left">
neuropathy) or lagophthalmos (facial neuropathy). Eyes should be inspected in a mirror daily</div>
<div align="left">
for redness. Redness or visual deterioration should be assessed promptly by health staff. Use</div>
<div align="left">
of lubricating eye drops or ointment should be encouraged where there is weakness in lid</div>
<div align="left">
closure.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">because eyes are vulnerable due to corneal sensory loss (trigeminal</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;"><div align="left">
Daily regimen for the management of anaesthetic limbs</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
1. Look </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">for reddened inflamed skin (hot-spots), blisters or ulceration of anaesthetic areas. Inspect</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
footwear for foreign bodies with the potential to damage feet, eg pebbles in shoe, nail in sole.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
2. Soak </div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">feet and hands if there is sensory loss, dryness, fissuring, callosity, or ulcer in water for</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
10-15 minutes daily.</div>
</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
3. Pare </div>
<div align="left">
scotch-brite pad or pumice stone, until normal tissue is reached. (Health staff can assist this</div>
<div align="left">
process periodically using a scalpel blade).</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">after soaking, abraded areas of built up callus or hardened skin around an ulcer with a</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
4. Oil </div>
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lanolin or vegetable oil are suitable types of emollient.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">after soaking and paring to keep the skin supple and retain moisture. Eucerin, vitamin A,</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
5. Rest </div>
<div align="left">
with leg elevated or avoid another long walk until healed. Health staff may assist healing where</div>
<div align="left">
ulceration has occurred by providing a sling, crutches, or a Bohler walking iron with plaster of</div>
<div align="left">
paris cast or newer alternatives.</div>
<div align="left">
Illustrated resources are available that are excellent and provide more detailed prevention of disability</div>
<div align="left">
advice for the various impairments. Dr. Grace Warren’s excellent manual, </div>
<div align="left">
limbs</div>
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in Darwin and Alice Springs. The TB/Leprosy Unit in Darwin can be contacted for details.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">where hot-spots or blisters have occurred, avoid pressure to the affected part, eg. rest</span></span><i><span style="font-family: Arial-ItalicMT; font-size: small;"><span style="font-family: Arial-ItalicMT; font-size: small;">The care of neuropathic</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">46 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">is highly recommended and is available in the Department of Health and Families libraries</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
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Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">43</span></span><b><span style="font-family: Arial-BoldMT; font-size: large;"><span style="font-family: Arial-BoldMT; font-size: large;"><div align="left">
Part 3. After MDT completion</div>
</span></span><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Follow-up of leprosy cases</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Follow-up after completion of a course of leprosy treatment is essential to ensure:</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• early detection of disease relapse; and</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
<div align="left">
The recommended duration of follow-up by CDC after leprosy cases have completed antimycobacterial</div>
<div align="left">
treatment will depend on the type of treatment received.</div>
<div align="left">
For an MDT regimen where rifampicin was used for</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• early detection of new NFI.</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• at least a 6-month (PB) period; or</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• 12 or 24-month (MB) period; and</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• in daily or monthly administration in combination with dapsone (and clofazimine in MB) there is</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
good WHO data confirming a low risk of relapse.</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Recent cases that received these regimens should be followed according to Part A of Table 18. The</div>
<div align="left">
highest incidence of relapse has been reported among MB cases that had a high pre-treatment BI</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
(≥4+). Cases with bacterial loads less than 4 (BI<4) before treatment have a much lower rate of</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
relapse after MDT completion and long term routine follow-up is not required.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
In addition to relapse, there is also the risk of new NFI, especially in the first 2 years after treatment</div>
<div align="left">
commences. Useful predictors of new NFI in the first 2 years after MDT starts are classification (MB</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
or PB) and/or the presence of NFI at the time of diagnosis of leprosy.</div>
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A 2003 study</div>
<div align="left">
commenced was:</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">37,38 </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">reported that the risk of new NFI for 2510 patients followed for 5 years after MDT</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
<div align="left">
•</div>
<div align="left">
•</div>
<div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">PB classification and no NFI at diagnosis – 1.6%</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">PB classification and NFI at diagnosis – 16%</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">MB classification and no NFI at diagnosis – 16%</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">MB classification and NFI at diagnosis – 65%</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
As 95% of NFI is likely to occur within 2 years PB cases with NFI at diagnosis require VMT-ST</div>
<div align="left">
monitoring every 3 months for 2 years and PB cases without NFI at diagnosis require annual</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
monitoring for 2 years. MB cases will benefit from VMT-ST monitoring monthly throughout the 12</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
or 24-month period of treatment and should then be followed up for 2 to 5 years after treatment</div>
<div align="left">
(Table 18).</div>
<div align="left">
For all cases, it is important to remind patients during each examination about the signs that</div>
<div align="left">
should prompt presentation to the health services between routine reviews. Scheduled follow-up</div>
<div align="left">
examinations by CDC staff are also an ideal time to enquire if other household members have signs</div>
<div align="left">
or symptoms of leprosy.</div>
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Part B of Table 18 should be used for cases who were treated initially with dapsone and then later</div>
<div align="left">
with rifampicin and/or clofazimine, but in whom the total duration of combined treatment was less</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">44</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
than 6 months (PB) or 12 or 24 months (MB). Patients who received dapsone monotherapy alone</div>
<div align="left">
have a high risk of relapse and their follow-up is as per Part C of Table 18.</div>
</span></span><b><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><span lang="JA" style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 18. Follow-up of leprosy cases after treatment completion</div>
<div align="left">
A. Treatment with WHO-MDT*</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Classification </div>
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Risk factors NFI at diagnosis BI NFI at</div>
<div align="left">
diagnosis</div>
<div align="left">
No Yes 0 to 3+ 4+ to 6+ Yes</div>
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CDC follow-up</div>
<div align="left">
after completion</div>
<div align="left">
of treatment</div>
<div align="left">
Annually</div>
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for 2 years</div>
<div align="left">
after MDT</div>
<div align="left">
completed</div>
<div align="left">
3 monthly</div>
<div align="left">
until 2 years</div>
<div align="left">
after MDT</div>
<div align="left">
completed</div>
<div align="left">
Annually</div>
<div align="left">
for 2 years</div>
<div align="left">
after MDT</div>
<div align="left">
completed</div>
<div align="left">
3 monthly</div>
<div align="left">
for 2 years</div>
<div align="left">
then annually</div>
<div align="left">
until 5 years</div>
<div align="left">
after MDT</div>
<div align="left">
completed</div>
<div align="left">
3 monthly</div>
<div align="left">
for 2 years</div>
<div align="left">
then annually</div>
<div align="left">
until 5 years</div>
<div align="left">
after MDT</div>
<div align="left">
completed</div>
<div align="left">
Type of follow-up Clinical</div>
<div align="left">
Smear</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">PB (after 6 months of MDT) MB (after 12 or 24 months of MDT)</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Clinical</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"># </span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Clinical</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">∙ Clinical</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">∙</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Eyes</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">§</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Clinical</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Smear</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Eyes</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">§</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
B. Treatment with 3 months of daily rifampicin and long term dapsone</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Bacterial index</div>
<div align="left">
on skin smear at</div>
<div align="left">
diagnosis</div>
<div align="left">
0 to 3+ 4+ to 6+</div>
<div align="left">
CDC follow-up</div>
<div align="left">
after completion</div>
<div align="left">
of treatment</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Discharge after a final</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
examination</div>
<div align="left">
Annually for 15 years</div>
<div align="left">
Type of follow-up Clinical</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Smear (if MB)</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Clinical</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Smear</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Eyes</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">§</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
C. Treatment with long term dapsone alone</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Bacterial index</div>
<div align="left">
on skin smear at</div>
<div align="left">
diagnosis</div>
<div align="left">
0 to 3+ 4+ to 6+</div>
<div align="left">
CDC follow-up</div>
<div align="left">
after completion</div>
<div align="left">
of treatment</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Discharge after a final</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
examination</div>
<div align="left">
Annually for 30 years</div>
<div align="left">
Type of follow-up Clinical</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Smear (if MB)</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Clinical</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">#</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Smear</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">†</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Eyes</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">§</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
* Multiple drug regimen where rifampicin and dapsone in combination (and clofazimine in MB leprosy) was given for at</div>
<div align="left">
least a 6 month (PB) or 12 or 24 month (MB) period, regardless of whether rifampicin was given monthly or daily.</div>
<div align="left">
# Clinical means skin, nerve, and nerve function impairment (VMT-ST) assessments, including visual acuity.</div>
<div align="left">
† Take follow-up smears from 2 sites with the highest BI at the time of diagnosis.</div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;"><div align="left">
§ </div>
</span></span><span style="font-family: ArialMT; font-size: xx-small;"><span style="font-family: ArialMT; font-size: xx-small;">Eyes means annual slit-lamp examination by an ophthalmologist to detect silent iritis.</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
<div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">45</span></span><b><span style="font-family: Arial-BoldMT; font-size: medium;"><span style="font-family: Arial-BoldMT; font-size: medium;"><div align="left">
Relapse of leprosy</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Relapse of leprosy in previously treated patients may occur, especially in patients who have not</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
been treated with a WHO multi-drug regimen. In the MDT era a cure is defined by the completion of</div>
<div align="left">
an MDT regimen within a fixed time period (page 28). Thus a relapse is defined as the appearance</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
of new signs of disease in person who has previously completed a course of treatment and been</div>
<div align="left">
declared ‘cured’. By contrast, a new case of leprosy is a person with leprosy who has never</div>
<div align="left">
previously been treated.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Treated PB cases presenting with new activity</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
When previously treated PB cases present with fresh activity in old lesions or the appearance of</div>
<div align="left">
new lesions, either relapse or a Type 1 reaction may be the cause. Furthermore a relapse may also</div>
<div align="left">
present as a Type 1 reaction. Although the clinical features described in Table 19 are of some use</div>
<div align="left">
in differentiating between the 2, there is still considerable overlap.</div>
<div align="left">
The most useful criterion is the timing of the new signs. Those which occur within 6 months of</div>
<div align="left">
completion of MDT are very likely to be due to Type 1 reaction, whereas those occurring more than</div>
<div align="left">
1 year after completion are more likely to be caused by a relapse.</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
Histological findings are not a useful adjunct. Granulomas in a biopsy do not prove evidence of a</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
relapse since they are still present in 40% of cases 2 years after the start of MDT. A lymphocytic</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
infiltrate can also be present in the absence of viable bacilli, being maintained by antigens of dead</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
bacilli.</div>
<div align="left">
It is reported that approximately 50% of patients presenting with new activity post-MDT will have</div>
<div align="left">
skin biopsies compatible with active (relapsed) leprosy, and half will have histopathology consistent</div>
<div align="left">
with Type 1 reaction.</div>
<div align="left">
A course of prednisolone 40mg/day for 4 weeks should be given and if signs and symptoms clear,</div>
<div align="left">
a Type 1 reaction is the likely diagnosis. If not, relapse is more likely and the new activity should be</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
classified as PB or MB in the usual way, and re-treated with MDT.</div>
</span></span><b><span style="font-family: Arial-BoldMT;"><div align="left">
Treated MB cases presenting with new activity</div>
</span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
Relapsed MB patients should be retreated with triple therapy regardless of any change in</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
classification. There are almost as many combinations of criteria for MB relapse as there are studies</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
on the relapse of leprosy after MB treatment. It has been acknowledged that MB relapse is easily</div>
<div align="left">
over-diagnosed if the following point is not considered:</div>
</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;"><div align="left">
•</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">• </span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">an increase in BI of 2+ over previously documented BI at that site is required that is confirmed</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;"><div align="left">
by 2 sets of skin smears 6 months apart.</div>
</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">46</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Guidelines for the Control of Leprosy in the Northern Territory</div>
</span></span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Table 19. Clinically distinguishing relapse from a late Type 1 reaction</div>
<div align="left">
Relapse Type 1 reaction</div>
<div align="left">
Speed of onset </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Slow Sudden</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Timing of onset </div>
<div align="left">
end of treatment</div>
<div align="left">
< 2 (PB) or 5 (MB) years after</div>
<div align="left">
end of treatment</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">> 2 (PB) or 5 (MB) years after</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
New lesions </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">+ -</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Reappearance of old lesions </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">+ +</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Bacterial index </div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">Increasing Stable or decreasing</span></span><b><span style="font-family: Arial-BoldMT; font-size: small;"><span style="font-family: Arial-BoldMT; font-size: small;"><div align="left">
Neuritis </div>
<div align="left">
nerves</div>
<div align="left">
Only in previously affected</div>
</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">In previously unaffected</span></span><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><span style="color: #333333; font-family: ArialMT; font-size: x-small;"><div align="left">
Department of Health and Families is a smoke free workplace </div>
</span></span></span><span style="font-family: ArialMT; font-size: x-small;"><span style="font-family: ArialMT; font-size: x-small;">55</span></span><span lang="JA" style="font-family: ArialMT; font-size: small;"><span lang="JA" style="font-family: ArialMT; font-size: small;">E______</span></span><span style="font-family: ArialMT; font-size: small;"><span style="font-family: ArialMT; font-size: small;">CCIS Case ID</span></span></b></b></b></b></b></b></b></b></b></b></b></b></b></i></b></b></b></b></b></i></b></b></b></b></b></i></i></b></i></b></i></b></i></b></b></b></b></i></i></i></i></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></i></b></b></b></b></b></b></b></b></i></b></b></b></b></i></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></i></b></b></b></b></i></b></b></b></b></b></i></b></b></b></i></b></b></b></b></b></b></i></b></b></b></b></b></b></b></b></b></i></b></i></b></b></b></i></b></i></b></b></i></b></i></b></i></b></i></i></b></i></b></b></b></b></b></i></b></b></i></b></b></b></b></b></i></b></i></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-72179854406785571302012-02-03T12:31:00.000-08:002012-02-03T12:31:43.267-08:00Method of diagnosis<div dir="rtl" style="text-align: right;" trbidi="on">
<b><span style="font-family: Arial,Bold;"> <div align="left">
1.7 Method of diagnosis</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Culture of </div>
</span><i><span style="font-family: TimesNewRoman,Italic;">C. diphtheriae </span><span style="font-family: TimesNewRoman;">from the infected site. Direct microscopy is of no value.</span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
8</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><b><span style="font-family: Arial,Bold;"><div align="left">
2.1 Collection of specimens from a suspected case</div>
</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
membrane and the membrane itself.</div>
</span><span style="font-family: TimesNewRoman;">The preferred specimen is a cotton tipped swab of the eroded epithelium underneath the</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
and should be obtained with a flexible alginate (wire) swab that reaches deep into the</div>
<div align="left">
back of the nose.</div>
</span><span style="font-family: TimesNewRoman;">Nasopharyngeal cultures are indicted in children who do not have an obvious membrane</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
wounds are taken, lesions should be cleansed with sterile normal saline and crusted</div>
<div align="left">
material removed. A cotton-tipped applicator should then be firmly applied to the base of</div>
<div align="left">
the wound.</div>
</span><span style="font-family: TimesNewRoman;">Any chronic, crusting, cutaneous lesion should also be swabbed. Before cultures of</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
</span><span style="font-family: TimesNewRoman;">Transport in ordinary semi-solid transport medium, such as Amies or Stuarts.</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
</span><span style="font-family: TimesNewRoman;">Specimens should be collected prior to administration of antibiotics.</span><b><span style="font-family: Arial,Bold;"><div align="left">
2.2 Case management</div>
</span><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
2.2.1 Clinical systemic diphtheria / results of toxigenicity pending</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
Confirm with the local laboratory that the specimen has been sent to the reference</div>
<div align="left">
laboratory for urgent PCR toxigenicity testing. A result should be available in 24-48</div>
<div align="left">
hours.</div>
<div align="left">
Since clinical systemic diphtheria is usually caused by a toxigenic strain it is a </div>
<div align="left">
emergency</div>
<div align="left">
includes the administration of antibiotics (to eliminate infection and prevent spread) and</div>
<div align="left">
equine diphtheria antitoxin on the basis of clinical diagnosis alone. Administration of</div>
<div align="left">
antitoxin is the most important aspect of treatment in this situation and must not be</div>
<div align="left">
delayed until bacteriological/toxigenicity confirmation. Life support measures,</div>
<div align="left">
including endotracheal intubation or emergency tracheotomy may be necessary to</div>
<div align="left">
overcome respiratory obstruction.</div>
</span><b><span style="font-family: TimesNewRoman,Bold;">medical</span><span style="font-family: TimesNewRoman;">. Management involves seeking advice from an experienced physician, and</span><b><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><div align="left">
Section 2 Clinical Management</div>
</span></span></span><i><span style="font-family: TimesNewRoman,BoldItalic;"><div align="left">
CDC must be urgently notified by telephone if disease is suspected on clinical grounds</div>
<div align="left">
(while waiting for laboratory confirmation)</div>
<div align="left">
Management of cases is based on the clinical condition</div>
<div align="left">
and the toxigenicity of the infection, if known.</div>
</span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
9</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
Cases should remain in strict respiratory isolation until 2 cultures from both the nose</div>
<div align="left">
and throat taken not less than 24 hours apart, and not less than 24 hours after ceasing</div>
<div align="left">
antibiotic therapy, are negative for diphtheria bacilli. If culture is impractical, isolation</div>
<div align="left">
may be ended after 14 days of appropriate antibiotic treatment.</div>
</span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
2.2.2 Toxigenic infection</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
The same isolation criteria apply as for systemic disease above. The management of</div>
<div align="left">
toxigenic infections in the absence of systemic disease involves seeking advice from an</div>
<div align="left">
experienced physician, as it may involve the administration of equine diphtheria</div>
<div align="left">
antitoxin. Vigorous cleansing of wounds, if present, and the administration of</div>
<div align="left">
antibiotics is recommended.</div>
<div align="left">
Diptheria infection does not necessarily confer immunity</div>
<div align="left">
stage of their illness, fully immunised individuals should receive a booster dose of</div>
<div align="left">
diphtheria containing vaccine (unless they have received a dose within the last 12</div>
<div align="left">
months).</div>
<div align="left">
‘catch-up’ vaccination and receive/complete the primary course and boosters in</div>
<div align="left">
accordance with the </div>
</span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;">4 </span></span><span style="font-family: TimesNewRoman;">so during the convalescent</span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;">5 </span></span><span style="font-family: TimesNewRoman;">Unimmunised or incompletely immunised individuals should commence</span><i><span style="font-family: TimesNewRoman,Italic;">Australian Immunisation Handbook </span><span style="font-family: TimesNewRoman;">recommendations.</span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
2.2.3 Non-toxigenic infection</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
Treatment of non-toxigenic infection will depend on the local manifestations of the</div>
<div align="left">
infection, and a decision on whether to treat will need to be made on individual</div>
<div align="left">
circumstances. Unimmunised or incompletely immunised individuals should</div>
<div align="left">
commence “catch-up’ vaccination and receive/complete the primary course and</div>
<div align="left">
boosters in accordance with the </div>
</span><i><span style="font-family: TimesNewRoman,Italic;">Australian Immunisation Handbook </span><span style="font-family: TimesNewRoman;">recommendations.</span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
10</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><b><span style="font-family: Arial,Bold;"><div align="left">
3.1 Case Definition and Notification</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
NT case definitions are the same as the National Notifiable Diseases Surveillance System</div>
<div align="left">
(NNDSS) definitions. Both confirmed and probable cases should be reported.</div>
</span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
3.1.1 Confirmed case</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
A confirmed case requires laboratory definitive evidence only.</div>
</span><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><div align="left">
• </div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;">Laboratory definitive evidence </span><span style="font-family: TimesNewRoman;">– isolation of </span><b><span style="font-family: TimesNewRoman,Bold;">toxigenic </span><i><span style="font-family: TimesNewRoman,Italic;">C. diphtheriae </span><span style="font-family: TimesNewRoman;">or</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
toxigenic </div>
</span><i><span style="font-family: TimesNewRoman,Italic;">C. ulcerans</span><b><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
3.1.2 Probable case</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
A probable case of diphtheria disease requires either:</div>
<div align="left">
laboratory suggestive evidence </div>
</span><b><span style="font-family: TimesNewRoman,Bold;">AND </span><span style="font-family: TimesNewRoman;">clinical evidence</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
OR</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Clinical evidence </div>
</span><b><span style="font-family: TimesNewRoman,Bold;">AND </span><span style="font-family: TimesNewRoman;">epidemiological evidence</span><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><div align="left">
• </div>
<div align="left">
production unknown)</div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;">Laboratory suggestive evidence </span><span style="font-family: TimesNewRoman;">– isolation of </span><i><span style="font-family: TimesNewRoman,Italic;">C diphtheria </span><span style="font-family: TimesNewRoman;">or </span><i><span style="font-family: TimesNewRoman,Italic;">C ulcerans </span><span style="font-family: TimesNewRoman;">(toxin</span><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><div align="left">
• </div>
<div align="left">
pharyngitis and/or laryngitis (with or without a membrane);</div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;">Clinical evidence </span><span style="font-family: TimesNewRoman;">– at least one of the following :</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
OR</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
toxic (cardiac or neurological) symptoms</div>
</span><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><span lang="JA" style="font-family: SymbolMT; font-size: x-small;"><div align="left">
• </div>
<div align="left">
contact between 2 people involving a plausible mode of transmission at a time</div>
<div align="left">
when :</div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;">Epidemiological evidence </span><span style="font-family: TimesNewRoman;">– an epidemiological link is established when there is:</span><span style="font-family: Wingdings-Regular;"><div align="left">
</div>
<div align="left">
more than 4 weeks after onset of symptoms)</div>
</span><span style="font-family: TimesNewRoman;">one of them is likely to be infectious (usually 2 weeks or less and seldom</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
AND</div>
</span><span style="font-family: Wingdings-Regular;"><div align="left">
</div>
<div align="left">
contact</div>
</span><span style="font-family: TimesNewRoman;">the other has an illness which starts within approximately 2-5 days after the</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
AND</div>
</span><span style="font-family: Wingdings-Regular;"><div align="left">
</div>
<div align="left">
involve many cases) is laboratory confirmed</div>
</span><span style="font-family: TimesNewRoman;">at least 1 case in the chain of epidemiologically linked cases (which may</span><b><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><span style="color: #818181; font-family: Arial,Bold; font-size: large;"><div align="left">
Section 3 Public Health Management</div>
</span></span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
11</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><b><span style="font-family: Arial,Bold;"><div align="left">
3.2 Active Surveillance</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Active surveillance includes follow-up of contacts, as detailed below. In addition,</div>
<div align="left">
community members with symptoms compatible with diphtheria up to 2 weeks after</div>
<div align="left">
diagnosis of the index case should be investigated. This includes anyone presenting with a</div>
<div align="left">
sore throat or runny nose, particularly if the nasal discharge is blood stained or only apparent</div>
<div align="left">
on one side.</div>
</span><b><span style="font-family: Arial,Bold;"><div align="left">
3.3 Definition of a contact</div>
</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
index case.</div>
</span><span style="font-family: TimesNewRoman;">All household members and other persons with history of habitual, close contact with the</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
during the previous week (i.e. mouth kissing or mouth to mouth resuscitation).</div>
</span><span style="font-family: TimesNewRoman;">Anyone who has had significant contact with nasopharyngeal secretions of the index case</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
hours with the index case in the week preceding the onset of illness (e.g. contacts in child</div>
<div align="left">
care centres, schools etc).</div>
</span><span style="font-family: TimesNewRoman;">Anyone who has spent 4 hours or more a day for 5 consecutive days, or more than 24</span><b><span style="font-family: Arial,Bold;"><div align="left">
3.4 Management of asymptomatic contacts</div>
</span><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
3.4.1 Contact management when the index case has:</div>
</span></span><span lang="JA" style="font-family: SymbolMT; font-size: small;"><span lang="JA" style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;">clinical systemic diphtheria OR</span></span><span lang="JA" style="font-family: SymbolMT; font-size: small;"><span lang="JA" style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;">confirmed toxigenic strain (with or without systemic disease)</span></span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
ordinary semi-solid transport medium.</div>
</span><span style="font-family: TimesNewRoman;">Take nasopharyngeal swabs (or nose and throat swabs) for culture and place in</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
containing vaccine. (NB a booster dose is not required if the last dose was given</div>
<div align="left">
less than 5 years earlier).</div>
</span><span style="font-family: TimesNewRoman;">Fully immunised contacts should be given a booster dose of a diphtheria</span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;">4</span></span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
immunisation following the recommendations in the </div>
<div align="left">
Immunisation Handbook.</div>
</span><span style="font-family: TimesNewRoman;">Unimmunised or incompletely immunised contacts should commence ‘catchup’</span><i><span style="font-family: TimesNewRoman,Italic;">Australian</span><b><span style="font-family: TimesNewRoman,BoldItalic;"><div align="left">
Management of contacts is based on the clinical condition of the index case</div>
<div align="left">
and the toxigenicity of the infection, if known.</div>
</span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
12</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
</span><span style="font-family: TimesNewRoman;">Antibiotic prophylaxis (see section 3.5).</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
association with children should be excluded from work until swabs prove them</div>
<div align="left">
not to be carriers or 48 hours post commencement of antibiotic prophylaxis.</div>
</span><span style="font-family: TimesNewRoman;">Adult contacts whose occupations involve handling food/milk products or close</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
<div align="left">
them not to be carriers or 48 hours post commencement of antibiotic</div>
<div align="left">
prophylaxis.</div>
</span><span style="font-family: TimesNewRoman;">Child contacts should be excluded from school, day care etc until swabs prove</span><span lang="JA" style="font-family: SymbolMT;"><div align="left">
• </div>
</span><span style="font-family: TimesNewRoman;">Observe all asymptomatic contacts closely for 7 days.</span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;"><div align="left">
3.4.2 Contact tracing is NOT required when the index case has:</div>
</span></span><span lang="JA" style="font-family: SymbolMT; font-size: small;"><span lang="JA" style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
<div align="left">
organism</div>
</span></span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;">no evidence of systemic disease with a confirmed non-toxigenic</span></span><span style="font-family: Arial,BoldItalic; font-size: xx-small;"><span style="font-family: Arial,BoldItalic; font-size: xx-small;">4,5 </span></span><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;">OR</span></span><span lang="JA" style="font-family: SymbolMT; font-size: small;"><span lang="JA" style="font-family: SymbolMT; font-size: small;"><div align="left">
• </div>
</span></span><b><i><span style="font-family: Arial,BoldItalic; font-size: small;"><span style="font-family: Arial,BoldItalic; font-size: small;">no evidence of systemic disease with toxigenicity pending*</span></span><span style="font-family: TimesNewRoman;"><div align="left">
*If the laboratory result comes back as a toxigenic strain, refer to section 3.4.1.</div>
</span><b><span style="font-family: Arial,Bold;"><div align="left">
3.5 Antibiotic prophylaxis for contacts of systemic diphtheria and/or</div>
<div align="left">
toxigenic infection</div>
</span><i><span style="font-family: TimesNewRoman,BoldItalic;"><div align="left">
Antibiotic prophylaxis should be given regardless of the immunisation status of the</div>
<div align="left">
contact.</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Weight < 30 kg: Benzathine penicillin (Bicillin LA), 600,000 units (450mg/1ml)</div>
<div align="left">
1ml as a single intramuscular dose.</div>
<div align="left">
Weight </div>
<div align="left">
2ml as a single intramuscular dose.</div>
</span><span lang="JA" style="font-family: SymbolMT;">≥ </span><span style="font-family: TimesNewRoman;">30 kg: Benzathine penicillin (Bicllin LA), 1,200,000 units (900mg/2ml)</span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
If penicillin allergy present or compliance assured:</div>
</span><span style="font-family: TimesNewRoman;"><div align="left">
Erythromycin orally for 7 days in 4 daily divided doses</div>
<div align="left">
Children 40mg / kg / day</div>
<div align="left">
Adults 1gm / day</div>
</span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
13</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><b><span style="font-family: TimesNewRoman,Bold;"><div align="left">
References</div>
</span><span style="font-family: TimesNewRoman; font-size: small;"><span style="font-family: TimesNewRoman; font-size: small;"><div align="left">
1. U.S Department of Health and Human Services. Centers for Disease Control and Prevention.</div>
<div align="left">
Manual for surveillance of vaccine preventable diseases 3rd Edition, 2002. URL: http://www.</div>
<div align="left">
cdc.gov/nip/publications/surv-manual/chpt01_dip.pdf accessed 29/09/2003.</div>
<div align="left">
2. Chin J, editor. Control of Communicable Diseases Manual. 17</div>
<div align="left">
American Public Health Association, 2000.</div>
<div align="left">
3. National Health and Medical Research Council. The Australian Immunisation Handbook. 8</div>
</span></span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;">th </span></span><span style="font-family: TimesNewRoman; font-size: small;"><span style="font-family: TimesNewRoman; font-size: small;">edition. Washington:</span></span><span style="font-family: TimesNewRoman; font-size: xx-small;"><span style="font-family: TimesNewRoman; font-size: xx-small;">th</span></span><span style="font-family: TimesNewRoman; font-size: small;"><span style="font-family: TimesNewRoman; font-size: small;"><div align="left">
edition. 2003. URL: http://immunise.health.gov.au/handbook.htm accessed 29/09/2003.</div>
<div align="left">
4. U.S Department of Health and Human Services. Centers for Disease Control and Prevention.</div>
<div align="left">
Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th Edition. URL: http://www.</div>
<div align="left">
cdc.gov/nip/publications/pink/dip.pdf accessed 12/03/2004.</div>
</span></span><span style="font-family: TimesNewRoman;"><div align="left">
5. </div>
<div align="left">
disease control. 1999. U.K Public Health Laboratory Service. URL: http://www.hpa.org.uk/</div>
<div align="left">
infections/topics_az/diphtheria/guidelines.pdf accessed 29/09/2003.</div>
</span><span style="font-family: TimesNewRoman; font-size: small;"><span style="font-family: TimesNewRoman; font-size: small;">Bonnet JM and Begg NT. Control of diphtheria: guidance for consultants in communicable</span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
14</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
15</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><span style="font-family: TimesNewRoman; font-size: x-small;"><span style="font-family: TimesNewRoman; font-size: x-small;"><div align="left">
16</div>
</span></span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><div align="left">
Guidelines for the Control of Diphtheria in the Northern Territory March 2004</div>
</span></span><b><span style="font-family: TimesNewRoman,BoldItalic;"><div align="left">
</div>
</span><span style="font-family: TimesNewRoman,Italic;">cdc</span><b><span style="font-family: TimesNewRoman,BoldItalic;">OR</span><i><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"><span style="font-family: TimesNewRoman,Italic; font-size: x-small;"></span></span></i></b></b></i></i></i></b></i></b></i></b></i></b></i></b></i></b></i></b></i></i></b></i></b></i></b></b></b></i></b></b></b></b></b></b></i></i></b></b></b></b></b></i></b></i></b></b></i></b></b></i></i></i></b></i></i></b></i></i></b></b></i></b></b></i></i></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-6467172382246315932012-02-03T04:29:00.000-08:002012-02-03T04:29:06.152-08:00Cholera: Information for Clinicians<div dir="rtl" style="text-align: right;" trbidi="on">
<b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: large;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: large;"> <div align="left">
Cholera: Information for Clinicians</div>
</span></span><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
December 1, 2010</div>
<div align="left">
Background</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
On November 26, 2010, the Ministère de la Sante Publique et de</div>
<div align="left">
la Population (MSPP) in Haiti reported 72,017 cases of cholera</div>
<div align="left">
and 1,648 deaths since mid October 2010.</div>
<div align="left">
extended to all of the country’s ten health departments and the</div>
<div align="left">
capital city of Port-au-Prince. No cholera outbreaks have been</div>
<div align="left">
reported in Haiti in the last century.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">1 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">The outbreak has</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><div align="left">
Vibrio cholerae</div>
<div align="left">
food-borne organism that can cause acute watery diarrhea,</div>
<div align="left">
vomiting, severe dehydration and death.</div>
<div align="left">
strain of cholera is confirmed as </div>
<div align="left">
serotype Ogawa, biotype El Tor.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">, the causative agent of cholera, is a water- and</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">The Haitian outbreak</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">serogroup O1,</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">3 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">All isolates of </span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">Vibrio cholerae</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
from the Haiti outbreak that have been typed demonstrate a common pulsed field gel electrophoresis pattern.</div>
<div align="left">
There have been two cases of cholera imported from Haiti confirmed to date; one in Florida and the second</div>
<div align="left">
in the Dominican Republic.</div>
<div align="left">
in returning travelers, to provide clinical guidance on diagnosis, management and infection control practices</div>
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of cholera, and to present information for travelers to areas with cholera disease.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">1, 4 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">The purpose of this document is to highlight the potential for cholera disease</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Epidemiology</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
In 2009, The World Health Organization reported a </div>
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worldwide, including 4,946 deaths.</div>
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limitations in reporting, surveillance and diagnostic capacity in the most vulnerable countries affected.</div>
</span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">total of 221,226 cholera cases from 45 countries</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;">5 </span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">This is known to be an underestimate of cholera infections due to</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;">6</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
Since the early 2000s the majority of cases have been reported from the African continent, with a lesser</div>
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incidence reported in Asia. Endemic cholera has not been reported in North America or Europe since the</div>
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middle of the 19</div>
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Lack of access to clean water and sanitation are the primary risk factors for cholera disease. </div>
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pylori </div>
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without immunity, cholera affects people of all ages. In cholera endemic regions, children less than 4 years</div>
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old are at highest risk of cholera. The incubation period of cholera is usually 2-3 days, with a range of a</div>
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few hours to 5 days.</div>
</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;">th </span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">century.</span></span></span><i><span style="color: #1a1718; font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPS-ItalicMT; font-size: small;">Helicobacter</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">infection and O blood group are associated with increased risk of severe disease.</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;">2 </span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">In populations</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
Regions with known cholera activity in 2009 are listed World Health Organization Cholera annual report</div>
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(</div>
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2010. </div>
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cases from Haiti have been identified in Ontario as of November 26</div>
</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;">http://www.who.int/wer/2010/wer8531.pdf</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">). </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">5 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">The current cholera outbreak in Haiti began in October</span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">In Ontario, there has been one laboratory confirmed case per year from 2005-2009. No imported</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: xx-small;">th</span></span></span><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: #1a1718; font-family: TimesNewRomanPSMT; font-size: small;">, 2010.</span></span></span><b><span style="font-family: TimesNewRomanPS-BoldMT;"><div align="left">
Key Messages:</div>
</span><span style="font-family: Symbol; font-size: x-small;"><span style="font-family: Symbol; font-size: x-small;"><div align="left">
• </div>
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returning from endemic areas with</div>
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symptoms of acute watery diarrhea with</div>
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onset <5 days after return.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Cholera should be suspected in travelers</span></span><span style="font-family: Symbol; font-size: x-small;"><span style="font-family: Symbol; font-size: x-small;"><div align="left">
• </div>
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aggressive rehydration and good hygiene.</div>
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Adjunctive antibiotics are recommended</div>
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for severe cases.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Management of cholera includes</span></span><span style="font-family: Symbol; font-size: x-small;"><span style="font-family: Symbol; font-size: x-small;"><div align="left">
• </div>
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“cholera” and should be submitted in usual</div>
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(Cary Blair) transport media for stool</div>
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C&S.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Stool specimens must specifically request</span></span><span style="font-family: Symbol; font-size: x-small;"><span style="font-family: Symbol; font-size: x-small;"><div align="left">
• </div>
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cholera to your public health department.</div>
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Cholera: Information for Clinicians</div>
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December 1, 2010</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Report all suspect and confirmed cases of</span></span><span style="font-family: TimesNewRomanPSMT;"><div align="left">
2</div>
</span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Clinical Presentation</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
Cholera infection can be either symptomatic or asymptomatic. Asymptomatic persons infected with cholera</div>
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can shed </div>
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within 5 days of exposure: symptoms include watery diarrhea or “rice water” stools (up to 0.5-1 liter per</div>
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hour), vomiting, and dehydration. Fever is rare (less than 5 %). Mild to moderate cases may be</div>
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indistinguishable from other infectious forms of diarrhea. Severe cases of cholera may present with</div>
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electrolyte abnormalities, hypotension, and renal failure.</div>
</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">in stools for 7-14 days after infection. Those who will develop symptoms do so</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Microbiological Diagnosis of </div>
</span></span><i><span style="font-family: TimesNewRomanPS-BoldItalicMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldItalicMT; font-size: medium;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;">in Ontario</span></span><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Who to test </div>
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region with known cholera.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Individuals who have profuse watery diarrhea < 5 days after returning from a</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Specimen type </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Stool</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Specimen container </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Stool culture containers with usual (Cary-Blair) transport media</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Requisition requirements </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Must specify “Cholera” or “</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: x-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: x-small;">Vibrio cholerae” </span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">on requisition</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Laboratory submission </div>
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Stool specimens will be forwarded from these laboratories to the OAHPP</div>
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Public Health Laboratories (PHL) for testing.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Submit specimen to local hospital/ private laboratory</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Urgent requests </div>
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submitting specimen.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Must be communicated directly to the OAHPP PHL at 416 526-5441, prior to</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Tests not available </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Serology, rapid stool tests</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Other considerations </div>
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considered. Testing should be performed as per routine practice.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Other bacterial, viral and parasitic causes of acute diarrhea should be</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Management of </div>
</span></span><i><span style="font-family: TimesNewRomanPS-BoldItalicMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldItalicMT; font-size: medium;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;">infection</span></span><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Medical evaluation </div>
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to medical evaluation if they have onset of watery diarrhea <5 days after their</div>
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return.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Travelers returning from regions with known cholera should present immediately</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Fluid and electrolyte</div>
<div align="left">
replacement</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
Mortality from cholera can be reduced from 10-50% to less than 1% with</div>
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appropriate fluid and electrolyte replacement. </div>
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the cornerstone of cholera therapy, and will save lives if given rapidly and in</div>
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adequate volume to replace and maintain losses.</div>
</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: x-small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: x-small;">Fluid and electrolyte therapy is</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
For full details of appropriate fluid and electrolyte replacement therapy for</div>
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cholera, including 1) using oral rehydration therapy in mild to moderate cases,</div>
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and 2) intravenous replacement in severe dehydration preferentially with Ringer’s</div>
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lactate, please see the CDC guidelines,</div>
</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
http://www.cdc.gov/haiticholera/clinicalmanagement/</div>
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2010.</div>
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Cholera: Information for Clinicians</div>
<div align="left">
December 1, 2010</div>
</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">, accessed November 27,</span></span><span style="font-family: TimesNewRomanPSMT;"><div align="left">
3</div>
</span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Antimicrobials</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
Antimicrobial therapy is of secondary priority to ongoing fluid and electrolyte</div>
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replacement, and is indicated for severe cholera disease only. Antibiotics should</div>
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not be prescribed for asymptomatic cholera infections.</div>
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In severe cholera, antimicrobial treatment is associated with decreases in the</div>
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following: 1) duration of diarrhea (from 4 to 2 days on average), 2) stool volume,</div>
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3) intravenous fluid requirements, and 4) clinical relapses.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">8</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
The initial strains of </div>
