Simple non-toxic goiter (euthyroid goiter). Diffuse toxic goiter Diffuse goiter 1 degree mcb 10

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols MH RK - 2017

Thyrotoxicosis [hyperthyroidism] (E05), Thyrotoxicosis, unspecified (E05.9), Chronic thyroiditis with transient thyrotoxicosis (E06.2)

Endocrinology

general information

Short description

Approved
Joint Commission on the Quality of Medical Services
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26

Thyrotoxicosis (hyperthyroidism) is an ethoclinic syndrome caused by an excess of thyroid hormones (TG) in the blood and their toxic effect on various organs and tissues.

"Thyrotoxicosis with diffuse goiter (diffuse toxic goiter, disease Graves,Basedova) "is an autoimmune disease that develops as a result of the production of antibodies to rTTG, clinically manifested by thyroid lesion with the development of thyrotoxicosis syndrome in combination with extrathyroid pathology (endocrine ophthalmopathy (EOP), pretibial myxedema, acropathy). Simultaneous systemic autoimmunity rare and not required for diagnosis (grade A.) In most cases, thyrotoxicosis with diffuse goiter is most clinically important for thyroid disease.
Thyrotoxicosis in patients with nodal / multi-nodal goiter occurs due to the development of functional autonomy of the thyroid node. Autonomy can be defined as the functioning of thyroid follicular cells in the absence of the main physiological stimulator - the pituitary TSH. With functional autonomy, thyroid cells get out of the control of the pituitary gland and synthesize TG in an excess amount. If the production of TG by autonomous formations exceeds the physiological need, the patient develops thyrotoxicosis. Such an event can occur as a result of the natural course of nodular goiter or after the intake of additional amounts of iodine with iodine supplements or as part of iodine-containing pharmacological agents. The process of developing functional autonomy lasts for years and leads to clinical manifestations of functional autonomy, mainly in persons of the older age group (after 45 years) (level B).

INTRODUCTORY PART

ICD-10 code (s):

ICD-10
The code	Name
E05	Thyrotoxicosis [hyperthyroidism]
E 05.0	Thyrotoxicosis with diffuse goiter
E 05.1	Thyrotoxicosis with toxic single-nodular goiter
E 05.2	Thyrotoxicosis with toxic multinodular goiter
E 05.3	Thyrotoxicosis with ectopia of thyroid tissue
E 05.4	Artificial thyrotoxicosis
E 05.5	Thyroid crisis or coma
E 05.8	Other forms of thyrotoxicosis
E 05.9	Thyrotoxicosis, unspecified
E 06.2	Chronic thyroiditis with transient thyrotoxicosis

Date of development / revision of the protocol:2013 (revised 2017).

Abbreviations used in the protocol:

AIT	-	autoimmune thyroiditis
BG	-	graves disease
TG	-	thyroid hormones
TSH	-	thyroid-stimulating hormone
MUTZ	-	multinodular toxic goiter
TA	-	thyrotoxic adenoma
T3	-	triiodothyronine
T4	-	thyroxine
Thyroid	-	thyroid
TAB	-	fine-angle thyroid aspiration biopsy
Ptg	-	parathorgomon
HCG	-	chorionic gonadotropin
AT to TPO	-	antibodies to thyroperoxidase
AT to TG	-	antibodies to thyroglobulin
AT to RTTG		antibodies to the TSH receptor
I 131	-	radioactive iodine
Image intensifier	-	endocrine ophthalmopathy

Protocol users:emergency doctors, general practitioners, therapists, endocrinologists.

Evidence level scale:

AND	High quality meta-analysis, systematic review of RCTs, or large RCTs with very low likelihood (++) of bias that can be generalized to the relevant population.
IN	High quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the relevant population ...
FROM	A cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population, or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population.
D	Description of a series of cases or uncontrolled research or expert opinion.
GPP	Best Clinical Practice: Recommended Good Clinical Practice is based on the clinical experience of members of the CP development working group

Classification

TOlassification:
1) Thyrotoxicosis due to increased production of thyroid hormones:
Graves' disease (HD);
· Toxic adenoma (TA);
· Iodine-induced hyperthyroidism;
· Hyperthyroid phase of autoimmune thyroiditis (AIT);
· TSH - due to hyperthyroidism.
- TSH-producing pituitary adenoma;
- syndrome of inappropriate TSH secretion (resistance of thyrotrophs to thyroid hormones).
· Trophoblastic hyperthyroidism.

2) Hyperthyroidism due to the production of thyroid hormones outside the thyroid gland:
· Metastases of thyroid cancer producing thyroid hormones;
Chorinonepithelioma.

3) Thyrotoxicosis, not associated with hyperproduction of thyroid hormones:
· Drug thyrotoxicosis (overdose of thyroid hormone preparations);
· Thyrotoxicosis, as a stage of de Quervain's subacute thyroiditis, postpartum thyroiditis.

Table 2: Classification of goiter size :

Table 3. Classification and pathogenesis of thyrotoxicosis:

Thyrotoxicosis form	Pathogenesis of thyrotoxicosis
Graves' disease	Thyroid stimulating antibodies
Thyrotoxic thyroid adenoma	Autonomous secretion of thyroid hormones
TSH-secreting pituitary adenoma	Autonomous secretion of TSH
Iodine-induced thyrotoxicosis	Excess iodine
AIT (hasitotoxicosis)	Thyroid stimulating antibodies
	Follicle destruction and passive entry of thyroid hormones into the blood (calloidorrhagia)
Medication thyrotoxicosis	Overdose of thyroid medications
T4 and T3-secreting ovarian teratoma	Autonomous secretion of thyroid hormones by tumor cells
HCG secreting tumors	TSH-like action of hCG
TSH receptor mutations
McCune-Albright-Breitsev Syndrome	Autonomous secretion of thyroid hormones by thyrocytes
Thyroid hormone resistance syndrome	The stimulating effect of TSH on thyrocytes due to the lack of "feedback"

Diagnostics

DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria

Complaints and anamnesis:
Complaints on:
• nervousness;
Sweating;
Heartbeat;
· Increased fatigue;
· Increased appetite and, despite this, weight loss;
General weakness;
· Emotional lability;
Shortness of breath;
• sleep disturbance, sometimes insomnia;
· Poor tolerance of elevated ambient temperatures;
Diarrhea;
Discomfort from the eyes - discomfort in the area of \u200b\u200bthe eyeballs, trembling of the eyelids;
· Menstrual irregularities.

IN anamnesis:
· The presence of relatives suffering from thyroid diseases;
· Frequent acute respiratory diseases;
· Local infectious processes (chronic tonsillitis).

Physical examination:
· An increase in the size of the thyroid gland;
Cardiac abnormalities (tachycardia, loud heart sounds, sometimes a systolic murmur at the apex, increased systolic and decreased diastolic blood pressure, atrial fibrillation attacks);
• disorders of the central and sympathetic nervous system (tremor of the fingers, tongue, whole body, sweating, irritability, feelings of anxiety and fear, hyperreflexia);
Metabolic disorders (heat intolerance, weight loss, increased appetite, thirst, accelerated growth);
Disorders of the gastrointestinal tract (loose stools, abdominal pain, increased peristalsis);
Eye symptoms (wide opening of the eye slits, exophthalmos, frightened or wary gaze, blurred vision, double vision, lagging of the upper eyelid when looking down and the lower one when looking up).

About 40-50% of people with HD develop Image intensifier, which is characterized by damage to the soft tissues of the orbit: retrobulbar tissue, oculomotor muscles; with the involvement of the optic nerve and the auxiliary apparatus of the eye (eyelids, cornea, conjunctiva, lacrimal gland). Patients develop spontaneous retrobulbar pain, pain during eye movements, erythema of the eyelids, edema or swelling of the eyelids, conjunctival hyperemia, chemosis, proptosis, limitation of the mobility of the oculomotor muscles. The most severe complications of EOP are: neuropathy of the optic nerve, keratopathy with the formation of a leucorrhoea, corneal perforation, ophthalmoplegia, diplopia, from the muscular system (muscle weakness, atrophy, myasthenia gravis, periodic paralysis)).

Laboratory research:
Table 4. Laboratory indicators for thyrotoxicosis:

Test*	Indications
TSH	Reduced less than 0.1mIU / L
Free T4	Promoted
Free T3	Promoted
AT to TPO, AT to TG	Enhanced
AT to the TSH receptor	Enhanced
ESR	Increased in subacute de Quervain's thyroiditis
Chorionic gonadotropin	Increased in choriocarcinoma

* The concentration of TSH in thyrotoxicosis should be low (< 0.1 мЕ/л), содержание в сыворотке свТ4 и свТ3 повышено (уровень А).
In some patients, there is a decrease in TSH levels without a simultaneous increase in the concentration of thyroid hormones in the blood (level A). This condition is regarded as subclinical thyrotoxicosis, unless it is due to other reasons (taking medications, severe non-thyroid diseases). Normal or elevated TSH levels against the background of high sT4 values \u200b\u200bmay indicate a TSH-producing pituitary adenoma, or selective resistance of the pituitary gland to thyroid hormones. Antibodies to rTTG are detected in 99-100% of patients with autoimmune thyrotoxicosis (level B). During treatment or spontaneous remission of the disease, antibodies can decrease, disappear (level A) or change their functional activity, acquiring blocking properties (level D).
Antibodies to TG and TPO are detected in 40-60% of patients with autoimmune toxic goiter (level B). In inflammatory and destructive processes in the thyroid gland of a non-autoimmune nature, antibodies may be present, but in low values \u200b\u200b(level C).
Routine determination of the level of antibodies to TPO and TG for the diagnosis of DTG is not recommended (level B). Determination of antibodies to PTO and TG is carried out only for the differential diagnosis of autoimmune and non-autoimmune thyrotoxicosis.

Instrumental research:
Table 5. Instrumental studies in thyrotoxicosis:

Research method	Note	UD
Ultrasound	The volume and echo structure of the thyroid gland are determined. In HD: a diffuse increase in the volume of the thyroid gland, the echogenicity of the thyroid gland is uniformly reduced, the echostructure is homogeneous, the blood supply is enhanced. With AIT: heterogeneity of echogenicity. At MUTZ: education in the thyroid gland. In thyroid cancer: hypoechoic formations with uneven contours of the node, growth of the node behind the capsule and calcification.	IN
Thyroid scintigraphy. Used isotope technetium 99mTc, I 123, less often I 131	With HD, an increase and uniform distribution of the isotope is noted. With functional autonomy, the isotope accumulates an actively functioning node, while the surrounding thyroid tissue is in a state of suppression. With destructive thyroiditis (subacute, postpartum), the seizure of the radiopharmaceutical is reduced. For TA and MUTZ, "hot knots" are characteristic, with cancer - "cold knots"	AND
	Thyroid scintigraphy is indicated for MUTZ, if the TSH level is below normal, or for the purpose of topical diagnosis of ectopic thyroid tissue or retrosternal goiter	IN
	In iodine-deficient regions, thyroid scintigraphy with MUTZ is indicated even if the TSH level is in the lower normal range	FROM
CT scan	These methods help diagnose retrosternal goiter, clarify the location of the goiter in relation to the surrounding tissue, determine the displacement or compression of the trachea and esophagus	IN
Magnetic resonance imaging
X-ray examination with barium contrast of the esophagus
TAB and cytological examination	Carried out in the presence of nodes in the thyroid gland. Puncture biopsy is indicated for all palpable nodules; the risk of having cancer is the same with solitary nodular formation and multinodular goiter. With neoplasms of the thyroid gland, cancer cells are detected. With AIT, lymphocytic infiltration.	IN

Table 6. Additional diagnostic methods for thyrotoxicosis:

Study type	Note	Probability of appointment
ECG	Diagnosis of rhythm disturbances	100%
Holter ECG 24-hour monitor	Diagnosis of heart disorders	70%
Chest x-ray / fluoroorography	Exclusion of a specific process, with the development of CHF	100%
Ultrasound of the abdominal organs	In the presence of CHF, toxic liver damage	50%
Echo cardiography	In the presence of tachycardia	90%
EGDS	In the presence of concomitant pathology	50%
Densitometry	Osteoporosis diagnosis	50%

Table 7 Indications for specialist consultation:
· Consultation of a neurologist / epileptologist - differential diagnosis with epilepsy;
· Consultation with a cardiologist - with the development of "thyrotoxic heart", CHF, arrhythmias;
· Consultation with an ophthalmologist - in combination with an image intensifier to assess the function of the optic nerve, assess the degree of exophthalmos, identify abnormalities in the work of extraocular muscles;
· Consultation of a surgeon - to resolve the issue of surgical treatment;
· Consultation of an oncologist - in the presence of a malignant process;
· Consultation with an allergist - with the development of side effects in the form of skin manifestations when taking thyreostatics;
· Consultation with a gastroenterologist - with the development of side effects when taking thyreostatics, in the presence of pretibial myxedema;
· Consultation of an obstetrician-gynecologist - during pregnancy;
· Consultation of a hematologist - with the development of agranulocytosis.