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2010 are susceptible to tetracycline (a proxy for doxycycline) and azithromycin,</div>
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resistant to sulfisoxazole and nalidixic acid, and show reduced susceptibility to</div>
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ciprofloxacin.</div>
</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: x-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: x-small;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">identified in Haiti in October and November</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">7</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
Recommended empiric therapy for individuals for suspected severe cholera</div>
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returning from Haiti as of November 27, 2010 is:</div>
</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: x-small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: x-small;"><div align="left">
Patient population Recommended antimicrobials</div>
<div align="left">
(First line)</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
Non pregnant adults Doxycycline 300 mg PO x 1 dose</div>
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Pregnant women Azithromycin 1gm PO x 1 dose</div>
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Children</div>
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(oral suspension recommended</div>
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for children less than 12 months/</div>
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children unable to swallow pills)</div>
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Azithromycin: 20 mg/kg X 1 dose</div>
<div align="left">
or</div>
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Erythromycin: 12.5 mg/kg QID x 3 days</div>
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Adapted from </div>
</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;">http://www.cdc.gov/haiticholera/clinicalmanagement/pdf/clinicalmanagement.pdf</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><div align="left">
accessed November 28, 2010.</div>
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Antimicrobial therapy must be chosen in accordance with individual clinical</div>
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circumstances. </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">8</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: small;"><div align="left">
Other medications </div>
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treatment of cholera</div>
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Zinc supplementation has been associated with decreased duration and severity</div>
<div align="left">
of diarrhea in children infected with cholera in a randomized controlled trial in</div>
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Bangladesh.</div>
<div align="left">
mg per day for 5-7 days may be considered.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">Antimotility agents, analgesics and antiemetics are not recommended in the</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">9 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: x-small;"><span style="font-family: TimesNewRomanPSMT; font-size: x-small;">If severe cholera is suspected, zinc supplementation with 10-30</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Infection control recommendations</div>
</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><div align="left">
Vibrio cholerae </div>
<div align="left">
sanitation systems mitigate ongoing transmission of cholera infections in Ontario.</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">is spread primarily by contaminated water and food sources. Access to clean water and modern</span></span><span style="font-family: Times-Roman; font-size: small;"><span style="font-family: Times-Roman; font-size: small;"><div align="left">
While it is very rare for cholera to spread directly from person to person, patients hospitalized with severe</div>
<div align="left">
cholera should be cared for in isolation using contact precautions until the diarrhea has resolved.</div>
</span></span><span style="font-family: Times-Roman; font-size: xx-small;"><span style="font-family: Times-Roman; font-size: xx-small;">10,11</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
When possible, hospitalized individuals with diarrhea possibly due to cholera should not share toilet facilities</div>
<div align="left">
with other patients.</div>
</span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: medium;"><div align="left">
Public health reporting</div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
All suspected and confirmed cases of cholera must be reported to the local health unit under the Ontario</div>
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Health Protection and promotion act.</div>
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Cholera: Information for Clinicians</div>
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December 1, 2010</div>
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4</div>
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Information for travelers to regions with cholera activity</div>
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Measures to reduce illness from </div>
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Health Agency of Canada and the US CDC websites (</div>
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php</div>
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These recommendations include ensuring safe water and food, and frequent hand washing. Additional</div>
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considerations include bringing a prescription antibiotic to take in case of travelers’ diarrhea, water</div>
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purification tablets, and oral rehydration salts.</div>
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found on the Foreign Affairs and International Trade Canada website at </div>
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asp </div>
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Cholera vaccination is recommended for travelers to endemic regions with a high risk of exposure such as</div>
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humanitarian relief workers, and travelers visiting areas of high risk with limited access to clean water and</div>
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food.</div>
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whole-cell </div>
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Dukoral </div>
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sold as Mutacol</div>
</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">Vibrio cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">for travelers to endemic regions are detailed on Public</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;">http://www.phac-aspc.gc.ca/tmp-pmv/info/choleraeng.</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">, </span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;">http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/cholera.aspx</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">, accessed Nov. 27, 2010).</span></span><span style="font-family: Cambria; font-size: xx-small;"><span style="font-family: Cambria; font-size: xx-small;">3 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">Travel advisories for Canadians travelling abroad can be</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: small;">http://www.voyage.gc.ca/indexeng.</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">(Accessed November 29, 2010).</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">12 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">Two oral cholera vaccines targeted to </span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">V. cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">O1 serogroup are available in Canada: 1) killed</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">V. cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">O1 with purified recombinant B-subunit of cholera toxoid (WC/rBS) sold as</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">TM </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">and 2) an attenuated live oral genetically modified </span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">V. cholerae </span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">O1 vaccine (CVD 103-HgR)</span></span><span style="font-family: Symbol; font-size: small;"><span style="font-family: Symbol; font-size: small;">®</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">. Studies of WC/rBS have demonstrated overall efficacy of 64-90% against infection with</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><div align="left">
Vibrio cholerae </div>
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administered 1-6 weeks apart, and in children aged 2 to 6 years 3 doses must be administered 1-6 weeks</div>
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apart. Full immunity is not attained until 10-14 days after completing the vaccination series, and protection</div>
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against cholera is estimated to be 6 months to 2 years. This vaccine is not protective against </div>
</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">O1 El Tor. In adults, the WC/rBS vaccine (Dukoral </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">TM</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;">) requires 2 doses of vaccine</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: small;">V. cholerae</span></span><span style="font-family: TimesNewRomanPSMT; font-size: small;"><span style="font-family: TimesNewRomanPSMT; font-size: small;"><div align="left">
O139, and is not approved for children less than 2 years old.</div>
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If travelling to a cholera endemic area, consultation with a clinician experienced in travel medicine is advised.</div>
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References</div>
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1. Pan American Health Organization (PAHO). </div>
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accessed November 26, 2010.</div>
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2. Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. </div>
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3. CDC Outbreak notice: Cholera in Haiti. </div>
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4. Goddard J. New York Times online Nov 17, 2010. </div>
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accessed Nov 26, 2010.</div>
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5. World Health Organization Cholera annual report 2009. </div>
</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;">http://new.paho.org/disasters/index.php?option=com_content&task=view&id=1423&Itemid=1 </span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">,</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">Lancet. </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2004 Jan 17;363(9404):223-33.</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;">http://wwwnc.cdc.gov/travel/content/outbreak-notice/haiti-cholera.aspx</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">, accessed November 27, 2010.</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;">http://www.nytimes.com/2010/11/18/us/18florida.html?scp=7&sq=haiti%20cholera&st=cse</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">,</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">Weekly Epidemiological Record</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">, 2010, 85(31):293-308.</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><div align="left">
http://www.who.int/wer/2010/wer8531.pdf</div>
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6. Zuckerman JN, Rombo L, Fisch A. The true burden and risk of Cholera: implications for prevention and control. </div>
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Aug;7(8):521-30</div>
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7. Centers for Disease Control and Prevention. Update: Cholera Outbreak — Haiti, 2010. </div>
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8. Lindenbaum J, Greenough WB and Islam MR. Antibiotic therapy of cholera, </div>
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9. Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A, Mah-e-Muneer S, Shafique S, Khanam M, Chowdhury R. Zinc</div>
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supplementation in children with cholera in Bangladesh: Randomized controlled trial. </div>
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10. Centers for Disease Control and Prevention. CDC Health Information for International Travel 2010. Atlanta: U.S. Department of Health and Human</div>
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Services, Public Health Service, 2009. Online Edition.</div>
</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">, accessed November 26, 2010.</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">Lancet Infect Dis. </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2007</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">MMWR Weekly</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">: Vol. 59, No. 45.November 19, 2010</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">Bull World Health Organ </span></span><b><span style="font-family: TimesNewRomanPS-BoldMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-BoldMT; font-size: xx-small;">36 </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">(1967), pp. 871–883.</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">BMJ </span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2008; 336:266-268.</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><div align="left">
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/cholera.aspx</div>
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11. Swaddiwudhipong W, Peanumlom P. A Case of Nosocomial Cholera during a Community Outbreak in a Thai-Myanmar Border Area. </div>
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Thai </div>
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12. Committee to Advise on Tropical Medicine and Travel. Statement on New Oral Cholera and Travellers' Diarrhea Vaccination. CCDR Volume 31 •</div>
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ACS-7 1 July 2005. </div>
</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">, accessed Nov. 27, 2010.</span></span><i><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPS-ItalicMT; font-size: xx-small;">J Med Assoc</span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">2010; 93 (9): 1112-4.</span></span><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="color: blue; font-family: TimesNewRomanPSMT; font-size: xx-small;">http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/05vol31/asc-dcc-7/index-eng.php</span></span></span><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;"><span style="font-family: TimesNewRomanPSMT; font-size: xx-small;">, accessed Nov 27, 2010.</span></span><span style="font-family: Times-Roman; font-size: xx-small;"><span style="font-family: Times-Roman; font-size: xx-small;"><div align="left">
This document was developed by the Ontario Agency for Health Protection and Promotion (OAHPP). OAHPP provides scientific and technical advice to</div>
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Ontario’s government, public health organizations and health care providers. OAHPP’s work is guided by the best available evidence. This best practice</div>
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document has been peer reviewed and reflects the consensus of experts advising OAHPP.</div>
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This document is intended to assist physicians in clinical decision-making by describing a range of generally acceptable approaches for diagnosis and</div>
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management. This document should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at</div>
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obtaining the same results. The ultimate judgment regarding care of a particular patient must be made by the physician in light of the individual</div>
circumstances presented by the patient. OAHPP is not responsible for the results of the use by anyone of this document.</span></span></i></i></b></i></i></i></i></i></b></i></i></i></i></i></i></b></b></i></b></b></b></i></b></b></b></i></b></b></b></b></b></i></b></b></b></i></b></i></b></b></i></b></i></i></i></b></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-88603256935782475582012-02-03T03:50:00.001-08:002012-02-03T03:50:57.559-08:00ROLE OF MICROBES IN FOOD CHAIN<div dir="rtl" style="text-align: right;" trbidi="on">
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ROLE OF MICROBES IN FOOD CHAIN <br />
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Over the last century many changes to methods of food production have taken place. Bacteria, microscopic in size, are vital participants in the process of food through the chain from soil to plants to the consuming animals and back to the soil. These tiny powerhouses break down organic materials by enzymatic digestion. <br />
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Over some decades of practice the changes in food production have had the effect of decreasing the populations of beneficial bacteria in our food supply and producing new strains of antibiotic-resistant bacteria.<br />
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Superbugs is the new way of describing bacteria that have naturally genetically modified in response to exposure to antibiotics. These superbugs are resistant to antibiotics so they cannot be eradicated with the plethora of drugs currently available. The attention and research in this area is increasing throughout the world. In its World Health Report 1996, the World Health Organization stated that "too few new drugs are being developed to replace those that have lost their effectiveness. In the race for supremacy, microbes are sprinting ahead.<br />
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That bacteria have adapted to the introduction of antibiotics into the food chain is not surprising. In its 'Oldest ever' fossils found report, the BBC News stated that "The oldest and tiniest fossils yet identified …..The bacterial creatures, which resemble "pond slime", were found in North West Australia and are estimated to be approximately three-and-a-half billion years old. Bacteria and algae like them are believed to have filled the primitive, super-heated oceans of the world during the earliest stages of life on this planet." Bacteria have successfully adapted to all manner of environmental changes and impacts. They have an immense capability to change. <br />
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Bacteria can acquire resistance genes through a few routes. Many inherit the genes from their forerunners. Other times, genetic mutations, which occur readily in bacteria, will spontaneously produce a new resistance trait or will strengthen an existing one. And frequently, bacteria will gain a defense against an antibiotic by taking up resistance genes from other bacterial cells in the vicinity. Indeed, the exchange of genes is so pervasive that the entire bacterial world can be thought of as one huge multicellular organism in which the cells interchange their genes with ease. <br />
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Changes that have affected bacteria in the human food chain: <br />
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Soil: Mass production of food has lead to short-cuts being adopted that leave out vital steps, in particular leaving pastures to rest with forage crops, legumes and animals. This slow composting of pastures returns organic matter and nutrients to the soil. Bacteria need dead organic matter to live and multiply and they travel through the food chain to us from the soil so if the soil is depleted this continues up the food chain.<br />
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Plants: In agriculture, antibiotics are applied as aerosols to acres of fruit trees, for controlling or preventing bacterial infections. High concentrations may kill all the bacteria on the trees at the time of spraying, but lingering antibiotic residues can encourage the growth of resistant bacteria that later colonize the fruit during processing and shipping. The aerosols also hit more than the targeted trees. They can be carried considerable distances to other trees and food plants, where they are too dilute to eliminate full-blown infections but are still capable of killing off sensitive bacteria and thus giving the edge to resistant versions. Here, again, resistant bacteria can make their way into people through the food chain, finding a home in the intestinal tract after the produce is eaten.<br />
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Livestock: The same drugs prescribed for human therapy are widely exploited in animal husbandry and agriculture. More than 40 percent of the antibiotics manufactured in the U.S. are given to animals. Some of that amount goes to treating or preventing infection, but the lion's share is mixed into feed to promote growth. In this last application, amounts too small to combat infection are delivered for weeks or months at a time. No one is entirely sure how the drugs support growth. Clearly, though, this long-term exposure to low doses is the perfect formula for selecting increasing numbers of resistant bacteria in the treated animals which may then pass the microbes to caretakers and, more broadly, to people who prepare and consume undercooked meat.<br />
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Humans: The western world's diet has increased in consumption of processed and devitalized food. The amount of sugar, fat, sodium, caffeine, preservatives, artificial colors and flavors in these foods encourages the growth of putrefactive organisms in the human digestive system. These types of foods put loads on the human system instead of providing nutrition. Modern medicines that kill non-resistant bacteria leave areas clear for resistant strains. People should also realize that although antibiotics are needed to control bacterial infections, they can have broad, undesirable effects on microbial ecology within the intestinal system and elsewhere. That is, they can produce long-lasting change in the kinds and proportions of bacteria and the mix of antibiotic-resistant and antibiotic-susceptible types not only in the treated individual but also in the environment and society at large. <br />
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Antibiotics in the Food Chain:<br />
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The widespread use of antibiotics has had far-reaching effects. Imagine a rich lawn of grass; there may be one or two weeds in it but they are not obvious and do not spoil the overall effect. Now imagine the same area after all of it has been sprayed with a herbicide designed to kill grasses indiscriminately. It is barren, but what happens next? Many weeds start to propagate over the entire area. Before the herbicide was applied the grass protected the area from the majority of unwanted weeds; without the grass weeds flourish. The same thing happens within our digestive system when we use antibiotics. Bacteria are wiped out indiscriminately leaving an environment for strong resistant bacteria to take over.<br />
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Back to the grassy area; if the area is replanted with grass and looked after the weeds will not take over, but it is a matter of using enough grass seed and regularly maintaining the area. If we do not repopulate our digestive system with beneficial bacteria and then maintain them, resistant bacteria can take over. <br />
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Multitudes of microorganisms inhabit our systems; all have a role to play somewhere. If they migrate to the wrong part of the system because that part has no competing bacteria they can then become a problem. Imagine our grassy area spreading its runners into a garden bed that has a lot of open, uncultivated areas; the grass itself becomes a weed. The same can happen with bacteria in our systems. <br />
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Candida albicans is a yeast normally found in the intestine. As long as the immune system is healthy Candida albicans is regulated and kept under control, it is considered a normal part of the intestinal flora. Many people who have a problem with Candida overgrowth in their system have histories of antibiotic use. Any imbalance in the populations of friendly bacteria provides an opportunity for other microorganisms to over-populate rampantly and infect other body organs and tissues. Candida albicans has been found in peoples' mouths when they are badly infected; its place is in the intestine. <br />
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Most bacteria help us. They work in our bodies, in the food chain, and in the decomposers of the world to maintain life. They are designed for specific roles and are a vital part of the world in which we live. They may well be the only solution to some of the ecological problems we face both within our systems and in the wider community. They are powerfully designed to do some great things.<br />
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Website References:<br />
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Alive...after 250 million years <br />
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Ancient bacteria trapped in a state of suspended animation for 250 million years are the world's oldest living things, claim US scientists............. <br />
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The Balance of Nature: Food Chains & Webs<br />
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Food Chains and Food Webs: In the living world, every form of life is food for another. Food chains and webs show how food and energy are passed between species................ <br />
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Bats, Bacteria and Biotechnology<br />
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Microorganisms play a crucial role in maintaining the delicate ecological balance of the earth. They revitalize the soil by recycling the minerals and nutrients of decaying matter, and many are essential to the healthy growth of plants. Microorganisms also affect our lives more directly in the manufacture of such items as food products, detergents, antibiotics and antitumor drugs.............. <br />
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Beginning with Bacteria<br />
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Microscopic in size, bacteria are the most numerous organisms in the compost pile. They are on all natural matter in the heap and reproduce at an amazing rate under the proper conditions. Their work initiates the activity of a succession of various organisms, each of which further breaks down complex materials to be utilized by its successor. These tiny powerhouses break down organic materials by enzymatic digestion, resulting in chemical oxidation that promotes their life processes.............. <br />
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The cost of taking nature out of farming <br />
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As the wide door swings open, the nostril-clenching stench almost knocks you over. Sunlight slices through the windowless gloom, across a jostling carpet of chickens stretching from wall to wall............<br />
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A disaster in the making<br />
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High amounts of antibiotics in food chain signal major problems: WASHINGTON (IPS)—Contrary to previous estimates, the amounts of antibiotics used in animal agriculture dwarf those used in human medicine, warns a new report by a public interest organization. The high quantities of antibiotics used in the rearing of pigs, cows and chickens is significant, says the Union of Concerned Scientists (UCS), because of the growing specter of antibiotic-resistant disease................<br />
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Food Chain<br />
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We've all heard the term Food Chain. What follows is my interpretation of the Food Chain as regard the stock reductions in many (if not all) fisheries. Let's take a look at how it works:..................... <br />
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Looking for One of the World's Most Dangerous Toxin Bacteria <br />
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People in the United States are sickened by their food once a year, on average. But the food poisoning that suddenly appeared in White City, Ore., in December 1981 was something else. It was terrifying, and dramatic, and it seemed to have no cause. In the end, however, that mini-epidemic turned out to be the first show of force by a new strain of bacteria that is now infesting the food supply, infecting as many as 20,000 Americans a year and killing 500.......<br />
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'Oldest ever' fossils found <br />
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The oldest and tiniest fossils yet identified will be unveiled at a meeting in Strasbourg next week. The bacterial creatures, which resemble "pond slime", were found in North West Australia and are estimated to be approximately three-and-a-half billion years old.......... <br />
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Powerful Bacteria<br />
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Many times when bacteria are mentioned, they are mentioned in a negative context. We are all aware that there are bacteria that can make us ill. An overwhelming percentage of bacteria is beneficial to us, however. Bacteria work within our bodies to do a number of good things. I can remember years ago, I was invited to visit the "germ-free" facility here in South Bend where germ-free animals are produced for certain kinds of research. I remember one of the workers at the lab complaining that they had a hard time getting rabbits to reproduce if there were no bacteria in their reproductive systems...........<br />
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Pollution Abatement & Reduction Council<br />
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As a commercial fisherman who has seen his industry transmogrified by our intrusive government from an individually based healthy way of life into profit centers for Government (via tarriffs), Corporations (via regulations) and Universities (via grants), I have come to the conclusion we have ALL been fighting the wrong battle, and not only the wrong battle, but one there is NO hope of ever winning. It's emotionally satisfying to be right, but we have all lost anyway and there's no changing that...............<br />
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-64863977140790628472012-01-31T09:28:00.000-08:002012-01-31T09:28:33.879-08:00Enzymes<div dir="rtl" style="text-align: right;" trbidi="on">
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="color: blue; font-size: large;"><em>Enzymes</em></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="color: blue; font-size: large;"><em>Prepared by</em></span></span></div>
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<span style="font-size: large;"><em><span style="color: blue;"><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Fahd Al-</span><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Dhabaan</span><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;"> </span></span></em></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="color: blue; font-size: large;"><em>Ph.D. student</em></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="color: blue; font-size: large;"><em>Faculty of Science</em></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="color: blue; font-size: large;"><em>King Saud University</em></span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-SG; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Enzymes Mode of Action</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Penetration and Infection of the Host</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Pathogens are attached directly into surface of host cells by mucilaginous substances which present on the surface of pathogens. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Mucilaginous substances consisting of mixture of polysaccharides, </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">glycoproteins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, lipids, and </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">fibrillar</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> materials, which, when moistened, become sticky and help the pathogen adhere to the host.</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">After attachment the pathogen grows toward the host surface and pierces the cell wall through mechanical force and enzymatic activity.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">For instance, phytopathogenic fungi can penetrate plant cell walls by secretion of degrading enzymes include pectinases, cellulases, proteases, and xylanases. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Pectinases are the most important in pathogenesis, as they are responsible for tissue maceration by degrading the pectic substances in the middle lamella and, indirectly, for cell death.</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; line-height: 90%; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pectinases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are a group of enzymes that hydrolyze pectin by different mechanisms. They are divided into two classes: </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pectinesterases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">depolymerases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">The </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pectinesterases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> remove </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">methoxy</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> groups from </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">methylated</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">galacturonides</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
<div style="direction: ltr; language: ar-SA; line-height: 90%; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">The </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">depolymerases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> catalyze the cleavage of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">glycosidic</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> bonds via hydrolysis (</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">hydrolases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">) or via β-elimination (</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">lyases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">).</span></span></div>
<div style="direction: ltr; language: ar-SA; line-height: 90%; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">We measure amount of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pectinase</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> by its activity assayed by </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">unit of rate</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> (IU). </span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">IU is defined as the production of one </span><span style="color: black; font-family: "Times New Roman"; language: el; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">μ</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">mole per minute under defined conditions.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Chemical Weapons of Pathogens</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">The chemical weapons are:</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Enzymes </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Toxins </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Growth regulators </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Polysaccharides</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">These substances vary in importance in </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathogenicity</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and from one disease to another.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">In soft rots, enzymes are important. Enzymes break down structural components of cells.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">In crown gall its growth regulators. Growth regulators exert hormonal effects.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Helminthosporium</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> of Victoria<span style="mso-spacerun: yes;"> </span>Oats its toxins. Toxins act directly on protoplast components or interfere with their function</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Pathogenic enzymes and virulence</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">The virulence of some bacteria is aided by the production of extracellular enzymes. <br />Coagulases are bacterial enzymes that coagulate (clot) the fibrinogen in blood</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Bacterial kinases are bacterial enzymes that break down fibrin and thus digest clots formed by the body to isolate the infection. </span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: ar-SA; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Constitutive and inducible enzymes</span></span></div>
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<span style="font-size: large;"><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Constitutive enzymes</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are produced by the cell continually if their substrates are found or not such as phosphorylases.</span></span></div>
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<span style="font-size: large;"><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Inducible enzymes</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are produced by the cell only if their substrates are found such as amylase to hydrolyze starch.</span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">FACTORS AFFECTING ENZYME ACTIVITY</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><br /><span style="mso-spacerun: yes;"><span style="font-size: large;"> </span></span></span><span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-GB; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Enzymes are large globular proteins</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-GB; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Some reaction kinetics</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-GB; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Effect of Temperature on Enzyme Activity</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 24pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">0°C</span></span></u></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Low temperatures </span><span style="color: black; font-family: Wingdings; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-char-type: symbol; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-symbol-font-family: Wingdings;">à</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> low Kinetic Energy of enzymes and substrates.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">No/Very few enzyme-substrate complexes are formed.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Enzymes are </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">inactivated.</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-GB; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">20°C (increasing temperature)</span></span></u></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Increasing</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> the temperature will lead to the </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">increase</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> in </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">kinetic energy</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> of enzyme and substrate molecules.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Enzyme and substrate molecules</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> move with increasing speed and collide more frequently with each other. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">This increases the rate of </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">enzyme-substrate complex</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> formation This increases the rate of </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">enzyme-substrate complex</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> formation and </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">product formation</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: restrictions; punctuation-wrap: simple; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">37°C</span></u><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: ar-SA; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></u></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">As the temperature continues to increase, the rate of enzyme activity also </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">increases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> until the </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">optimal</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">temperature </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">is reached.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Optimal temperature</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> is the temperature at which the enzyme works </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">best.</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-SG; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="mso-spacerun: yes;"> </span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-SG; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Rate of product formation is highest!</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-SG; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-SG; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Denaturation</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Effect of pH on enzyme activity</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Enzyme works best within a narrow pH range. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Each enzyme works best at particular pH, known as its optimum pH level. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">At extreme pH levels, enzymes lose their shape and function and become denatured.<span style="mso-spacerun: yes;"> </span></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: restrictions; punctuation-wrap: simple; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Effect of Substrate on Enzyme Activity</span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Effect of Calcium on Enzyme Activity</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Calcium is considered cofactor or coenzyme which activates the enzyme.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Calmodulin (calcium modulated protein). Binding of Ca</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">++</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> to calmodulin changes its shape and allows binding and activation of certain enzymes</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Effect of Age on Enzyme Activity</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Enzyme activity tends to decline substantially as we age. </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-GB; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mj-ea;">The effect of pH on cell walls</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">-</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pH = -log [H</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">+</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">]</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;"></span></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Acids</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and bases</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Acid has a higher amount of H</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">+</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> ions. pH lower than 7.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Bases contain OH</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">-</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> ions. pH above 7.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Water which is neutral has an equal amount of </span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">H</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">+</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and OH</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea; mso-text-raise: 30%; vertical-align: super;">-</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> ions (hydroxide). pH of 7.</span></span></div>
<div style="direction: ltr; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-size: 44pt; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Acidic and basic media leads to destruction of cell wall and cell membrane. Therefore leads to cell d</span>eath.</span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-size: 44pt; font-weight: bold; language: ar-SA; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"></span></div>
<div style="direction: rtl; language: ar-SA; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: restrictions; punctuation-wrap: simple; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; font-size: 44pt; language: ar-SA; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"></span></div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-79173343573154808982012-01-31T02:42:00.001-08:002012-01-31T02:42:17.720-08:00Real-time PCR<div dir="rtl" style="text-align: right;" trbidi="on">
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<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: left;">
<a href="" name="_Toc38168510"><u><span lang="EN-AU" style="font-family: "Lucida Sans","sans-serif"; font-size: 22pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";"><strong>Real-time PCR<o:p></o:p></strong></span></u></a></div>
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<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt;">
<span style="mso-bookmark: _Toc38168510;"><span lang="EN-AU" style="font-family: "Trebuchet MS","sans-serif"; font-size: 19pt; line-height: 150%;"><strong>A New Tool for the Future<o:p></o:p></strong></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span lang="EN-AU" style="font-family: "Microsoft Sans Serif","sans-serif"; font-size: 12.5pt; line-height: 150%;"><strong>By<o:p></o:p></strong></span></span></div>
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<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt;">
<span style="mso-bookmark: _Toc38168510;"><span lang="EN-AU" style="font-family: "Microsoft Sans Serif","sans-serif"; font-size: 12.5pt; line-height: 150%;"><strong>Lecturer of Virology, Faculty
of Veterinary Medicine, <st1:place w:st="on"><st1:placename w:st="on">Cairo</st1:placename>
<st1:placetype w:st="on">University</st1:placetype></st1:place>, <o:p></o:p></strong></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span lang="EN-AU" style="font-family: "Microsoft Sans Serif","sans-serif"; font-size: 12.5pt; line-height: 150%;"><strong>12211, Giza-Egypt<o:p></o:p></strong></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 15pt; line-height: 150%;"><strong>Introduction:<o:p></o:p></strong></span></u></span></div>
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<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 26.95pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; font-weight: normal; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">The advent of
nucleic acid amplification and detection has resulted in a change from conventional
laboratory methods that rely on phenotypic characterization of pathogens and
antigens, to molecular techniques that enable more sensitive and rapid
identification of infectious agents. Real-time PCR is developed at 1992 as an
evolution of the basic PCR technique developed by Millus et al., and gained
wide acceptance due to its improved rapidity, sensitivity, specificity and the
reduced risk of crossover contamination. The principle of real-time PCR is
based principally on continuous detection of the amplified PCR product while the
amplification progress. This approach provides a great deal of insight into the
kinetics of the reaction and enables quantification of the target sequence in
the tested samples.<o:p></o:p></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 15pt; line-height: 150%;"><strong>Real-Time
versus End-Point PCR:<o:p></o:p></strong></span></u></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span style="font-size: large;">Real-time PCR has a multitude of technical
advantages that render it superior to conventional end-point PCR. These
advantages include: <span style="mso-spacerun: yes;"> </span></span></span></div>
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<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">A)
Sensitivity<o:p></o:p></span></u></b></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Real-Time PCR is the most sensitive molecular application method on the
market of molecular biology. Using its unique chemistries, it is now possible
to detect less copy numbers than with conventional PCR. Highly optimized
real-time PCR systems can detect down to a single copy of the target sequence
and can distinguish between few copies in the tested sample.<o:p></o:p></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">B)
Quantification<o:p></o:p></span></u></b></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">While the results obtained from conventional PCR is qualitative,
real-time PCR offers quantitative data. Qualitative results only give an
indication if the sample is positive or negative. The advantage of Real-Time
PCR is that quantitative analysis could be performed and copy numbers or microbial
load could be determined.<o:p></o:p></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">C)
Speed<o:p></o:p></span></u></b></span></div>
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<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Real-Time PCR is considered to be one of the fastest detection methods
in the field of diagnostic molecular biology. Conventional PCR usually takes up
to one day period to get final results. This delay is basically regarding to
the presence of three distinct steps of reaction: Nucleic acid extraction, PCR
cycling and post PCR analysis. With Real-Time amplification, time is obviously
reduced by omitting the post PCR step and decreasing the cycling protocol
duration, a matter that allows data collection and analysis within one to few
hours.<o:p></o:p></span></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="margin: 0cm 0cm 0pt 14.15pt;">
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<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">D)
Precision:<o:p></o:p></span></u></b></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Real-Time PCR is nearly automated technology that requires very little
human interference. All the data are collected and analyzed by computer
software. This feature usually diminishes the human errors commonly experienced
in the conventional PCR as a consequence of visual interpretation of results
due to the lower gel resolution and size based discrimination of the amplified
fragments.<o:p></o:p></span></span></div>
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<br /></div>
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<span style="mso-bookmark: _Toc38168510;"><a href="" name="OLE_LINK2"></a><a href="" name="OLE_LINK1"><span style="mso-bookmark: OLE_LINK2;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">E) Minimizing contamination issues<o:p></o:p></span></u></b></span></a></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="mso-bookmark: OLE_LINK1;"><span style="mso-bookmark: OLE_LINK2;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Since in Real-Time PCR the results are obtained during the run or
shortly after the run has finished, there is no need to open PCR tubes
containing amplified product. The risk of contaminating the work environment is
therefore strongly reduced.<o:p></o:p></span></span></span></span></div>
<span style="mso-bookmark: OLE_LINK2;"></span><span style="mso-bookmark: OLE_LINK1;"></span>
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<div class="MsoBodyTextIndent" dir="LTR" style="margin: 0cm 0cm 0pt 14.15pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
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<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">F)
Minimizing Workload:<o:p></o:p></span></u></b></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Real-Time PCR is much simpler than conventional PCR and requires less
experience, workload time and effort from the laboratory technician. <span style="mso-spacerun: yes;"> </span>In the traditional PCR, the product has to be
run on agarose gel after the cycling process has finish to verify the results,
while in Real-Time PCR, results are obtained immediately after the run or even
earlier while the assay is still running.<o:p></o:p></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">G)
Minimizing Workspace:<o:p></o:p></span></u></b></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Space and construction are the major problems encounter designing special
molecular biology laboratories. In traditional PCR, three to four separate
rooms equipped with workstation cabinet, PCR thermal cycler, electrophoresis
chambers, power supplies, gel documentation system and some other accessories
should be available. These facilities require adequate space and special
constructions, which is not necessary in real-time PCR, where only a single or
double room containing a workstation cabinet, the Real-time PCR instrument and
some accessories are required.<o:p></o:p></span></span></div>
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<br /></div>
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<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">H)
Mutation analysis<o:p></o:p></span></u></b></span></div>
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<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Traditionally mutation analysis is performed by conventional PCR
followed by a digestion with an appropriate restriction enzyme. In many cases,
known mutation cannot be analysis by the above method, since the lack of a
restriction enzyme side in this area. As a consequence, the PCR product needs
to be sequenced. Mutation analysis using Real-Time Amplification is able to
detect any known mutation using allelic discrimination assays or FRET assays.<o:p></o:p></span></span></div>
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<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">I)
Higher throughput:<o:p></o:p></span></u></b></span></div>
<br />
<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; letter-spacing: -0.1pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">The number of samples that could be tested by
conventional PCR is limited by the practice of electrophoresis. A maximum of 20
or 30 samples could be tested at one shot in most cases. In real-time PCR, the
high speed data collection and automatic analysis of results enabled detection
of the full-capacity of the instrument at a time (up to 100 samples).<o:p></o:p></span></span></div>
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<span style="mso-bookmark: _Toc38168510;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">J)
Less Danger:<o:p></o:p></span></u></b></span></div>
<br />
<div class="MsoBodyTextIndent" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168510;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">The use of highly carcinogenic substances like Ethidium bromide,
SYBRgreen,...etc in staining of the agarose gel is a necessary step for
visualizing the PCR product and getting results in end-point PCR. As a result
of removal of the post PCR analysis in real-time PCR, there is no need for
exposure to these dangerous substances that considered a potentional health
hazard.<o:p></o:p></span></span></div>
<br />
<div class="MsoBodyTextIndent" dir="LTR" style="margin: 0cm 0cm 0pt; text-align: justify; text-indent: 21.6pt; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<strong><span style="mso-bookmark: _Toc38168510;"><u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 15pt; line-height: 150%;">2.
Real-Time </span></u></span><u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 15pt; line-height: 150%;">PCR bases:<o:p></o:p></span></u></strong></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 14pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">A) PCR phases:<o:p></o:p></span></u></b></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt; text-justify: kashida; text-kashida: 0%;">
<span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">In
order to understand the limitation of end point PCR and how real-time PCR was
developed, it is essential to outline the phases of PCR run. A standard PCR run
is composed of 25- 40 cycle, these cycles can be broken into three distinct
phases:<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt 18pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">1- Exponential phase:</span></b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;"> Exact
doubling of product is accumulating at every cycle. The reaction is highly
specific and precise (reaction efficiency nearly 100%).<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt 18pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">2- Linear (High variability) Phase:</span></b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;"> The
reaction components begin to consume. The reaction is slowing down and products
are starting to degrade (reaction efficiency less than 100%).<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt 18pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">3- Plateau (End point):</span></b><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;"> The
reaction has stopped with no more products accumulated. If left for a long
period, the PCR products will begin to degrade. At this phase, the products are
analyzed in agarose gel for conventional PCR.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 14pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">B) Real-time PCR principle:<o:p></o:p></span></u></b></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify; text-indent: 27pt;">
<span style="font-size: large;">The real-time PCR is basically relied on
the same principle adopted for PCR amplification of specific DNA fragments. It
also needs the inclusion of a fluorescent reporter that binds either
specifically or non-specifically to the amplification product and generates a
fluorescent signal. The amount of emitted fluorescence is proportional to the
amount of the PCR product accumulated. During the initial cycles the signal is
week and can not be distinguished from the background. As the amount of product
accumulates, the signal increases exponentially and a responsive curve
develops. <span style="mso-spacerun: yes;"> </span>This curve is used to define
for calculation of the initial copy number of the target gene or sequence in
the sample at the beginning of reaction. </span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify;">
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<br /></div>
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<br /></div>
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<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
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<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168511;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 14pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">C)
Real-time PCR chemistries: <o:p></o:p></span></u></b></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168511;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">Four major chemistries are currently
in use for real-time PCR detection.</span> </span><span style="mso-bookmark: _Toc38168511;"><span style="font-size: 14pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-size: 10.0pt;">They include:<o:p></o:p></span></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 3pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span style="mso-bookmark: _Toc38168511;"><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">1-
Intercalating dye</span></u></b></span><b><u><span lang="EN-GB" style="font-family: "Lucida Sans","sans-serif"; font-size: 13pt; line-height: 150%; mso-bidi-font-family: "Times New Roman";">:<o:p></o:p></span></u></b></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">Intercalating dyes, such as SYBR-Green I, RiboGreen, BEBO, YOYO, ....etc
bind to double stranded DNA.<o:p></o:p></span></span></div>
<br />
<div align="left" dir="ltr">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; margin: auto auto auto 12.5pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; width: 582px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0); border-style: solid solid none; border-width: 1pt 1pt 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 211.7pt;" valign="top" width="282">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1025" style="height: 99pt; width: 198pt;" type="#_x0000_t75">
<v:imagedata o:title="Renee11" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\16\clip_image003.png">
</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 207pt;" valign="top" width="276">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1026" style="height: 100.5pt; width: 198pt;" type="#_x0000_t75">
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</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 211.7pt;" valign="top" width="282">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">A<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">SYBR-Green (S) does not
bind to single stranded DNA and the intensity of fluorescent signal when S
excited by (E) is low.<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border: 0px rgb(0, 0, 0); padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 207pt;" valign="top" width="276">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">B<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;"><span style="mso-spacerun: yes;"> </span>SYBR-Green (S) binds to double stranded DNA
and the intensity of fluorescent signal when S excited by (E) increases.</span><i style="mso-bidi-font-style: normal;"><span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU;"><o:p></o:p></span></i></div>
</td>
</tr>
</tbody></table>
</div>
<br />
<div class="MsoBodyText" dir="LTR" style="margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify; text-indent: 26.95pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">SYBR-Green is a fluorescent
dye that binds to the minor groove of DNA double helix. The unbound dye
exhibits little fluorescence in solution, but upon binding to double-stranded
DNA the fluorescence is enhanced. This is utilized in real-time amplification.
As DNA is amplified during an amplification reaction, the dye binds to the
amplified product and the fluorescent signal is increased cycle after cycle.<o:p></o:p></span></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify; text-indent: 26.95pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">Intercalating dyes can simply
be added to the amplification reaction tubes along with all the other
traditional amplification components: water, buffer, MgCl</span><span style="font-size: small;"><sub>2</sub></span><span style="font-size: large;">, dNTP’s,
Taq-Polymerase, primers and template. This is an easy and cost effective
approach to real-time detection, as it does not require the design of sequence
specific probes and new primer sets. <o:p></o:p></span></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">Intercalating dyes are not sequence specific and
bind to any dsDNA including non-specific products and primer dimers. Therefore,
it is necessary to differentiate between target and artifact signals.
Intercalating dyes allow for the melting of amplification products at the end
of a run. This is called the melt curve analysis. During the melt curve, the
real-time machine continuously monitors the fluorescence of each sample as it
is slowly heated from a temperature below the melting point of the products to
a temperature above the melting point of the products. Amplification products
will melt at different temperatures based on their lengths and G/C content. As
products melt, a decrease in fluorescence is realized and measured by the
instrument. By taking the differential of the melt curve, the melting peaks can
be calculated. The melting peaks reflect the products amplified during the
reaction. These peaks are analogous to the bands on an electrophoresis gel.<o:p></o:p></span></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt;">
<br /></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><v:shape fillcolor="#09c" id="_x0000_s1026" strokecolor="white" style="height: 139.35pt; mso-position-horizontal-relative: char; mso-position-vertical-relative: line; width: 306pt;" type="#_x0000_t75"><span style="font-size: large;">
<v:fill color2="#039">
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<v:shadow color="#000514">
<o:lock aspectratio="f" v:ext="edit">
<w:wrap type="none">
<w:anchorlock>
</w:anchorlock></w:wrap></o:lock></v:shadow></v:imagedata></v:fill></span></v:shape><o:p></o:p></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<a href="" name="_Toc38168512"><b><u><span lang="EN-GB" style="font-size: 14pt; line-height: 150%;">B) Dual-Labeled Probes</span></u></b></a><b><u><span lang="EN-GB" style="font-size: 14pt; line-height: 150%;"> (Hydrolysis or TaqMan
Probes):<o:p></o:p></span></u></b></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 28.8pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">Dual labeled probes are short oligos with a
fluorescent reporting dye attached to the 5’-end and a quencher molecule
attached to the 3’-end. Because the probes are only 15-25 bp long, the reporter
dye and quencher are in close proximity to each other and little fluorescence
is detected. During the cycling process, Taq DNA-polymerase extends from each
primer. The DNA polymerase has an exonuclease activity that cleaves the
downstream probe as it extends. As the probe is degraded, the reporter dye is
separated from the quencher. <o:p></o:p></span></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
<br />
<div align="left" dir="ltr">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; margin: auto auto auto 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; width: 588px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0); border-style: solid solid none; border-width: 1pt 1pt 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 198pt;" valign="top" width="264">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1028" style="height: 100.5pt; width: 198pt;" type="#_x0000_t75">
<v:imagedata o:title="Renee13" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\16\clip_image009.png">
</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 225pt;" valign="top" width="300">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1029" style="height: 99pt; width: 198pt;" type="#_x0000_t75">
<v:imagedata o:title="Renee14" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\16\clip_image011.png">
</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 198pt;" valign="top" width="264">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">A<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">Energy emitted by the
donor fluorophore (D) when excited by (E) is absorbed by the nearby quencher
(A).<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border: 0px rgb(0, 0, 0); padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 225pt;" valign="top" width="300">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">B<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">The polymerase exonuclease activity separates the
fluorophore donor (D) from the quencher (A) by hydrolysis and resulting in an
increase in fluorescent signal when D excited by E.<o:p></o:p></span></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
</td>
</tr>
</tbody></table>
</div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">With every cycle of amplification an increase in
reporting dye is detected by the real-time instrument due to the cleavage of
the probes. Because the reporting dye is cleaved, melt curve analysis is not
possible. Dual labelled probes offer higher specificity and sensitivity compared
to intercalating dyes. There are two reasons for this. First, dual labelled
probes are sequence specific and only bind to complimentary regions. The second
reason is that the dual labelled probe for each amplified copy releases only
one molecule of fluorescent dye.<o:p></o:p></span></span></div>
<br />
<div class="MsoBodyText" dir="LTR" style="margin: 0cm 0cm 0pt; text-align: justify; text-indent: 27pt;">
<br /></div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<a href="" name="_Toc38168513"><b><u><span lang="EN-GB" style="font-size: 14pt; line-height: 150%;">C) FRET Probe System</span></u></b></a><b><u><span lang="EN-GB" style="font-size: 14pt; line-height: 150%;"> (Hybridization or
LightCycler Probes):<o:p></o:p></span></u></b></div>
<br />
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt;">
<span lang="EN-AU" style="line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 14.0pt;"><span style="font-size: large;">FRET probes rely on the transfer of energy from
one fluorescent dye to another. Two separate sequence specific oligos are
fluorescently labelled, one molecule (donor) on the 3’-end and the other (acceptor)
on the 5’-end. The probes are designed so that they hybridise adjacently to
each other on the target sequence and bring the donor and acceptor fluorophores
in close proximity. This allows transfer of energy from the donor to the
acceptor fluorophore, which emits a signal of a different wavelength. Either
the decrease in the fluorescence of the donor or the increase in fluorescence
of the acceptor can then be detected. Therefore, only when both probes are
bound is fluorescence detectable. <o:p></o:p></span></span></div>
<br />
<div align="left" dir="ltr">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; margin: auto auto auto 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; width: 588px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0); border-style: solid solid none; border-width: 1pt 1pt 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 207pt;" valign="top" width="276">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1030" style="height: 98.25pt; width: 198pt;" type="#_x0000_t75">
<v:imagedata o:title="Renee15" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\16\clip_image013.png">
</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 216pt;" valign="top" width="288">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<span lang="EN-AU" style="font-size: 12pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-size: 10.0pt;"><v:shape fillcolor="window" id="_x0000_i1031" style="height: 103.5pt; width: 198pt;" type="#_x0000_t75">
<v:imagedata o:title="Renee16" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\16\clip_image015.png">
</v:imagedata></v:shape><o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 207pt;" valign="top" width="276">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">A<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">Energy emitted from the
donor after excitation by (E) is low when the probes are not hybridized.<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border: 0px rgb(0, 0, 0); padding: 0cm 5.4pt; width: 18pt;" valign="top" width="24">
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify;">
<br /></div>
</td>
<td style="background-color: transparent; border-color: windowtext rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid none none; border-width: 1pt 0px 0px; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 216pt;" valign="top" width="288">
<div align="center" class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: center;">
<b><span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">B<o:p></o:p></span></b></div>
<div class="MsoBodyText" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-family: "Arial","sans-serif"; font-size: 10pt; letter-spacing: -0.2pt; line-height: 150%; mso-ansi-language: EN-AU; mso-bidi-font-style: italic;">Hybridization of the
probes brings the donor (D) and acceptor (A) fluorophores into close
proximity resulting in increased energy transfer and fluorescence emitted
from the acceptor.<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
</div>
<br />
<div class="MsoNormal" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 0pt;">
<br /></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 15pt; line-height: 150%;"><strong>3. Applications of Real-Time:<o:p></o:p></strong></span></u></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-size: 14pt; font-weight: normal; line-height: 150%;"><span style="mso-list: Ignore;">A.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span lang="EN-AU" style="font-size: 14pt; font-weight: normal; line-height: 150%;">Pathogen detection
and quantitation either virus, bacteria, protozoa, fungi, algae,…etc.<o:p></o:p></span></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;"><span style="mso-list: Ignore;">B.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;">Genotypic
of different pathogenic organism. <o:p></o:p></span></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-size: 14pt; font-weight: normal; line-height: 150%;"><span style="mso-list: Ignore;">C.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span lang="EN-AU" style="font-size: 14pt; font-weight: normal; line-height: 150%;">Quantitative
analysis of gene expression in immunological studies, cancer research and drug
therapy efficacy.<o:p></o:p></span></div>
<br />
<div class="MsoTitle" dir="LTR" style="line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;"><span style="mso-list: Ignore;">D.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;">Mutation
detection and analysis of different aspects of genetic diversity.<o:p></o:p></span></div>
<br />
<div style="border-color: currentColor currentColor windowtext; border-style: none none solid; border-width: medium medium 1.5pt; mso-element: para-border-div; padding: 0cm 0cm 1pt;">
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-list: l0 level1 lfo1; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;"><span style="mso-list: Ignore;">E.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span lang="EN-AU" style="font-size: 14pt; font-weight: normal; letter-spacing: -0.1pt; line-height: 150%;">Quality
control of different biological materials and Assays validation.<o:p></o:p></span></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; margin: 0cm 0cm 0pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<br /></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<u><span lang="EN-AU" style="font-family: "Georgia","serif"; font-size: 14pt; letter-spacing: -0.1pt; line-height: 150%;"><strong>References:<o:p></o:p></strong></span></u></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span style="font-weight: normal; letter-spacing: -0.1pt; mso-ansi-language: EN-US;">1- Kubista, M.; Andrade, J.;
Bengtsson, M.; Forootan, A. et al., (2006). The real time polymerase chain reaction.
Molecular Aspects of Medicine, 27: 95-125. <o:p></o:p></span></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span style="font-weight: normal; letter-spacing: -0.1pt; mso-ansi-language: EN-US;">2- Mackay, <st1:place w:st="on">I.</st1:place>
M. (2004). Real-time PCR in the microbiology laboratory. European Society of
Clinical Microbiology and Infectious Diseases.<o:p></o:p></span></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span style="font-weight: normal; letter-spacing: -0.1pt; mso-ansi-language: EN-US;">3- Klein, D. (2002).
Quantification using real-time PCR technology: application and limitation.
TRENDS in Molecular Medicine, 8 (6): 257-260.<o:p></o:p></span></div>
<div class="MsoTitle" dir="LTR" style="border: currentColor; line-height: 150%; margin: 0cm 0cm 6pt 18pt; mso-border-bottom-alt: solid windowtext 1.5pt; mso-padding-alt: 0cm 0cm 1.0pt 0cm; padding: 0cm; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;">
<span lang="DE" style="font-weight: normal; letter-spacing: -0.1pt; mso-ansi-language: DE;">4- Mackay, I.; Arden, K. E. and
Nitsche, A. (2002). </span><span style="font-weight: normal; letter-spacing: -0.1pt; mso-ansi-language: EN-US;">Real-time PCR in Virology. Nucelic Acids Research, 30
(6): 1292-1305.<o:p></o:p></span></div>
</div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-81690731131267460942012-01-31T02:11:00.000-08:002012-01-31T02:11:17.726-08:00Mechanisms of some Toxins<div dir="rtl" style="text-align: right;" trbidi="on">
<br />
<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Mechanisms of some Toxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
<div dir="ltr" style="text-align: center;">
<span style="font-size: large;">
</span></div>
<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Prepared by</span></span></div>
<div dir="ltr" style="text-align: center;">
<span style="font-size: large;">
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<span style="font-size: large;"><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Fahd Al-</span><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">Dhabaan</span><span style="color: #333399; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 5; mso-fareast-font-family: +mj-ea;">
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Ph.D. student</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">King Saud University</span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxin</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> is a chemical of biological origin other than an enzyme that
plays an important role in a plant disease.</span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Most </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are produced by plant pathogenic fungi such as </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Alternaria</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">alternata</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> or bacteria such as </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pseudomonas
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">seruginosa</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, but some are produced by higher
plants, and one has been reported to be the product of an interaction between a
plant and a bacterial pathogen.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Properties of Pathotoxins</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Some </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are selective in their action
but others are nonselective.</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Some of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> act as plant growth regulators.</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> are considered </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">microtoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> due to small size of their
molecules.</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> cause plant diseases as well as
fungal-fungal destruction.</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Chemistry and mode of action of pathotoxins</span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> mean toxins which cause </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathogenicity</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> to organisms. </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Pathotoxins</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> group included various members
of toxins each of which has specific manner such as gibberellins, </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">fusicoccin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, and </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">tentoxin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">.</span></span></div>
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<u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Gibberellins</span></span></u></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="mso-spacerun: yes;">
</span>The gibberellins were produced by the fungus </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Gibberella</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">fujikuroi</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and cause disease of rice. This
fungus which produces gibberellins infects the plant and form long internodes,
which typify the effects of this group of plant hormones</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
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<span style="font-size: large;"><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusicoccin</span></u><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="mso-spacerun: yes;">
</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusicoccin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> produced by the fungus </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusicoccum</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">amygdali</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, which causes a wilt disease of
peach and almond trees, is another nonselective </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pathotoxin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> with growth-regulator
properties. </span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">This chemical also causes stomata
to open</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
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<span style="font-size: large;"><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Tentoxin</span></u><u style="text-underline: single;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="mso-spacerun: yes;">
</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Tentoxin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> is a product of </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Alternaria</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">alternata</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, it causes a striking variegated
</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">chlorosis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> in cucumber, cotton, lettuce,
and many other sensitive plants, but has no effect on tobacco, radish, willow,
or other insensitive species. </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Tentoxin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> binds specifically to coupling factor 1 in chloroplasts of
sensitive species, and presumably acts by disrupting energy generation in the </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">photophosphorylative</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> electron transport system. </span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Figure </span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><br /><span style="font-size: large;">
Leaf spots and </span></span><span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">chlorosis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> caused by the </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Alternaria</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">alternata</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">toxin</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Victorin</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> (HV-toxin)</span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Victorin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> is produced by the fungus </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Cochliobolus</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
(</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Helminthosporium</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">)
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">victoriae</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Cochliobolus</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">victoriae</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">infects the basal portions of
susceptible oat plants and produces a toxin that is carried to the leaves,
causes a leaf blight, and destroys the entire plant. Toxin production in the
fungus is controlled by a single gene (</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Vb</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">).</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Victorin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> cause loss of electrolytes from
cells and increased respiration. Subsequently leads to decreased both of growth
and protein synthesis.</span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">The toxin not only produces all
the external symptoms of the disease induced by the pathogen, but it also
produces similar </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">histochemical</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> and biochemical changes in the host, such as changes in cell
wall structure </span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Victorin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> has been purified and its
chemical structure has been determined to be a complex chlorinated, partially
cyclic </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">pentapeptide</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span></span></div>
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<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">The primary target of the toxin
seems to be the cell plasma membrane where </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">victorin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> seems to bind to several
proteins. The possible site of action of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">victorin</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> seems to be the </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">glycine</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">decar-boxylate</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> complex</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">. </span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Fusaric acid</span></span></div>
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<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusaric</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> acid is a </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">picolinic</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> acid derivative produced from
various </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusarium</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> species such as </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Fusarium</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">oxysporum</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">, and has been proposed for a
various therapeutic applications. However, it is primarily used as a research
tool. </span></span></div>
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<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Its mechanism of action is not
well understood. It likely inhibits </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Dopamine beta-</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">hydroxylase</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">(the enzyme that converts
dopamine to </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">norepinephrine</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">). It may also have other actions, such as the inhibition of
cell proliferation and DNA synthesis.</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">Factors affecting the toxicity</span></span></div>
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<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Toxin dose:</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> Toxicity depends on the dose of
the poison introduced into the host, so that the proportional relationship
between the dose of poison and toxicity. The more toxic dose increased the
effect of toxicity.</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">Time of poison
abuse:</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> Toxicity increases over time from the beginning of the poison
abuse where the toxin spreads and dips in the body of the host and be able to
cause damage or death. </span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
</span></span></div>
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<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">3. Age of host:</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> Age of host is a significant
factor which depend upon it the extent of toxicity. High toxicity be on two
phases of the life on opposite sides either in the early or later stages of age
due to weakened immunity and little or no resistance to the poison. Youth is
the stage of power that can be faced the toxicity correlated with other
factors.</span></span></div>
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<div dir="ltr" style="language: en-US; margin-bottom: 0pt; margin-top: 0pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;">4. Nutrition of
host:</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> The host can resists the influence of the poison and slows
down its spreading if there is proper nutrition because vitamins and proteins
delay the activity of the toxin. And vice versa, toxicity increases if the host
body was weak due to malnutrition.</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"> </span></span></div>
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<span style="color: black; font-family: Arial; font-weight: bold; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Andalus; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mj-ea;"><span style="font-size: large;">
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-32658219967049233172012-01-31T02:01:00.000-08:002012-01-31T02:01:45.400-08:00Enzymes<div dir="rtl" style="text-align: right;" trbidi="on">
<br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 14.4pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: center; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: 60pt;"><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-size: 60pt; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><br />
<br />
</span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">Enzymes</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><br /><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 14.4pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Definition of
Enzymes</span></span></div>
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</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 9.6pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Enzymes</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> are proteins that catalyze (i.e</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">.</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">, increase the rates) of chemical
reactions. </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 9.6pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">In enzymatic reactions, the
molecules at the beginning of the process, called </span><span style="color: #ff3399; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: +mn-ea;">substrates</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">, are converted into different
molecules, called </span><span style="color: #ff3399; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: +mn-ea;">products</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">. </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Role of Enzymes
in Pathogenicity</span></span></div>
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</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Enzymes secreted by fungi are
important factors of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">pathogenicity</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">. </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Dermatophytes</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> penetrate the keratinous layer
of the epidermis as well as hairs and nails and cause superficial infections.</span><span style="color: black; font-family: "Times New Roman"; language: ar-SA; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Dermatophytes</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> produce proteases and lipases
which help them invade the hosts tissues. </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">The enzymes disrupt the structure
of protein and lipid components of lipid cell membranes and lead to the
impairment of the membranes function or to their disruption. </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
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</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Plant cell walls are composed
of<span style="mso-spacerun: yes;"> </span>polysaccharides.<span style="mso-spacerun: yes;"> </span>the pathogens secrete the </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">degradative</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> enzymes which degrade the
cellulose and pectin by the addition of water to break the </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">glycosidic</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> bonds. There are many cell wall
degrading enzymes such as:</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Cellulases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Pectinases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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</span><br />
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Hemicellulases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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</span><br />
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Proteases</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">5.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Lignases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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</span><br />
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">6.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Cutinases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
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<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
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</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span><span style="mso-special-format: bullet;"><span style="font-size: large;">•</span></span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">Figure 1
<br />
Structure of Plant Cell Wall</span></span></div>
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<span><span style="mso-special-format: bullet;"><span style="font-size: large;">•</span></span></span><span style="font-size: large;"><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Figure
2<br />
The glycosidic bond is represented by the central oxygen atom, which holds the
two monosaccharides</span><span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 8.64pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Hydrolytic
Enzymes of Candida albicans</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Candida
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">albicans</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> has hydrolytic enzymes which are
</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">extracellularly</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> secreted. They may play an
important role in the </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">pathogenicity</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">candidosis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">.</span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Candida
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">albicans</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> causes inflammatory lesions in
the mucous membrane of oral cavity. </span></span></div>
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<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">There is study aimed to find
differences in the activity of hydrolytic enzymes of </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Candida
</span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">albicans</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> isolated from patients with
diseases of the </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">periodontium</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> and mucous membrane of the oral cavity. </span></span></div>
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<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
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</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Of 235 patients examined: </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">31 were diagnosed with gingivitis
(inflammation of </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">gingiva</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">) </span></span></div>
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<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">38 with </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">glossitis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (inflammation of tongue) </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">28 with </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">leukoplakia</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (white patch on a mucous
membrane that will not rub off) </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">37 with adult </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">periodontitis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (inflammation of gingival
surrounding membranes of adults)<span style="mso-spacerun: yes;"> </span></span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">5.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">25 with juvenile </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">periodontitis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (inflammation of gingival
surrounding membranes of juvenile) </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">6.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">36 </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">stomatitis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">prothetica</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (inflammation of oral mucosa
which will die and others instead) </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; line-height: 90%; margin-bottom: 0pt; margin-left: 0.58in; margin-top: 6.72pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.58in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">7.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">40 with </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">stomatitis</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">atrophica</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> (inflammation of oral mucosa
which will decrease in the size). </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 10.56pt; mso-line-break-override: restrictions; punctuation-wrap: simple; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 3; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 8.64pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: bullet;">•</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">In 196 patients (83.4 %), fungi
belonging to </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Candida</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> species were detected. Among
them 146 strains of </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Candida </span><span style="color: black; font-family: "Times New Roman"; font-style: italic; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">albicans</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> were found. Where detection of
19 </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">hydrolases</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"> were found. </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.38in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.38in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 8.64pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span><span style="mso-special-format: bullet;"><span style="font-size: large;">•</span></span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">Factors
catalyzing enzymatic <br />
cell wall hydrolysis </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Optimum temperature for enzymatic
activity.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Optimum pH for enzymatic
activity.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Presence of specific enzyme
receptors on the surface of cell wall.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Presence of enzyme substrate
abundance.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">5.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Secretion of enzyme
extracellularly. </span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">6.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Absence of cuticle containing
pectin as in plant roots</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; text-indent: -0.67in; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 8.64pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span><span style="mso-special-format: bullet;"><span style="font-size: large;">•</span></span></span><span style="color: black; font-family: "Times New Roman"; font-weight: bold; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">Factors
inhibiting enzymatic <br />
cell wall hydrolysis</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">1.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Unsuitable environmental
conditions which affect enzymatic activity such as temperature (< 20 or >
42 °C) and pH (< 6 or > 8).</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">2.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Absence of enzyme substrate.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">3.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Absence of specific enzyme
receptors on the surface of cell wall.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: justify; text-indent: -0.67in; text-justify: inter-ideograph; unicode-bidi: embed; vertical-align: baseline;">
<span style="font-size: large;"><span><span style="mso-special-format: "numbullet3,1";">4.</span></span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">Secretion of enzyme </span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">intracellularly</span><span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;">.</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: ltr; language: en-US; margin-bottom: 0pt; margin-left: 0.67in; margin-top: 7.68pt; mso-line-break-override: none; punctuation-wrap: hanging; text-align: left; text-indent: -0.67in; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: "Times New Roman"; language: en-US; mso-ascii-font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
<span style="font-size: large;">
</span><br />
<div style="direction: rtl; language: en-US; margin-bottom: 0pt; margin-right: 0.38in; margin-top: 7.68pt; mso-line-break-override: restrictions; punctuation-wrap: simple; text-align: right; text-indent: -0.38in; unicode-bidi: embed; vertical-align: baseline;">
<span style="color: black; font-family: Arial; language: en-US; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-color-index: 1; mso-fareast-font-family: +mn-ea;"><span style="font-size: large;">
</span></span></div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-39777932848381717822012-01-31T01:22:00.001-08:002012-01-31T01:22:34.618-08:00Interactive effects of Arbuscular mycorrhizal fungi and<div dir="rtl" style="text-align: right;" trbidi="on">
<br />
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<b><span style="font-family: "Arial","sans-serif"; font-size: 14pt;">Interactive
effects of Arbuscular mycorrhizal fungi and</span></b><b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif"; font-size: 14pt;"><o:p></o:p></span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 14pt;">rhizobial
strains on chickpea growth and nutrient</span></b><b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif"; font-size: 14pt;"><o:p></o:p></span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 14pt;">content
in plant<o:p></o:p></span></b></div>
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<b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif"; font-size: 14pt;">التأثيرات التفاعلية لسلالات فطريات الميكوريزا
الشجيرية وسلالات بكتريا الريزوبيوم<o:p></o:p></span></b></div>
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<b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif"; font-size: 14pt;">على نمو نبات الحمص ومحتواه الغذائى<o:p></o:p></span></b></div>
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<span style="font-family: "Arial","sans-serif";">Alireza
Tavasolee<sup>1*</sup>, Nasser Aliasgharzad<sup>1</sup>, Gholamreza
SalehiJouzani<sup>2</sup>, Mohsen Mardi<sup>2</sup> and Ahmad Asgharzadeh<sup>3</sup></span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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<span dir="LTR"></span><sup><span style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>1</span></sup><span style="font-family: "Arial","sans-serif";">Department of Soil Science, University
of Tabriz, Iran.</span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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<span dir="LTR"></span><sup><span style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>2</span></sup><span style="font-family: "Arial","sans-serif";">Agricultural Biotechnology Research
Institute (ABRII) Karaj, Iran.</span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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<span dir="LTR"></span><sup><span style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>3</span></sup><span style="font-family: "Arial","sans-serif";">Soil and Water Research Institute (SWRI),
Tehran, Iran.</span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Accepted
25 May, 2011<o:p></o:p></span></div>
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<b><u><span style="font-family: "Arial","sans-serif";">Abstract<o:p></o:p></span></u></b></div>
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<span style="font-family: "Arial","sans-serif";">Legumes form a tripartite symbiosis
with Arbuscular mycorrhizal fungi (AMF) and rhizobia. Chickpea plants were
inoculated with six strains of <b><i>Mesorhizobium ciceri</i></b> and three AMF
species, <b><i>Glomus intraradices</i></b> (GI), <b><i>G. mosseae</i></b> (GM)
and <b><i>G. etunicatum</i></b> (GE). The plants inoculated with a number of
AMF species and bacterial strains increased overall plant dry mass compared to
non-inoculated plants. GE was the most efficient in increasing plant dry
matter. Individual AMF species were more effective than when mixed (GI+GM+GE).