Diagnostic algorithm:

Differential diagnosis

Differential diagnosis

Table 8 Differential diagnosis of thyrotoxicosis:

Diagnosis	In favor of the diagnosis
Graves' disease	Diffuse changes on the scintigram, an increased level of antibodies to TPO, the presence of EOP and pretibial myxedema
Multinodular toxic goiter	Scintigraphic heterogeneity
Standalone Hot Nodes	"Hot" lesion on the scan
Subacute de Quervain's thyroiditis	The thyroid gland is not visualized on a scan, increased levels of ESR and thyroglobulin, pain syndrome
Iatrogenic thyrotoxicosis, amiodarone-induced thyrotoxicosis	Taking interferon, lithium preparations, or medicines containing a large amount of iodine (amiodarone) in history
TSH-producing pituitary adenoma	Increased TSH level, lack of TSH response to stimulation with thyroliberin
Choriocarcinoma	Increased human chorionic gonadotropin levels
Thyroid cancer metastases	In most cases there was a prior thyroidectomy
Subclinical thyrotoxicosis	Thyroid iodine uptake may be normal
Recurrence of thyrotoxicosis	After HD treatment
Struma ovarii - ovarian teratoma containing thyroid tissue accompanied by hyperthyroidism	increased uptake of the radiopharmaceutical in the pelvic area when scanning the whole body

In addition, differential diagnosis is carried out with conditions similar in clinical presentation to thyrotoxicosis and cases of suppression of TSH levels without thyrotoxicosis:
· Anxiety states;
· Pheochromocytoma;
· Syndrome of euthyroid pathology (suppression of TSH levels in severe somatic non-thyroid pathology) does not lead to the development of thyrotoxicosis.

Treatment abroad

Undergo treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Preparations (active ingredients) used in treatment

Groups of drugs according to ATC used in treatment

Treatment (outpatient clinic)

TACTICS OF TREATMENT AT THE AMBULATORY LEVEL: patients with previously diagnosed Graves' disease without decompensation of the disease, do not require radioiodine therapy, surgical treatment, without thyrotoxic crisis are subject to outpatient treatment .

Non-drug treatment:
· Mode: depends on the severity of the condition and the presence of complications. Exclude physical activity, because with thyrotoxicosis, muscle weakness and fatigue increase, thermoregulation is impaired, and the load on the heart increases.
· Diet: before euthyroidism is established, it is necessary to limit the intake of iodine with contrast agents into the body, because iodine in most cases contributes to the development of thyrotoxicosis. Caffeine should be avoided as caffeine can increase the symptoms of thyrotoxicosis.

Drug treatment:
Conservative thyreostatic therapy:
To suppress the production of thyroid hormones in the thyroid gland, it is necessary to use thiamazole... Thiamazole is used in a daily dose of 20-40 mg. In the case of severe clinical and biochemical hyperthyroidism, the doses can be increased by 50-100%. The mode of administration is usually 2-3 times a day, it is permissible to take the drug once a day.
Side effects of thyrostatic therapy are possible: allergic reactions, liver pathology (1.3%), agranulocytosis (0.2-0.4%). With the development of fever, arthralgia, ulcers in the tongue, pharyngitis or severe malaise, the use of thyrostatics should be stopped immediately and an extended leukogram should be determined. The duration of conservative treatment with thyreostatics is 12-18 months.
* TSH in the treatment of thyrotoxicosis remains suppressed for a long time (up to 6 months). Therefore, the determination of the TSH level for dose adjustment of the thyreostatic is not used. The first control of the TSH level is carried out no earlier than 3 months after reaching euthyroidism.

The thyrostatic dose should be adjusted depending on the level of free T4. The first control of free T4 is prescribed 3-4 weeks after the start of treatment. The thyrostatic dose is reduced to a maintenance dose (7.5-10 mg) after the normal level of free T4 is reached. Then control of free T4 is carried out once every 4-6 weeks using the "Block" scheme and once every 2-3 months with the "Block and replace (levothyroxine 25-50 mcg)" scheme in adequate doses.

Before canceling thyrostatic therapy, it is advisable to determine the level antibodies to the TSH receptor, since it helps in predicting the outcome of treatment: patients with a low level of AT-rTTG have a better chance of permanent remission.

Most patients with a resting heart rate exceeding 100 beats per minute, or with concomitant cardiovascular disease should be prescribed β-blockerswithin 3-4 weeks (anaprilin 40-120 mg / day, atenolol 100 mg / day, bisoprolol 2.5-10 mg / day).

When combined with EOP and the presence of symptoms of adrenal insufficiency, resort to corticosteroid therapy: prednisolone 10-15 mg or hydrocortisone 50-75 mg intramuscularly.

Treatment of thyrotoxicosis during pregnancy:
If a suppressed TSH level is detected in the first trimester (less than 0.1 mU / l) in all patients, it is necessary to determine the levels of T4 and T3. Differential diagnosis of HD and gestational thyrotoxicosis is based on the detection of goiter, antibodies to rTTG, EOP; detection of antibodies to TPO does not allow this (level B). Thyroid scintigraphy is absolutely contraindicated. The treatment of choice for thyrotoxicosis during pregnancy is antithyroid drugs.

PTU and thiamazole freely penetrate the placental barrier, enter the fetal bloodstream and can cause the development of hypothyroidism and goiter and the birth of a child with reduced intelligence. Therefore, thyrostatics are prescribed in the lowest possible doses, sufficient to maintain thyroid hormones at a level 1.5 times higher than the level in non-pregnant women, and TSH below the level characteristic of pregnant women. The dose of thiamazole should not exceed 15 mg per day, the dose of propylthiouracil * - 200 mg per day.

Control of svT4 is carried out after 2-4 weeks. After reaching the target level of svT4, the thyreostatic dose is reduced to a maintenance dose (thiamazole to 5-7.5 mg, propicil to 50-75 mg). The svT4 level must be monitored monthly. By the end of the second and in the third trimester, due to increased immunosuppression, immunological remission of HD occurs and in most pregnant women the thyrostatic is canceled.
The drug of choice in the first trimester is a vocational school, in the second and third - thiamazole (level C). This is due to the fact that taking thiamazole in isolated cases may be associated with congenital anomalies that develop during the period of organogenesis in the first trimester. If PTU is unavailable and intolerant, niamazole may be prescribed. In patients receiving thiamazole, if pregnancy is suspected, it is necessary to carry out a pregnancy test as soon as possible and, when it occurs, to transfer them to a PTU, and at the beginning of the second trimester to return to thiamazole.
If the patient initially received PTU, it is recommended to transfer her to thiamazole in the same way at the beginning of the second trimester.
Using a block and replace scheme contraindicated during pregnancy (level A). The block and replace scheme involves the use of higher doses of thyreostatics, which can lead to the development of hypothyroidism and goiter in the fetus.
In case of severe course of thyrotoxicosis and the need to take high doses of antithyroid drugs, as well as thyreostatic intolerance (allergic reactions or severe leukopenia) or refusal of the pregnant woman to take thyrostatics, surgical treatment is indicatedwhich can be done during the second trimester (level C).

Table 9. Treatment of Graves' disease in pregnant women:

Diagnostic time	Features of the situation	Recommendations
HD diagnosed during pregnancy	HD diagnosed in the first trimester	Start taking Propylthiouracil *.
	HD diagnosed after the first trimester	Start taking thiamazole. Measure the titer of AT to RTTG, if it is increased, repeat within 18-22 weeks and 30-34 weeks. If thyroidectomy is necessary, the second trimester is optimal.
HD diagnosed before pregnancy	Takes thiamazole	Transfer to Propylthiouracil * or cancel thyreostatics as soon as a pregnancy test is confirmed. Measure the titer of AT to RTTG, if it is increased, repeat within 18-22 weeks and 30-34 weeks.
	In remission after discontinuation of thyreostatics.	Determine thyroid function to confirm euthyroidism. Do not measure the AT titer to RTTG.
	Received radioiodine therapy or had thyroidectomy	Measure the titer of AT to RTTG in the first trimester, if increased - repeat in the period of 18-22 weeks

After thyroidectomy or extremely subtotal resection of the thyroid gland, replacement therapy with levothyroxine is prescribed at the rate of 2.3 μg / kg of body weight.

Carrying out radioiodine therapypregnant contraindicated... If I 131 was accidentally assigned to a pregnant woman, she should be informed about the radiation risk, including the risk of destruction of the thyroid gland in the fetus, if 131 I was taken after 12 weeks of pregnancy. There are no recommendations for or against termination of pregnancy, during which the woman received 131 I.

With a transient hCG-induced decrease in TSH levels in early pregnancy, thyreostatics are not prescribed.
If a woman is diagnosed with thyrotoxicosis in the postpartum period, it is necessary to conduct a differential diagnosis between HD and postpartum thyroiditis. For women with severe symptoms of the thyrotoxic phase of postpartum thyroiditis, β-blockers may be recommended.

Treatment of drug-induced thyrotoxicosis:
For the treatment of manifest iodine-induced thyrotoxicosis, β-blockers are used as monotherapy or in combination with thiamazole.
In patients who develop thyrotoxicosis during therapy interferon-α or interleukin-2, it is necessary to carry out a differential diagnosis between BG and cytokine-induced thyroiditis.

Against the background of therapy amiodarone assessment of thyroid function is recommended before, 1 and 3 months after the start of treatment, then with an interval of 3-6 months. The decision to stop taking amiodarone against the background of frolicking thyrotoxicosis should be made individually, based on the consultation of a cardiologist and the presence or absence of an effective alternative antiarrhythmic therapy. Thiamazole should be used for the treatment of type 1 amiodarone-induced thyrotoxicosis, and glucocorticosteroids for the treatment of type 2 amiodarone-induced thyrotoxicosis. In severe amiodarone-induced thyrotoxicosis, which does not respond to monotherapy, as well as in situations where the type of disease cannot be accurately determined, the appointment of a combination of thyreostatics and glucocorticoids is indicated. Thyroidectomy should be performed in patients with amiodarone-induced thyrotoxicosis in the absence of the effect of aggressive combination therapy with thiamazole and prednisolone.

Approaches to the treatment of HD in patients with endocrine ophthalmopathy:
Thyrostatic therapy in patients with HD and EOP is preferable to use a block and replace scheme (level C). Surgical treatment of HD in combination with image intensifier is recommended to be performed in the volume of total thyroidectomy in order to prevent the progression of image intensifier in the postoperative period (level B).

All patients with HD and EOP require mandatory medical correction of postoperative hypothyroidism from day 1 after surgery, followed by regular determination of the TSH level at least once a year.

Radioiodine therapy can be recommended as a safe method of treating thyrotoxicosis in HD in patients with EOP, which does not lead to a worsening of its course, provided that a stable euthyroid state is achieved in the post-radiation period against the background of replacement therapy with levothyroxine (level C).

When planning surgical treatment or RIGHT HD, it is necessary to take into account the degree of activity of the image intensifier... Patients with an inactive phase of the image intensifier (CAS<3) предварительная подготовка не требуется, назначается только симптоматическое лечение (уровень А). В активную фазу (CAS≥5) до проведения хирургического лечения или РЙТ необходимо лечение глюкокортикоидами (уровень В). При низкой активности процесса (CAS=3-4) глюкокортикоиды назначаются, в основном, после радикального лечения. Пациентам с тяжелой степенью ЭОП и угрозой потери зрения проведение RIGHT is contraindicated... Patients with HD and EOP require smoking cessation and weight loss (level B).