Bacterial treatments had increasing effect on root colonization by GI, GM and
GI+GM+GE. The results revealed that dual inoculation with AMF and <b><i>Rhizobium</i></b>
enhanced nitrogen, phosphorus, zinc, iron and copper content in plants but
these increasing effects was different between fungal and bacterial treatments.<o:p></o:p></span></div>
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<b><u><span lang="AR-SA" style="font-family: "Arial","sans-serif";">الملخص<o:p></o:p></span></u></b></div>
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<span lang="AR-SA" style="font-family: "Arial","sans-serif";">تكون
البقوليات علاقة تكافلية ثلاثية مع فطريات الميكوريزا الشجيرية </span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>(AMF)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> وبكتريا
الريزوبيا. فى هذا البحث تم حقن نباتات الحمص بست سلالات من </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Mesorhizobium ciceri</span></i></b><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> (البكتريا)<b><i> </i></b>وثلاثة أنواع من جنس </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Glomus</span></i></b><span dir="RTL"></span><b><i><span style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> </span></i></b><span lang="AR-SA" style="font-family: "Arial","sans-serif";">(أحد
أجناس فطر الميكوريزا) وهم كالآتى </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Glomus intraradices</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";"> (GI)</span><span dir="RTL"></span><b><i><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> ، </span></i></b><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">G. mosseae</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";"> (GM)</span><span dir="RTL"></span><b><i><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> ،</span></i></b><span dir="LTR"></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span> G. etunicatum</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";"> (GE)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>.<b><i> </i></b>ولوحظ
أن النباتات التى تم حقنها بسلالات البكتريا وسلالات فطر الميكوريزا تزيد كتلتها
الجافة (الوزن الجاف) عن تلك التى لم يتم حقنها. وبمقارنة تأثير سلالات الفطر على
النبات وجد أن النوع الثالث </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">G.
etunicatum</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";">
(GE)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> هو الأكثر فعالية فى زيادة الوزن الجاف. وقد ثبت أن حقن كل سلالة
فطرية على حدى أكثر فعالية من حقن النبات بخليط من السلالات الثلاثة </span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>(GI+GM+GE)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>. وقد أثبت البحث
أن المعالجات البكتيرية زادت من إنشاء المستعمرات البكتيرية على الجذور مع الاتحاد
مع كل من فطر</span><span dir="LTR"></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span> Glomus intraradices</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";"> (GI)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>، </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">G. mosseae</span></i></b><span dir="LTR" style="font-family: "Arial","sans-serif";"> (GM)</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> ،
وخليط من السلالات الثلاثة </span><span dir="LTR" style="font-family: "Arial","sans-serif";">GI+GM+GE</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>. وقد كشفت النتائج على أن الحقن المزدوج من فطر الميكوريزا (أيا
كانت السلالة المستخدمة) وبكتريا الريزوبيوم (أيا كانت السلالة المستخدمة) يزيد من
محتوى النيتروجين والفوسفوروالزنك والحديد والنحاس فى النبات. ولكن هذه الزيادات
تختلف حسب السلاة المستخدمة من الفطر والبكتريا.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
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<u><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><span style="mso-spacerun: yes;"> </span></span></u><b><u><span style="font-family: "Arial","sans-serif";">Introduction</span></u></b><u><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></u></div>
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<span style="font-family: "Arial","sans-serif";">Most legumes possess two main types of root symbiosis
with microorganisms, namely atmospheric N2-fixing bacteria and mycorrhizal
fungi, thus establishing a triple association capable of supplying plants,
especially for N and P requirements <b>(Silveira and Cardoso, 2004)</b>.
Arbuscular mycorrhizal<i> </i>fungi (AMF) usually enhance nodulation and
nitrogen fixation in legumes, but the extent of these effects depends on AMF
species <b>(Valdenegro et al., 2001)</b>. The increase in total N has been
explained mainly by an increase in N2-fixation as a result of a higher P uptake
through the AM hyphae rather than increased soil N uptake <b>(Mortimer et al.,
2008)</b>. Although, there are many studies on the interactions between AMF and
bacteria, the underlying mechanisms behind these associations are not yet well
understood, and their functional properties still require further studies. The
main objectives of this study were to investigate interactions between
different strains of <b><i>Mesorhizobium ciceri</i></b><i> </i>and AMF species
on plant growth, nutrient content and AMF root colonization.</span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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<b><u><span lang="AR-SA" style="font-family: "Arial","sans-serif";">المقدمة<o:p></o:p></span></u></b></div>
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<span lang="AR-SA" style="font-family: "Arial","sans-serif";">أغلب
البقوليات تمتلك نوعين أساسيين من العلاقة التكافلية بين الجذر والكائنات الدقيقة
وهما (1) البكتريا المثبتة للنيتروجين الجوى و (2) فطريات الميكوريزا وبذلك تكون
هناك علاقة تكافلية ثلاثية قادرة على دعم النبات ، وخصوصا بالنسبة لاحتياجات
النبات من النيتروجين والفوسفور <b>(سيلفيرا و كاردوسو 2004)</b>. إن فطريات
الميكوريزا الشجيرية عادة ما تدعم تكوين العقد البكتيرية الجذرية وتثبيت
النيتروجين فى البقوليات ولكن مدى هذه التأثيرات تتوقف على نوع فطر الميكوريزا
الشجيرية <b>(فالدينجرو وآخرون 2001)</b>. وتفسر الزيادة الكلية <span style="mso-spacerun: yes;"> </span>فى محتوى النيتروجين فى النبات الناتج من تثبيت
النيتروجين كنتيجة لأخذ الفوسفور من الخيوط المغزلية لفطر الميكوريزا الشجيرية
أكثر من أخذ النيتروجين من التربة الزراعية <b>(مورتيمر وآخرون 2008)</b>. بالرغم
من أن هناك دراسات عديدة تمت على التفاعلات البينية بين فطريات الميكوريزا
الشجيرية والبكتريا الا أن الآليات الكامنة وراء هذا الارتباط ما زالت غير مفهومة وخصائصها
الفنية ما زالت تحتاج الى دراسات أخرى. إن الأهداف الأساسية لهذه الدراسة هى البحث
عن نتائج التفاعلات البينية بين السلالات المختلفة لبكتريا </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Mesorhizobium ciceri</span></i></b><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> وعدة أنواع من فطر الميكوريزا الشجيرى وتأثيرها على نمو النبات ،
المحتوى الغذائى ، تكوين مستعمرات من فطر الميكوريزا الشجيرى على جذور النبات. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<b><u><span style="font-family: "Arial","sans-serif";">Comments<o:p></o:p></span></u></b></div>
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<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">The title of the manuscript fit its content. All results
explained the interactive effects between arbuscular mycorrhizal fungi and
rhizobia strains which have been used in this investigation.<o:p></o:p></span></div>
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<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 18pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">Depending on the present result we can say that all
objectives had been achieved. However, chickpea as a legume has been used only,
while the investigator could used other more economic legumes such as beans and
alfalfa.<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">I propose to complete this work with other legumes and
also with other arbuscular mycorrhizal fungi. Also, I recommends by isolation
and survey of soil arbuscular mycorrhizal fungi and determination the most
common one and conduct the same study on it. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">I think that the investigator has answered on most
inquiries but some other inquiries into questions. For example, what are
effects of arbuscular mycorrhizal fungi on non-leguminous plants which have
high economic importance such as tomato, potato, etc. The comparative study
between arbuscular mycorrhizal fungi treatment with leguminous and
non-leguminous plant must be done. In this way can easily determine the
positive effect and significance of bacterial nodules on leguminous plants
after combination with arbuscular mycorrhizal fungi.<o:p></o:p></span></div>
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<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 18pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">This study is good and well structured and written. However,
some abbreviated exponential characters in tables do not be clarified such as x<sup><span style="background: rgb(153, 153, 153);">a</span></sup>, x<sup><span style="background: rgb(153, 153, 153);">b</span></sup>,
x<sup><span style="background: rgb(153, 153, 153);">ab</span></sup> and x<sup><span style="background: rgb(153, 153, 153);">c</span></sup> (X is a number included in table).
Results and discussion are well written and express the results of
investigation and compare with the others. It is worth mentioning that, most
references cited in this investigation are recent up to 2010.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-87019871663913022772012-01-31T01:21:00.000-08:002012-01-31T01:21:03.672-08:00Effects of Arbuscular Mycorrhizal Inoculation<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><span style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;">Effects
of Arbuscular Mycorrhizal Inoculation<o:p></o:p></span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;">and
Fertilization on the Growth of <i>Acacia mangium </i>Seedlings</span></b><span style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;"><o:p></o:p></span></div>
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<b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;">تأثيرات حقن فطر الميكوريزا الشجيرى والخصوبة <span style="mso-spacerun: yes;"> </span>على نمو شتلات نبات السنط<o:p></o:p></span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%;">V
Jeyanny*, SS Lee & K Wan Rasidah<o:p></o:p></span></b></div>
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<i><span style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%;">Forest
Research Institute Malaysia, 52109 Kepong, Selangor Darul Ehsan, Malaysia<o:p></o:p></span></i></div>
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<i><span style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%;">Received
September 2010</span></i><b><span style="font-family: "Arial","sans-serif"; font-size: 10pt; line-height: 150%;"><o:p></o:p></span></b></div>
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<b><u><span style="font-family: "Arial","sans-serif";">Abstract<o:p></o:p></span></u></b></div>
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<b><i><span style="font-family: "Arial","sans-serif";">Acacia
mangium</span></i></b><i><span style="font-family: "Arial","sans-serif";"> </span></i><span style="font-family: "Arial","sans-serif";">is a popular species for forest
plantation and is widely used for the production of furniture, particleboard,
pulp and paper and wood chips. Proper fertilization and soil enhancement will
further increase its growth and yield for sustainable forest plantation.
Arbuscular mycorrhizas (AM) and fertilization have shown promising results in
increasing plant growth and biomass through increased nutrient uptake. However,
the combined use of AM inoculation and fertilization in fast-growing species
such as <b><i>A. mangium</i></b><i> </i>needs to be further assessed. The
effects of the treatment on the growth of <b><i>A. mangium</i></b><i> </i>seedlings,
chemical contents of the growth media and shoot nutrient concentrations were investigated.
Pot trails of uninoculated control without fertilization (control),
uninoculated with fertilization (+NPK), inoculated without fertilization (+AM)
and inoculated with fertilization (+AM+NPK) were laid out in a complete randomized
design. Seedling growth was monitored for three months in the nursery. Shoot height,
stem diameter and number of phyllodes were recorded monthly. Root and shoot
biomass, root:shoot ratio, mycorrhizal infection rates, nutrient concentrations
in media and shoot were determined at the end of the experiment. Treatments
with +NPK and +AM+NPK significantly increased plant growth and media nutrient
contents of <b><i>A. mangium</i></b><i> </i>seedlings. Shoot nutrient
concentrations of +AM fungi were relatively increased with inoculation.<b><o:p></o:p></b></span></div>
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<b><u><span lang="AR-SA" style="font-family: "Arial","sans-serif";">الملخص<o:p></o:p></span></u></b></div>
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<span lang="AR-SA" style="font-family: "Arial","sans-serif";">إن نبات السنط
هو أكثر النباتات شيوعا فى زراعة الغابات ويستخدم على نطاق واسع فى صناعة الأثاث
والخشب الحبيبى فضلا عن إنتاج رقائق الخشب والورق واللباب. إن توفر الخصوبة
المناسبة للتربة الزراعية سوف يزيد من نمو وانتاج النبات بشكل دائم داخل زراعة
الغابات. ومن الجدير بالذكر أن وجود فطريات الميكوريزا الشجيرية مع الخصوبة
العالية للتربة الزراعية يعطى نتائج واعدة فى زيادة النمو والكتلة الحية للنبات مرتبطا
بأخذ المواد الغذائية من التربة الزراعية. ولكن اتحاد فطريات الميكوريزا الشجيرية
مع الخصوبة العالية للتربة الزراعية لنبات سريع النمو مثل نبات السنط يحتاج الى
مزيد من التقييم. وعلى هذا الأساس تم دراسة تأثيرات المعالجة على نمو شتلات نبات
السنط ، المحتوى الكيميائى لوسط النمو ، وتركيزات المواد الغذائية فى المجموع
الخضرى. وقد تم إجراء عدة محاولات (تجارب) فى الأصص الزراعية بحيث يحتوى أحد الأصص
على تربة زراعية غير خصبة وغير محقونة بفطر الميكوريزا الشجيرى وتسمى التجربة
العيارية أو </span><span dir="LTR" style="font-family: "Arial","sans-serif";">control</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> ، ويحتوى أحد الأصص الأخرى على تربة زراعية خصبة (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+NPK</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) غير محقونة بفطر
الميكوريزا الشجيرى (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>- AM</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) ،
وأص آخر يحتوى على تربة زراعية محقونة بفطر الميكوريزا الشجيرى (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+AM</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) ولكنها غير خصبة
(</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>-NPK</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) ، وأص أخير
يحتوى على تربة زراعية محقونة بفطر الميكوريزا الشجيرى (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+AM</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) وخصبة (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+NPK</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>). ولقد تم رصد نمو الشتلات الزراعية داخل المشتل لمدة ثلاثة أشهر.
وفى كل شهر تم أخذ قراءات ارتفاع المجموع الخضرى ، قطر الساق ، عدد السويقات. وفى
نهاية التجربة تم تحديد الكتلة الحية للمجموع الخضرى والمجموع الجذرى ، معدلات
وجود فطر الميكوريزا الشجيرى فى الساق والجذر ونسبة وجوده فى كل منهما ، وتركيزات
المواد الغذائية فى الوسط المحيط وفى المجموع الخضرى. وقد ثبت أن معالجة النبات بزيادة
خصوبة التربة الزراعية (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+NPK</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) أو بزيادة الخصوبة وحقنها بفطر الميكوريزا الشجيرى (</span><span dir="LTR"></span><span dir="LTR" style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>+AM+NPK</span><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>) يزيد بشكل ملحوظ
من نمو النبات والمحتوى الغذائى لشتلات نبات السنط. وقد وجد أيضا أن المحتوى
الغذائى لفطر الميكوريزا الشجيرى نفسه يزيد عند حقنه فى التربة الزراعية.<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Pots<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Fertilization (NPK)<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Arbuscular Mycorrhizas (AM)<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Prosperity of the plant<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Control<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">-NPK<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">-AM<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">-<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">P-1<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+NPK<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">-AM<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">++<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">P-2<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">-NPK<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+AM<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">P-3<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+NPK<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+AM<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">+++<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">(-) = weak; (+) = good;
(++) = very good; (+++) = excellent<o:p></o:p></span></div>
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<b><u><span style="font-family: "Arial","sans-serif";">Introduction<o:p></o:p></span></u></b></div>
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<b><i><span style="font-family: "Arial","sans-serif";">Acacia mangium</span></i></b><span style="font-family: "Arial","sans-serif";"> is a popular species for large-scale forest
plantations in Malaysia and many other countries in South-East Asia <b>(Harwood
2011)</b>. A member of the Leguminosae, this species was first introduced to
Malaysia in the early 1960s <b>(Yap</b></span><span dir="RTL"></span><b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>1986
</span></b><span dir="LTR"></span><b><span style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>)</span></b><span style="font-family: "Arial","sans-serif";">. <b><i>Acacia</i></b>
species are known to form arbuscular mycorrhizas (AM). There are reports
confirming the presence of spores of <b><i>Gigaspora</i></b> and <b><i>Glomus</i></b>
in potted plants of <b><i>A. mangium</i></b> in the nursery <b>(Reddell </b></span><span dir="RTL"></span><b><span dir="RTL" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span><span style="mso-spacerun: yes;"> </span><span lang="AR-SA">& </span></span></b><b><span style="font-family: "Arial","sans-serif";">Warren 1987)</span></b><span style="font-family: "Arial","sans-serif";">. In another study, the inoculation levels
of AM persisted into the field even after two years of out planting <b>(Azizah
et al. 1994</b></span><span dir="RTL"></span><b><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>(</span></b><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";"><span dir="LTR"></span>.
<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Arbuscular mycorrhizas are known to enhance soil nutrient
uptake, particularly phosphorus (P), and increase plant yield. These microbes have
also been reported to improve drought resistance <b>(Sieverding 1991)</b>, plant
water retention <b>(Kyllo et al. 2003)</b> and carbon sequestration in soil <b>(Treseder
& Turner 2007)</b>. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Arbuscular mycorrhizas have shown promising results in increasing
plant height and biomass of forest species in China through increased nutrient uptake
<b>(Brundrett et al. 1995)</b>. In Malaysia, it was reported that <b><i>A.
mangium</i></b><i> </i>planted on degraded ex-tin mining areas showed better
plant growth when inoculated with AM <b>(Azizah et al. 1994)</b>. Later
investigations showed that incorporation of AM during out planting trials for
three-month-old <b><i>A. mangium</i></b><i> </i>seedlings increased relative
growth rates (diameter and height) for a period of up to six months in the field
<b>(Lee et al. 2006)</b>. The beneficial effect of AM on P uptake in poor soils
has also been well documented <b>(Martensson & Carlgren 1994, Ghosh &
Verma 2006)</b>. It has also been reported that P fertilizers combined with
mycorrhizas have enhanced growth of <b><i>Albizia falcataria</i></b><i>,</i> <b><i>Parkia
speciosa</i></b><i> </i><b>(Norani 1989)</b>, <b><i>Hopea</i></b><i> </i>spp. <b>(Lee
& Alexander 1994)</b> and <b><i>Azadirachta excelsa</i></b><i> </i><b>(Ong
et al<i>. </i>2002)</b>.<o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">Establishing productive stands of forest tree species for
forest plantation is vital, whereby management strategies should start from the
nursery. Seedling stocks which are nutrient enriched, viable and productive in
all soil types, particularly marginal areas, will have an upper hand in
withstanding adverse environmental conditions to produce substantial yield <b>(Xu
& Timmer 1999)</b>. Incorporation of fertilizer with AM inoculation in
forest tree nurseries has been successful in increasing the efficiency of plant
mineral uptake and growth <b>(Singh 1998)</b>. However, information on the
combined effects of AM and fertilization on <b><i>A. mangium</i></b><i> </i>in
the nursery is still scarce. Therefore, this preliminary study was carried out
to investigate the effectiveness of a combination of AM inoculum and fertilization
on <b><i>A. mangium</i></b><i> </i>seedlings in the nursery. The outcome from this
investigation will further assist nursery managers in the decision-making
process of whether to include this technique in their goal of achieving maximum
production of viable planting stocks.<o:p></o:p></span></div>
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<b><u><span lang="AR-SA" style="font-family: "Arial","sans-serif";">المقدمة<o:p></o:p></span></u></b></div>
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<div class="MsoNormal" dir="RTL" style="line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
<span lang="AR-SA" style="font-family: "Arial","sans-serif";">إن
نبات السنط هو أكثر الأنواع النباتية شيوعا فى زراعة الغابات فى ماليزيا ودول أخرى
عديدة فى جنوب شرق آسيا <b>(هاروود 2011)</b>. إن نبات السنط هو أحد أفراد العائلة
البقولية الذى يزرع فى ماليزيا منذ بداية عام 1960م <b>(ياب 1986)</b>. ومن
المعروف أن أنواع نبات السنط تكون علاقة تكافلية مع فطريات الميكوريزا الشجيرية ،
وهناك تقارير أكدت على وجود جراثيم لفطرى<span style="mso-spacerun: yes;"> </span></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Gigaspora</span></i></b><span dir="RTL"></span><b><i><span style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> </span></i></b><span lang="AR-SA" style="font-family: "Arial","sans-serif";">و<b><i>
</i></b></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Glomus</span></i></b><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> داخل نبات السنط المزروع فى الأصص الزراعية داخل المشتل <b>(ديلل
و وارين 1987)</b>. وقد ثبت فى دراسة أخرى أن جراثيم فطريات الميكوريزا الشجيرية
تظل موجودة فى التربة الزراعية لمدة عامين من نهاية الزرع والتجربة <b>(عزيزاه
وآخرون 1994)</b>. <o:p></o:p></span></div>
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<span lang="AR-SA" style="font-family: "Arial","sans-serif";">إن
فطريات الميكوريزا الشجيرية تقوى إمتصاص المواد الغذائية من التربة الزراعية
وخصوصا الفوسفور ، تزيد من إنتاج النبات. هذه الميكروبات تساعد على مقاومة الجفاف <b>(سيفيردين
1991)</b> ، الاحتفاظ بالمحتوى المائى للنبات <b>(كايلو وآخرون 2003)</b> واحتجاز
الكربون فى التربة الزراعية <b>(تريسدير و تيرنر 2007)</b>. <o:p></o:p></span></div>
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<span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span style="mso-tab-count: 1;"> </span>إن فطريات الميكوريزا الشجيرية تعطى
نتائج واعدة فى زيادة ارتفاع والكتلة الحية للنبات المزروع فى غابات الصين وذلك
بزيادة معدل إمتصاص المواد الغذائية <b>(بيرندريت وآخرون 1995)</b>. وفى ماليزيا
ثبت أن زراعة نبات السنط فى المناطق المتدهورة بسبب التعدين وإنتاج القصدير يعطى
نموا أفضل عندما يحقن بفطريات الميكوريزا الشجيرية <b>(عزيزاه وآخرون 1994)</b>. وهناك
أبحاث أخيرة أثبتت أن دمج فطريات الميكوريزا الشجيرية مع شتلات نبات السنط التى
وقتئذ يكون عمرها ثلاثة أشهر يؤدى إلى زيادة معدلات النمو النسبى (إرتفاع وقطر
النبات) لفترة تصل إلى ستة أشهر <b>(لى وآخرون 2006)</b>. كما ثبت أن أحد
التأثيرات الايجابية لفطريات الميكوريزا الشجيرية هو زيادة امتصاص الفوسفور من
التربة الزراعية الفقيرة <b>(مارتينسون و كارلجرين 1994 ، غوش و فيرما 2006)</b>.
وقد ثبت أن مخصبات الفوسفور عندما تتحد مع فطريات الميكوريزا الشجيرية تقوى من نمو
نبات ألبيزيا المنجلية </span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Albizia
falcataria</span></i></b><span dir="RTL"></span><span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> و نبات باركيا
الباهر<span style="mso-spacerun: yes;"> </span></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Parkia speciosa</span></i></b><span dir="RTL"></span><span style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>
<b><span lang="AR-SA">(نورانى 1989)</span></b><span lang="AR-SA"> ، ونبات الهوبيا </span></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Hopea</span></i></b><span dir="RTL"></span><span style="font-family: "Arial","sans-serif";"><span dir="RTL"></span>
<b><span lang="AR-SA">(لى و اليكسندر 1994)</span></b><span lang="AR-SA"> ، ونبات
أزارديراختا العالية </span></span><b><i><span dir="LTR" style="font-family: "Arial","sans-serif";">Azadirachta
excelsa</span></i></b><span dir="RTL"></span><span style="font-family: "Arial","sans-serif";"><span dir="RTL"></span> <b><span lang="AR-SA">(أونج وآخرون 2002)</span></b><span lang="AR-SA">.<o:p></o:p></span></span></div>
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<div class="MsoNormal" dir="RTL" style="line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<span lang="AR-SA" style="font-family: "Arial","sans-serif";"><span style="mso-tab-count: 1;"> </span>إن إنشاء الشجيرات المنتجة لأنواع
الشجر الغابى شىء فى غاية الأهمية والحيوية ، التى بها تبدأ استراتيجيات ادارة
المشاتل. <span style="mso-tab-count: 1;"> </span>إن الشتلات الغنية بالمواد
الغذائية والحيوية والمنتجة فى جميع أنواع الترب الزراعية وخصوصا المناطق الهامشية
، ستكون لها اليد العليا فى تحمل الظروف البيئية المختلفة لانتاج غلة كبيرة من
النبات <b>(كسو و تيمر 1999)</b>. إن دمج المخصبات الزراعية مع فطريات الميكوريزا
الشجيرية فى شتلات النباتات الغابية تزيد من نمو النبات وعل إمتصاص المواد
الغذائية <b>(سينغ 1998)</b>. وبالرغم من هذا فان المعلومات عن دمج المخصبات
الزراعية مع فطريات الميكوريزا الشجيرية فى شتلات نبات السنط ما زالت قليلة جدا.
وبالتالى فان هذه الدراسة المبدأية أجريت لمعرفة تأثير اتحاد المخصبات الزراعية مع
فطريات الميكوريزا الشجيرية فى شتلات نبات السنط داخل المشتل. إن مخرجات هذا البحث
سوف تقدم المزيد من المساعدة لمديرى المشاتل الزراعية فى عملية اتخاذ القرار فى
مدى إمكانية دخول هذه التقنية فى أهدافهم لتحقيق انتاج الحد الأقصى من مخزون
النباتات الحيوية.<o:p></o:p></span></div>
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<b><u><span style="font-family: "Arial","sans-serif";">Comments<o:p></o:p></span></u></b></div>
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<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span dir="RTL"></span><span dir="RTL" style="font-family: "Arial","sans-serif";"><span dir="RTL"></span><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "Arial","sans-serif";">The
title of the manuscript fit its content. The included results explained the
combined and independent effects of arbuscular mycorrhizas (AM) and fertilizers
represented in supplementation of nitrogen, phosphorus and potassium.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 18pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">Depending on the present results we can say that all
objectives had been achieved. Specially, <b><i>Acacia mangium</i></b> as a
member of Leguminosae had been used due to its highly economic importance such
as production of gum and its wood participates in furniture industry.<o:p></o:p></span></div>
<br />
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<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">I propose to perform the same study with crops such as
legumes and comparison will do against forested plants. <o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 18pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">I think that the investigator has answered on most
inquiries but some other inquiries into questions. For example, what are
effects of arbuscular mycorrhizal fungi on non-leguminous forested plants. As
mentioned in the introduction of this paper<b><i> Acacia mangium</i></b> is a
member of Leguminosae <b>(Yap 1986)</b>, this means that the bacterial nodules
are found inside the roots and subsequently increase the soil fertility by
nitrogen fixation. With the foregoing, fertilization effect due not only to NPK
supplementation but also due to bacterial nodulation. Therefore, we can say
that the investigator did not pay attention <span style="mso-spacerun: yes;"> </span>to this matter which led to the presence of
inaccurate results for the process of agriculture fertility and impact on plant.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 18pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 18.0pt; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><span style="font-family: "Arial","sans-serif";">This study is good and well structured and written.