List of essential drugs (100% likely to be used):
Table 9 Drugs used to treat HD:

Pharmacological group	International non-proprietary drug name	Mode of application	Evidence level
Antithyroid drug	Thiamazole H03BB02	Tablets 5 and 10 mg orally, daily dose of 10-40 mg (1-3 doses)	IN
	Propylthiuracil * H03BA02	Tablets of 50 mg orally, a daily dose of 300-400 mg (for 3 admission)
β-blockers
Nonselective (β1, β2)	Propranolol C07AA05	Oral 10-40 mg 3-4 times a day	IN
Cardioselective (β1)	Atenolol C07AB03	Oral tablets, 25-100 mg 1-2 times a day	IN

List of additional medicines (less than 100% likely to be used):
Table 10. Drugs used for adrenal insufficiency:
* apply after registration on the territory of the Republic of Kazakhstan

Surgical intervention:not.

Further management[4-6]:
· Monitoring of patients receiving thyrostatic therapy is carried out for the early detection of side effects such as rash, liver pathology, agranulocytosis. It is necessary to study the levels of T4 and TSH every 4 weeks for the early detection of hypothyroidism and the appointment of replacement therapy. Within a year after reaching euthyroidism, laboratory assessment of thyroid function is carried out 1 time in 3-6 months, then every 6-12 months.
· In pregnant women with BG, it is necessary to use the lowest doses of thyrostatics, ensuring the achievement of the level of thyroid hormones slightly above the reference range, with suppressed TSH. Thyroid function during pregnancy should be assessed monthly and the dose of thyrostatic should be changed as needed.

After radioactive iodine therapyI 131 thyroid function decreases progressively. Control of TSH level - every 3-6 months. Hypothyroidism usually develops 2-3 months after treatment, and when it is detected, it is necessary to immediately prescribe levothyroxine.

After thyroidectomy for HD it is recommended:
· Stop taking antithyroid drugs and ẞ-blockers;
Start taking levothyroxine in a daily dose corresponding to the patient's body weight (1.6-1.8 μg / kg), 6-8 weeks after starting taking levothyroxine, determine the TSH level and, if necessary, adjust the dose (taking levothyroxine is a lifelong substitution therapy , determination of the level of TSH should be carried out at least 2-3 times a year);
In the first days after surgery, it is necessary to determine the level of calcium (preferably free calcium) and PTH and, if necessary, prescribe calcium and vitamin D preparations.
In hypoparathyroidism, the main method of treatment is hydroxylated vitamin D preparations (alfacalcidol, calcitriol). Dose selection is made strictly individually based on the serum calcium level, which is determined once every 3 days. The starting dose of the drug depends on the level of free calcium (less than 0.8 mmol / l: 1-1.5 mcg / day; 0.8-1.0 mmol / l: 0.5-1 mcg / day).

There is no minimum or maximum dose of vitamin D. Adequate dose criterion - the level of ionized calcium is not higher than 1.2 mmol / l for 10 days; after the selection of an adequate dose, the calcium level is monitored continuously once every 2-4 weeks, if necessary, the dose of the drug is adjusted. Additionally, calcium preparations are prescribed at a dose of 500-3000 mg / day to ensure sufficient calcium intake into the body.

In the future, patients who have undergone thyroidectomy and are receiving replacement therapy with levothyroxine should be monitored in the usual way, as for patients with hypothyroidism (hypoparathyroidism).
After I 131 therapy or surgical treatment, the patient should be observed for all his life in connection with the development of hypothyroidism.

Treatment effectiveness indicators:
· Reduction or elimination of symptoms of thyrotoxicosis, allowing the transfer of the patient to outpatient treatment;
· Reduction in the size of the goiter;
· Reduction of the dose of thyreostatics required to maintain euthyroidism;
· Disappearance or decrease in the content of antibodies to TSH receptors.

Treatment (hospital)

TACTICS OF TREATMENT AT STATIONARY LEVEL: patients with newly diagnosed thyrotoxicosis, for radioiodine therapy and surgical treatment, as well as in a state of decompensation and thyrotoxic crisis are subject to inpatient treatment .

Patient observation chart, patient routing

Non-drug treatment:see ambulatory level.

Radioactive iodine therapy:
Indicationsfor therapy with radioactive iodine are:
· Postoperative recurrence of thyrotoxicosis;
· Recurrent course of thyrotoxicosis during treatment with thyreostatics;
Intolerance to thyrostatics.

In patients with HD who do not develop remission of the disease 1-2 years after therapy with thiamazole, it is necessary to consider the issue of treatment with radioactive iodine or thyroidectomy.
In persons with severe thyrotoxicosis, when the total T4 level is\u003e 20 μg / dL (260 nmol / L) or the sT4 level is\u003e 5 ng / dL (60 pmol / L), thiamazole and β-blockers must be prescribed before I 131 therapy in order to normalize these indicators. Drug treatment with thyrostatics is usually discontinued 10 days before the appointment of I 131 (in cases of severe thyrotoxicosis, it is possible to discontinue treatment within 3-5 days). Thyrostatics are not canceled before radioactive iodine therapy in patients with severe thyrotoxicosis and / or with large goiter to prevent thyrotoxic crisis.

Drug treatment:see ambulatory level.

Thyrotoxic crisis (TC)- a rare disease characterized by multisystem injury and mortality in 8% -25% of cases. Diagnostic criteria for TC - unified diagnostic criteria (BWPS scale).

All patients with TC require observation in the intensive care unit, monitoring of all vital functions should be carried out. Treatment should be started immediately, without waiting for the results of a hormonal blood test.

Table 11. Treatment of thyrotoxic crisis:

LS

Dose

The International Statistical Classification of Diseases and Related Health Problems is a document developed under the leadership of WHO to provide a unified approach to the methods and principles of treatment of diseases.

It is revised every 10 years, changes and amendments are introduced. Today, there is ICD-10 - a classifier that makes it possible to determine an international protocol for the treatment of a particular disease.

Principles of classification of endocrine diseases

Class IV. E00 - E90. Diseases of the endocrine system, eating disorders and metabolic disorders, also includes diseases and pathological conditions of the thyroid gland. The nosology of the ICD-10 code is from E00 to E07.9.

• Congenital iodine deficiency syndrome (E00 - E00.9)
• Diseases of the thyroid gland associated with iodine deficiency and similar conditions (E01 - E01.8).
• Subclinical hypothyroidism due to iodine deficiency (E02).
• Other forms of hypothyroidism (E03 - E03.9).
• Other forms of non-toxic goiter (E04 - E04.9).
• Thyrotoxicosis (hyperthyroidism) (E05 - E05.9).
• Thyroiditis (E06 - E06.9).
• Other diseases of the thyroid gland (E07 - E07.9).

All these nosological units are not one disease, but a number of pathological conditions, which have their own characteristics - both in the causes of occurrence and in the methods of diagnosis. Therefore, the treatment protocol is determined by the combination of all factors and taking into account the severity of the condition.

The disease, its causes and classic symptoms

First, let's remember that the thyroid gland has a special structure. It consists of follicular cells, which are microscopic balls filled with a specific fluid - a keloid. Due to pathological processes, these balls begin to grow in size. It is on the nature of this growth, whether it has an effect on the production of hormones by the gland, and the developing disease will depend.

Despite the fact that diseases of the thyroid gland are diverse, often the causes of their occurrence are similar. And in some cases, it is not possible to establish it exactly, since the mechanism of action of this gland is still not fully understood.

• Heredity is called the fundamental factor in the development of pathologies of the endocrine glands.
• Environmental impact - unfavorable environmental conditions, radiological background, iodine deficiency in water and food, the use of food chemicals, additives and GMOs.
• Diseases of the immune system, metabolic disorders.
• Stress, psycho-emotional instability, chronic fatigue syndrome.
• Age-related changes associated with hormonal changes in the body.

Often, the symptoms of thyroid diseases also have a general tendency:

• feeling of discomfort in the neck, tightness, difficulty swallowing;
• losing weight without changing the diet;
• disruption of the sweat glands - excessive sweating or dryness of the skin may be observed;
• sudden mood swings, susceptibility to depression or excessive nervousness;
• decreased thinking acuity, memory impairment;
• complaints about the digestive tract (constipation, diarrhea);
• malfunctions of the cardiovascular system - tachycardia, arrhythmia.

All these symptoms should suggest that you need to see a doctor - at least a local therapist. And he, after conducting primary research, will refer you to an endocrinologist if necessary.

Some thyroid diseases are less common than others due to various objective and subjective reasons. Consider those that are statistically most common.

Types of thyroid pathologies

Thyroid cyst

Small in size, benign tumor. It is generally accepted that a cyst can be called a formation that exceeds 15 mm. in diameter. Anything below this limit is follicle expansion.

It is a mature, benign tumor that many endocrinologists classify as a cyst. But the difference is that the cavity of the cystic formation is filled with keloid, and the adenoma is the epithelial cells of the thyroid gland.

Autoimmune thyroiditis (AIT)

A disease of the thyroid gland, characterized by inflammation of its tissue caused by a malfunction of the immune system. As a result of such a malfunction, the body produces antibodies that begin to "attack" its own thyroid cells, saturate them with leukocytes, which causes inflammatory processes. Over time, their own cells are destroyed, stop producing the required amount of hormones, and a pathological condition called hypothyroidism occurs.

Euteriosis

This is an almost normal state of the thyroid gland, in which the function of producing hormones (TSH, T3 and T4) is not impaired, but there are already changes in the morphological state of the organ. Very often, this condition can be asymptomatic and last a lifetime, and the person will not even suspect the presence of the disease. This pathology does not require specific treatment and is often detected by chance.

Nodular goiter

Nodular goiter code according to ICD 10 - E04.1 (with a single node) is a neoplasm in the thickness of the thyroid gland, which can be either cavity or epithelial. A single node is rarely formed and indicates the beginning of the process of neoplasms in the form of multiple nodes.

Multinodular goiter

Multinodular goiter ICD 10 - E04.2 is an uneven increase in the thyroid gland with the formation of several nodes, which can be both cystic and epithelial. As a rule, this type of goiter is characterized by increased activity of the endocrine organ.

Diffuse goiter

It is characterized by a uniform expansion of the thyroid gland, which affects the decrease in the secretory function of the organ.

Diffuse toxic goiter is an autoimmune disease characterized by diffuse enlargement of the thyroid gland and persistent pathological production of excessive amounts of thyroid hormones (thyrotoxicosis).

This is an increase in the size of the thyroid gland, which does not affect the production of normal amounts of thyroid hormones and is not a consequence of inflammation or neoplastic formations.

Thyroid disease caused by iodine deficiency in the body. Distinguish between euthyroid (increase in organ size without affecting hormonal function), hypothyroid (decrease in hormone production), hyperthyroid (increase in hormone production) endemic goiter.

An increase in the size of an organ, which can be observed in both a sick person and a healthy one. The neoplasm is benign and is not considered a tumor. Specific treatment does not require until the moment when changes in the organ or an increase in the size of the formation begin.

Separately, mention should be made of such a rare disease as thyroid hypoplasia. This is a congenital disease characterized by an underdevelopment of the organ. If this disease occurs during life, then it is called thyroid atrophy.

Thyroid cancer

One of the less common pathologies, which is detected only by specific diagnostic methods, since the symptoms are similar to all other thyroid diseases.

Diagnostic methods

Almost all pathological neoplasms rarely develop into a malignant form (thyroid cancer), only with a very large size and untimely treatment.

The following methods are used for diagnosis:

• medical examination, palpation;
• analysis of the titer of antibodies to thyroid tissue
• ultrasound examination of the thyroid gland;
• analysis for hormones;
• fine needle biopsy if necessary.

In some cases, treatment may not be required at all if the size of the lesions is very small. The specialist simply observes the patient's condition. Sometimes neoplasms spontaneously dissolve, and sometimes they rapidly begin to increase in size.

The most effective treatments

Treatment can be conservative, that is, medication. The drugs are prescribed in strict accordance with laboratory tests. Self-medication is unacceptable, since the pathological process requires specialist control and correction.

In the presence of clear indications, surgical measures are carried out when part of the organ that is subject to the pathological process is removed, or the entire organ.

Treatment of autoimmune thyroid diseases has several differences:

• medication - aimed at destroying excess hormones;
• radioactive iodine treatment or surgery - leads to the destruction of the gland, which entails hypothyroidism;
• computer reflexology is designed to restore the functioning of the gland.

Diseases of the thyroid gland, especially in the modern world, are quite common. If you turn to a specialist in time and carry out all the necessary therapeutic measures, you can significantly improve the quality of life, and in some cases completely get rid of the disease.