However, the previous comment on absence of the effect of bacterial nodulation
on plant is urgent matter. Results and discussion are well written and expressed
the objectives of investigation and compare with the others. It is worth
mentioning that, most references cited in this investigation are recent up to
2011 and the oldest one at 1980.<span style="mso-spacerun: yes;"> </span></span><span dir="RTL" lang="AR-SA" style="font-family: "Arial","sans-serif";"><o:p></o:p></span></div>
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-37284690932086654872012-01-31T01:18:00.001-08:002012-01-31T01:18:10.643-08:00MICROBIAL INTERACTIONS<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><u><span style="font-size: 14pt; line-height: 150%;">MICROBIAL INTERACTIONS<o:p></o:p></span></u></b></div>
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<b><u>Microbial
Interactions in the Mycorrhizosphere <o:p></o:p></u></b></div>
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Soil microorganisms have an important influence on soil fertility and
plant health <b>(Gianinazzi and Schuepp, 1994)</b>. Symbiotic mycorrhizal
fungi, such as arbuscular mycorrhizal (AM) fungi form a key component of the
microbial populations influencing plant growth and uptake of nutrients. In
addition to increasing the absorptive surface area of their host plant root
systems, the hyphae of these symbiotic fungi provide an increased area for interactions
with other microorganisms, and an important pathway for the translocation of
energy-rich plant assimilates to the soil. Traditionally, the influence of
plant assimilates on microbial communities has been defined in relation to the
rhizosphere, the narrow zone of soil surrounding living roots <b>(Hiltner,
1904)</b>. The natural roles of mycorrhizosphere organisms may have been marginalized
in intensive agriculture, since microbial communities in conventional farming
systems have been modified due to tillage <b>(Sturz, <i>et al</i>. 1997;
McGonigle, and Miller, 1996)</b>.<span style="mso-spacerun: yes;"> </span>and
high inputs of inorganic fertilizers, herbicides and pesticides <b>(Gianinazzi,
and Schuepp, 1994; Gianinazzi, <i>et al</i>. 2002).<o:p></o:p></b></div>
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<span style="font-size: 10pt;">Fig. 1. Schematic view of
possible interactions among different components of the mycorrhizosphere. The
drawing is not to scale and underestimates the relative surface area of the
external mycorrhizal mycelium.<o:p></o:p></span></div>
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<b><u>Microbial Interactions in the
Rumen<o:p></o:p></u></b></div>
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Cellulose and other plant
fiber polymers are fermented in the rumen by a cellulolytic biofilm containing
a complex mixture of microbial species. Polymer hydrolysis and fermentation are
accompanied by the release of plant secondary “defense” chemicals such as
tannins, saponins and coumarins. The release and microbial transformation of
these compounds<b> (Dawson, <i>et al</i>. 1997) </b>modifies the gut
environment and the processes therein. Although ruminants have traditionally
been seen as “mobile fermentors”<b> (Hungate, 1966), </b>there is increasing
awareness of their contribution to global warming through methane production
and their possible role as reservoirs for pathogens such as <b><i>Escherichia
coli</i></b><i> </i>O157.<b><o:p></o:p></b></div>
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Nutritional interactions
in the cellulolytic biofilm are based primarily upon interspecies competition
for and transfer of nutrients and/or protons. Many saccharolytic bacteria and methanogens
stimulate microbial growth and cellulolysis by removing products or supplying nutrients
such as branched-chain VFA<b> (Wolin, <i>et al</i>. 1997)</b>. For example the propionate
producing bacterium <b><i>Selenomonas ruminantium</i></b><i> </i>uses sugars
and H2 produced by the anaerobic cellulolytic fungus <b><i>Neocallimastix
frontalis</i> (Marvin, <i>et al</i>. 1990), </b>and the presence of <b><i>S. ruminantium</i></b><i>
</i>enhances cellulolysis<b>. <o:p></o:p></b></div>
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In contrast, co-culture
of cellulolytic species reveals the existence of competitive and inhibitory
interactions, co-cultures often demonstrating reduced fiber degradation
compared to that achieved by the more active organisms grown axenically. This
may be based on competition for cellulose, perhaps through competition for
attachment sites as the bacteria spread from their initial point of attachment,
or competition for soluble nutrients. Thus, cultures of <b><i>Ruminococcus flavefaciens</i></b><i>
</i>strains 007 and 17 were found to be more active in degrading fibrous substrates
such as barley straw and clover than were cultures of <b><i>Fibrobacter
succinogenes</i></b><i> </i>strains S85 and BL2 or mixed cultures containing
both species<b> (Saluzzi, <i>et al</i>. 1993), </b>possibly reflecting interactions
of this type<b>.<o:p></o:p></b></div>
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Methanogenesis in the
ruminant gut is calculated to account for 15-25% of the global methane emission
of around 7.5 x 1012 g yr-1<b> (Kirchgessner, <i>et al</i>. 1995)</b>. Methane
is the major electron sink product of the fiber-degrading
cellulolytic-methanogen consortium; by comparison the amylolytic-methanogen
consortium produces relatively more propionate and less methane<b>
(Kirchgessner, <i>et al</i>. 1995)</b>. Classical two-component co-cultures are
not an appropriate model for rumen methanogenesis. Thus, the addition of <b><i>S.
ruminantium</i></b><i> </i>to co-cultures of <b><i>N. frontalis</i></b><i> </i>and
<b><i>Methanobrevibacter smithii</i></b><i> </i>reduced methanogenesis compared
to that obtained in the 2- component cultures, presumably because the
bacterium, which competes successfully for sugars released upon cellulose
hydrolysis, produces less H2 than the fungus (<b>Marvin, <i>et al</i>. 1990)</b>.
The rumen microbes are seen as the “first line of defense” against toxic plant
secondary compounds ingested by ruminants. In addition to effects on animals,
plant defense chemicals may have significant effects on the composition and
activity of the rumen microbiota. Tropical legumes such as <b><i>Sesbania,
Acacia</i></b><i> </i>and <b><i>Calliandra</i></b><i> </i>have shown marked
effects on some microbial species <b>(Osuji and Odenyo, 1997; Salawu, <i>et al</i>.
1998).<o:p></o:p></b></div>
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Recently, concern has
arisen about the emergence of human pathogens, such as the verocytotoxic <b><i>Escherichia
coli</i></b><i> </i>serotype O157, for which farm animals may act as a reservoir,
shedding of the pathogen in faeces resulting in contamination of the human food
chain. This serotype does not produce disease symptoms in adult animals,
although neonatal cattle may be susceptible<b> (Dean, <i>et al</i>. 1997)</b>.
The survival of <b><i>E. coli</i></b><i> </i>O157, was reduced in cattle dosed
with commensal <b><i>E. coli</i></b><i> </i>and <b><i>Proteus mirabilis </i></b>strains
recovered from ruminant faeces <b>(Zhao, <i>et al</i>. 1998). <i>Pseudomonas
aeruginosa</i> </b>from the rumen of sheep inhibited growth of <b><i>E. coli</i></b><i>
</i>O157 <i>in vitro</i><b> (Duncan, <i>et al</i>. 1997)</b>. The <b><i>P.
aeruginosa</i></b><i> </i>strains from different animals produced different
bacteriocins (pyocins), which may have an ecological role in determining the
dominant biotype present. Two pigments from <b><i>P. aeruginosa</i></b><i> </i>(pyocyanin
and fluorescein) were shown to inhibit both commensal and O157-serotype strains
of <b><i>E. coli</i>.</b> Pyocyanin had the greater effect but, as reported
previously <b>(Hassan and Fridovitch, 1980)</b> was more inhibitory in the
presence of oxygen than its absence. It seems that some of the bacteria
interacting most directly with <b><i>E. coli</i></b><i> </i>in the ruminant gut
are other relatively minor members of the gut microbiota. Variations in the
presence and numbers of these bacteria may contribute to differences between
animals in the survival and shedding of <b><i>E. coli</i></b>. The co-excretion
of such bacteria may also influence the survival of <b><i>E. coli</i></b><i> </i>in
shed faeces and in the soil. Pyocyanin would presumably be active if present in
faeces exposed to air. </div>
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I
would like to express on my humble opinion in microbial interactions topic.
Microbial interactions in all environmental sites are either useful or harmful.
Some microbes have intrinsic pathogenicity due to presence of certain genes
encoded virulence and pathogenicity. These microbes are harmful and cause many
diseases for human, animal, plants, protozoan and even for prokaryotes such as
bacteria. Other microbes consider friends to environment because they live in
the environment as symbiotic relationship. These useful microbes present in all
environmental sources as microflora (microbes take their requirements from
environmental source and give the later its requirements). Both of useful and
harmful microbial interactions enter in the formation of environmental balance
in nature.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></div>
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<b><u>References<o:p></o:p></u></b></div>
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<b>Dawson
KA, Rasmussen MA, Allison MJ (1997)</b> Digestive disorders and nutritional</div>
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toxicity. In: Hobson
PN, Stewart CS (Eds) The Rumen microbial ecosystem. Blackie, London, p 633-660<b><u>.<o:p></o:p></u></b></div>
<br />
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<b>Dean-Nystrom
EA, Bosworth BT, Cray WC, Moon HW (1997)</b> Pathogenicity of <i>Escherichia
coli </i>O157:H7 in the intestines of neonatal calves Infect Immun 65:1842-1848<b><u>.<o:p></o:p></u></b></div>
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<b>Duncan
SH, Doherty CJ, Govan JRW, Stewart CS (1997)</b> Sheep rumen isolates of <i>Pseudomonas
aeruginosa </i>inhibitory to an <i>Escherichia coli </i>O157 strain. Abs 95th
Ann Mtng Amer Soc Microbiol p.419<b><u><o:p></o:p></u></b></div>
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<b>Gianinazzi,
S. and Sch€uepp, H. (1994)</b> Impact of arbuscular mycorrhizas on sustainable
agriculture and natural ecosystems. Birkh€auser Verlag, Basel. p. 226.</div>
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<b>Gianinazzi,
S., Sch€uepp, H., Barea, J.M. and Haselwandter, K. (2002)</b> Mycorrhizal
technology in agriculture – From genes to bioproducts. Birkh€auser, Basel.</div>
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<b>Hassan
HM, Fridovitch I (1980) </b>Mechanism of the antibiotic action of pyocyanin. J Bacteriol
141:156-163<b><u><o:p></o:p></u></b></div>
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<b>Hiltner,
L. (1904)</b> € Uber neuere Erfahrungen und Problem auf dem Gebiet der
Bodenbakteriologie unter besonderer Ber€uksichtigung der Gr€und€ungung und
Brache (On recent insights and problems in the area of soil bacteriology under
special consideration of the use of green manure and fallowing). Arb. Dtsch. Landwirt.
Ges. 98, 59–78.<b><u><o:p></o:p></u></b></div>
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<b>Hungate
RE (1966)</b> The rumen and its microbes. Academic Press, London & NY<b><u><o:p></o:p></u></b></div>
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<b>Kirchgessner
M, Windisch W, Muller HL (1995)</b> Nutritional factors for the quantification
of methane production. In: v. Engelhardt W, Leonhardt-Marek S, Breves G,
Gieseke D (Eds) Ruminant physiology, digestion, metabolism, growth and reproduction.
Proc 8th Internl Symp Ruminant Physiology. Ferdinande Enke Verlag, Stuttgart,
p. 333-348<b><u><o:p></o:p></u></b></div>
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<b>Marvin-Sikkema
FD, Richardson AJ, Stewart CS, Gottschal JC, Prins RA (1990) </b>Influence of
hydrogen-consuming bacteria on cellulose degradation by anaerobic fungi. Appl
Environ Microbiol 56:3793-3797<b><u><o:p></o:p></u></b></div>
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<b>McGonigle,
T.P. and Miller, M.H. (1996)</b> Development of fungi below ground in
association with plants growing in disturbed and undisturbed soils. Soil Biology
& Biochemistry 28, 263–269.</div>
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<b>Osuji
PO, Odenyo AA (1997)</b> The role of legume forages as supplements to low
quality roughages-ILRI experience. Anim Fd Sci Technol 69:27-38<b><u><o:p></o:p></u></b></div>
<br />
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<b>Salawu
MB, Acamovic T, Stewart CS (1998)</b> Inhibition of microbial growth and enzyme
production by <i>Calliandra calothyrsus </i>leaf extracts. In: Garland T (Ed)
Proc 5<sup>th</sup><span style="mso-spacerun: yes;"> </span>Internl Symp
Poisonous Plants. CAB International, Wallingford, p 509-513<b><u><o:p></o:p></u></b></div>
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<b>Saluzzi
L, Smith A, Stewart CS (1993)</b> Analysis of bacterial phospholipid markers
and plant monosaccharides during forage degradation by <i>Ruminococcus
flavefaciens </i>and <i>Fibrobacter succinogenes </i>in co-culture. J Gen
Microbiol 139:2865-2873<b><u><o:p></o:p></u></b></div>
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<b>Sturz,
A.V., Carter, M.R. and Johnston, H.W. (1997)</b> A review of plant disease,
pathogen interactions and microbial antagonism under conservation tillage in
temperate humid agriculture. Soil & Tillage Research 41, 169–189.</div>
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<b>Wolin
MJ, Miller TL, Stewart CS (1997)</b> Microbe-microbe interactions. In: Hobson</div>
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PN, Stewart CS (Eds)
The Rumen microbial ecosystem. Chapman & Hall, London, p 467-491.<b><u><o:p></o:p></u></b></div>
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<b>Zhao
T, Doyle MP, Harmon BG, Brown CA, Mueller POE, Parks AH (1998) </b>Reduction of
carriage of enterohemorrhagic <i>Escherichia coli </i>O157:H7 in cattle by inoculation
with probiotic bacteria. J Clin Microbiol 36: 641-647<b><u><o:p></o:p></u></b></div>
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-25056032821748537692012-01-31T01:17:00.001-08:002012-01-31T01:17:22.635-08:00Influence of micro-organisms on the air<div dir="rtl" style="text-align: right;" trbidi="on">
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</span></span></div>
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<span style="font-size: 14pt; line-height: 150%;"><strong><u>Influence of micro-organisms on the
air<o:p></o:p></u></strong></span></div>
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<span style="font-size: small;">Most of our life is spent indoors.
Therefore, indoor air pollution may present a greater risk to human health than
exposure to atmospheric air contaminants. One kind of indoor air pollutant is
airborne microorganisms – bacteria and fungi. They are factors of potential
infectious, allergenic and immunotoxic effects. Indoor microflora is reported
to be responsible for health problems, especially among children. Bioaerosols
decrease air quality and affect human health, also causing some diseases such
as tuberculosis, diphteria, legionellosis, fever, rhinitis, nausea and asthma. </span></div>
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<span style="font-size: small;">The activity of people and equipment
within enclosed spaces is thought to be the principal factor contributing to
the buildup and spread of airborne microbial contamination. Another major
emission sources of indoor microbiological pollutants are animals, plants, air
conditioning systems, building materials, particles of soil and dust. A lot of
these come from outdoor air, especially in summer and autumn. School facilities
are densely populated, so it’s making the problem of maintaining good quality
indoor environments more difficult. </span></div>
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<span style="font-size: small;">Poor indoor air quality causes in many
cases illness requiring absence from school or can cause acute health symptoms,
decreasing performance while at school. Children are more likely to suffer the
consequences of indoor pollutants than adults, because they are still
developing physically. It has been stated that especially the presence of
moulds in indoor air of schools poses a serious risk to children. All moulds
have the potential to cause health effects such as headaches, breathing
difficulties, skin irritation, allergic reaction and aggravation of asthma
symptoms. Epidemiological data suggest that mould exposure may increase the
risk for asthma up to five-fold at school age. </span></div>
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<span style="font-size: small;">
</span></div>
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<span style="font-size: small;">Asthma is the principal cause of school
absences (up to 20% of lost school days in elementary and high schools). Also,
14% of school children revealed a positive reaction to fungal allergens in skin
prick tests and serum IgE reactions. An elevated occurrences of wheezing and
fever in children was connected with high numbers of fungi in the air. To
estimate a hazard of microbiological air pollution a number of fungi and
various groups of bacteria indoors should be determined, as precisely as
possible. </span></div>
<div align="center" class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: small;">
</span></div>
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<span style="font-size: small;">World Health Organization (WHO)
guidelines for the protection of public health from health risks due to
dampness, associated microbial growth and contamination of indoor spaces. The
guidelines are based on a comprehensive review and evaluation of the
accumulated scientific evidence by a multidisciplinary group of experts
studying health effects of indoor air pollutants as well as those specialized
in identification of the factors that contribute to microbial growth indoors.</span></div>
<div align="center" class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: small;">
</span></div>
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<span style="font-size: small;">Problems of indoor air quality are
recognized as important risk factors for human health in both low-income and
middle- and high-income countries. Indoor air is also important because
populations spend a substantial fraction of time within buildings. In
residences, day-care centers, retirement homes and other special environments,
indoor air pollution affects population groups that are particularly vulnerable
due to their health status or age. Microbial pollution involves hundreds of
species of bacteria and fungi that grow indoors when sufficient moisture is
available. Exposure to microbial contaminants is clinically associated with
respiratory symptoms, allergies, asthma and immunological reactions.</span></div>
<div align="center" class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: small;">
</span></div>
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: TimesNewRomanPSMT; mso-bidi-font-family: TimesNewRomanPSMT;"><span style="font-size: small;">The microbial indoor air pollutants of
relevance to health are widely heterogeneous, ranging from pollen and spores of
plants coming mainly from outdoors, to bacteria, fungi, algae and some protozoa
emitted outdoors or indoors. They also include a wide variety of microbes and
allergens that spread from person to person. There is strong evidence regarding
the hazards posed by several biological agents that pollute indoor air;
however, the WHO working group convened in October 2006 concluded that the
individual species of microbes and other biological agents that are responsible
for health effects cannot be identified. This is due to the fact that people
are often exposed to multiple agents simultaneously, to complexities in
accurately estimating exposure and to the large numbers of symptoms and health
outcomes due to exposure.<o:p></o:p></span></span></div>
<div align="center" class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: small;">
</span></div>
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: TimesNewRomanPSMT; mso-bidi-font-family: TimesNewRomanPSMT;"><span style="font-size: small;">The exceptions include some common
allergies, which can be attributed to specific agents, such as house-dust mites
and pets. The presence of many biological agents in the indoor environment is
due to dampness and inadequate ventilation. Excess moisture on almost all
indoor materials leads to growth of microbes, such as mould, fungi and
bacteria, which subsequently emit spores, cells, fragments and volatile organic
compounds into indoor air. Moreover, dampness initiates chemical or biological
degradation of materials, which also pollutes indoor air. Dampness has
therefore been suggested to be a strong, consistent indicator of risk of asthma
and respiratory symptoms (e.g. cough and wheeze). The health risks of
biological contaminants of indoor air could thus be addressed by considering
dampness as the risk indicator.</span></span></div>
<div align="center" class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: small;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">The indoor environment in any building is a result of
the interaction between the site, climate, building system (original design and
later modifications in the structure and mechanical systems), construction
techniques, contaminant sources (building materials and furnishings, moisture,
processes and activities within the building and outdoor sources) and building
occupants. Microbial sources may arise from pollen, dust or fungal spores.
Stagnant water in the vicinity of buildings may also give rise to microbial
sources which may ca</span></span>
</div>
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Most of our life is spent indoors.
Therefore, indoor air pollution may present a greater risk to human health than
exposure to atmospheric air contaminants. One kind of indoor air pollutant is
airborne microorganisms – bacteria and fungi. They are factors of potential
infectious, allergenic and immunotoxic effects. Indoor microflora is reported
to be responsible for health problems, especially among children. Bioaerosols
decrease air quality and affect human health, also causing some diseases such
as tuberculosis, diphteria, legionellosis, fever, rhinitis, nausea and asthma. </div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
The activity of people and equipment
within enclosed spaces is thought to be the principal factor contributing to
the buildup and spread of airborne microbial contamination. Another major
emission sources of indoor microbiological pollutants are animals, plants, air
conditioning systems, building materials, particles of soil and dust. A lot of
these come from outdoor air, especially in summer and autumn. School facilities
are densely populated, so it’s making the problem of maintaining good quality
indoor environments more difficult. </div>
<br />
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Poor indoor air quality causes in many
cases illness requiring absence from school or can cause acute health symptoms,
decreasing performance while at school. Children are more likely to suffer the
consequences of indoor pollutants than adults, because they are still
developing physically. It has been stated that especially the presence of
moulds in indoor air of schools poses a serious risk to children. All moulds
have the potential to cause health effects such as headaches, breathing
difficulties, skin irritation, allergic reaction and aggravation of asthma
symptoms. Epidemiological data suggest that mould exposure may increase the
risk for asthma up to five-fold at school age. </div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Asthma is the principal cause of school
absences (up to 20% of lost school days in elementary and high schools). Also,
14% of school children revealed a positive reaction to fungal allergens in skin
prick tests and serum IgE reactions. An elevated occurrences of wheezing and
fever in children was connected with high numbers of fungi in the air. To
estimate a hazard of microbiological air pollution a number of fungi and
various groups of bacteria indoors should be determined, as precisely as
possible. </div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
World Health Organization (WHO)
guidelines for the protection of public health from health risks due to
dampness, associated microbial growth and contamination of indoor spaces. The
guidelines are based on a comprehensive review and evaluation of the
accumulated scientific evidence by a multidisciplinary group of experts
studying health effects of indoor air pollutants as well as those specialized
in identification of the factors that contribute to microbial growth indoors.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Problems of indoor air quality are
recognized as important risk factors for human health in both low-income and
middle- and high-income countries. Indoor air is also important because
populations spend a substantial fraction of time within buildings. In
residences, day-care centers, retirement homes and other special environments,
indoor air pollution affects population groups that are particularly vulnerable
due to their health status or age. Microbial pollution involves hundreds of
species of bacteria and fungi that grow indoors when sufficient moisture is
available. Exposure to microbial contaminants is clinically associated with
respiratory symptoms, allergies, asthma and immunological reactions.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: TimesNewRomanPSMT; mso-bidi-font-family: TimesNewRomanPSMT;">The microbial indoor air pollutants of
relevance to health are widely heterogeneous, ranging from pollen and spores of
plants coming mainly from outdoors, to bacteria, fungi, algae and some protozoa
emitted outdoors or indoors. They also include a wide variety of microbes and
allergens that spread from person to person. There is strong evidence regarding
the hazards posed by several biological agents that pollute indoor air;
however, the WHO working group convened in October 2006 concluded that the
individual species of microbes and other biological agents that are responsible
for health effects cannot be identified. This is due to the fact that people
are often exposed to multiple agents simultaneously, to complexities in
accurately estimating exposure and to the large numbers of symptoms and health
outcomes due to exposure.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-indent: 18pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<span style="font-family: TimesNewRomanPSMT; mso-bidi-font-family: TimesNewRomanPSMT;">The exceptions include some common
allergies, which can be attributed to specific agents, such as house-dust mites
and pets. The presence of many biological agents in the indoor environment is
due to dampness and inadequate ventilation. Excess moisture on almost all
indoor materials leads to growth of microbes, such as mould, fungi and
bacteria, which subsequently emit spores, cells, fragments and volatile organic
compounds into indoor air. Moreover, dampness initiates chemical or biological
degradation of materials, which also pollutes indoor air. Dampness has
therefore been suggested to be a strong, consistent indicator of risk of asthma
and respiratory symptoms (e.g. cough and wheeze). The health risks of
biological contaminants of indoor air could thus be addressed by considering
dampness as the risk indicator.</span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">The indoor environment in any building is a result of
the interaction between the site, climate, building system (original design and
later modifications in the structure and mechanical systems), construction
techniques, contaminant sources (building materials and furnishings, moisture,
processes and activities within the building and outdoor sources) and building
occupants. Microbial sources may arise from pollen, dust or fungal spores.
Stagnant water in the vicinity of buildings may also give rise to microbial
sources which may ca</span></div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-90264161000748035562012-01-31T01:15:00.001-08:002012-01-31T01:15:54.645-08:00Effect of pH values on the growth of Fusarium species<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><span style="font-size: 14pt; line-height: 200%;">Effect of pH values on the growth of <i>Fusarium</i> species<o:p></o:p></span></b></div>
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<b>Abstract<o:p></o:p></b></div>
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There was narrow range of
pH values used (4.5 to 9.0). With each value three trails were exerted and also
with each trail three replicates (plates) were performed. Thereby, the mean was
calculated for each replicate at each trail from 1<sup>st</sup> to 7<sup>th</sup>
day. Also, the total mean for all trails at all days was calculated which in
turn indicates the highest fungal growth at each pH value and incubation period
(days). The results were taken daily from first to seventh day where the
diameter of fungal mat was measured by centimeters. According to the results
which illustrate in table number 1 the best pH value for Fusarium sp growth is
4.5 due to preferable acidity of fungi. At all values of pH no any growth at
first and second days but the growth begins from third day. The best day for
fungal growth at all pH values is 7<sup>th</sup> day.<span style="mso-spacerun: yes;"> </span></div>
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<b>Key words<o:p></o:p></b></div>
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Optimizations;
Fungal growth; Acidity, Alkalinity and PDA</div>
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<br /></div>
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<b>Introduction<o:p></o:p></b></div>
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A few studies concerning
fungal growth have dealt with the predictive modeling approach (Vali´k <i>et al</i>.
1999 and Panagou <i>et al</i>. 2003). Several factors act on the growth of <i>Fusarium</i>
such as the pH values (Bekada <i>et al</i>. 2004). One of the most influential
factors affecting the fungal community in soil is pH. pH strongly influences abiotic
factors, such as carbon availability (Andersson <i>et al</i>. 2000 and Kemmitt <i>et
al</i>. 2006). In addition, soil pH may control biotic factors, such as the
biomass composition of fungi (Fierer <i>et al</i>. 2006), in both forest (Bååth
<i>et al</i>. 2003; Blagodatskaya and T.-H. Anderson 1998 and Frostegård <i>et
al</i>. 1993), and agricultural soils (Arao, 1999 and Bardgett <i>et al</i>.
2001). Our aim was to assess the fungal growth was affected by medium pH.</div>
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<b>Materials and Methods<o:p></o:p></b></div>
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<i>Fungal Isolate<o:p></o:p></i></div>
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<a href="" name="OLE_LINK1">The isolate of</a> <i>Fusarium</i>
sp was used as test microorganism.</div>
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<i>Inoculum preparation<o:p></o:p></i></div>
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The isolate of <i>Fusarium</i>
sp was grown on Potato Dextrose Agar medium for 7 days at 28 ± 0.5°C to obtain
heavily sporulating cultures. <b><o:p></o:p></b></div>
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<i>Growth medium<o:p></o:p></i></div>
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<b><span style="mso-spacerun: yes;"> </span></b><span style="mso-tab-count: 1;"> </span>The
standard growth medium used in the experiment was Potato Dextrose Agar (Difco) for
two purposes <i>Fusarium</i> sp cultivation and measurement of its growth.</div>
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<i>Measurement<o:p></o:p></i></div>
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<b><span style="mso-spacerun: yes;"> </span></b><span style="mso-tab-count: 1;"> </span>The
diameters (y, expressed in mm) of the colonies were measured in horizontal
directions daily, at the same time (t, expressed in days) (Gervais <i>et al</i>.
1988). </div>
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<i>Different pH values<o:p></o:p></i></div>
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After preparation and
distribution of Potato Dextrose Agar medium in various conical flasks each of
which has definite pH value which was adjusted by 0.1N HCl and 0.5M NaOH for
acidity and alkalinity adjustment respectively. </div>
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<b>Results<o:p></o:p></b></div>
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This study was begun with
using <i>Fusarium</i> sp for studying the effect of different pH values on its
growth and this fungus is illustrated as shown in figure 1. In this experiment
there was narrow range of pH values used (4.5 to 9.0). With each value three
trails were exerted and also with each trail three replicates (plates) were
performed. Thereby, the mean was calculated for each replicate at each trail
from 1<sup>st</sup> to 7<sup>th</sup> day. Also, the total mean for all trails
at all days was calculated which in turn indicates the highest fungal growth at
each pH value and incubation period (days). The results were taken daily from
first to seventh day where the diameter of <i>Fusarium</i> sp mat was measured
by centimeters. According to the results which illustrate in table number 1 the
best pH value for Fusarium sp growth is 4.5 due to preferable acidity of fungi.
At all values of pH no any growth at first and second days but the growth
begins from third day. The best day for fungal growth at all pH values is 7<sup>th</sup>
day. <span style="mso-spacerun: yes;"> </span></div>
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</v:imagedata></v:shape><b><o:p></o:p></b></div>
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<b>Fig. 1: Culture of <i>Fusarium</i> sp (14 Xg)<o:p></o:p></b></div>
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<br /></div>
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<br /></div>
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<b>Table 1:</b> Influence of different pH values on the growth of <i>Fusarium</i>
sp</div>
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<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td rowspan="2" style="background-color: transparent; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 41.5pt;" valign="top" width="55">
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<b><span style="font-size: 10pt;">pH value<o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">Trails<o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">Replicates<o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">(plates)<o:p></o:p></span></b></div>
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<td colspan="7" style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 289.2pt;" valign="top" width="386">
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<b><span style="font-size: 10pt;">Measurement of <i>Fusarium</i> sp mat diameter (cm)
/ day<o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">1<sup>st</sup> <o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">2<sup>nd</sup> <o:p></o:p></span></b></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<b><span style="font-size: 10pt;">3<sup>rd</sup> <o:p></o:p></span></b></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<b><span style="font-size: 10pt;">4<sup>th</sup> <o:p></o:p></span></b></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<b><span style="font-size: 10pt;">5<sup>th</sup> <o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">6<sup>th</sup> <o:p></o:p></span></b></div>
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<b><span style="font-size: 10pt;">7<sup>th</sup> <o:p></o:p></span></b></div>
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<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
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<span style="font-size: 10pt;">First<o:p></o:p></span></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
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<span style="font-size: 10pt;">I<o:p></o:p></span></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
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<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
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<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<span style="font-size: 10pt;">3.0<o:p></o:p></span></div>
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<span style="font-size: 10pt;">4.1<o:p></o:p></span></div>
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<span style="font-size: 10pt;">5.0<o:p></o:p></span></div>
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<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.4<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
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<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.8<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.6<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.3<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.9<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.7<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Second<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.1<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.8<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">6.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.9<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Third<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.9<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 11;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.4<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 12;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.6<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 13;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.3<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">6.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">8.3<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 14;">
<td colspan="2" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 110.7pt;" valign="top" width="148">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">TOTAL MEAN<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">6.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">8.0<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 15;">
<td rowspan="13" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 41.5pt;" valign="top" width="55">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.0<o:p></o:p></span></div>
</td>
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">First<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 16;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 17;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.4<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 18;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.3<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.8<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.0<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 19;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Second<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 20;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.9<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 21;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.2<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 22;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.4<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.4<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.7<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.8<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 23;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Third<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 24;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.2<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 25;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">8.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 26;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.4<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.2<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.8<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">8.2<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 27;">
<td colspan="2" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 110.7pt;" valign="top" width="148">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">TOTAL MEAN<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.3<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.6<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.6<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 28;">
<td rowspan="13" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 41.5pt;" valign="top" width="55">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.5<o:p></o:p></span></div>
</td>
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">First<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.2<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 29;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 30;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 31;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.7<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.9<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.4<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">6.2<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 32;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Second<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.6<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.7<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 33;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.9<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 34;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">5.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.2<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 35;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.9<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.3<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.0<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 36;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Third<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.0<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 37;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">7.4<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 38;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">3.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">4.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">6.8<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 39;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">3.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">7.0<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 40;">
<td colspan="2" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 110.7pt;" valign="top" width="148">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">TOTAL MEAN<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.8<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">4.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">5.1<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">6.7<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 41;">
<td rowspan="13" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 41.5pt;" valign="top" width="55">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">9.0<o:p></o:p></span></div>
</td>
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">First<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.4<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.3<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 42;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.7<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.7<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 43;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.7<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 44;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">1.4<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.5<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 45;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Second<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.2<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.1<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 46;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.6<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 47;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.7<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 48;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">1.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.4<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 49;">
<td rowspan="4" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 46.15pt;" valign="top" width="62">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">Third<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">I<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.2<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 50;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">II<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">1.9<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.5<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 51;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">III<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">0.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<span style="font-size: 10pt;">2.8<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 52;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 64.55pt;" valign="top" width="86">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">Mean<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">1.8<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
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<b><span style="font-size: 10pt;">2.5<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 53; mso-yfti-lastrow: yes;">
<td colspan="2" style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 110.7pt;" valign="top" width="148">
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<b><span style="font-size: 10pt;">TOTAL MEAN<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 48.5pt;" valign="top" width="65">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 42.45pt;" valign="top" width="57">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">0.0<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">1.5<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 39.65pt;" valign="top" width="53">
<div align="center" class="MsoNormal" dir="LTR" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
<b><span style="font-size: 10pt;">2.4<o:p></o:p></span></b></div>
</td>
</tr>
</tbody></table>
</div>
<br />
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<br /></div>
<br />
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<b>Discussion<o:p></o:p></b></div>
<br />
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The effect of definite
range of pH of Potato Dextrose Agar medium (PDA) was studied on the growth of <i>Fusarium</i>
sp along seven days. The results were observed daily which referred to 4.5 as a
best pH value which led to the maximum growth especially at seventh day. For
the sake of accuracy of the results there are three trails have been made for
each pH value and with each trail triplicates have been done. The optimum
growth of <i>Fusarium</i> sp and most fungi tend to acidic environment more
than alkaline once, so the pH 4.5 was considered a best value and pH 9.0 was
considered worst value for fungal growth. Another study reported that the
optimal pH value for growth of <i>Mucor racemosus</i> is at 4.5 (Le Bars-Bailly
<i>et al</i>. 1999). Similar results were obtained by Panagou <i>et al</i>.
(Panagou <i>et al</i>. 2003); Vali'k <i>et al</i>. (Vali´k, L <i>et al</i>.
1999); Vali'k and Pieckova (Vali’K, L. and E. Pieckova, 2001). However, the
secondary model shows no significant effect of pH on the rate maximum growth of
<i>Mucor racemosus</i>, this has been confirmed both by the results of the
variance analysis. Some mycologists stated that the largest effect of pHs above
pH 4.5 was on fungal growth, and there were opposing pH effects. This resulted
in a 30-fold increase in the relative importance of fungi as indicated by the
growth ratio; the highest ratio was at about pH 4.5 (Bååth, and K. Arnebrant.
1995). The increase in cumulative respiration and biomass accumulation
following substrate addition to soils below pH 4.5 did not differ markedly from
the results for soil samples above pH 4.5, indicating that aluminum toxicity
was not the limiting factor for the microbial communities in this soil.
Irrespective of the mechanism, it is clear that the general inhibitory effects
below pH 4.5 in the acid strip are very different from the pH effects above pH
4.5. For this reason, the analyses of the results and the remainder of the
discussion concerning the influence of pH on microbial parameters focus
exclusively on the pH range above pH 4.5.</div>
<br />
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<br /></div>
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<b>References<o:p></o:p></b></div>
<br />
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Andersson,
S., I. Nilsson, and P. Saetre.<b> </b>2000. Leaching of dissolved organic carbon
(DOC) and dissolved organic nitrogen (DON) in moor humus as affected by
temperature and pH. Soil Biol. Biochem. 32:1–10.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Arao,
T. 1999. In situ detection of changes in soil bacterial and fungal activities
by measuring 13C incorporation into soil phospholipid fatty acids from 13C
acetate. Soil Biol. Biochem. 31<b>:</b>1015–1020.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Bååth,
E., and K. Arnebrant.<b> </b>1995. Growth rate and response of bacterial communities
to pH in limed and ash-treated forest soils. Soil Biol. Biochem. <b>26:</b>995–1001.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Bååth,
E., and T. H. Anderson.<b> </b>2003. Comparison of soil fungal/bacterial ratios
in a pH gradient using physiological and PLFA-based techniques. Soil Biol.
Biochem. 35<b>:</b>955–963.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Bardgett,
R. D., A. C. Jones, D. L. Jones, S. J. Kemmitt, R. Cook, and P. Hobbs. 2001.
Soil microbial community patterns related to the history and intensity of
grazing in sub-montane ecosystems. Soil Biol. Biochem. 33<b>:</b>1653–1664.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Bekada,
A.M.A., A. Bensoltane, A.L. Medouakh, B. Benakriche and D. Ait saada, 2004. Determination
of the critical points relating to <i>Mucor </i>sp<i> </i>contamination during
the manufacture of soft cheese standard camembert. Egyptian J. Applied Sci.,
19: 11B.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Blagodatskaya,
E. V., and T.-H. Anderson.<b> </b>1998. Interactive effects of pH and substrate
quality on the fungal-to-bacterial ratio and qCO2 of microbial communities in
forest soils. Soil Biol. Biochem. 30<b>:</b>1269–1274.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Fierer,
N., and R. B. Jackson.<b> </b>2006. The diversity and biogeography of soil bacterial
communities. Proc. Natl. Acad. Sci. USA 103<b>:</b>626–631.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Frostegård,
Å., E. Bååth, and A. Tunlid.<b> </b>1993. Shifts in the structure of soil microbial
communities in limed forest as revealed by phospholipid fatty acid analysis.
Soil Biol. Biochem. 25<b>:</b>723–730.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Gervais,
P., M. Bensoussan and W. Grajek, 1988. Water activity and water content:
comparative effects on the growth of <i>Penicillium roqueforti </i>on a solid
substrate. Appl. Microbiol. Biotechnol., 27: 389-392.</div>
<br />
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Kemmitt,
S. J., D. Wright, K. W. T. Goulding, and D. L. Jones.<b> </b>2006. pH regulation
of carbon and nitrogen dynamics in two agricultural soils. Soil Biol. Biochem. 38<b>:</b>898–911.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Le
Bars-Bailly, S., J.D. Bailly and H. Brugère, 1999. Accidents caused by fungus
in cheese. Revue Médecine Vétérinaire., 150: 413-430.</div>
<br />
<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Panagou,
E.Z., P.N. Skandamis and J.E Nychas, 2003. Modelling the combined effect of temperature,
pH and aw on the growth rate of <i>Monascus rubber</i>, a heat-resistant fungus
isolated from green table olives. J. Applied Microbiol., 94: 146-156.</div>
<br />
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Vali´k,
L., J. Baranyi and F. Gorner, 1999. Predicting fungal growth: The effect of water
activity on <i>Penicillium roqueforti</i>. Intl. J. Food Microbiol., 47:
141-146.</div>
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Vali’K,
L. and E. Pieckova, 2001. Growth modelling of heat-resistant fungi: The effect
of water activity. Intl. J. Food Microbiol., 63: 11-17.</div>
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<br /></div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-35383360340070472912012-01-31T01:13:00.001-08:002012-01-31T01:13:59.222-08:00What is an Ecosystem<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><i><u><span style="font-family: "Arial","sans-serif"; font-size: 22pt; mso-fareast-font-family: "Times New Roman";">Ecosystem<o:p></o:p></span></u></i></b></div>
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<b><span style="color: #0070c0; font-family: "Arial","sans-serif"; font-size: 16pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"> </span></span></b><b><span style="color: #0070c0; font-family: "Arial","sans-serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";">What is an Ecosystem?<o:p></o:p></span></b></div>
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<b><span style="font-size: 15pt; line-height: 150%;"><a href="http://www.environmentabout.com/wp-content/uploads/2011/02/Ecosystem-Types-and-Classification.jpg"><span style="color: #630fc2; font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-no-proof: yes; text-decoration: none; text-underline: none;"><v:shapetype coordsize="21600,21600" filled="f" id="_x0000_t75" o:preferrelative="t" o:spt="75" path="m@4@5l@4@11@9@11@9@5xe" stroked="f">
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<b><span style="color: #0f0e0f; font-family: "Arial","sans-serif"; font-size: 15pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">An ecosystem is a
community of organisms that interact with each other and non living components
for sustainable development and adaptation to changing conditions. There are
different type of ecosystems around us which involves living organisms and non
living organisms. If we combine all the ecosystems present on earth, it is
called Biosphere.<o:p></o:p></span></b></div>
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<b><span style="color: #0070c0; font-family: "Arial","sans-serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";">Components of an
Ecosystem:<o:p></o:p></span></b></div>
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<b><span style="color: #e36c0a; font-family: "Arial","sans-serif"; font-size: 15pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">There are two
components of an ecosystem; <o:p></o:p></span></b></div>
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<span style="color: #e36c0a; font-family: Symbol; font-size: 15pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span style="color: #e36c0a; font-family: "Arial","sans-serif"; font-size: 15pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Biotic (living) <span style="mso-spacerun: yes;"> </span>components .<o:p></o:p></span></b></div>
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<span style="color: #e36c0a; font-family: Symbol; font-size: 15pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-weight: bold; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span style="color: #e36c0a; font-family: "Arial","sans-serif"; font-size: 15pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Abiotic (non living) components.<o:p></o:p></span></b></div>
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<b><u><span style="color: #666600; font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 18.0pt;">Abiotic
Components<o:p></o:p></span></u></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
<b>abiotic components</b> of a grassland ecosystem are the non-living features
of the ecosystem that the living organisms depend on. Each abiotic component
influences the number and variety of plants that grow in an ecosystem, which in
turn has an influence on the variety of animals that live there. The four major
abiotic components are: <b>climate</b>, <b>parent material and soil</b>,<b>
topography</b>,<b> </b>and<b> natural disturbances.</b></span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Climate</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">includes
the rainfall, temperature and wind patterns that occur in an area, and is the
most important abiotic component of a grassland ecosystem. Temperature, in
tandem with precipitation, determines whether grasslands, forests, or some
combination of these two, form. The amount and distribution of the rainfall an
area receives in a year influences the types and productivity of grassland
plants. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
climate in our grassland ecosystems is usually hot and dry in the spring and
summer growing season, and cool or cold in winter dormant season. Precipitation
in the winter falls mostly as snow rather than rain. During the hottest months
of the year (the height of summer) more water evaporates from parts of the grasslands
than falls as rain, creating a <b>moisture deficit</b>. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><br style="mso-special-character: line-break;" />
<br style="mso-special-character: line-break;" />
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Parent Material and Soil<o:p></o:p></span></b></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Parent
material</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">is
the geological material that lies on top of the bedrock and is the foundation
on which soil has developed. Much of the parent material underlying BC's
grasslands was deposited as the last ice sheets melted away. The actual
composition of the material at any specific location depends on how and where
it was deposited in relation to the ice. In the Rocky Mountain Trench, for
example, some material was deposited under a moving glacier, while on the
Chilcotin plateau some was deposited under a stationary ice sheet; in many
places throughout the grasslands material was carried and deposited by water
on, in, or under the ice. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
material dropped in place under the ice varies in thickness from a thin veneer
to several metres, and contains all sizes of rocks and particles from boulders
to silts. Rivers and streams that flowed on, under and beyond the ice left
hummocky ridges of water-rounded materials of all sizes. Material deposited in
ice-damned lakes formed layers of fine silts. Winds picked up fine particles
and blew them across the newly ice-free land surface, depositing thick layers
of the particles in some places. These wind-blown materials are called <b>aeolian
</b>deposits.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Soil</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> develops in the
upper portion of the parent material and is a mixture of abiotic and biotic
components: minerals, organic matter, water and air. The type of parent
material in a particular area influences the texture of the soil, how well
water flows through it, and hence the chemistry and nutrients of the soil. This
combination of texture, water flow and chemistry determines the vegetation that
grows in the area. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
fine silt soils found on the terraces of the Okanagan, Kootenay and Thompson
valleys hold water near to the surface where it either evaporates or is soaked
up by the dense fine roots of grasses; trees are not common in these areas. By
contrast, in areas with gravelly soils water moves quickly down to depths below
the grass roots to levels where tree roots grow. As such, more trees are likely
to be found in these areas.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Grasslands
have a rich layer of organic matter that forms the top surface of the soil.
This layer has developed largely as a result of the breakdown of plant roots.
Roots form as much as half the volume of a grass plant and up to 50% are
replaced every year. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="color: #666600; font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 18.0pt;">Biotic
Components</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 18.0pt;"><o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><br />
</span><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The <b>biotic
components</b> of a grassland ecosystem are the living organisms that exist in
the system. These organisms can be classified as <b>producers,</b> <b>consumers</b>
or <b>decomposers</b>.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><u><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Producers</span></u></b><b><u><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">are
able to capture the sun’s energy through photosynthesis and absorb nutrients
from the soil, storing them for future use by themselves and by other
organisms. Grasses, shrubs, trees, mosses, lichens, and cyanobacteria are some
of the many producers found in a grassland ecosystem. When these plants die
they provide energy for a host of insects, fungi and bacteria that live in and
on the soil and feed on plant debris. Grasses are an important source of food
for large grazing animals such as California Bighorn Sheep, Mule Deer and Elk,
and for much smaller animals such as marmots, Pocket Gophers and mice. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><u><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Consumers</span></u></b><b><u><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">are
organisms that do not have the ability to capture the energy produced by the
sun, but consume plant and/or animal material to gain their energy for growth
and activity. Consumers are further divided into three types based on their
ability to digest plant and animal material:</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<ul type="disc">
<li class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Herbivores </span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">eat only plants,
such<b> </b>as the elk that graze the grasslands of the Columbia valley,
or an insect nibbling on the leaf of a sticky geranium.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Omnivores</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> eat both plants
and animals, such as the black bear.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Carnivores</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> eat only
animals, such as the red-tailed hawk or western rattlesnake. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></li>
</ul>
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<b><u><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Decomposers</span></u></b><b><u><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">include
the insects, fungi, algae and bacteria both on the ground and in the soil that
help to break down the organic layer to provide nutrients for growing plants.
There are many millions of these organisms in each square metre of grassland. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Soil
</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">has
many biotic functions in a grasslands ecosystem. It provides the material in
which plants grow, holds moisture for plants to absorb, is the "recycling
bin" for plant and animal matter, and provides an important habitat for
soil organisms. Soil is a vital link between the biotic and abiotic parts of a
grassland ecosystem.</span><span dir="RTL" lang="AR-SA" style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-ascii-font-family: Garamond; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: Garamond;"><o:p></o:p></span></div>
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<b><span style="color: #666600; font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 18.0pt;">Ecosystem
Processes</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 18.0pt;"><o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><v:shape alt="" id="_x0000_i1028" style="height: 230.25pt; width: 420pt;" type="#_x0000_t75">
<v:imagedata o:href="http://bcgrasslands.org/understanding/eco_processes.jpg" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\01\clip_image006.jpg">
</v:imagedata></v:shape><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Energy Flow </span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
<br />
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Refer
to the <b><span style="color: #ffcc00;">yellow</span></b><span style="color: #ffcc00;">
</span><span style="color: #002200;">arrows in the diagram to help you understand
the way that energy moves through an ecosystem.</span></span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<v:shape alt="Energy Flow-Nicole Brand" id="_x0000_s1026" o:allowoverlap="f" style="height: 233.25pt; margin-left: 0px; margin-top: 0px; mso-position-horizontal: left; mso-position-vertical-relative: line; mso-wrap-distance-bottom: 3.75pt; mso-wrap-distance-left: 3.75pt; mso-wrap-distance-right: 3.75pt; mso-wrap-distance-top: 3.75pt; position: absolute; width: 313.5pt; z-index: 251656192;" type="#_x0000_t75"><span style="font-family: Calibri;">
<v:imagedata o:title="341FC7B980D94FBFB5D48D7031B200A9B0B64D21" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\01\clip_image007.jpg">
<w:wrap type="square">
</w:wrap></v:imagedata></span></v:shape><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Energy enters an
ecosystem in the form of heat from the sun. This energy is absorbed by
organisms such as plants, and is then converted to other forms of energy and
stored. Once stored, energy is used for necessary life functions, such as
growth, movement and reproduction. Plants, animals and microorgnaisms release
energy in the form of heat, for example through breathing and sweating. Energy
is also released from an ecosystem during a fire.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Plants
only capture about one percent of the energy that reaches the earth from the
sun. In grasslands, that small amount of energy is used by the grasses and
other plants, or <b>producers</b>. Some animals eat only these plants. Other
animals eat both grasses and other plants, and animals, while yet other animals
only eat animals. Animals are called <b>consumers.</b> </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Food Chain</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">This
movement of energy from producers to consumers is called a <b><span style="color: #cc3300;">Food Chain</span>.</b></span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<v:shape alt="Food Chain-Nicole Brand" id="_x0000_s1027" o:allowoverlap="f" style="height: 229.5pt; margin-left: 256.25pt; margin-top: 0px; mso-position-horizontal: right; mso-position-vertical-relative: line; mso-wrap-distance-bottom: 3.75pt; mso-wrap-distance-left: 3.75pt; mso-wrap-distance-right: 3.75pt; mso-wrap-distance-top: 3.75pt; position: absolute; width: 296.25pt; z-index: 251657216;" type="#_x0000_t75"><span style="font-family: Calibri;">
<v:imagedata o:title="4D9BB688B89B4092F9D10BDAEF83EC41E762FBDB" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\01\clip_image009.jpg">
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</w:wrap></v:imagedata></span></v:shape><b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Food Chains</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> are found in two
parts of an ecosystem. The <b>"grazing" food chain</b> includes the
producers and consumers that cycle energy from living plants. The <b>"detritus"
food chain</b> cycles energy from non-living remains of both plants and animals
(also called detritus). </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
<b>"grazing" food chain</b> has a number of steps that start with the
producers, or the plants, and flows through a series of levels of consumers. At
each step only about 10% of the energy is passed up through the chain. The rest
is passed back into the atmosphere as heat through breathing and decomposition.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">In
the first step plants convert the sun’s energy to chemical energy through a
process called <b>photosynthesis</b>. The chemical energy is stored both as
food and as structural elements in the plant. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
next step involves the <b>primary consumers</b>, animals that eat only plants.
In a grassland ecosystem this includes animals such as California Bighorn
Sheep, Mule Deer, Elk, marmots, Pocket Gopher and mice. At step three are the <b>secondary
consumers</b>, also called predators; these animals<b> </b>eat primary
consumers. In a grassland ecosystem this includes a Coyote eating a mouse, a
woodpecker eating an ant, or a frog eating an insect. At step four are the <b>tertiary
consumers</b> that eat secondary consumers, and sometimes primary consumers as
well. In a grassland ecosystem this includes a snake eating a frog. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
<b>"detritus" food chain</b> is a system where the energy produced by
the breakdown of dead plant and animal matter is cycled into the
"grazing" food chain. Detritus is organic matter formed by decaying
animal or plant tissue, or fecal matter. <b>Detritus eaters </b>(or
detritivores) such as<b> </b>insects, worms and other small organisms feed on
dead plants, waste products from animals and dead animals. <b>Decomposers</b>
are fungal or bacterial organisms that work within the dead material to help
break it down, activating decay and decomposition. This important part of the
ecosystem takes the last of the energy that was originally absorbed by the
plants and returns it to the soil.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Carbon</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> can be traced
through the ecosystem in a cycle that is similar to the water cycle. Plants
take in carbon in the form of carbon dioxide from the atmosphere through <b>respiration</b>.
Through a process called <b>photosynthesis</b>, the carbon dioxide combines with
oxygen to form <b>carbohydrates</b> that range from simple sugars to the
complex carbohydrate cellulose, which forms cell walls. When plants are eaten
the carbon is transferred to the <b>consumers</b>. As plant material is broken
down in the digestive system of an animal, carbon is absorbed as a nutrient for
use by that animal. It is released back into the atmosphere as carbon dioxide
through respiration and through the decomposition of dead animals and fecal
matter. Grassland fires also release carbon dioxide into the atmosphere.</span><span dir="RTL" lang="AR-SA" style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Water Cycling</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">All
organisms require both <b>water</b> and <b>nutrients</b> (food) to survive. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Where
do the water and nutrients come from and how do they move around a grassland
ecosystem?</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
water cycle is </span><v:shape alt="Water cycle-Nicole Brand" id="_x0000_s1028" o:allowoverlap="f" style="height: 207.75pt; margin-left: 0px; margin-top: 15.7pt; mso-position-horizontal-relative: text; mso-position-vertical-relative: line; mso-wrap-distance-bottom: 3.75pt; mso-wrap-distance-left: 3.75pt; mso-wrap-distance-right: 3.75pt; mso-wrap-distance-top: 3.75pt; position: absolute; width: 342pt; z-index: 251658240;" type="#_x0000_t75"><span style="font-family: Calibri;">
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</w:wrap></v:imagedata></span></v:shape><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">illustrated by the <b><span style="color: #0000cc;">blue parts</span></b><span style="color: #0000cc;"> </span>of
the diagram. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Water</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> exists in three
forms: solid (ice and snow), liquid and gas (water vapour). Water is the vital
link between the ecosystem and the weather or climate. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Water
falls from clouds onto the grasslands as <b>rain </b>or <b>snow</b>. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Rain</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> runs off plants and
rocks onto the ground, where some water is absorbed into the soil. The rest
runs over the surface of the ground and collects in low areas to form into
wetlands, lakes and rivers. Finally, some water that reachs the ground is
evaporated back into the atmosphere.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Snow</span></b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">, which is
crystallized water droplets, may form a blanket over the grasslands during the
winter. Snow undergoes similiar processes to rain when it reaches the ground.
Some of it evaporates back into the atmosphere, and as snow melts, the water
produced is absorbed into the soil, or runs over the ground into wetlands,
lakes and rivers. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Plants
take up some of the water contained in the soil through their roots. Other
water that permeates (soaks through) the soil flows into wetlands, lakes, and
rivers. The rest becomes part of the water table. The water table is water that
remains in the soil, filling the pores between rocks and soil particles. Water
is returned to the atmosphere as water vapour through evaporation and
transpiration. Transpiration is a process performed by plants whereby water
molecules leave the plant's surface through evaporation.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
water that reaches wetlands, lakes and rivers flows eventually to the ocean,
with some of it evaporating along the way. Evaporation provides the moisture in
clouds that condenses to form droplets of rain or snow. These droplets of water
return to the earth as precipitation, and the cycle starts again.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
portions of grassland ecosystems that occur in low elevations and especially on
south-facing slopes suffer from a <b>water deficit </b>during the hottest and
driest months of the year. The amount of water that is released into the
atmosphere through transpiration and evaporation is larger than the amount that
falls as rain at this time of year. Grassland plants have adopted a variety of
ways to survive under these difficult growing conditions.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Bright
yellow sagebrush buttercups are some of the earliest flowers to be seen in the
grasslands early spring. They start to grow before all the snow has left the
grasslands, their shallow roots take advantage of all the water stored in the
thawed upper layers of the soil. By the end of May the available moisture is
well below the reach of the roots of the plants, and little remainsof the
sagebrush buttercup but some dried out leaves.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Plants
such as low pussytoes and silky lupine start growing a little later in the
spring and bloom before the summer drought begins. They may grow again as soil
moisture increases after fall showers. Some of the bunchgrasses have a similar
early growth habit but become semi-dormant during the summer drought. They put
on a significant amount of growth when fall rains arrive. Deeply-rooted shrubs
such as big sagebrush and rabbitbrush start growing later in the year and are
covered with yellow flowers in the fall.</span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<br /></div>
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<b><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Nutrient Cycling</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
nutrient cycle follows the <b><span style="color: #009900;">green parts </span></b>of
the diagram below. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<v:shape alt="Nutrient cycle-Nicole Brand" id="_x0000_s1029" o:allowoverlap="f" style="height: 273pt; margin-left: 278pt; margin-top: 0px; mso-position-horizontal: right; mso-position-vertical-relative: line; mso-wrap-distance-bottom: 3.75pt; mso-wrap-distance-left: 3.75pt; mso-wrap-distance-right: 3.75pt; mso-wrap-distance-top: 3.75pt; position: absolute; width: 318pt; z-index: 251659264;" type="#_x0000_t75"><span style="font-family: Calibri;">
<v:imagedata o:title="9051FFBB16F1B7E1247CB838CF6121D8A27D8BD5" src="file:///C:\Users\Sony\AppData\Local\Temp\msohtmlclip1\01\clip_image012.jpg">
<w:wrap type="square">
</w:wrap></v:imagedata></span></v:shape><span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">All organisms need
many <b>nutrients</b>, for food and for proper functioning, in order to thrive.
Nutrients are found in the soil as the products of decomposition of dead
matter, both plant and animal, and of waste materials such as animal feces and
urine; dust; water runoff and erosion; and through weathering of rocks. They
are also released from plants by fire and through nitrogen fixation by
cyanobacteria. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Garamond","serif"; font-size: 15pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Nutrients
combine with water in the soil and are transported through the roots of the
plant to those parts that need them. They are then passed through the <b>food
chain</b> as the consumers eat the plants and each other. The final
decomposition of both producers and consumers returns the nutrients back to the
soil. </span><span style="font-family: "Times New Roman","serif"; font-size: 15pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-27712379448520628892012-01-30T22:27:00.001-08:002012-01-30T22:27:34.557-08:00Water Pollution and Treatment<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><u><span style="font-size: 14pt; line-height: 150%;">Water Pollution and Treatment<o:p></o:p></span></u></b></div>
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<b><u>Introduction<o:p></o:p></u></b></div>
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<span lang="EN-GB" style="color: black; mso-ansi-language: EN-GB;">Water pollution is broad
term that includes contamination of different water bodies such as lakes,
rivers, oceans, and groundwater. Water pollution is caused by pollutants,
mostly in form of different chemicals that are discharged either directly or
indirectly into the water bodies without the adequate treatment to remove their
harmful effects. Water pollution is not only huge ecological problem but also
huge health problem. It is believed that water pollution is the leading
worldwide cause of deaths and diseases responsible for around 15,000 deaths
each day <b>(Tawfiq and Olsen 1993).<o:p></o:p></b></span></div>
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<span lang="EN-GB" style="color: black; mso-ansi-language: EN-GB;">The two main causes of
water pollution are waste water and sewage waste. Each year the world generates
around 400 billion tons of industrial waste, and lot of this waste gets
discharged into different water bodies causing serious water pollution problem.
Diarrhoea, caused by water pollution, is worldwide responsible for 1,5 million
deaths of children each year <b>(AI-Abdali et al. 1996).<o:p></o:p></b></span></div>
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<b><u><span lang="EN-GB" style="color: black; mso-ansi-language: EN-GB;">Arabian Gulf Pollution<o:p></o:p></span></u></b></div>
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<span lang="EN-GB" style="color: black; mso-ansi-language: EN-GB;">The Arabian Gulf is a
shallow marginal sea of the Indian Ocean. It is a semi-closed basin which
extends for nearly 1000 km from Shatt A1-Arab, the nexus of the Tigris,
Euphrates, and Karun Rivers in the northwest, to the Strait of Hormuz in the
southeast, and covers a surface area of about 239000 km 2 (Fig. 1).<o:p></o:p></span></div>
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<b><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Fig. 1.
Bathymetric map of the Arabian Gulf<o:p></o:p></span></b></div>
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Oil
and natural gas represent the main source of pollution in the Arabian Gulf
Region. A region, which represents the biggest oil producing area in the
world, began to suffer from the problem especially after the industrial
development and the growth of urban settlements. Therefore, pollution caused by
sea-bed drilling and exploitation, oil spill from vessels and tankers, urban
sewage are the main sources of present and future pollution in the regio<span style="color: black;">n</span><span style="color: black; font-size: 9.5pt; line-height: 150%;"> </span><b><span style="color: black;">(R</span>eynolds 1993).</b></div>
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The
discharge of untreated industrial waste (liquid and gases) from oil refineries
and industry particularly Petrochemicals and fertilizer plants are rapidly
increasing along the Gulf. The development of urban centers in the Gulf are
forms another source of pollution owning to the discharge of great quantities
of untreated sewage into the Gulf. Consequently the Arabian Gulf region became
polluted. It is expected that the problem will be very serious if steps
for pollution control have not been taken.</div>
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<b>Massoud
et al., (1996) </b>reported that: A case for pollution problems is found in
Kuwait where Shuiba village has suffered severely from air pollution.
These facts and information about housing planning was obliged to migrate the
people to a new location far from the Shuiba industrial complex. So plans for
pollution control are very urgent to save the region and to create clean and
healthy environment. Some ideas to realize this aim can be
performed. </div>
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Firstly,
the regional co-operation is very important for abating pollution. All
Gulf States should co-operate in taking the necessary measures for dealing with
the pollution problem in the region. Establishment of a regional Oil
Center for pollution research is very urgent. This center will help all
the states to co-operate in the fields of scientific research, to exchange data
as well as other scientific information. </div>
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Secondly,
owing to the danger of large oil spill, the Gulf states ensure adequate
equipments and qualified personnel to deal with this problem.</div>
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Thirdly,
the industrial authorities in the Gulf States must take all necessary measures
to prevent and combat pollution through sound plans. Factories must use
the new equipments, which reduce or prevent the dangerous pollution.</div>
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Finally,
dumping the sewage into the Gulf without treatment must bee forbidden by law
and all states must establish stations to treat sewage water and plants to
convert urban solid wastes into fertilizers. This has been, partly,
achieved in Kuwait.</div>
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<b><u>Red Sea Pollution<o:p></o:p></u></b></div>
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<span style="color: black;">The major threats to the marine environment of the Red Sea
and Gulf of Aden are related to land-based activities. These include
urbanization and coastal development (for example, dredge and fill operations),
industries including power and desalination plants and refineries, recreation
and tourism, waste water treatment facilities, power plants, coastal mining and
quarrying activities, oil bunkering and habitat modification such as the
filling and conversion of wetlands</span><b> (Horowitz 1991)</b><span style="color: black;">. <o:p></o:p></span></div>
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<b>AI-Ghadban et
al., (1996) </b>reported that:<b> </b><span style="color: black;">Physical
alteration and destruction of habitats, by such activities as urbanization,
coastal development (for example, dredge and fill operations and coastal mining
and quarrying, are considered the major environmental threat in several
countries of the region - Jordan, Saudi Arabia, Egypt - and are among the most
important in Sudan and Yemen.</span></div>
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<div style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
<span style="color: black;">Saudi Arabia is a considerable number of large scale
coastal construction projects - including recreational facilities, hotels and
restaurants - have been developed in the last few years that have caused
significant destruction of marine habitats and marine environment.</span> <span style="color: black;">Saudi Arabia is most of the treatment plants in Jeddah are
overloaded and, hence, the effectiveness of treatment is very low, hence, the
low quality of treated effluent from the plants. In Saudi Arabia's Red Sea
coastal cities of Jeddah and Yanbu, domestic waste water treatment is
considered quite adequate. The advanced Yanbu treatment plant produces waste
water suitable for irrigation, and only a limited amount is discharged to the
sea</span><b> (Massoud et al. 1996)</b><span style="color: black;">.</span></div>
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<span style="color: black;">Saudi Arabia. In Jeddah an industrial area comprising
approximately 300 small and medium-sized industries is situated in the southern
part of the city. In Yanbu, a large industrial facility is located in Madenat
Yanbu Al-Sinayah, comprising two oil refineries, petrochemical plants, a power
plant, food industry and other small industries. These industries are connected
to industrial waste water treatment plants</span><b> (Massoud et al. 1996)</b><span style="color: black;">.</span></div>
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<div style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
<span style="color: black;">Much of the rapid expansion of Saudi Arabia's urban centers
has been achieved through the extensive use of desalinated water to meet
demands of the population and industry. As of 1992, there were 18 desalination
plants operating along Saudi Arabia's Red Sea coast with a total combined
capacity of 726,343 cu m/ day.</span> <span style="color: black;">The resulting impact
on the marine ecosystems due to thermal pollution and the elevated levels of
salt and chlorine in the return waters vary with the volumes of water and the
location of the discharge. Discharges into the marine environment from the
Jeddah plants include chlorine and anti-sealant chemicals as well as brine
which exceeds by 1.3 times the ambient salinity of the Red Sea, at a
temperature of 41°C (approximately 9°C above the average ambient Red Sea
temperature)</span><b> (Massoud et al. 1996)</b><span style="color: black;">.</span></div>
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<div style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
<span style="color: black;">A power and desalination complex at Yanbu provides potable
water for the community within the city and for the industrial facilities, as
well as process water and industrial cooling seawater for various industries.