The concept of nodular goiter in ICD 10 revision

This nosological unit belongs to the class of diseases of the endocrine system, eating disorders and metabolic disorders (E00-E90), the block of thyroid diseases (E00-E07).

Speaking of nodular goiter, it is important to remember that this concept generalizes according to the microbiology 10 different forms of thyroid diseases, which differ in terms of their occurrence and morphological characteristics. In other words, these are nodes or neoplasms that are in the gland and have their own capsule. The process can be single - or multi-node, depending on the number. At the same time, this disease can cause a visible cosmetic defect, determined by palpation, or generally be confirmed only with the help of ultrasound diagnostics. Thus, the following morphological types of goiter are distinguished:

• Nodal
• Diffuse
• Diffuse-nodal

Classification

However, the ICB 10 revision nevertheless laid the basis for the classification not only morphology, but also the causes of occurrence, highlighting:

• Endemic goiter due to iodine deficiency
• Non-toxic goiter
• Thyretoxicosis

Endemic goiter with iodine deficiency

According to microbiology 10, this nosological unit belongs to the code E01. This pathology is characterized by hyperthyroidism. That is, the activity of the thyroid gland without clinical manifestations of the toxic effect of thyroid hormones. Thyrotoxicosis syndrome can be talked about when pronounced symptoms of intoxication with thyroid hormones appear.

Etiology

As the name implies, the cause of this disease is iodine deficiency in the body, with the only difference at what stage the body is deficient in this element. If the deficiency is due to a violation of the absorption of iodine in the intestine, or congenital pathologies of the thyroid gland, in which the production of the hormone is disrupted, this is a variant of relative insufficiency. An absolute deficiency occurs in endemic areas where water, soil and food are critically low in iodine.

Pathogenesis

With iodine deficiency, the synthesis of hormones T3, T4 decreases, and by the type of feedback in the pituitary gland, the production of thyroid-stimulating hormone increases, which stimulates the hyperplastic reaction in the tissues of the thyroid gland. In the future, the process can become isolated, that is, with the formation of a nodular goiter or diffuse. However, the mixed type is not excluded.

Sporadic forms

In ICB 10 under the code E04, non-toxic forms of goiter are considered. Scientists still talk about the conventionality of dividing this term into the concept of endemic and sporadic, since the pathogenesis and causes of the latter are not fully understood. In the ICD 10 revision, the non-toxic form is subdivided into single-node, multi-node and diffuse.

Etiology

Genetic factors in the development of the sporadic form play an important role. It has been established that not all residents of endemic areas develop hyperthyroidism, but families with congenital genetic diseases associated with a defect in the X chromosome are more prone to it. As a result, the body may change the threshold of sensitivity to iodine deficiency, as well as to thyrotropic stimulation. The classical reasons include the lack of the amino acid tyrosine, which is necessary for the synthesis of thyroxine. Taking medications containing perchlorates, lithium salts, thiourea.

Thyrotoxicosis syndrome is separately indicated under the code E05 in microbiology 10. This clinical syndrome is caused by the negative influence of excess TSH. Thyrotoxicosis is a consequence of diseases of the thyroid gland, namely:

• diffuse toxic goiter
• autoimmune thyroiditis
• excessive intake of iodine preparations or thyroid hormones into the body
• toxic adenoma
• pituitary adenomas
• increased sensitivity to thyroid hormones

Diffuse goiter of the thyroid gland: symptoms and manifestations of the disease

The article describes the symptoms of diffuse toxic goiter, all the variety of its manifestations, the concept of the forms of this severe pathology is given. It also lists and characterizes the degree of development of the disease with visual photos and video materials.

Severe chronic endocrine disease - diffuse thyroid goiter whose symptoms come from almost all systems of the human body, has an autoimmune nature. Its development is associated with the appearance of a defect in the immune system, manifested in the production of antibodies directed against the TSH receptors that stimulate the thyroid gland.

The consequence of this is:

1. Uniform proliferation of thyroid tissue.
2. Hyperfunction of the gland.
3. An increase in the concentration of hormones produced by the thyroid gland - thyroxine (T4) and triiodothyronine (T3).

The hypertrophied thyroid gland has its own name - goiter.

Etiology and pathogenesis of the disease

This pathology most often affects women in the age group 20 - 50 years. In children and the elderly, diffuse goiter occurs very rarely. As for the causes of the disease and the mechanisms that trigger the autoimmune process, they currently remain a task for endocrinology that has yet to be solved.

So far, we can only talk about hereditary predisposition, which is realized under the influence of a complex of factors, both internal and external:

1. Mental trauma.
2. Diseases of an infectious and toxic nature.
3. Organic lesions of brain structures (trauma, encephalitis).
4. Autoimmune pathologies.
5. Smoking (see Thyroid and Smoking: Dangers Lurk).
6. Endocrine disorders and so on.

Further, thyroid hormones, produced with a significant excess of norms, accelerate metabolic reactions, which leads to a rapid depletion of energy resources, both of the tissues of individual organs and of the entire human body in general. First of all, the structural elements of the central nervous and cardiovascular systems suffer. A detailed description of all stages of the development of pathology is described in the video in this article.

Classification

In such a disease as diffuse goiter, the symptoms largely depend on its form and degree of manifestation. Pathology has several classifications.

Depending on the increase in the thyroid gland, the following degrees of the disease are distinguished:

1. Zero - no goiter.
2. The first - the goiter is determined by palpation, but not visually distinguishable. The size of the lobes does not exceed the length of the distal phalanx of the first finger.
3. Second - Goiter is determined both by palpation and visually.

Goiter, depending on the shape, happens:

1. Diffuse.
2. Uzlov.
3. Diffuse-nodal (mixed).

By the severity of the process:

1. Easy degree.
2. Average.
3. Heavy.

Depending on the functional state of the thyroid gland, a goiter can be:

1. Euthyroid.
2. Hypotherioid.

By localization, it can be:

1. Normal.
2. Partially retrosternal.
3. Koltsev.
4. Dystoped from the embryos.

The symptomatology of the disease depends on all the characteristics mentioned in the classification.

Manifestations of the disease, depending on the severity of the pathological process

Diffuse-toxic goiter, the symptoms of which are very diverse, depending on the severity of the process, has the following manifestations:

1. In a mild form, neurotic complaints predominate. Tachycardia is observed, but the heart rate does not exceed 100 beats / min, without rhythm disturbances. Other endocrine glands are not included in the pathological process.
2. With an average severity of the diffuse thyroid gland, the symptoms are somewhat different - weight loss is added to tachycardia exceeding 110 beats / min, reaching 10 kg within a month.
3. The severe form is characterized by progressive weight loss, up to cachexia. In addition, the first signs of dysfunction of the heart, as well as the liver and kidneys, appear.

A severe form of the development of the disease, as a rule, is observed in the absence of treatment for diffuse toxic goiter for a long time, as well as when people without proper knowledge are trying to cope with this disease with their own hands.

Features of the manifestation of the euthyroid state

Since the thyroid gland functions normally in euthyroid goiter, but the clinical picture depends entirely on the degree of enlargement of the gland. Zero degree against the background of maintaining the normal working capacity of the organ is absolutely not manifested. As the size of the thyroid gland increases, its effect on other systems of the body appears and gradually increases.

For example, diffuse grade 1 euthyroid goiter has symptoms that are still not very obvious:

1. General weakness.
2. Increased fatigue.
3. Headaches.
4. Unpleasant sensations appear behind the sternum, in the projection of the heart.

1. Difficulty breathing.
2. Constriction in the neck.
3. Difficulty swallowing.
4. Compression of the trachea, leading to asthma attacks and dry cough.

In order to prevent the aggravation of the condition, you should promptly seek medical help and not self-medicate. In addition, it should be remembered that the more advanced the disease is, the higher the cost of treatment.

Features of the manifestations of diffuse nodular goiter

In addition to diffuse goiter, there are also mixed (diffuse-nodular) and nodular forms. Diffuse goiter is a uniform increase in the thyroid gland, provided that there are no local seals in the tissues. With a nodular form, pathological nodular growths appear in normal structures.

Mixed goiter is a complex of nodular formations and diffuse growth. It occupies one of the first places in the structure of thyroid pathologies in terms of frequency of occurrence.

The first stages of the disease may show scanty symptoms or not at all. But further progression of the pathological process makes the manifestation of the disease more vivid.

The development of diffuse-nodular goiter occurs in three degrees according to the WHO international classification or five according to the Russian:

• Zero degree (I according to WHO). Has no symptoms, is found by chance during examination of other organs
• First degree (I according to WHO). It is manifested by a slight increase in the patient's weight, an unreasonable decrease in body temperature, chronic fatigue, hypotension.
• Second degree (II according to WHO). It is manifested by problems with swallowing, pain in the head and neck when performing bends of the torso and head. Since diffusely nodular goiter, the symptoms of which are gradually increasing, continues to grow and increase the production of hormones, then manifestations of hyperthyroidism begin to join - blood pressure rises, edema, exophthalmos appear, pathological psychomotor reactions, tremors. Also, due to compression of the trachea by thyroid tissues, shortness of breath develops.
• Third degree (II according to WHO). At this stage of its development, the diffusely nodular goiter of the thyroid gland shows even more pronounced symptoms. The cardiovascular, endocrine and nervous systems are affected. The shape of the neck is greatly changed. The skin is either dry or waterlogged, due to the excessive production of hormones containing iodine, it develops a reddish tint. From the digestive tract - diarrhea alternates with constipation. The patient is worried about severe tremor, hypotension, bradycardia up to 40 beats / min or tachycardia more than 100 beats / min. Despite the increased appetite, patients lose weight. Changing the position of the head, they feel a sharp attack of suffocation. They are tormented by constant shortness of breath.
• Fourth degree (III by WHO). It differs from the previous one only in the shape and size of the goiter, which completely changes the configuration of the neck.
• Fifth degree (WHO III). The extreme severity of the course of the disease is characterized by which many systems of the human body suffer: endocrine, nervous, digestive, cardiovascular. Death is sometimes possible. The size of the goiter is huge, which decorously changes the patient's appearance. His voice becomes husky or completely disappears. Decreases in intelligence, memory, reproductive functions.

Doctors use both types of classification, but the Russian one is more valuable, since with its help the course of goiter is described in much more detail.

One of the most powerful manifestations of the depletion of thyroid gland resources - hypothyroidism, which developed in childhood - is cretinism. It is characterized by a pronounced lag in physical, mental, mental and intellectual development, short stature, tongue-tied, slow maturation of bones, in some cases deafness.

Certain syndromes characteristic of diffuse goiter

The defeat of each system of the body leads to the appearance of specific complaints, in addition, there are a number of separate syndromes characteristic of this disease in hyperthyroidism.

The cardiovascular system

Disruption of the normal functioning of the heart and blood vessels is manifested:

1. Tachycardia at rest (up to 130 beats / min), in which pulsation is felt in various parts of the body, such as the arms, abdomen, head, chest.
2. An increase in systolic blood pressure and a drop in diastolic blood pressure.
3. Severe myocardial dystrophy (especially in the elderly).
4. Cardiosclerosis.

Disorders of the cardiovascular system pose a direct threat to the patient's life. The fight against them should be carried out by the joint efforts of endocrinologists and cardiologists, and patients should clearly follow the treatment instructions developed by these specialists.

Catabolic syndrome

It is characterized by the following manifestations:

1. Sharp emaciation (up to 15 kg) with increased appetite.
2. General weakness.
3. Hyperhidrosis.
4. Subfebrile condition in the evenings (occurs in a limited number of elderly patients).
5. Thermoregulation disorder.

The latter manifestation is characterized by a constant sensation of heat, due to which patients do not freeze even at a noticeably low ambient temperature.

Organs of vision

Thyrotoxicosis leads to endocrine ophthalmopathy, characterized by the following symptoms:

1. Widening of the eye slits.
2. Incomplete closure of the eyelids, leading to "sand in the eyes", dryness of the mucous membrane of the eyes, chronic conjunctivitis.
3. Glazed eyes.
4. Glitter of eyes.
5. Periorbital edema in combination with the proliferation of periorbital tissues.

The last symptom is perhaps the most threatening, as it leads to compression of the optic nerve and the eyeball, increased intraocular pressure, pain in the eyes, and even complete blindness.