The total quantity of cooling water used by various industries is about 190,000
cu m/day.</span></div>
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<div style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
<span style="color: black;">Jeddah has eight desalination plants which discharge
cooling seawater (at about 39°C) and concentrated brine (with a concentration
of 50,000 ppm) into the sea, using an outfall channel.</span> <span style="color: black;">There are four oil refineries located along the eastern
side of the Red Sea. Although treatment facilities are provided for all the
refineries and data on the quality of the treated effluent is generally
acceptable, the refineries poses a threat to the marine environment in the
absence of adequately enforced regulations related to effluent discharges into
the coastal and marine environment.</span> <span style="color: black;">In Yanbu,
off-loaded ballast water is discharged into the Red Sea after removal of
residual oil, although 8.8 tones/year of oil and grease are discharged into the
sea</span><b> (Massoud et al. 1996)</b><span style="color: black;">.</span></div>
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<span style="color: black;">Saudi Arabia. Large recreational cities and centers have
been developed along the Jeddah coastline without any adequate evaluation of
potential environmental impacts. The construction of these large projects has
required significant dredge and fill operations, which adversely impact the
coastal environment. In addition to the direct destruction of marine life and
key habitats, the suspended fine materials resulting from these activities can
result in widespread damage to marine life. Such sedimentation results in the
suffocation of the benthic communities and has an adverse effect on the
surrounding ecosystems (mangroves, seagrass beds and coral reefs) and, as a
consequence, a decline in the productivity of the sea as measured by shrimping
grounds and other demersal fisheries. The practice of extending plots onto the
coast and into the sea can change the current pattern, morphology and
substrate, thus affect the marine life, and usually provide new sources of
continuous degradation</span><b> (Massoud et al. 1996)</b><span style="color: black;">.<o:p></o:p></span></div>
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<b><u><span style="color: black;">Methodology
of water pollution treatment<o:p></o:p></span></u></b></div>
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<b>Preliminary Wastewater Treatment<o:p></o:p></b></div>
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Preliminary wastewater treatment is the
removal of such wastewater constituents that may cause maintenance or
operational problems in the treatment operations, processes, and ancillary systems.
It consists solely of separating the floating materials (like dead animals,
tree branches, papers, pieces of rags, wood etc.) and the heavy settleable
inorganic solids. It also helps in removing the oils and greases, etc. from the
sewage. This treatment reduces the BOD of the wastewater, by about 15 to 30%. Examples
of preliminary operations are:</div>
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• Screening and communition for the removal of debris
and rags.</div>
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• Grit removal for
the elimination of coarse suspended matter that may cause wear or clogging of
equipment.</div>
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• Floatation / skimming for the removal of oil and
grease.</div>
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<b>Primary wastewater treatment<o:p></o:p></b></div>
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In primary treatment, a portion of the
suspended solids and organic matter is removed from the wastewater. This
removal is usually accomplished by physical operations such as sedimentation in
Settling Basins. The liquid effluent from primary treatment, often contains a
large amount of suspended organic materials, and has a high BOD (about 60% of
original). Sometimes, the preliminary as well as primary treatments are
classified together, under primary treatment. The organic solids, which are
separated out in the sedimentation tanks (in primary treatment), are often
stabilized by anaerobic decomposition in a digestion tank or are incinerated.
The residue is used for landfills or as a soil conditioner. The principal
function of primary treatment is to act as a precursor to secondary treatment.</div>
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<b>Secondary Wastewater Treatment<o:p></o:p></b></div>
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Secondary treatment involves further
treatment of the effluent, coming from the primary sedimentation tank and is
directed principally towards the removal of biodegradable organics and suspended
solids through biological decomposition of organic matter, either under aerobic
or anaerobic conditions. In these biological units, bacteria will decompose the
fine organic matter, to produce a clearer effluent. The treatment reactors, in
which the organic matter is decomposed (oxidized) by aerobic bacteria are known
as <b><i>Aerobic biological units</i></b>; and may consist of:</div>
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• <b>Filters </b>(intermittent sand filters as well as
trickling filters),</div>
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• <b>Aeration tanks, </b>with the feed of recycled
activated sludge (i.e. the sludge, which is settled in secondary sedimentation
tank, receiving effluents from the aeration tank). </div>
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• <b>Oxidation ponds and aerated lagoons. </b>Since all
these aerobic units, generally make use of primary settled sewage; they are
easily classified as secondary units. The treatment reactors, in which the
organic matter is destroyed and stabilized by anaerobic bacteria, are known as <b><i>Anaerobic
biological units </i></b>and may consists of:</div>
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• <b>Anaerobic lagoons,<o:p></o:p></b></div>
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• <b>Septic tanks,<o:p></o:p></b></div>
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• <b>Imhoff tanks, </b>etc.</div>
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Out of these units, only anaerobic
lagoons make use of primary settled sewage, and hence, only they can be
classified under secondary biological units. Septic tanks and Imhoff tanks,
which use raw sewage, are not classified as secondary units. The effluent from
the secondary biological treatment will usually contain a little BOD (5 to 10%
of the original), and may even contain several mg/l of DO. The organic solids/
sludge separated out in the primary as well as in the secondary settling tanks
is disposed off by stabilizing under anaerobic conditions in a Sludge digestion
tank.</div>
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<b>Tertiary/ Advanced Wastewater Treatment and
Wastewater Reclamation<o:p></o:p></b></div>
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<div style="background: white; line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;">
Advanced
wastewater treatment, also called tertiary treatment is defined as the level of
treatment required beyond conventional secondary treatment to remove
constituents of concern including nutrients, toxic compounds, and increased
amounts of organic material and suspended solids and particularly to kill the
pathogenic bacteria. In addition to the nutrient removal processes, unit
operations or processes frequently employed in advanced wastewater treatment
are chemical coagulation, flocculation, and sedimentation followed by
filtration and chlorination. Less used processes include ion exchange and
reverse osmosis for specific ion removal or for the reduction in dissolved
solids. Tertiary treatment is generally not carried out for disposal of sewage
in water, but it is carried out, while using the river stream for collecting
water for re-use or for water supplies for purposes like industrial cooling and
groundwater recharge. <span lang="EN" style="mso-ansi-language: EN;">Disinfection,
typically with chlorine, can be the final step before discharge of the effluent.
However, some environmental authorities are concerned that chlorine residuals
in the effluent can be a problem in their own right, and have moved away from
this process. Disinfection is frequently built into treatment plant design, but
not effectively practiced, because of the high cost of chlorine, or the reduced
effectiveness of ultraviolet radiation where the water is not sufficiently
clear or free of particles.<o:p></o:p></span></div>
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</v:imagedata></v:shape><o:p></o:p></span></div>
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<b><u><span style="color: black;">Water
Pollution Control<o:p></o:p></span></u></b></div>
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The suggested approach for water
pollution control may be applied at various levels; from the catchment or river
basin level to the level of international co-operation (Fig. 2).</div>
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<br /></div>
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<div align="center" class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: center; unicode-bidi: embed;">
Initial analysis
of water pollution management issues</div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 426.1pt;" valign="top" width="568">
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Impact issues</li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">User
management issues</li>
</ul>
</td>
</tr>
</tbody></table>
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<span style="font-size: 36pt; line-height: 150%;">↓<o:p></o:p></span></div>
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Assessment of
management functions and objectives for all administrative levels</div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 426.1pt;" valign="top" width="568">
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<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Required
management interventions </li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Long term
objectives</li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Potentials
and constraints</li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Short term
strategy</li>
</ul>
</td>
</tr>
</tbody></table>
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<span style="font-size: 36pt; line-height: 150%;">↓<o:p></o:p></span></div>
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Management tools
and instruments</div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt; width: 426.1pt;" valign="top" width="568">
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<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Monitoring
system</li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Water quality
modelling tools</li>
<li class="MsoNormal" style="direction: ltr; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-align: center; unicode-bidi: embed;">Environmental
impact assessment and cross-sectoral co-ordination</li>
</ul>
</td>
</tr>
</tbody></table>
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<span style="font-size: 36pt; line-height: 150%;">↓<o:p></o:p></span></div>
<br />
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Action
plan for water pollution control</div>
<br />
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<br /></div>
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<b>Figure
2. Elements and processes of an action plan for water pollution control</b></div>
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<div style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;">
<b><u>References:<o:p></o:p></u></b></div>
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<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
AI-Abdali, F.;
Massoud, M.S.; A1-Ghadban, A.N. Bottom sediments of the Arabian Gulf: III.Trace
metal contents as indicators of pollution and implications for the effect and
fate of Kuwait oil slick. Environ. Pollut. 93: 285-301; 1996.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<br /></div>
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A1-Ghadban, A.N.;
Massoud, M.S.; AI-Abdali, F. Bottom sediments of the Arabian Gulf: I.
Sedimentological characteristics. J. Univ. Kuwait (Sci.) 23: 71-88; 1996.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<br /></div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Horowitz, A.G. A
primer on sediment trace element chemistry. Second edition. Chelsea, MI: Lewis
Publishers Inc.; 1991.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<br /></div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Massoud, M.S.;
AI-Abdali, F.; AI-Ghadban, A.N.; AI-Sarawi, M. Bottom sediments of the Arabian
Gulf: II. TPH and TOC contents as indicators ofoil pollution and implications
for the effect and fate of Kuwait oil slick. Environ. Pollut. 93: 271-284;
1996.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<br /></div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Reynolds, R.N.
Physical oceanography of the Gulf, Strait of Hormuz, and the Gulf of Oman:
Results of the Mt. Mitchell expedition. Mar, Pollut. Bull. 27: 35-59; 1993.</div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
<br /></div>
<br />
<div class="MsoNormal" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt 27pt; mso-layout-grid-align: none; text-align: justify; text-indent: -27pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
Tawfiq, N.; Olsen,
D.A. Saudi Arabia's response to the 1991 Gulf oil spill. Mar. Pollut. Bull. 27:
333-345; 1993.</div>
</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-75304173367442798022012-01-30T22:26:00.001-08:002012-01-30T22:26:30.231-08:00Microbial air pollution<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><u><span style="font-size: 14pt; line-height: 150%;">Microbial air pollution<o:p></o:p></span></u></b></div>
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Most of our life is spent indoors. Therefore, indoor air pollution may
present a greater risk to human health than exposure to atmospheric air
contaminants <b>(LIS A. et al., 2001)</b>. One kind of indoor air pollutant is
airborne microorganisms – bacteria and fungi <b>(JONES A.P., 1999)</b>. They
are factors of potential infectious, allergenic and immunotoxic effects. Indoor
microflora is reported to be responsible for health problems, especially among
children <b>(DI GIORGIO C. et al., 1996)</b>. Bioaerosols decrease air quality
and affect human health, also causing some diseases such as tuberculosis,
diphteria, legionellosis, fever, rhinitis, nausea and asthma <b>(MAUS R. Et
al., 2001)</b>.</div>
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The activity of people
and equipment within enclosed spaces is thought to be the principal factor
contributing to the buildup and spread of airborne microbial contamination <b>(GODDARD
K.R., 1964)</b>. Another major emission sources of indoor microbiological
pollutants are animals, plants, air conditioning systems, building materials,
particles of soil and dust. A lot of these come from outdoor air, especially in
summer and autumn <b>(JONES A.P., 1999)</b>.</div>
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School facilities are
densely populated, so it’s making the problem of maintaining good quality
indoor environments more difficult <b>(BAYER C.W., 2001)</b>. Poor indoor air
quality causes in many cases illness requiring absence from school or can cause
acute health symptoms, decreasing performance while at school. Children are
more likely to suffer the consequences of indoor pollutants than adults,
because they are still developing physically <b>(BAYER C.W., 2001 and LIS A. et
al., 2001)</b>.</div>
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It has been stated that
especially the presence of moulds in indoor air of schools poses a serious risk
to children. All moulds have the potential to cause health effects such as
headaches, breathing difficulties, skin irritation, allergic reaction and
aggravation of asthma symptoms <b>(Mold Remediation, 2001)</b>. Epidemiological
data suggest that mould exposure may increase the risk for asthma up to
five-fold at school age <b>(IMMONEN J., 2000)</b>. Richards noticed that asthma
is the principal cause of school absences (up to 20% of lost school days in
elementary and high schools) <b>(BAYER C.W., 2001)</b>. <b>Taskinen et al.,
(2000)</b>, proved that 14% of school children revealed a positive reaction to
fungal allergens in skin prick tests and serum IgE reactions. Elevated
occurrences of wheezing and fever in children was connected with high numbers
of fungi in the air <b>(JONES A.P., 1999)</b>.</div>
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To estimate a hazard of
microbiological air pollution a number of fungi and various groups of bacteria
indoors should be determined, as precisely as possible. In this study the level
of microbial contamination in some education objects was estimated using a
MAS-100 air sampler. </div>
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<b>References<o:p></o:p></b></div>
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LIS A. Jakość mikroklimatu w salach
przedszkolnych a warunki komfortu cieplnego i potencjał psychofizyczny przebywających
w nich osób. <span lang="DE" style="mso-ansi-language: DE;">Mat. konf. VI
Ogólnopolskiej Konferencji: Problemy Jakości Powietrza Wewnętrznego w Polsce
„Jakość powietrza w budynkach edukacyjnych”, Warszawa, listopad 2001.<o:p></o:p></span></div>
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JONES A.P. Indoor air quality and
health. Atmospheric Environment, 33, 1999.</div>
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DI GIORGIO C., KREMPFF A., GUIRAUD H., BINDER
P., TIRET C., DUMENIL G. Atmospheric pollution by airborne microorganisms in
the city of Marseilles<span dir="RTL"></span><span dir="RTL" lang="AR-SA"><span dir="RTL"></span>.</span><span dir="LTR"></span><span lang="AR-SA"><span dir="LTR"></span>
</span>Atmospheric Environment, 30, 1, 1996<span dir="RTL"></span><span dir="RTL" lang="AR-SA"><span dir="RTL"></span>.</span></div>
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MAUS R., GOPPELSRÖDER A., UMHAUER H. Survival
of bacterial and mold spores in air filter media. Atmospheric Environment, 35,
2001<span dir="RTL"></span><span dir="RTL" lang="AR-SA"><span dir="RTL"></span>.</span></div>
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GODDARD K.R. Effect of ventilation on
distribution of airborne microbial contamination – field studies. in:
Proceeding of a Symposium „Surface contamination”, ed. B.R. Fish Pergamon
Press, Gattlinburg Tennessee, 1964<span dir="RTL"></span><span dir="RTL" lang="AR-SA"><span dir="RTL"></span>.</span></div>
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BAYER
C.W.ASHRAE Looks at School IAQ. Western HVACR News, January 2001.</div>
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Mold
Remediation in Schools and Commercial buildings. The document of EPA Office of
Air and Radiation, Indoor Environment Division 6609J, EPA 402-K-01-001, March 2001.</div>
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IMMONEN
J., MEKLIN T., TASKINEN T., NEVALAINENE A., KORPPI M. Skin Prick Test findings
in students from moisture and mould damaged schools: A three-year follow – up
study. . in: Proceedings of Healthy Buildings, vol 1., ed. Seppänen O., Säteri
J., Finland, 2000.</div>
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TASKINEN T.,
LAITINEN S., MEKLIN T., HUSMAN T<span dir="RTL"></span><span dir="RTL" lang="AR-SA" style="mso-ansi-language: DE;"><span dir="RTL"></span>.,</span><span dir="LTR"></span><span lang="AR-SA"><span dir="LTR"></span> </span>NEVALAINEN A., KORPPI M. Skin test and
serum IgE reactions to moulds in relation to exposure in children. . in<span dir="RTL"></span><span dir="RTL" lang="AR-SA" style="mso-ansi-language: DE;"><span dir="RTL"></span>:</span><span dir="LTR"></span><span lang="AR-SA"><span dir="LTR"></span>
</span>Proceedings of Healthy Buildings, vol 1., ed. Seppänen O<span dir="RTL"></span><span dir="RTL" lang="AR-SA" style="mso-ansi-language: DE;"><span dir="RTL"></span>.,</span><span dir="LTR"></span><span lang="AR-SA" style="mso-ansi-language: DE;"><span dir="LTR"></span>
</span>Säteri J., Finland, 2000<span dir="RTL"></span><span dir="RTL" lang="AR-SA" style="mso-ansi-language: DE;"><span dir="RTL"></span>.</span></div>
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-48839539102709788132012-01-30T22:25:00.001-08:002012-01-30T22:25:40.837-08:00EFFLUENT TREATMENT<div dir="rtl" style="text-align: right;" trbidi="on">
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<b><u><span style="font-size: 16pt; line-height: 150%;">EFFLUENT TREATMENT<o:p></o:p></span></u></b></div>
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<span lang="EN" style="mso-ansi-language: EN;">Wastewater
treatment (effluent treatment) is closely related to the <a href="http://water.worldbank.org/water/node/83330"><span><strong>standards </strong></span></a>and/or expectations set for the
effluent quality. Wastewater treatment processes are designed to achieve
improvements in the quality of the wastewater. The various treatment processes
may reduce: <o:p></o:p></span></div>
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<span lang="EN" style="mso-ansi-language: EN;"><span style="mso-list: Ignore;">1.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span lang="EN" style="mso-ansi-language: EN;">Suspended solids</span></b><span lang="EN" style="mso-ansi-language: EN;"> (physical particles that can clog rivers or
channels as they settle under gravity). <o:p></o:p></span></div>
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<span lang="EN" style="mso-ansi-language: EN;"><span style="mso-list: Ignore;">2.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span lang="EN" style="mso-ansi-language: EN;">Biodegradable organics</span></b><span lang="EN" style="mso-ansi-language: EN;"> (e.g. BOD) which can serve as “food” for
microorganisms in the receiving body. Microorganisms combine this matter with
oxygen from the water to yield the energy they need to thrive and multiply;
unfortunately, this oxygen is also needed by fish and other organisms in the
river. Heavy organic pollution can lead to “dead zones” where no fish can be
found; sudden releases of heavy organic loads can lead to dramatic “fish
kills”. <o:p></o:p></span></div>
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<span lang="EN" style="mso-ansi-language: EN;"><span style="mso-list: Ignore;">3.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span lang="EN" style="mso-ansi-language: EN;">Pathogenic bacteria</span></b><span lang="EN" style="mso-ansi-language: EN;"> and other disease causing organisms These are
most relevant where the receiving water is used for drinking, or where people
would otherwise be in close contact with it. <o:p></o:p></span></div>
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<span lang="EN" style="mso-ansi-language: EN;"><span style="mso-list: Ignore;">4.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><span dir="LTR"></span><b><span lang="EN" style="mso-ansi-language: EN;">Nutrients</span></b><span lang="EN" style="mso-ansi-language: EN;">, including nitrates and phosphates. These
nutrients can lead to high concentrations of unwanted algae, which can
themselves become heavy loads of biodegradable organic load Treatment processes
may also neutralize or removing industrial wastes and toxic chemicals. This
type of treatment should ideally take place at the industrial plant itself,
before discharge of their effluent in municipal sewers or water courses.<o:p></o:p></span></div>
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<b>What is sewage/ wastewater?<o:p></o:p></b></div>
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<b>Sewage/ Wastewater </b>–
is essentially the water supply of the community after it has been fouled by a
variety of uses. From the standpoint of sources of generation, waste water may
be defined as a combination of the liquid (or water) carrying wastes removed
from residences, institutions, and commercial and industrial establishments,
together with such groundwater, surface water, and storm water as may be
present. Generally, the wastewater discharged from domestic premises like
residences, institutions, and commercial establishments is termed as “Sewage /
Community wastewater”. It comprises of 99.9% water and 0.1% solids and is
organic because it consists of carbon compounds like human waste, paper,
vegetable matter etc. Besides community wastewater / sewage, there is
industrial wastewater in the region. Many industrial wastes are also organic in
composition and can be treated physico-chemically and/or by micro-organisms in
the same way as sewage.</div>
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<b>Why should sewage be treated before
disposal?<o:p></o:p></b></div>
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Wastewater treatment
involves breakdown of complex organic compounds in the wastewater into simpler
compounds that are stable and nuisance-free, either physico-chemically and/or
by using micro-organisms (biological treatment). The adverse environmental impact
of allowing untreated wastewater to be discharged in groundwater or surface
water bodies and/ or land are as follows:</div>
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1.
The decomposition of the organic materials contained in wastewater can lead to
the production of large quantities of malodorous gases.</div>
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2.
Untreated wastewater (sewage) containing a large amount of organic matter, if discharged
into a river / stream, will consume the dissolved oxygen for satisfying the Biochemical
Oxygen Demand (BOD) of wastewater and thus deplete the dissolved oxygen of the
stream, thereby causing fish kills and other undesirable effects.</div>
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3.
Wastewater may also contain nutrients, which can stimulate the growth of
aquatic plants and algal blooms, thus leading to eutrophication of the lakes
and streams.</div>
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4.
Untreated wastewater usually contains numerous pathogenic, or disease causing
microorganisms and toxic compounds, that dwell in the human intestinal tract or
may be present in certain industrial waste. These may contaminate the land or
the water body, where such sewage is disposed. For the above-mentioned reasons
the treatment and disposal of wastewater, is not only desirable but also
necessary.</div>
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<b>Sewage/ wastewater treatment: a
historical perspective<o:p></o:p></b></div>
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Before the late 1800s,
the general means of disposing human excrement was the outdoor privy while the
major proportion of the population used to go for open defecation. Sewage
treatment systems were introduced in cities after Louis Pasteur and other
scientists showed that sewage borne bacteria were responsible for many infectious
diseases. The Early attempts, in the 900s, at treating sewage usually consisted
of acquiring large farms and spreading the sewage over the land, where it
decayed under the action of micro-organisms. It was soon found that the land
became 'sick'. Later attempts included the discharge of wastewater directly
into the water bodies, but it resulted in significant deterioration of the
water quality of such bodies. These attempts relied heavily on the
self-cleansing capacities of land and water bodies and it was soon realized
that nature couldn’t act as an indefinite sink. Methods of wastewater treatment
were first developed in response to the adverse conditions caused by the
discharge of wastewater to the environment and the concern for public health. Further,
as cities became larger, limited land was available for wastewater treatment
and disposal, principally by irrigation and intermittent filtration. Also, as
populations grew, the quantity of wastewater generated rose rapidly and the
deteriorating quality of this huge amount of wastewater exceeded the
self-purification capacity of the streams and river bodies. Therefore, other
methods of treatment were developed to accelerate the forces of nature under
controlled conditions in treatment facilities of comparatively smaller size.</div>
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In general from about
1900 to the early 1970s treatment objectives were concerned with:</div>
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1. The removal of suspended and
floatable material from wastewater.</div>
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2. The treatment of biodegradable
organics (BOD removal).</div>
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3.
The elimination of disease-causing pathogenic micro-organisms. From the early
1970 to about 1990s, wastewater treatment objectives were based primarily on aesthetic
and environmental concerns. The earlier objectives of reduction and removal of
BOD, suspended solids, and pathogenic micro-organism’s continued, but at higher
levels. Removal of nutrients such as Nitrogen and Phosphorus also began to be
addressed, particularly in some of the streams and lakes. Major initiatives
were taken around the globe, to achieve more effective and widespread treatment
of wastewater to improve the quality of the surface waters. This effort was a
result of:</div>
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1.
An increased understanding<i> </i>of the environmental effects caused by
wastewater discharges.</div>
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2.
A developing knowledge<i> </i>of the adverse long term effects caused by the
discharge of some of the specific constituents found in wastewater. Since 1990,
because of increased scientific knowledge and an expanded information base, wastewater
treatment has begun to focus on the health concerns related to toxic and
potentially toxic chemicals released into the environment. The water quality
improvement objectives of the 1970s have continued, but the emphasis has
shifted to the definition and removal of toxic and trace compounds, that could
possibly cause long-term health effects and adverse environmental impacts. As a
consequence, while the early treatment objectives remain valid today, the
required degree of treatment has increased significantly, and additional
treatment objectives and goals have been added.</div>
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<b>Unit operations and processes in
sewage treatment<o:p></o:p></b></div>
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The degree of treatment
can be determined by comparing the influent wastewater characteristics to the
required effluent wastewater characteristics after reviewing the treatment
objectives and applicable regulations. The contaminants in wastewater are
removed by physical, chemical, and biological means. The individual methods
usually are classified as physical unit operations, chemical unit processes, and
biological unit processes, Although these operations and processes occur in a
variety of combinations in treatment systems, it has been found advantageous to
study their scientific basis separately because the principles involved do not
change.</div>
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<b>Physical Unit Operations<o:p></o:p></b></div>
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Treatment methods in
which the application of physical forces predominates are known as physical
unit operations. Screening, mixing, flocculation, sedimentation, floatation,
filtration, and gas transfer are examples of physical unit operations.</div>
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<b>Chemical Unit Processes<o:p></o:p></b></div>
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Treatment methods in
which the removal or conversion of contaminants is brought about by the addition
of chemicals or by other chemical reactions are known as chemical unit
processes. Precipitation and adsorption are the most common examples used in
wastewater treatment. In chemical precipitation, treatment is accomplished by
producing a chemical precipitate that will settle. In most cases, the settled
precipitate will contain both the constituents that may have reacted with the
added chemicals and the constituents that were swept out of the wastewater as the
precipitate settled. Adsorption involves the removal of specific compounds from
the wastewater on solid surfaces using the forces of attraction between bodies.</div>
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<b>Biological Unit Processes<o:p></o:p></b></div>
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Treatment methods in
which the removal of contaminants is brought about by biological activity are
known as biological unit processes. Biological treatment is used primarily to
remove the biodegradable organic substances (colloidal or dissolved) in
wastewater. Basically, these substances are converted into gases that can
escape to the atmosphere and into biological cell tissue that can be removed by
settling. Biological treatment is also used to remove nutrients (nitrogen and
phosphorus) in wastewater.</div>
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<b>Classification of sewage/ wastewater treatment
methods<o:p></o:p></b></div>
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The unit operations and
unit processes mentioned above are grouped together to provide various levels
of treatment described below: </div>
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<b>Preliminary Wastewater Treatment<o:p></o:p></b></div>
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Preliminary wastewater
treatment is the removal of such wastewater constituents that may cause maintenance
or operational problems in the treatment operations, processes, and ancillary systems.
It consists solely of separating the floating materials (like dead animals,
tree branches, papers, pieces of rags, wood etc.) and the heavy settleable
inorganic solids. It also helps in removing the oils and greases, etc. from the
sewage. This treatment reduces the BOD of the wastewater, by about 15 to 30%. Examples
of preliminary operations are:</div>
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• Screening and communition for the removal
of debris and rags.</div>
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•
Grit removal for the elimination of coarse suspended matter that may cause wear
or clogging of equipment.</div>
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• Floatation / skimming for the removal
of oil and grease.</div>
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<b>Primary wastewater treatment<o:p></o:p></b></div>
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In primary treatment, a
portion of the suspended solids and organic matter is removed from the wastewater.
This removal is usually accomplished by physical operations such as
sedimentation in Settling Basins. The liquid effluent from primary treatment,
often contains a large amount of suspended organic materials, and has a high
BOD (about 60% of original). Sometimes, the preliminary as well as primary
treatments are classified together, under primary treatment. The organic
solids, which are separated out in the sedimentation tanks (in primary
treatment), are often stabilized by anaerobic decomposition in a digestion tank
or are incinerated. The residue is used for landfills or as a soil conditioner.
The principal function of primary treatment is to act as a precursor to
secondary treatment.</div>
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<b>Secondary Wastewater Treatment<o:p></o:p></b></div>
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Secondary treatment
involves further treatment of the effluent, coming from the primary sedimentation
tank and is directed principally towards the removal of biodegradable organics
and suspended solids through biological decomposition of organic matter, either
under aerobic or anaerobic conditions. In these biological units, bacteria will
decompose the fine organic matter, to produce a clearer effluent. The treatment
reactors, in which the organic matter is decomposed (oxidized) by aerobic
bacteria are known as <b><i>Aerobic biological units</i></b>; and may consist
of:</div>
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• <b>Filters </b>(intermittent sand
filters as well as trickling filters),</div>
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• <b>Aeration tanks, </b>with the feed
of recycled activated sludge (i.e. the sludge, which is settled in secondary
sedimentation tank, receiving effluents from the aeration tank). </div>
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• <b>Oxidation ponds and aerated
lagoons. </b>Since all these aerobic units, generally make use of primary
settled sewage; they are easily classified as secondary units. The treatment
reactors, in which the organic matter is destroyed and stabilized by anaerobic bacteria,
are known as <b><i>Anaerobic biological units </i></b>and may consists of:</div>
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• <b>Anaerobic lagoons,<o:p></o:p></b></div>
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• <b>Septic tanks,<o:p></o:p></b></div>
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• <b>Imhoff tanks, </b>etc.</div>
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Out of these units, only
anaerobic lagoons make use of primary settled sewage, and hence, only they can
be classified under secondary biological units. Septic tanks and Imhoff tanks,
which use raw sewage, are not classified as secondary units. The effluent from
the secondary biological treatment will usually contain a little BOD (5 to 10%
of the original), and may even contain several mg/l of DO. The organic solids/
sludge separated out in the primary as well as in the secondary settling tanks
is disposed off by stabilizing under anaerobic conditions in a Sludge digestion
tank.</div>
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<b>Tertiary/ Advanced Wastewater
Treatment and Wastewater Reclamation<o:p></o:p></b></div>
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Advanced wastewater treatment, also called tertiary treatment
is defined as the level of treatment required beyond conventional secondary
treatment to remove constituents of concern including nutrients, toxic
compounds, and increased amounts of organic material and suspended solids and
particularly to kill the pathogenic bacteria. In addition to the nutrient
removal processes, unit operations or processes frequently employed in advanced
wastewater treatment are chemical coagulation, flocculation, and sedimentation
followed by filtration and chlorination. Less used processes include ion
exchange and reverse osmosis for specific ion removal or for the reduction in
dissolved solids. Tertiary treatment is generally not carried out for disposal
of sewage in water, but it is carried out, while using the river stream for
collecting water for re-use or for water supplies for purposes like industrial
cooling and groundwater recharge. <span lang="EN" style="mso-ansi-language: EN;">Disinfection,
typically with chlorine, can be the final step before discharge of the
effluent. However, some environmental authorities are concerned that chlorine
residuals in the effluent can be a problem in their own right, and have moved
away from this process. Disinfection is frequently built into treatment plant
design, but not effectively practiced, because of the high cost of chlorine, or
the reduced effectiveness of ultraviolet radiation where the water is not
sufficiently clear or free of particles.<o:p></o:p></span></div>
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<b><i>Nutrient Removal or Control<o:p></o:p></i></b></div>
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The removal or control of
nutrients in wastewater treatment is important for several reasons:</div>
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• Wastewater discharges to confined
bodies of water cause or accelerate the process of</div>
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eutrophication.</div>
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•
Wastewater discharges to flowing streams tax oxygen resources for the removal
of Nitrogenous BOD thereby depleting the aquatic life.</div>
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•
Wastewater discharges when used for groundwater recharging that may be used indirectly
for public water supplies could cause health problems like blue baby diseases in
children.</div>
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The nutrients of
principal concern are nitrogen and phosphorus and they can be removed by biological,
chemical, or a combination of processes. In many cases, the nutrient removal processes
are coupled with secondary treatment; for example, metal salts may be added to
the aeration tank mixed liquor for the precipitation of phosphorus in the final
sedimentation tanks, or biological denitrification may follow an activated
sludge process that produces a nitrified effluent.</div>
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<b><i>Toxic Waste Treatment / Specific
Contaminant Removal<o:p></o:p></i></b></div>
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Physico-chemical
treatment such as chemical coagulation, flocculation, sedimentation, and filtration
reduces many toxic substances such as heavy metals. Some degree of removal is
also accomplished by conventional secondary treatment. Wastewaters containing
volatile organic constituents may be treated by air stripping or by carbon
adsorption. Small concentrations of specific contaminants may be removed by ion
exchange.</div>
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<b>Factors affecting selection and
design of sewage/wastewater treatment systems<o:p></o:p></b></div>
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The collection, treatment
and disposal of liquid waste (sewage) is referred to as Sewerage. Sewage
systems include all the physical structures required for collection, treatment
and disposal of the wastes. In other words, discharged waste water's that are
collected in large sewerage networks, transporting the waste from the site of
production to the site of treatment comprise Sewage treatment networks
(Sewerage system). The most important factors that should be borne in the mind
before the selection and design of any sewage/ wastewater treatment system are:</div>
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<b>1. Engineering Factors<o:p></o:p></b></div>
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•
Design period, stage wise population to be served and expected sewage flow and
fluctuations.</div>
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•
Topography of the area to be served, its slope and terrain; Tentative sites available
for treatment plant, pumping stations and disposal works.</div>
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•
Available hydraulic head in the system upto high flood level in case of
disposal into a river or high tide level in case of coastal discharges.</div>
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•
Groundwater depth and its seasonal fluctuations affecting construction, sewer infiltration.</div>
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• Soil bearing capacity and type of
strata to be met in construction.</div>
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•
On site disposal facilities, including the possibilities of segregating sullage
and sewage and reuse or recycling of sullage water within the households.</div>
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<b>2. Environmental Factors<o:p></o:p></b></div>
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•
Surface water, groundwater and coastal water quality where wastewater has to be
disposed after treatment</div>
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•
Odour and mosquito nuisance which affects land values, public health and well being.</div>
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•
Public health considerations by meeting the requirements laid down by the regulatory
agencies for effluent discharge standards, permissible levels of microbial and
helminthic quality requirements and control of nutrients, toxic and accumulative
substances in food chain.</div>
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<b>3. Process considerations<o:p></o:p></b></div>
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<div class="MsoNormal" dir="LTR" style="direction: ltr; line-height: 150%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;">
• Wastewater flow and characteristics.</div>
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• Degree of treatment required.</div>
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• Performance characteristics.</div>
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•
Availability of land, power requirements, equipments and skilled staff for
handling and maintenance.</div>
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<b>4. Cost considerations<o:p></o:p></b></div>
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• Capital costs for land, construction,
equipments etc.</div>
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•
Operating costs including staff, chemicals, fuels and electricity, transport, maintenance
and repairs etc.</div>
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<b>References<o:p></o:p></b></div>
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1.