Nervous system

Thyrotoxicosis primarily leads to mental instability from mild excitability and tearfulness to aggressiveness and difficulty concentrating.

Also, the disease leads to other disorders:

1. Depression.
2. Sleep disorders.
3. Tremors of varying severity.
4. Muscle weakness with a decrease in the volume of the muscles of the limbs.
5. Increased tendon reflexes.

In severe forms of thyrotoxicosis, patients may develop persistent mental disorders of the patient and his personality.

Skeleton bones

A prolonged course of thyrotoxicosis, with an excess of thyroxine, leads to the leaching of phosphorus and calcium ions from the bones, which causes:

1. Destruction of bone tissue.
2. Decrease in bone mass, as well as their density.
3. Bone pain.

The fingers on the hands gradually become like "drum sticks".

Gastrointestinal tract

Digestive disorders are expressed in pain syndrome, stool instability up to diarrhea, sometimes nausea and vomiting. The severe form of the disease leads to thyrotoxic hapatosis - fatty degeneration of the liver and cirrhosis.

Endocrine glands

Since all the constituent parts of the endocrine system are interconnected, malfunctioning of the thyroid gland leads to malfunctions of many other glands.

The adrenal glands can suffer from relative thyrogenic insufficiency, the symptoms of which are:

1. Skin hyperpigmentation (especially in open areas).
2. Hypotension.

Disruption of the ovaries due to thyrotoxicosis is a rather rare phenomenon in which such changes occur:

1. The frequency and intensity of menstruation decreases.
2. Fibrocystic breast disease develops.

Moderate thyrotoxicosis may not affect a woman's reproductive function. The threat here is different - antibodies that stimulate the thyroid gland are able to pass the transplacental barrier, leading in some cases to the manifestation of transient neonotal thyrotoxicosis in newborns.

The sexual sphere of men suffers quite often and is expressed in gynecomastia and erectile dysfunction.

Respiratory system

In patients with thyrotoxicosis, there is an increase in respiration, as well as a tendency to develop pneumonia.

Skin

Thyrotoxicosis affects the skin condition. It becomes soft, warm and moist. Sometimes vitiligo develops, the skin folds darken, which is especially noticeable in the elbows, neck, lower back. Hair falls out, nails are affected by onychomycosis and thyroid acropachia.

A small number of patients suffer from pretibial myxedema, which is expressed in swelling, induration, and erythema of the skin on the feet and legs, which also itch.

In order for diffuse goiter not to reach its late stages and not endanger not only the health, but also the life of the patient, when the first signs of the disease appear, you should immediately contact a therapist or endocrinologist.

Etiology and pathogenesis

Hyperthyroidism is an excessive secretion of thyroid hormones, which accelerates many processes in the body. This is one of the most common hormonal disorders. Most often, the development of hyperthyroidism occurs between the ages of 20 and 50 years. Women are more likely to suffer from hyperthyroidism. Sometimes the predisposition to hyperthyroidism is inherited. Lifestyle doesn't matter.

With excessive secretion of thyroid hormones, many of the processes in the body receive additional stimulation, which leads to their acceleration. In about 3 out of 4 cases, the disorder is due to Graves disease, an autoimmune disorder in which the body's immune system produces antibodies that damage the thyroid tissue, leading to increased secretion of thyroid hormones. Graves' disease is inherited, it is believed that we can talk about its genetic basis. In rare cases, hyperthyroidism can be associated with other autoimmune diseases, especially skin disease and blood disorder (pernicious anemia).

Symptoms

The following symptoms are characteristic of hyperthyroidism:

Weight loss despite increased appetite and increased food intake;

Heart palpitations, often accompanied by arrhythmias;

Tremor (shaking) of the hands;

Too warm, damp skin, as a result of increased sweating;

Poor heat tolerance;

Anxiety and insomnia;

Increased bowel activity;

The formation of a tumor in the neck caused by an enlarged thyroid gland;

Muscle weakness;

Disorder of the menstrual cycle.

Patients with hyperthyroidism due to Graves' disease may also have bulging.

Diagnostics and treatment

If you suspect the development of hyperthyroidism, a blood test should be done to determine the elevated level of thyroid hormones in the blood and the presence of antibodies that damage the thyroid tissue. If a tumor is felt in the area of \u200b\u200bthe thyroid gland, a radionuclide test should be done to check the gland for nodules.

There are three main treatments for lowering thyroid hormone levels. The most common of these is the use. This method is used in the treatment of hyperthyroidism caused by Graves' disease. The method is aimed at suppressing the secretion of thyroid hormones. Radioactive iodine therapy is the most effective treatment for thyroid nodules. The course consists of doses of radioactive iodine consumed by the patient in the form of a solution. Iodine builds up in the thyroid gland, destroying it.

Many patients recover completely as a result of treatment. However, recurrence of hyperthyroidism is possible, especially in patients with Graves' disease. During surgery or radioactive iodine treatment, the remaining part of the thyroid gland may not be able to produce enough hormones. Therefore, it is very important to check your hormone levels regularly after treatment.

Class IV. Diseases of the endocrine system, eating disorders and metabolic disorders (E00-E90)

Note. All neoplasms (both functionally active and inactive) are included in class II. The corresponding codes in this class (for example, E05.8, E07.0, E16-E31, E34. -), if necessary, can be used as additional codes to identify functionally active neoplasms and ectopic endocrine tissue, as well as hyperfunction and hypofunction of the endocrine glands, associated with neoplasms and other disorders classified elsewhere.
Excludes: complications of pregnancy, childbirth and the postpartum period (O00-O99), symptoms, signs and deviations from the norm, identified in clinical and laboratory studies, not classified elsewhere (R00-R99), transient endocrine and metabolic disorders, specific for fetus and newborn (P70-P74)

This class contains the following blocks:
E00-E07 Diseases of the thyroid gland
E10-E14 Diabetes mellitus
E15-E16 Other disorders of glucose regulation and pancreatic internal secretion
E20-E35 Disorders of other endocrine glands
E40-E46 Malnutrition
E50-E64 Other types of malnutrition
E65-E68 Obesity and other types of excess nutrition
E70-E90 Metabolic disorders

The following categories are marked with an asterisk:
E35 Disorders of endocrine glands in diseases classified elsewhere
E90 Eating and metabolic disorders in diseases classified elsewhere

DISEASES OF THE THYROID GLAND (E00-E07)

E00 Congenital iodine deficiency syndrome

Includes: endemic conditions associated with iodine deficiency in the natural environment, both directly,
and due to iodine deficiency in the mother's body. Some of these conditions cannot be considered true hypothyroidism, but are the result of inappropriate secretion of thyroid hormones in the developing fetus; there may be a connection with natural goitrogenic factors. If necessary, an additional code (F70-F79) is used to identify concomitant mental retardation.
Excludes: subclinical hypothyroidism due to iodine deficiency (E02)

E00.0 Congenital iodine deficiency syndrome, neurological form. Endemic cretinism, neurological form
E00.1 Congenital iodine deficiency syndrome, myxedema form.
Endemic cretinism:
... hypothyroid
... myxedema form
E00.2 Congenital iodine deficiency syndrome, mixed form.
Endemic cretinism, mixed form
E00.9Unspecified congenital iodine deficiency syndrome.
Congenital hypothyroidism due to iodine deficiency NOS. Endemic cretinism NOS

E01 Diseases of the thyroid gland associated with iodine deficiency and related conditions

Excludes: congenital iodine deficiency syndrome (E00. -)
subclinical hypothyroidism due to iodine deficiency (E02)

E01.0 Diffuse (endemic) goiter associated with iodine deficiency
E01.1 Multinodular (endemic) goiter associated with iodine deficiency. Nodular goiter associated with iodine deficiency
E01.2 Goiter (endemic) associated with iodine deficiency, unspecified. Endemic goiter NOS
E01.8 Other diseases of the thyroid gland associated with iodine deficiency, and similar conditions.
Acquired hypothyroidism due to iodine deficiency NOS

E02 Subclinical hypothyroidism due to iodine deficiency

E03 Other forms of hypothyroidism

Excludes: hypothyroidism associated with iodine deficiency (E00-E02)
hypothyroidism following medical procedures (E89.0)

E03.0 Congenital hypothyroidism with diffuse goiter.
Congenital goiter (non-toxic):
... NOS
... parenchymal
E03.1 Congenital hypothyroidism without goiter. Thyroid aplasia (with myxedema).
Congenital:
... thyroid atrophy
... hypothyroidism NOS
E03.2Hypothyroidism caused by drugs and other exogenous substances.
If it is necessary to identify the cause, an additional external cause code (class XX) is used.
E03.3 Post-infectious hypothyroidism
E03.4Thyroid atrophy (acquired).
Excludes1: congenital atrophy of thyroid gland (E03.1)
E03.5 Myxedema coma
E03.8 Other specified hypothyroidism
E03.9 Unspecified hypothyroidism. Myxedema NOS

E04 Other forms of non-toxic goiter

Excludes: congenital goiter:
... NOS)
... diffuse) (E03.0)
... parenchymal)
goiter associated with iodine deficiency (E00-E02)

E04.0 Non-toxic diffuse goiter.
Goiter is non-toxic:
... diffuse (colloidal)
... plain
E04.1 Non-toxic single nodular goiter. Colloid node (cystic) (thyroid).
Non-toxic monodose goiter Thyroid (cystic) node NOS
E04.2 Non-toxic multinodular goiter. Cystic goiter NOS. Polydose (cystic) goiter NOS
E04.8 Other specified forms of non-toxic goiter
E04.9 Non-toxic goiter, unspecified. Goiter NOS. Nodular goiter (non-toxic) NOS

E05 Thyrotoxicosis [hyperthyroidism]

Excludes: chronic thyroiditis with transient thyrotoxicosis (E06.2)
neonatal thyrotoxicosis (P72.1)

E05.0Thyrotoxicosis with diffuse goiter. Exophthalmic or toxic call NOS. Graves' disease. Diffuse toxic goiter
E05.1Thyrotoxicosis with toxic single-nodular goiter. Thyrotoxicosis with toxic mononodose goiter
E05.2 Thyrotoxicosis with toxic multinodular goiter. Toxic nodular goiter NOS
E05.3 Thyrotoxicosis with ectopia of thyroid tissue
E05.4 Artificial thyrotoxicosis
E05.5 Thyroid crisis or coma
E05.8 Other forms of thyrotoxicosis. Hypersecretion of thyroid-stimulating hormone.

E05.9 Thyrotoxicosis, unspecified. Hyperthyroidism NOS. Thyrotoxic heart disease (I43.8)

E06 Thyroiditis

Excludes: postpartum thyroiditis (O90.5)

E06.0 Acute thyroiditis. Thyroid abscess.
Thyroiditis:
... pyogenic
... purulent
If it is necessary to identify the infectious agent, use an additional code (B95-B97).
E06.1 Subacute thyroiditis.
Thyroiditis:
... de Quervain
... giant cell
... granulomatous
... non-purulent
Excludes: autoimmune thyroiditis (E06.3)
E06.2 Chronic thyroiditis with transient thyrotoxicosis.
Excludes1: autoimmune thyroiditis (E06.3)
E06.3Autoimmune thyroiditis. Thyroid Hashimoto. Hasitotoxicosis (passing). Lymphadenomatous goiter.
Lymphocytic thyroiditis. Lymphomatous struma
E06.4 Medication thyroiditis
E06.5Thyroiditis:
... chronic:
... NOS
... fibrous
... woody
... Riedel
E06.9Thyroiditis, unspecified

E07 Other diseases of the thyroid gland

E07.0Hypersecretion of calcitonin. C-cell hyperplasia of the thyroid gland.
Hypersecretion of thyrocalcitonin
E07.1 Dyshormonal goiter. Family dyshormonal goiter. Pendred's Syndrome.
Excludes: transient congenital goiter with normal function (P72.0)
E07.8 Other specified diseases of the thyroid gland. Defect in tyrosine-binding globulin.
Hemorrhage)
Heart attack) (c) thyroid (yy) gland (y)
Euthyroid disorder syndrome
E07.9 Unspecified thyroid disease

Diabetes mellitus (E10-E14)

If necessary, an additional external cause code (class XX) is used to identify the drug causing diabetes.

The following fourth characters are used with headings E10-E14:
.0 Coma
Diaberic:
... coma with or without ketoacidosis (ketoacidotic)
... hypersmolar coma
... hypoglycemic coma
Hyperglycemic coma NOS

1 With ketoacidosis
Diabetic:
... acidosis)
... ketoacidosis) without mention of coma

2 With kidney damage
Diabetic nephropathy (N08.3)
Intracapillary glomerulonephrosis (N08.3)
Kimmelsteel-Wilson syndrome (N08.3)

3 With eye damage
Diabetic:
... cataract (H28.0)
... retinopathy (H36.0)

4 With neurological complications
Diabetic:
... amyotrophy (G73.0)
... autonomic neuropathy (G99.0)
... mononeuropathy (G59.0)
... polyneuropathy (G63.2)
... autonomous (G99.0)

5 With impaired peripheral circulation
Diabetic:
... gangrene
... peripheral angiopathy (I79.2)
... ulcer

6 With other specified complications
Diabetic arthropathy (M14.2)
... neuropathic (M14.6)

7 With multiple complications

8 With unspecified complications

9 No complications

E10 Insulin-dependent diabetes mellitus

[cm. above headings]
Included: diabetes (mellitus):
... labile
... with onset at a young age
... with a penchant for ketosis
... type I
Excluded: diabetes mellitus:
... newborns (P70.2)
period (O24 .-)
glycosuria:
... NOS (R81)
... renal (E74.8)

E11 Non-insulin dependent diabetes mellitus

Included: diabetes (mellitus) (non-obese) (obese):
... with onset in adulthood
... no propensity for ketosis
... stable
... type II
Excluded: diabetes mellitus:
... malnutrition-related (E12 .--)
... in newborn (P70.2)
... during pregnancy, during childbirth and in the postpartum
period (O24 .-)
glycosuria:
... NOS (R81)
... renal (E74.8)
impaired glucose tolerance (R73.0)
postoperative hypoinsulinemia (E89.1)

E12 Malnutrition-related diabetes mellitus

[cm. the above subheadings]
Includes: malnutrition-related diabetes mellitus:
... insulin dependent
... insulin independent
Excludes: diabetes mellitus during pregnancy, during childbirth
and in the puerperium (O24 .-)
glycosuria:
... NOS (R81)
... renal (E74.8)
impaired glucose tolerance (R73.0)
diabetes mellitus of newborn (P70.2)
postoperative hypoinsulinemia (E89.1)

E13 Other specified forms of diabetes mellitus

[cm. the above subheadings]
Excluded: diabetes mellitus:
... insulin dependent (E10 .-)
... malnutrition-related (E12 .--)
... neonatal (P70.2)
... during pregnancy, during childbirth and in the postpartum
period (O24 .-)
glycosuria:
... NOS (R81)
... renal (E74.8)
impaired glucose tolerance (R73.0)
postoperative hypoinsulinemia (E89.1)

E14 Diabetes mellitus, unspecified

[cm. the above subheadings]
Includes: diabetes NOS
Excluded: diabetes mellitus:
... insulin dependent (E10 .-)
... malnutrition-related (E12 .--)
... newborn (P70.2)
... non-insulin dependent (E11. -)
... during pregnancy, during childbirth and in the postpartum
period (O24 .-)
glycosuria:
... NOS (R81)
... renal (E74.8)
impaired glucose tolerance (R73.0)
postoperative hypoinsulinemia (E89.1)

OTHER IMPAIRMENTS OF GLUCOSE REGULATION AND INTERNAL SECRETION

PANCREAS (E15-E16)

E15 Non-diabetic hypoglycemic coma. Non-diabetic insulin coma caused by drugs
means. Hyperinsulinism with hypoglycemic coma. Hypoglycemic coma NOS.
If it is necessary to identify the drug that caused the non-diabetic hypolycemic coma, an additional external cause code (class XX) is used.

E16 Other disorders of internal secretion of pancreas

E16.0 Medical hypoglycemia without coma.
If it is necessary to identify the medicinal product, use an additional code for external reasons (class XX).
E16.1Other forms of hypoglycemia. Functional non-hyperinsulinemic hypoglycemia.
Hyperinsulinism:
... NOS
... functional
Hyperplasia of pancreatic beta islet cells NOS. Encephalopathy after hypoglycemic coma
E16.2 Unspecified hypoglycemia
E16.3 Increased secretion of glucagon.
Pancreatic islet cell hyperplasia with glucagon hypersecretion
E16.8 Other specified disorders of pancreatic internal secretion. Hypergastrinemia.
Hypersecretion:
... hormone-releasing growth hormone
... pancreatic polypeptide
... somatostatin
... vasoactive intenstinal polypeptide
Zollinger-Ellison syndrome
E16.9Unspecified impairment of internal secretion of the pancreas. Islet cell hyperplasia NOS.
Pancreatic endocrine cell hyperplasia NOS

DISORDERS OF OTHER ENDOCRINE GLANDS (E20-E35)

Excludes: galactorrhea (N64.3)
gynecomastia (N62)

E20 Hypoparathyroidism

Excludes: Di Georg syndrome (D82.1)
post-medical hypoparathyroidism (E89.2)
tetany NOS (R29.0)
transient hypoparathyroidism of newborn (P71.4)

E20.0 Idiopathic hypoparathyroidism
E20.1 Pseudohypoparathyroidism
E20.8Other forms of hypoparathyroidism
E20.9 Unspecified hypoparathyroidism. Parathyroid tetagia

E21 Hyperparathyroidism and other disorders of the parathyroid [parathyroid] gland

Excluded: osteomalacia:
... in adults (M83.-)
... in childhood and adolescence (E55.0)

E21.0 Primary hyperparathyroidism. Hyperplasia of the parathyroid glands.
Generalized fibrous osteodystrophy [Recklinghausen bone disease]
E21.1Secondary hyperparathyroidism, not elsewhere classified.
Excludes1: secondary renal hyperparathyroidism (N25.8)
E21.2Other forms of hyperparathyroidism.
Excludes2: familial hypocalciuric hypercalcemia (E83.5)
E21.3 Hyperparathyroidism, unspecified
E21.4 Other specified disorders of the parathyroid gland
E21.5 Unspecified parathyroid disease

E22 Pituitary hyperfunction

Excludes: Itsenko-Cushing's syndrome (E24.-)
Nelson syndrome (E24.1)
hypersecretion:
... adrenocorticotropic hormone [ACTH], unrelated
with Itsenko-Cushing syndrome (E27.0)
... ACTH pituitary (E24.0)
... thyroid-stimulating hormone (E05.8)

E22.0Acromegaly and pituitary gigantism.
Arthropathy associated with acromegaly (M14.5).
Growth hormone hypersecretion.
{!LANG-2119664265a42cc0a6c6ed94e9563638!}
{!LANG-7c017a1af5c6879f728233a50a6df620!}
{!LANG-3f95629b114d39ad937759783f17c481!}
{!LANG-f2cf2b4c27c98e4c825c48e615036939!}
{!LANG-2c339252603c0b090a9f6a9a7d7d9ed5!}{!LANG-d4b545fa8cf760762e8cc712d98572b1!}
{!LANG-7b30ad37c67ee9d565b9bcab16a17910!}{!LANG-d8fe78dd76c10b3d20faaafa9a47f8e1!}
{!LANG-4483d90e31182291a244850377ea9019!}{!LANG-ede109ed7583e85b8181dff116debb89!}
{!LANG-53a8044ade2a23254d7ea35f91369b36!}{!LANG-21e757b551678de9da8264dd053aef85!}

{!LANG-2fd809fbba06e083c2b34c8ac216d84c!}

{!LANG-054eb25a19e989be6161116a78191362!}
{!LANG-3ed81f086a4427feb0c041224a1f4ba3!}

{!LANG-942a8219c016b68b3113904a35c2b8db!}{!LANG-82818c45a45e9f75aab462589459e391!}
{!LANG-2aafb89a9269320ecffd9931ffbcd0cb!}
{!LANG-a6d6cf3ea31981cbe3aee26307ef9cd4!}
{!LANG-e8ccaae0e121b64c299db54a4e735978!}
{!LANG-f190f147ba8903dfe81f282202600d10!}
{!LANG-879e061bc4a6530fe342d00700f6196c!}
{!LANG-b5693f07ac0079ad5522af3dc35a75da!}
{!LANG-6fa5d78ab8c4ddadd1c0a6109f1c5461!}
{!LANG-daa3c21ad6298a801a93a96e401bb416!}
{!LANG-26e5301b26927ca869d3b9de80f521ec!}
{!LANG-15a716185bc8346a9b6a0b67bcb77535!}
{!LANG-8dd40efcd576cc3a78b875694580debc!}
{!LANG-8021d1bc794525aa5d92434fe457dc9c!}
{!LANG-7633dfaaaa7a4d7b28f5d2094b69778d!}
{!LANG-7b931846857d8143a780788e28165635!}
{!LANG-7452b7699f52e3b80da3b824992212ca!}{!LANG-245ad13211ac8e2bff0a5cdbd79a58b4!}
{!LANG-86e6ef3cc21ddfcc1407859d0db6f994!}{!LANG-5646be7396dd35e6b630c4058153ccd4!}
{!LANG-0bf223b1258da38f9490a10037659de3!}
{!LANG-e6ce78a6a9a0707360da383c57b3713a!}{!LANG-edf9264496855ad0dd84cf33100d45a3!}
{!LANG-29db0c93c247d67ffbba4a54e9df441d!}
{!LANG-57eb24a2c83d5edbddba4166e469933b!}{!LANG-491c4fe9d6baedfae659a6ec11ee702f!}
{!LANG-c240ac9babd546596c1fb82a490e36ad!}{!LANG-5d00593ad077a76d2eb5781dc2a6aacf!}

{!LANG-0853eaf8936ccff6e3eb73079c4c91b2!}

{!LANG-e6c310bc303a0ed3c8baf2826f6880bc!}{!LANG-1fb6b6de8f81bb48d5d28920681ba2a5!}
{!LANG-26b5e47ec195adacee53e1bedb4cddec!}
{!LANG-73042cf14dbeb28c2c7b15f113aaacf6!}{!LANG-5247d24ef080039b2ec59cd1725fca1a!}
{!LANG-cdb672df67773e23e991845bd05eb5f2!}{!LANG-9861c09297d3b10869e4340ae431a697!}
{!LANG-4a5e56d1c423fe53fe91cc551be0c71c!}
{!LANG-26698dd60de5bbcd88ff888c332ce2f7!}{!LANG-5ac46865ee70f0703b203f003a7ec260!}
{!LANG-1d45001a52b8d9c9df6729b9547143e2!}{!LANG-49288c8d1999846e18ca9a62d1ea902f!}
{!LANG-a08f24a0932fbff9e0fe59153b43ccb7!}{!LANG-367e8a8c526740ae738362fc3913a900!}
{!LANG-5702d0f6ce3a67fc8b06858daff0fbb2!}{!LANG-fd38267e75b8c29182254992c04bbf0a!}

{!LANG-e214d4128f216fe6b06c387d59848067!}

{!LANG-66f14d9b4ff110a81a97d0cab409bab1!}
{!LANG-6d56dc9af28c7e8eb65de717b887c39a!}
{!LANG-963d5d4610e585db3f903fc827df2858!}
{!LANG-dce69b02af5cdb2053df9fe2f6d67084!}
{!LANG-48bb67a3d7707e5a8654ee1446cefaf7!}
{!LANG-5e9bd3e842f928d09a5f4c408f30d5a3!}
{!LANG-5a48dcc01151dae7f43bd01fdd3cc607!}
{!LANG-c35b1118f2dfaf804d35a4b757a15043!}
{!LANG-5e9bd3e842f928d09a5f4c408f30d5a3!}
{!LANG-ee61fb5bc8fca0894ab5f5a8acdd799c!}
{!LANG-14160dc23ffc0c66fe3847e1d6f66995!}
{!LANG-a9f193bd482a9baeb5c587b6ceeec133!}
{!LANG-aa916ea17ff06ee8cbb0ce0d0695eafd!}

{!LANG-cf6077a21ea37b435b8cd090ea559110!}{!LANG-af6915f9fec11e86db8807d6f8709f6b!}
{!LANG-e33916e56b60538d666ea8d54ba90d58!}{!LANG-460534d9fa2e7516d93d580337df18e4!}
{!LANG-527dac26eda9d42ce387adaf2782b330!}
{!LANG-f06956238228b3e74de0999382936f87!}{!LANG-9af95292290dd7d3a6b1114c14579c7a!}