Pittier, P. and Chudoba, J., "Biodegradability of Organic Substances in
the Aquatic Environment", CRC Press, 1990.</div>
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</div>فهد بن عبدالله بن محمد ال ضبعانhttp://www.blogger.com/profile/02798510127146826335noreply@blogger.com0tag:blogger.com,1999:blog-1250794412228211836.post-73623373835251021692010-12-31T08:32:00.000-08:002010-12-31T08:32:37.296-08:00"Throw the light on Treponema pallidum"<div dir="rtl" style="text-align: right;" trbidi="on"><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">مقدمة<span style="mso-spacerun: yes;"> </span></span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Introduction</span></u></b><span dir="rtl"></span><span dir="rtl"></span><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> <b>pallidum</b></span></i><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">هي نوع من أنواع البكتريا الحلزونية ، ولها ثلاث سلالات (تحت نوع) </span></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">subspecies</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> ممرضة مثال الزهري </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">syphilis</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>، البيجل </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">bejel</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>، البينتا </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">pinta</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> والعليقى </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">yaws</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. ومن الأمور التي تميز هذه البكتريا هي أنها لا تصبغ بصبغة جرام نظرا لرفعها البالغ والشديد حيث لا تستطيع الصبغة الارتباط بجدارها الخلوي. هناك أربعة سلالات على الأقل تابعة لهذه البكتريا والتي تسبب أمراض كالآتي:</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 19.3pt 0pt 0cm; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;"><span style="font-size: 14pt; line-height: 200%;"><span style="mso-list: Ignore;">1.<span style="font: 7pt 'Times New Roman';"> </span></span></span><span dir="rtl"></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تسبب مرض الزهري.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 19.3pt 0pt 0cm; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;"><span style="font-size: 14pt; line-height: 200%;"><span style="mso-list: Ignore;">2.<span style="font: 7pt 'Times New Roman';"> </span></span></span><span dir="rtl"></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum endemicum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تسبب مرض البيجل.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 19.3pt 0pt 0cm; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;"><span style="font-size: 14pt; line-height: 200%;"><span style="mso-list: Ignore;">3.<span style="font: 7pt 'Times New Roman';"> </span></span></span><span dir="rtl"></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum carateum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تسبب مرض البينتا.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 19.3pt 0pt 0cm; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18pt; text-justify: kashida; text-kashida: 0%;"><span style="font-size: 14pt; line-height: 200%;"><span style="mso-list: Ignore;">4.<span style="font: 7pt 'Times New Roman';"> </span></span></span><span dir="rtl"></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum pertenue</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تسبب مرض العليقى.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(<a href="file:///F:/Treponema%20pallidum/Treponema-1.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-1.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تتبع الوضع التصنيفي العالمي الآتي:</span></div><div align="center"><table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" dir="rtl" style="border-bottom: medium none; border-collapse: collapse; border-left: medium none; border-right: medium none; border-top: medium none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-dir: bidi; mso-yfti-tbllook: 480;"><tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: windowtext 1pt solid; mso-border-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">مملكة</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: windowtext 1pt solid; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">البكتريا الحقيقية</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: windowtext 1pt solid; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Eubacteria</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: windowtext 1pt solid; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Kingdom</span></div></td></tr>
<tr style="mso-yfti-irow: 1;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">شعبة</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">البكتريا الحلزونية</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Spirochaetes</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Phylum</span></div></td></tr>
<tr style="mso-yfti-irow: 2;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">طائفة</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">الحلزونيات</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Spirochaetes</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Class</span></div></td></tr>
<tr style="mso-yfti-irow: 3;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">رتبة</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">الحلزونيات</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Spirochaetales</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Order</span></div></td></tr>
<tr style="mso-yfti-irow: 4;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">عائلة</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">الحلزونيات</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Spirochaetaceae</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Family</span></div></td></tr>
<tr style="mso-yfti-irow: 5;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">جنس </span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">تريبونيما</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Genus</span></div></td></tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;"><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: windowtext 1pt solid; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 45.05pt;" valign="top" width="60"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">نوع</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 133.2pt;" valign="top" width="178"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">باليدوم</span></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 139.15pt;" valign="top" width="186"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Pallidum</span></i></b></div></td><td style="background-color: transparent; border-bottom: windowtext 1pt solid; border-left: windowtext 1pt solid; border-right: #f0f0f0; border-top: #f0f0f0; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding-bottom: 0cm; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0cm; width: 82.05pt;" valign="top" width="109"><div align="center" class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: center;"><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Species</span></div></td></tr>
</tbody></table></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-6.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>6</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span></span></b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> عبارة عن بكتريا حلزونية متحركة تصيب الإنسان عن طريق الاتصال الجنسي ، وتدخل العائل عن طريق اختراق الأنسجة الطلائية العمادية والحرشفية ؛ كما يمكن أن تنتقل البكتريا إلى الجنين عبر المشيمة خلال المراحل الأخيرة في الحمل وبذلك يصاب الجنين بمرض الزهري الذي يسمى في هذه الحالة بالزهري الخلقي </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">congenital syphilis</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. إن التركيب اللولبي أو الحلزوني لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> يسمح لها بالحركة البريمية خلال الأوساط اللزجة مثل الأغشية المخاطية حيث تصل إلى دم العائل وجهازه الليمفاوي. إن السلالات المسببة لأمراض البيجل، البينتا والعليقى لا يمكن تمييزها عن السلالة المسببة لمرض الزهري من حيث الشكل الظاهري والاختبارات المصلية إلا أنهم لا ينتقلون جنسيا. </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(<a href="file:///F:/Treponema%20pallidum/Treponema-1.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-1.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>مرض الزهري من الأمراض التي تنتقل عن طريق الاتصال الجنسي بسبب بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">التي تكون غير قادرة على العيش خارج العائل (الإنسان)، وتعتمد اعتمادا كليا عليه في استمرارية الحياة. ومن الجدير بالذكر أن هذه البكتريا قادرة على الهروب من الجهاز المناعي للإنسان وتظل تنمو وتتكاثر في الجسم دون ظهور أي أعراض وذلك في المراحل الأولى للمرض، وبتقدم مراحل المرض تبدأ الأعراض في الظهور والتي من الممكن علاجها بعد ذلك والسيطرة عليها. بالرغم من أن بكتريا </span></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تنمو ببطء داخل العائل إلا أنها تعتمد عليه في تخليق جميع احتياجاتها الخلوية وتؤثر في جميع أعضاء الجسم ثم الوفاة في حالة تمكن المرض من الجسم. يستطيع الإنسان التماثل للشفاء عند تناوله العلاج بجرعاته الموصى بها قبل وصول المرض إلى مراحله المتقدمة. ينتقل المرض من الشخص المصاب إلى الشخص السليم عن طريق الاتصال الجنسي، نقل الدم الملوث وعن طريق التلامس المباشر مع قرح مرض الزهري.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-6.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>6</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>إن أحد الدراسات التي اهتمت ببكتريا مرض الزهري </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> توصلت إلى عزل سبعة سلالات لولبية حلزونية من براز الخنزير وقد ذكرت هذه الدراسة "اعتمادا على الصفات الظاهرية والجينية للعزلات كان هناك سلالتين تابعتين لبكتريا </span><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> وسلالتين لهما نوعين جديدين يتبعا جنس </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> وهما </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema parcinum</span></i></b><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> sp. Nov.</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> و </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema berlinense</span></i></b><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> sp. Nov.</span></b><span dir="rtl"></span><span dir="rtl"></span><b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span dir="rtl" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></b><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-2.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>2</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>قبل عام 1970م لم تكن المعلومات متوفرة عن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> غير أنها بكتريا ممرضة ولكن بعد اكتشاف التقنيات الحديثة مثل المجهر الالكتروني وجهاز الفصل الكهربي الجيلاتينى والتقنيات الحيوية الكيميائية والطرق البيولوجية الجزيئية وتتابع الأحماض النووية ساعد وبشكل جذري فهم بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> من حيث الشكل الظاهري وصفات نموها داخل وخارج العائل، واحتياجاتها من المواد الغذائية والأكسجين والعناصر الأخرى. وكذلك معرفة مسارات الأيض الغذائي فضلا عن مدى حساسيتها للمواد المضادة للميكروبات </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Steven, <i>et al</i>. 2001)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span></b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">حساسة للمضاد الحيوي البنسلين<b><i> </i></b>الذي ما زال يعتبر العلاج الأول لمرض الزهري. البنسلين والمضادات الحيوية الأخرى التابعة لمجموعة البيتا لاكتام تعتبر مضادات حيوية قاتلة لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><b><i><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span></i></b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">نظرا لقدرتها على تثبيط الإنزيمات المرتبطة بالغشاء السيتوبلازمى والتي تدخل في تخليف طبقة الببتيدوجليكان المكونة للجدار الخلوي </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Ghuysen, 1988)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. وعموما فان البكتريا تحتوى على العديد من البروتينات المخصصة لارتباط البنسلين </span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Penicillin Binding Proteins)</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> والتي تنقسم إلى صنفين بروتينات ذات وزن جزيئي عالي وبروتينات ذات وزن جزيئي منخفض. </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(Ghuysen, 1991; Massova and Mobashery, 1998)<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl"><span dir="rtl"></span><span dir="rtl"></span> <i><span style="mso-spacerun: yes;"> </span></i><span lang="AR-SA"></span></span></span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span></span></b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن البكتريا الحلزونية التابعة لرتبة الحلزونيات تتميز بشكلها الظاهري الفريد المميز وهو الشكل اللولبي المموج المنتظم </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Hovind-Hougen, 1983)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. إن خلايا بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> يتراوح طولها من 5 إلى 15 ميكروميتر وقطرها من 16, إلى 2, ميكروميتر. إن المظهر الجانبي المتموج لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> له طول موجي واتساع تقريبا 1.1 ميكروميتر و 4, ميكروميتر على التوالي. </span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">المادة الوراثية </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Genome</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>في 17 يوليو 1998م أصدرت مجلة العلوم أن هناك مجموعة من علماء علم الأحياء ذكروا كيف استطاعوا تحديد تتابع الحامض النووي لبكتريا </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>.<i>Treponema pallidum</i></span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Fraser, <i>et al</i>. 1998).</span></b><span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>إن التتابع الحديث لمجموعة الأحماض النووية لعديد من البكتريا الحلزونية سمح بالتحليل الشامل لإيجاد التشابهات والاختلافات داخل شعبة البكتريا الحلزونية. إن بكتريا مرض الزهري لها حامض نووي من اصغر الأحماض النووية داخل هذه الشعبة حيث يصل حجمه إلى 1.14 مليون زوج من القواعد النيتروجينية كما له قدرات أيضية محدودة وهذا يعكس صغر الحامض النووي للبكتريا واعتمادها على نسيج الثدييات كعائل لها </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Clark, <i>et al</i>. 2009)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> أولية النواة لها حامض نووي صغير ومثلها مثل حقيقيات النواة في أن خلاياها تخضع لعمليات النسخ والترجمة والتضاعف والإصلاح لتكوين الأحماض النووية الجديدة والبروتين كما أن لها أنظمة القص والتعديل. إن تتابع حامضها النووي يشبه إلى حد كبير تتابع الحامض النووي لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Borrelia burgdurferi</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">التي تسبب مرض الايم </span></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">lyme disease</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> وهو مرض يسبب الطفح الجلدي مع التهابات جلية شديدة في الإنسان. إن التتابع الكلى للحامض النووي لهذه البكتريا هو 1.138.006 زوج من القواعد النيتروجينية.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-6.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>6</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>إن الباحثين بمجال الهندسة الوراثية والبيولوجية الجزيئية استطاعوا أن يحددوا أن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> غير قادرة على تخليق العوامل المرافقة للإنزيمات، الأحماض الدهنية والنيوكليوتيدات وبالتالي فإنها تعمل على نقل كل الاحتياجات الغذائية من عائلها حتى تستطيع تخليق البروتين.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-2.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>2</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">اللقاح </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Vaccine</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>لا يوجد لقاح لمرض الزهري حيث أن الغشاء الخارجي لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> يحتوى على عدد قليل جدا من البروتينات التي تعمل على تكوين الأجسام المضادة في الدم عند دخول البكتريا المضعفة في الجسم. هناك مجهودات بذلت للتوصل إلى لقاح آمن وفعال لمرض الزهري ولكن باءت كلها بالفشل وذلك لقلة بروتينات الغشاء الخارجي وعدم التعرف عليها حتى الآن </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Tomson, <i>et al</i>. 2007)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">تركيب الخلية والأيض الغذائي </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Cell structure and metabolism</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لها شكل لولبي أو حلزوني ذات غشاء مزدوج. إن أفراد رتبة البكتريا الحلزونية لها سوطان يوجدان على أحد طرفي الخلية وهما طويلان يمتدان على طول الخلية وينشآن من الفراغ البلازمي للخلية بين الغشاء الداخلي والخارجي وهما أداة الحركة في الخلية. بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> قادرة على استخدام المواد الكربوهيدراتية كمصدر وحيد للطاقة ولكنها غير قادرة على تخليق الأحماض الدهنية والعوامل المساعدة للإنزيمات وأغلب الأحماض الأمينية ولهذا تعتمد على عائلها في الحصول على هذه الاحتياجات. </span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>تسمى بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> بحالة السقوط أو التباعد الأيضى وذلك لاعتمادها المطلق على عائلها في الحصول على المواد الغذائية ولنفس السبب لا يستطيع الباحثين زرع هذه البكتريا خارج أنسجة العائل على بيئات صناعية. بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> تسمى أيضا بالبكتريا الممرضة الخفية </span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(stealth pathogen)</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لأنها تفتقر إلى البروتينات السطحية الموجودة على الغشاء الخارجي فبالتالي لا يستطيع الجهاز المناعي الإحساس بها فهي تخل الجسم وكأنها متخفية. إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> هي بكتريا قليلة الاحتياج للأكسجين </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">microaerophilic</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> ولذلك فهي تحتاج إلى كمية ضئيلة منه للنمو، وهى لا تملك الجينات المسئولة عن إفراز الإنزيمات التي تحميها ضد الأكسجين وسميته مثال </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">superoxidase dimutase</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> و </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">peroxidase</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> و </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">catalase</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>، وبالرغم من هذا فهي تمتلك إنزيم </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">NADH oxidase</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> الذي يستهلك الكمية الضئيلة من الأكسجين المستخدمة. بكتريا<span style="mso-spacerun: yes;"> </span></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لا تمتلك نظام نقل الالكترونات التنفسي </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">respiratory transport electron chain</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span dir="rtl" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span></span></b><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-2.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>2</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">بيئة الميكروب </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Ecology</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لها نظام فريد في اعتمادها على عائلها. إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> هي العامل المسبب<b><i> </i></b>لمرض الزهري، وجميع الدراسات التي تناولت هذه البكتريا أثبتت أن هذه البكتريا إجبارية التطفل أي لا تستطيع العيش والحياة خارج عائلها وذلك لافتقارها إلى تخليق المواد الغذائية الضرورية ؛ وبهذا تصبح بيئة هذه البكتريا هي العائل فقط.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="rtl" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><b><span style="mso-spacerun: yes;"> </span></b></span><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(<a href="file:///F:/Treponema%20pallidum/Treponema-2.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span>2</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr"></span>.htm</span></a>).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span dir="rtl"></span><span dir="rtl"></span><b><i><u><span style="font-size: 16pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span></span></u></i></b><b><u><span style="font-size: 16pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><span lang="AR-SA">الأمراض التي يسببها الميكروب </span></span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Pathology</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">هي العامل المسبب لمرض الزهري و ينتقل خلال الإنسان من الشخص المصاب إلى الشخص السليم مسببا الأمراض و يستطيع أن يسبب تهتك لأنسجة العضو المصاب ، هذا الميكروب ينتقل فقط عن طريق الاتصال الجنسي و كذلك ينتقل من الأم المصابة إلى جنينها عن طريق المشيمة ، ولا ينتقل عن طريق استخدام أشياء المريض مثل الملابس والأدوات. من الممكن أن ينتقل المرض من الشخص المصاب إلى الشخص السليم عن طريق لمس قرح مرض الزهري الطافحة على الجلد. إن قرح مرض الزهري تتكون على فتحة الشرج الخارجية والداخلية، المهبل، المستقيم، وأيضا على الفم. المرحلة الأولية من مرض الزهري تكون قرحة دائرية صلبة لا تسبب الم يمكن شفاءها بشكل سريع مع تناول العلاج ولكن إذا لم يتم العلاج بشكل سريع سوف ينتقل المرض من المرحلة الأولية إلى المرحلة الثانية والأخيرة. </span></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">أحيانا لا يمكن التأكد من أن القرح المتكونة على فتحة الشرج عند الرجل والمهبل عند الأنثى بسبب مرض الزهري ولهذا يستلزم الأمر إجراء اختبار الزهري، أما المرحلة الثانية لمرض الزهري تكون مصحوبة بظهور الطفح الجلدي وإن لم تعالج سوف ينتقل المرض إلى المرحلة الأخيرة التي تسبب تحطيم العضو المصاب وبالتالي فإنها تؤثر على تناسق الأعضاء وقد تؤدى إلى الوفاة. </span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">يمكن علاج مرض الزهري باستخدام المضادات الحيوية مثل البنسلين الذي يحقن في العضل. إن مريض الزهري يكون معرضا وبشكل كبير إلى الإصابة بمرض الإيدز(نقص المناعة المكتسبة </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">HIV</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> ). يمكن منع انتشار المرض باستخدام وسيلة آمنة عند الاتصال الجنسي مثل الغطاء المطاطي للقضيب (</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">condom</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>) ولكن هذا الغطاء يكون فعالا إذا استخدم مع شخص سليم عند الاتصال الجنسي مع امرأة سليمة غير مصابة بالمرض.</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span> </span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن مرض الزهري العصبي هي مشكلة المريض المصاب بالزهري في منطقة الجهاز العصبي المركزي واختبارات هذا المرض تتم بواسطة استخدام سائل الدماغ الشكوى ، وهناك أربعة أنواع من مرض الزهري العصبي كالآتي:</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">1- مرض الزهري عديم الأعراض </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Asymptomatic neurosyphilis</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">2- مرض الزهري لأوعية السحايا الدماغية </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Meningovascular syphilis</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>3- مرض الزهري المسبب لشلل خفيف </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">General paresis syphilis</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>4-مرض الزهري المسبب للحبات الظهري </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Tabes dorsalis syphilis</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">ولكن النوع الثالث والرابع غير معروفين حتى الآن. خلال مرض الزهري لأوعية السحايا الدماغية تظهر مع المريض أعراض المرض الأولية ثم ينتقل المرض إلى المرحلة المتأخرة. يستغرق هذا المرض فترة حضانة كبيرة من 10 شهور حتى سبع سنوات.إن أعراض المرحلة الأولية للمرض تكون متغيرة ومنها الصداع، الضعف، فقدان الحس، التهاب الشرايين. كما أن المريض يعانى أيضا من صدمة بسبب قلة اندفاع الدم من الشرايين.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(file://F:\Treponema pallidum\Treponema-6.htm).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">العلاج </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">The treatment</span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن علاج مرض الزهري يتغير بشكل مفاجئ ومثير حيث يشتمل الدواء والعلاج على الحمامات الساخنة ، الزئبق والوجبة البسيطة ويسمى هذا العلاج بالعلاج البدائي<b>.</b></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Ross,<i> et al</i>. 2005)</span></b><span style="font-size: 14pt; line-height: 200%;">. <span dir="rtl" lang="AR-SA"></span></span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن اكتشاف المضادات الحيوية واستخدامها في علاج </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> اثبت أن هذه البكتريا المسببة لمرض الزهري شديدة الحساسية للبنسلين.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Mahoney, <i>et al</i>. 1943; and Mahoney, <i>et al</i>. 1944).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن المضاد الحيوي البنسلين </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">G</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> بنزوات هو العلاج المفضل لمرض الزهري (ماعدا الزهري العصبي</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span> </span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">وأنواع معينة من الزهري الخلقي </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(CDC, 2006)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> مع العلم أن هناك مضادات حيوية أخرى تستخدم في العلاج مثال التتراسيكلين، الماكروليدات والسيفالوسبورينات.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(CDC, 2006; and long, <i>et al</i>. 2006).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">هذه البدائل تكون نافعة في علاج المرضى الذين لديهم حساسية من المضاد الحيوي البنسلين، بعضهم يعطى عن طريق الفم وهم أكثر ملائمة وقبول إلى الجسم من المضادات الحيوية التي تعطى حقنا في العضل. خلال الثلاث عقود الماضية وخصوصا منذ عام 2004م <span style="mso-spacerun: yes;"> </span>ظهرت حالة المقاومة للمضادات الحيوية بواسطة البكتريا وبالتالي فإن علاج الزهري أخفق بواسطة المضادات الحيوية الموصى بها وخصوصا مقاومة مجموعة الماكروليدات أولا الاريثروميسين ثم الازيثروميسين. وبالرغم من ذلك تظل بكتريا<b><i> </i></b></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> حساسة للبنسلين ومضادات حيوية أخرى.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن مقاومة بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> للمضاد الحيوي الازيثروميسين ظهرت وتزايدت في الولايات المتحدة الأمريكية، كند، أيرلندا وهذا مما أدى إلى مزيد من الحاجة إلى اكتشاف مضادات حيوية جديدة لعلاج بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لا يمكن مقاومتها. إذا استخدم المضاد الحيوي الازيثروميسين لعلاج مرض الزهري فإن الأطباء يكونوا حذرين من فشل العلاج نظرا للمقاومة العالية لهذا المضاد الحيوي من هذه البكتريا.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(Kenneth and Jeffrey, 2008).<span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA"><span dir="rtl"></span><span dir="rtl"></span> </span></span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن من احد الخصائص الطبية المهمة لأي مسبب مرضى هو مدى حساسيته للعوامل المضادة للميكروبات، إن العلاج داخل الأنسجة يظل هو المعيار الذهبي لتقدير كفاءة العوامل المضادة لميكروب </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Lukehart, <i>et al</i>. 1984; Lukehart and Baker, 1987; Lukehart, <i>et al </i>.1990).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">ولكن تقدير كفاءة العلاج معمليا يتم عن طريق عمل مسح شامل للمركبات المستخدمة في العلاج وتحديد التركيز الفعال لكل مركب. في الماضي كان يعتبر فقدان حركة ميكروب </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> <b><i>pallidum</i></b></span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span>أو فقدان ضراوتها أو تثبيط نموها مقياسا لتقدير مدى حساسية هذا الميكروب للعوامل المضادة </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Rein, 1976 )</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">التمثيل الغذائي <span style="mso-spacerun: yes;"> </span></span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Metabolism</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;"></span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">إن كثيرا من النتائج التي توصلت إليها التجارب على بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">والتي اهتمت بمعرفة مسارات التمثيل الغذائي لهذه البكتريا خصوصا تفاعلات الهدم وإنتاج الطاقة كانت خلال فترة 1970م</span></span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>.(Cox, 1983)</span></b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> </span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span>يعتبر الجلوكوز أهم مصدر للكربون والطاقة لهذه البكتريا، ويتم تكوين البيروفات كمنتج لعملية التمثيل الغذائي، من بين 22 مادة نشوية وجد أن الجلوكوز و البيروفات يتم تكسيرهما إلى غاز ثاني أكسيد الكربون</span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(CO<sub>2</sub>) </span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span dir="ltr"></span><span dir="ltr"></span><b><span style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Nicholes and Baseman, 1975; Schiller and Cox, 1977).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">الجلوكوز وسكرياتة الثنائية المالتوز والمانوز قادرين على دعم تضاعف بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema</span></i></b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> <b><i>pallidum</i></b></span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span>في نظام </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Field steel </span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>، أما السكريات السداسية الأخرى والخماسية والبيروفات غير قادرين على إتمام هذا الغرض. </span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(Norris, S. J. and N. J. Farely. Unpublished).</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span><span lang="AR-SA">البكتريا الحلزونية غير قادرة على التمثيل الغذائي للأحماض الدهنية بواسطة عملية الأكسدة بيتا </span></span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span><span style="mso-spacerun: yes;"> </span></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">.β-oxidation</span><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(Schiller and Cox, 1977)</span></b><span dir="rtl"></span><span dir="rtl"></span><span dir="rtl" lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> لها مسار</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">glycolytic </span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span><span style="mso-spacerun: yes;"> </span>النشط ولكن الجينات المسئولة عن إنتاج الإنزيمات المتممة لدورة كريب غير موجودة على الحامض النووي لهذه البكتريا. </span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Fraser, <i>et al</i>. 1998)</span></b><span dir="rtl"></span><span dir="rtl"></span><b><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>.</span></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 200%;">استزراع<span style="mso-spacerun: yes;"> </span>الجين<span style="mso-spacerun: yes;"> </span></span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 200%;">Gene Cloning</span></u></b></div><div class="MsoNormal" dir="rtl" style="line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%;"><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">عدم قدرة زرع بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> خارج الأنسجة الحية يكون سببا في عدم معرفة الانتجينات التي تلعب دورا في ضراوة البكتريا وإحداث مرض الزهري ولهذا دائما تزرع داخل الأنسجة الحية<span style="mso-spacerun: yes;"> </span></span><span dir="ltr"></span><span dir="ltr"></span><b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span>(Fieldsteel, <i>et al</i>. 1982)</span></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. لا توجد طريقة عملية حتى الآن تجعلنا قادرين على الحصول على بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> بكميات وفيرة لعمل التحاليل المطلوبة لمعرفة انتيجنات هذه البكتريا. إن استزراع الحامض النووي </span><span dir="ltr"></span><span dir="ltr"></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"><span dir="ltr"></span><span dir="ltr"></span><span style="mso-spacerun: yes;"> </span>DNA</span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;">لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">داخل بكتريا </span></span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">E.coli</span></i></b><span dir="ltr" style="font-size: 14pt; line-height: 200%;"> k-12</span><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> يعتبر وسيله بديله للحصول على كميات كبيرة من انتيجنات بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span>. إن التركيب الكيميائي المتصل للمواد المضادة لبكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> غير معروفة ولذلك تم اختيار بكتريا </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">E.coli</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> <span lang="AR-SA">لاستزراع </span></span><span dir="ltr" style="font-size: 14pt; line-height: 200%;">DNA</span><span dir="rtl"></span><span dir="rtl"></span><span style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> </span><b><i><span dir="ltr" style="font-size: 14pt; line-height: 200%;">Treponema pallidum</span></i></b><span dir="rtl"></span><span dir="rtl"></span><span lang="AR-SA" style="font-size: 14pt; line-height: 200%;"><span dir="rtl"></span><span dir="rtl"></span> بداخلها حتى يتم معرفة الأجسام المضادة لها.</span><span dir="ltr" style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">(Jan, <i>et al</i>. 1983)</span></b><span style="font-size: 14pt; line-height: 200%;">.<span style="mso-spacerun: yes;"> </span></span></div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><br />
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</div><div class="MsoNormal" dir="rtl" style="line-height: 150%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%;"><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 150%;">المراجع العلمية </span></u></b><b><u><span dir="ltr" style="font-size: 16pt; line-height: 150%;">References</span></u></b><b><u><span lang="AR-SA" style="font-size: 16pt; line-height: 150%;"></span></u></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">CDC. Sexually transmitted diseases treatment guidelines, 2006</span></b><span style="font-size: 14pt; line-height: 200%;">. MMWR. Morb. Mortal. Wkly Rep 2006; 55:1–100.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;">Clark, D.P.; Dunlap, P.V; Madigan, J.T.; Martinko, J.M.; Brock, 2009. </span></b><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;">Biology of Microorganism. San Francisco: Pearson. 2009. 79 p.</span><span style="font-size: 14pt; line-height: 200%;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Cox, C.D., 1983.</span></b><span style="font-size: 14pt; line-height: 200%;"> Metabolic activities. In: Pathogenesis and immunology of</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span style="font-size: 14pt; line-height: 200%;">Treponemal infection. R.F. Schell and D.M. Musher, eds. Marcel Dekker, Inc., New York. p. 57-70.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Fieldsteel, A. H.; D. L. Cox; and R. A. Moeckli, 1982.</span></b><span style="font-size: 14pt; line-height: 200%;"> Further studies on replication of virulent Treponema pallidum in tissue cultures of SflEp cells. Infect. Immun. 35:449-455.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;"><a href="file:///F:/Treponema%20pallidum/Treponema-1.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-1.htm</span></a>.</span></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;"><a href="file:///F:/Treponema%20pallidum/Treponema-2.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-2.htm</span></a>.</span></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;"><a href="file:///F:/Treponema%20pallidum/Treponema-6.htm"><span style="color: blue;">file://F:\Treponema pallidum\Treponema-6.htm</span></a>.</span></b></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span class="citationjournal"><b><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;">Fraser, CM.; Norris, SJ.; Weinstock, GM. <i>et al.</i> 1998.</span></b></span><span class="citationjournal"><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;"> <a href="http://www.sciencemag.org/cgi/pmidlookup?view=long&pmid=9665876"><span style="color: blue;">Complete genome sequence of Treponema pallidum, the syphilis spirochete</span></a>. <i>Science (journal)</i> 281(5375):375–88.<a href="http://en.wikipedia.org/wiki/PubMed_Identifier" title="PubMed Identifier"><span style="color: blue;">PMID</span></a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/9665876"><span style="color: blue;">9665876</span></a></span></span><span class="printonly"><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;">. </span></span><span lang="EN" style="font-size: 14pt; line-height: 200%; mso-ansi-language: EN;"></span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Ghuysen, J.-M. (1988).</span></b><span style="font-size: 14pt; line-height: 200%;"> <i>Rev. Infect. Dis. </i>10, 726–732.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Ghuysen, J.-M. (1991).</span></b><span style="font-size: 14pt; line-height: 200%;"> <i>Annu. Rev. Microbiol. </i>45, 37–67.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; mso-layout-grid-align: none; text-align: justify; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Hovind-Hougen, K. 1983.</span></b><span style="font-size: 14pt; line-height: 200%;"> Pathogenesis and immunology of Treponemal</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt; text-align: justify; text-indent: 36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><span style="font-size: 14pt; line-height: 200%;">infection. Marcel Dekker, Inc., New York.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Jan, D. V.; Embden, H. J.; Van, D. D.; Ron, V. V. E.; Han, G.; Van D. H. J., 1983.</span></b><span style="font-size: 14pt; line-height: 200%;"> Molecular Cloning and Expression of <i>Treponema pallidum </i>DNA in <i>Escherichia coli</i> K-12 Infec. and Immu., Oct. 1983, p. 187-196.</span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Kenneth, A. Katza; and Jeffrey, D. Klausnerb, 2008.</span></b><span style="font-size: 14pt; line-height: 200%;"> Azithromycin resistance in Treponema pallidum. Curr Opin Infect Dis 21:83–91. </span></div><div class="MsoNormal" style="direction: ltr; line-height: 200%; margin: 0cm 0cm 0pt 36pt; mso-layout-grid-align: none; text-align: justify; text-indent: -36pt; text-justify: kashida; text-kashida: 0%; unicode-bidi: embed;"><b><span style="font-size: 14pt; line-height: 200%;">Long, CM.; Klausner, JD.; Leon, S. <i>et al</i>., 2006.</span></b><span style="font-size: 14pt; line-height: 200%;"> Syphilis treatment and HIV infection in a population-based study of persons at high risk for sexually transmitted disease/HIV infection in Lima, Peru. 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