{!LANG-8ba8b0f50ea391e46c3540f189016670!}

{!LANG-08670343030ab6de5ca007aafa40961f!}{!LANG-30d3633a509198432decb499c12b690a!}
{!LANG-bfa5535c47bf06b56e6ed73b52dce6af!}
{!LANG-b356847513aae785f67656003a110738!}{!LANG-3aa84aacdfc02da5e74903afb7f4da3d!}
{!LANG-00045083fe1881fe7dfdfb076d650e52!}{!LANG-03f9e8e5f1fee57e17da46226a7fe409!}
{!LANG-1702fc99664ae8bb71e8413cb8cffad9!}{!LANG-bf1dae9d2729f55c5a8817b37cfa504a!}

{!LANG-8b19b4db33d055cefd55b4aa8c6f85b0!}

{!LANG-932896bbfcc847735bb915d9cf9882b7!}{!LANG-a521c226612bc2ae50dd952c4d6869db!}
{!LANG-c82465f7187702ac1071c86fe9519f92!}
{!LANG-c21b30c5c8c340d6e748d630cff86ec9!}
{!LANG-7ea40a15a67675de5d7e97e7e01a8749!}{!LANG-52f844c0eaed48256953967ff0fe51fa!}
{!LANG-5b1702d1290b91968a81f7bd88de6d93!}
{!LANG-210d4bdf04fd0ba9aa15869194f3959e!}{!LANG-0bcb6d52e4e37491b792c298c18370f7!}
{!LANG-b3562df06fa7cf3b8403a5504a914ac5!}{!LANG-a51488be00ae34bfa5acb5b7c2c4188d!}
{!LANG-7715a24df198d36b2cd8d903c87e1627!}{!LANG-6bcb50daa7ccc0bd11e6ffce0e8808c1!}
{!LANG-ae667e2bca9948804dbc8fb3bad76120!}
{!LANG-4ab5174cbd49d177fa3c178b2e87b356!}
{!LANG-c46f6cac8c40846cce12244152c90bff!}
{!LANG-7eef60a0c23f72a68584e7986803656e!}
{!LANG-05a368884a0fcfc5db65d680beafed23!}
{!LANG-f7e3fd20554f204a18020e7acf5c8e0c!}{!LANG-3ae2c951ca5522d8d881bbc7abb602cd!}
{!LANG-2a3c2fcecd10ad9cb86237c964cca3ae!}
{!LANG-157953d6a939f04cbe5065af53777692!}{!LANG-2348ccb803ebba015c420632a4134ebd!}
{!LANG-a6eb935f896a156df8e8cb0cb8d45f67!}{!LANG-134d12a35f7c43956a27b55dfd345152!}

{!LANG-ad7b0305a969e8d34001092af26fd837!}

{!LANG-060d765ab85011af66c30b4de761ebdb!}
{!LANG-7d015b7f48d3c04723c51ed5df5684fb!}

{!LANG-12c7acb28bf4d223ccc6c139ebce6ac3!}{!LANG-7a7a21e268a3faf01706e716a266033e!}
{!LANG-734c8b441d78d697aab44406c5268256!}{!LANG-3d570b00f78fbbb19da708883bef606a!}
{!LANG-98f352e6446474666de962e05e38883e!}{!LANG-b87e56bce9de4b89014e59a5fb689ccb!}
{!LANG-b98d955f95c0faf4c744a65c68265d07!}{!LANG-fbe7f04ff0212a604b49ae5fa105455a!}
{!LANG-60a297d924e4ffc92b0cff1d79971de6!}
{!LANG-34c23a07d043d9aa76da93713ff74b2f!}
{!LANG-143ebbc21fe59d00a18a561a6e8dc986!}
{!LANG-13b79d2e0ff23fc5c73321a8a1988c18!}
{!LANG-1cc016958d67115b6f47f3587bcf123e!}{!LANG-41dd977a3c08c85f9d45692e2c391bda!}
{!LANG-c193d4f811f6dce44497fac44da172bd!}{!LANG-c6887b4e7c1548f66b140b414bb69905!}

{!LANG-d88840810163c671581d2757f46b077d!}

{!LANG-af17402ed7264903397858d454c6343b!}
{!LANG-a0e956a13c49246436a6c6be4ad1b8b0!}
{!LANG-b9216483c73eab2265fe886ee77eed53!}
{!LANG-9b390566c5e2c8650804b27880f22088!}
{!LANG-cfc785120e959e47b1b7d5cf3f230c78!}

{!LANG-8c7813a0ae7d79c7f26bceccb34c9c8b!}{!LANG-2015b135e7a9ef2d5192ef1d05bf9c22!}
{!LANG-8e71dc5526108c4c83757446c764f5af!}{!LANG-53799e40fc664e2af36e4b058062704e!}
{!LANG-9e26372998f8d7b697c59006fd83555c!}
{!LANG-39c149a90f2d40c328a382225b78ec47!}
{!LANG-0bcafc8606baf5cbfc5b0f12408e66b2!}
{!LANG-ea6b21a9f711fb20270a0d027511a76a!}{!LANG-62f579b573a75a9192d50d3722ae6005!}
{!LANG-aaad25d784fafb342dee6f09f553f0d1!}{!LANG-f07e40b7c4232f66f9964880abcff1ac!}

{!LANG-1734b3706e41a28a4f8c17bd31ed58a6!}

{!LANG-3420bcdc2e98c182b7707e360319bef5!}{!LANG-4c87f1873e09d42f061fba719b9891c8!}
{!LANG-18717120706278e73136f2c3f6969d89!}
{!LANG-b2a72b832b554880f3c8bf600d0e3ba8!}{!LANG-b39ffa5441cdde369863733147c9c151!}
{!LANG-40b1995e1ef49451cd9ccd1733d13adf!}
{!LANG-1dc73a99bf7f6f0f7fa9b484ada6b8cb!}
{!LANG-6ff37695d129419786a23c53198175fc!}
{!LANG-34418fb6c03df8225bd2d9202fc6b163!}
{!LANG-f247565fc3d98140a7ecdcdd695aff61!}{!LANG-bc156402c4190459c393f6cd31e08461!}
{!LANG-5f966613816dab77c78ad986fc63c8d5!}{!LANG-a542094956bf11562efd52be434b71ab!}

{!LANG-b34cfbec1ea45db741d03bc0a8834adb!}

{!LANG-93037e8d584a5a8b927b92f68a9945b8!}
{!LANG-d0d736f304c5b7aa5cdc69a5eccb85fe!}
{!LANG-7c49b1cc1cf85226a95b580c3e3ea88d!}

{!LANG-59b2e540ead00d3746bf2282d1f9c928!}{!LANG-e1083e8d23a1089eb5abf12647557872!}
{!LANG-f4164a1192d5bf1e06ded8a1fada2a6e!}{!LANG-d14de0df16225de3d8b9666eca8b4807!}
{!LANG-9ad38095fbabfe180de1ebbbae60b22c!}
{!LANG-4fddbb8b712dffc9059e2be38fca4807!}{!LANG-b83482100122986c251990de6b0fe557!}
{!LANG-e70aa785c4c92f2f84424f4ec22ee7e2!}{!LANG-859f9de2d0274be55f3fddaafb2f5f34!}

{!LANG-608660bbb7a3dec40052a807ab3741e9!}

{!LANG-80ea14c61a0a2539266a0126cf176f62!}

{!LANG-4e05025c600ed8ec33cdfecdf2ffdcd3!}{!LANG-d980ae33bcea5d77c4566d830461738f!}
{!LANG-3500988fd6ed560032564ddd6a57d711!}{!LANG-e2b02d99fd22f971661d1430644cedc5!}
{!LANG-1c586208995fdc8d1f869a417f1c7c12!}{!LANG-0f391bbdeb05a1aababc833b0a5fd263!}
{!LANG-3e0295086f2986662c529471177ff7b8!}{!LANG-7d67176873a03a3327fdc5e6842c3946!}

{!LANG-88e387e0d4c0b2e5f92fbdfb3b72eb87!}

{!LANG-d83e39c3264c639a84af0ad5cbae78f5!}

{!LANG-6c20ffeb997adbdecb74667c3a5a5cad!}{!LANG-c74437c3124009dd3a679be7feec8fe8!}
{!LANG-f2d36975ef387a6e279e01abfe7c820e!}
{!LANG-9ec58f13f69a42859bc88f68da413492!}{!LANG-71a9aad9422338645a28f406399f27c1!}
{!LANG-08c9a94454cea66553d7b8868d653a85!}{!LANG-a2245955c3245e28d305341994d9403c!}
{!LANG-4354b06bd69a0f1b65c8d629e481cfd5!}{!LANG-a827e5974a2c4eb517ddc321d854ec5d!}
{!LANG-c2e37a8c87a15f29f257c68ff0801e90!}
... NOS
{!LANG-8bb326ff83bf73c7e8821f48c68abcf9!}
{!LANG-f17c7f2d1b5f1f79b91e2832fe95fc61!}
{!LANG-82e14754380ec9b5c9e093e9bdaf7737!}
{!LANG-b9247e81df8f0ab5862c74d1c0fdf69b!}
{!LANG-9052621d6336d7a75e323ea93a88ddb6!}
{!LANG-3e72939726c67f493fbeb6f39719d0b4!}
{!LANG-094967c33b1bcba4f9ca1f4f100305d8!}
{!LANG-dde0ba3c4a8017ac15eb1033e94d6c5f!}
{!LANG-b02d7c38a63025e8e13aee0cf9229c59!}
{!LANG-f0a16eee18e534ec4c9c1634759aef65!}
{!LANG-471df88cc87017c2282ff24e3d3b604f!}
{!LANG-296a9f6763dc676ffafc67760c85d0a9!}
{!LANG-03cc3a9a32f95e5a460b0149f437b457!}
{!LANG-5e17f7305535eeb6cc8568238538beb6!}
{!LANG-721a9ff48d82aa478909ef31e6ecffcd!}{!LANG-75bded03f750f3da9dc562dea75bd7da!}
{!LANG-69dec69d53c7a32f998dea1b7b0d1bf8!}{!LANG-2af3e747118f49d522ea1b2e0e8f6ed7!}
{!LANG-e569f26ab978b9d68c44366a9275f4f6!}
{!LANG-98dc167c6277bac596bb3cda46d8599b!}{!LANG-d92dd1099ce23122fe5a4480b83f3d63!}
{!LANG-b228ee8b3e543f69596e9f3d22093e49!}{!LANG-fb7c54c7ce018e007d8cff3d073e2e5c!}
{!LANG-d440941757c15e643173f4a8d7b67543!}
{!LANG-6341dbc81a869f9eb29df4dc6a72a176!}
{!LANG-3a979823cae95686f14c3fcbc6ae59fe!}

{!LANG-7ff5ecdbdf8c6d59d624d91320f4d4b3!}

{!LANG-8bbcccadf046b30e4cab0a666db8b027!}{!LANG-6ed986f02ef4ed060560cfd4d67fc3c5!}
{!LANG-530ae5e25f2da627524ff9c31e4ef60f!}
{!LANG-882f82fe00786100e2a55f7356cf46e4!}{!LANG-e3ed8a6ad4bfb65f3dd486e93867cb3e!}
{!LANG-e02ae6d77a78f4d32b3d242549ac33d2!}
{!LANG-250e85f907cda4e26334fd2e0ebe55f3!}{!LANG-28d6b9830a00e052445a6b6e282eb3d3!}

{!LANG-4457e465a1d4499be9a52e1b1efbb0b5!}

{!LANG-8400e43a3aacb07591d2d7ddf8a52118!}
{!LANG-61240038a2ebdc1e706c0f34e94aa7cd!}

{!LANG-feb52bd40f54bafb3350ed959b991b2b!}
{!LANG-aa364877b70206e5ba9c690d46879401!}
{!LANG-552ad5e2bf66e32cf46ef935d5df4599!}
{!LANG-eee2bb2e720f7b824155848196dbabb7!}
{!LANG-e0b51d4d72f85f0dced685a7e0bac3bc!}

{!LANG-a2b922d8938dca479ff9fd7c35f03e0a!}

{!LANG-b64372566e14c740cdadb2de301b87c9!}

{!LANG-945d8a58f6ce66924be7fac67d6c2705!}

{!LANG-59972a603e7608d89b1cde5e13fa6227!}
{!LANG-46cec8ab32e2ae796775d92c6e81348e!}

{!LANG-d3e140d384e3505eee3d7ed9c1a61571!}

{!LANG-48fbf28200b5fe9da14813256aa9c6a3!}
{!LANG-26ef980f0bc054a5ae360d4ae4094125!}
{!LANG-18d34d6c1f9f8fc34476441137393f42!}

{!LANG-d991b6d48836464ea290e4167a2f43c5!}

{!LANG-602bc2dcb93b435d285b13ad0703c194!}

{!LANG-918d3c5a51a792c0a15766930c13d93d!}

{!LANG-d4374db5375f1e4e66216bcafb6106dd!}{!LANG-732d19e84c9292ef299d4200f279e8ca!}
{!LANG-8551726bceaa5387e57ec62a369f36d5!}
{!LANG-579efa7850b9f92dc245586c4ab6a7a4!}

{!LANG-3e02ad75ad3d2e54ad4aa764eed307e5!}{!LANG-8c96cf7a3a1020770c0a9aa4f2be5ac2!}
{!LANG-a1e57260335353b9cfe55c8b7cdf6024!}

{!LANG-d7d78c3143bc4680215d087c3fa943cd!}

{!LANG-bd5c5d653032f7b4d5e1389f7d31a089!}
{!LANG-115540260491767843c9b3b34af2e288!}
{!LANG-d9ffad579fc193ff5a9ed838fd86e64c!}
{!LANG-e721d959785b2b0c4a8de3a77ab207f2!}

{!LANG-0237e694afee0625fdb2551d8c6e75ce!}

{!LANG-589640167a51bb200450a50f2ce2c5d2!}
{!LANG-d7f7fe07ba1e734d2e8cdad487d04a84!}

{!LANG-f77e2f0415699bf7f9e054d13c47df43!}

{!LANG-c8ad945f6104a0a85fee1deef8bf0793!}

{!LANG-723e2451392b650136ae3c2296fb40fe!}

{!LANG-3411ebb0dbb04220116bb1df668bf3d5!}

{!LANG-cf402dd613600d17a0a5e2e42753d26b!}{!LANG-4cc7245807120a5ea74b197ab69101ba!}
{!LANG-0763b12ca1c1a0f1626467a11e424853!}{!LANG-e43962a84aea29c2447d8c7ea5f16a77!}
{!LANG-a8def624294453c7c5bc74aff474b2cb!}{!LANG-481636f335d41cd1855317b20ff40fcc!}
{!LANG-2bcccb8b9dbdfc20ce80a9d7f5af3f7b!}{!LANG-748dfb814a17335a653a129fecf56403!}
{!LANG-030af37cb91fee81894b8af5936cef1c!}{!LANG-07b76d5a77c83848b64b8781bd68bd36!}
{!LANG-b630219d11b5bde76eca0f98ec9e53c6!}{!LANG-91ee28a915387ee90f4ad85a01b380c2!}
{!LANG-6b06c94c46891665a37f2ba4dc600fc3!}{!LANG-69eeefde723a099f2c85dde3d966d0a3!}
{!LANG-c104ff07e4d09842745938db8d0c8eff!}{!LANG-3a1e3777fbe01a178e195043296abd8f!}
{!LANG-62b68d59072dac88879082fb519858f8!}{!LANG-b4fc5d3951d2ac3c1964a3d4477a1b30!}
{!LANG-b8dc224ec53405a9c743009de96bee34!}
{!LANG-ff6aa02073810d807220848233b59cc5!}
{!LANG-cbcf677f7c1ecc45a03b0100a5cf1bf1!}{!LANG-980c3db630b5aea933ac07433b623923!}

{!LANG-39df02bde8c4a4b1125fa692b6656680!}

{!LANG-6117f7995069baf2638dea150e316509!}

{!LANG-beb34e0601170c14c71b9ac33a094acf!}{!LANG-e61dbb9af9b94fed4117fdaf694ae0f9!}
{!LANG-27c00f6e87b48211f16ff2f22c8e52c0!}
{!LANG-8e14c03afce2dfe6e4958f1b024bb768!}
{!LANG-956a879f33646c2d52adb84a4560b893!}
{!LANG-385c7f833a389d9d61967a9ef4982cdb!}{!LANG-71e0c12214b0c4e9164287fb215fb16c!}
{!LANG-9778daa6d39b150bbc31a7304f58c503!}{!LANG-3c0e8de5a92037531f56c8387fcdaa0d!}
{!LANG-ab7b3e32d78d3536bd313ba4ebed3057!}{!LANG-a3a5d81a6fe8106ad4e2164683ac280c!}

{!LANG-972ab5a3924d3abb87f7a676a957af2b!}

{!LANG-3b54b918c6306253eac012f312594c4f!}
{!LANG-c8f4d876f35563772524be44ad66aa25!}
{!LANG-024b9188e1776d55e75ed59b336c1a10!}
{!LANG-6537b9022276cfef1c26610f0c560d19!}
{!LANG-e6a735f36b172284f8ee6d3a6c315dd5!}

{!LANG-cecbdf172337bf51c9b2f3692aedf004!}

{!LANG-d1accb24a2da93d97b28c009352dd542!}
{!LANG-1f7a9bd07a56df77b55f112b3e6711ef!}

{!LANG-4cc61e4243505394138defb613251504!}{!LANG-0305e9bb873760f0f9a358fdcb646c66!}
{!LANG-9830ebc7743d568993fce9a0b84a6b89!}{!LANG-7a62231c3fe03db4b3269404fa6ac72d!}
{!LANG-340644ed9282f8ec6e988ae97468d97c!}
{!LANG-c1ab92660767e43a87f61b6748fc91e1!}{!LANG-be9387e9dce82c1076cecb1003ba2dea!}
{!LANG-01037795f3f16574f90bbd9fa4b3a018!}
{!LANG-4f2b3e69a42da1dc27b32a3e298e32df!}
{!LANG-89f59f0652a3a8d7f5e71035bf954175!}
{!LANG-4d2dc7775c017c332655fa7fceaebe72!}
{!LANG-d16e093975917b8597a61037d20d9667!}
{!LANG-502cf1185d89bcdd542d9c532e606393!}
{!LANG-25204caf2e27a4dcbb8e3bbb1bab5d70!}
{!LANG-843a6fea809f4c7e19485ce7103a7816!}{!LANG-ceca84415a744094846f6656b11f8a96!}

{!LANG-b9ba5620ca2bc21d152d7b83d6ba1dcb!}

{!LANG-9ed8142ba69d2428a84bc8de0ae95952!}
{!LANG-d4b0a9093f9fffbbe45626644d6f344d!}
{!LANG-80841faee8913c0e604f1d170e83bc80!}

{!LANG-5bd02ea2187476f95ee9d4eacf12bb31!}

{!LANG-cb507dcf6e9f95630d7b03021bfba771!}
{!LANG-8de8993ebbe10d6d0bf735526fcdcdeb!}

{!LANG-c3dfd1d5ca437c905ff37de5772bfdf3!}{!LANG-cfd3d01498f229e9029830531bc952d0!}
{!LANG-fadabcb822bd305a5da22ae327609285!}
{!LANG-da73a5aafb8d9617551404973285c18a!}
{!LANG-d0c5dbf895bba68aae5ec970f8a2876d!}
{!LANG-bb9e73218dda6f939ae883cbce7e28b4!}
{!LANG-a273e2ed8470f1f8062d8e677943f5bf!}
{!LANG-cd4c384a258b10a97ff0ad82e4ada344!}
{!LANG-3ac6dead3f1f4565841fffc5c83b4bd9!}
{!LANG-e041fb9a22d5422451d14ad9ccb94f67!}
{!LANG-5ec42efe364b3c8420ce6e5b3c2deef1!}
{!LANG-f948d3b5e34c3a6a7007f4fc1eb0d1b9!}{!LANG-76e40f15c53c76f3b27e519096f9f90c!}

{!LANG-abac0910ba329818faf72fffe9a80543!}

{!LANG-687c9c6c7040bbe2acdc315d056da8d6!}

{!LANG-f2e64b3c5f0ca6c7cc98233c7bd594ab!}{!LANG-ea8bc56f1395aea879796298e319f3c6!}
{!LANG-6a1670985d58be0f1a8be7feb535fa35!}{!LANG-745242ae16054a2795420fa7d705cf01!}
{!LANG-2386bb8bff5bb193c1c24ad219149280!}
{!LANG-771da13e1494ff84004fe1d65b69e555!}
{!LANG-80847ec4670b1817cdab41b7de0b4610!}{!LANG-fee0fa5ddb45137fd7a65f004b6ccc45!}
{!LANG-f5996de8fb491e5a8863f41620f58fd0!}{!LANG-e748eacf9037d39925ca051be65e0ebf!}

{!LANG-f920f3f47e05389d730a3fb182b13ff0!}

{!LANG-0489d7bb46846f405e90e677b459443d!}
{!LANG-6c3cd1c567995cfbecee015d2a91df7f!}

{!LANG-803c3e6c074f803c77f67f133e9cd7d3!}

{!LANG-c4ea49e4aa71a31b5c14aeabedee9b70!}
{!LANG-09b71c08f0569a4224c95a575358fcb1!}

{!LANG-f7aa22d2d3448d69570859b5852b68d2!}

{!LANG-e60fc5e37a75f215c1d676151653610c!}

{!LANG-9bb86f4238b9ba4ef1ecd452f8a14e66!}
{!LANG-0c325bcb0cf20fe71515eca838e43ec5!}
{!LANG-ffd2a4aceea4c9467baf7334c471cb1e!}

{!LANG-9339e6e8237a023b7f9384e6b0b45cd3!}{!LANG-c9baeab2cad72c13e7ac4086cdb0f216!}
{!LANG-dcb33c2b8e90e4cef588993d84096b5b!}{!LANG-55d300ffa92bc5b3518348dd36349c8e!}
{!LANG-4bfce8b346cefb153787c7910760b8aa!}
{!LANG-d6cf79846283d6a68dd81305c756c94e!}{!LANG-6b682cbed0e33c2da344052559ec53b8!}
{!LANG-6c4dc62a52c09f4629d62d1d33c1c75c!}{!LANG-531884f212ed2b2d2b1423be49c233ef!}
{!LANG-cd9adb5d20783543a2b417509eb92a4e!}{!LANG-1e4e8aba67cf1f9e05014f4fd23da935!}
{!LANG-b5431c6fa03ddf06bfc67b6559167f5e!}{!LANG-275bc2f51ff98e92a2f2ba09c36cb352!}
{!LANG-1114efe0799fc502f5c0254be599a6a6!}{!LANG-d6bc6fd16599379853f427e6a8d0703c!}
{!LANG-39681b4c0e38c471267499e5ce291068!}{!LANG-6ca22296710929f5de14b4f0665c3473!}
{!LANG-c988003135f8c100fbdba83bbf234148!}{!LANG-3c2cb10582a78612c5cbd274ccddc9b7!}
{!LANG-1ae7a863f4c55c9c1a1de2926497d5c0!}{!LANG-b669ded7b8fd8de811bbad6439f3dfec!}

{!LANG-997e142e0e12d5e324823fe5511be49c!}

{!LANG-54ac54e5de991c987f88d9eb0e2db819!}
{!LANG-e28ba1e9d0582f5b718f6316ba38e247!}
{!LANG-4aa4492004ae74902da9c68e5e396c3d!}
{!LANG-812bdbe7479dd2ebc7f79c2fb45461cc!}

{!LANG-c8135466a9f31e8dfd600e1c005a5989!}{!LANG-7a947690c6bc08e33b3daddc770300ef!}
{!LANG-d3d67df287435ae261d1b68a85d1e8f0!}{!LANG-bc5f265c69069d395d02668d77124405!}
{!LANG-482ca643759bf1df4afe53dc51fd0b44!}{!LANG-87cf899d295df6964b4ab6821eb73f3b!}
{!LANG-fccfd61a5815743aa85eaddf218aa3c3!}{!LANG-2932f114365f641421d006e559d9e118!}

{!LANG-db347cfa07ed6ea5b4dbfbe7d4072cea!}

{!LANG-d4a539970fa8c7e5fde1cdbc82d2f030!}{!LANG-09a612e5059743248f2804220f42333a!}
{!LANG-654a6deb2e8f6a68266c473c81a535e5!}
{!LANG-c8174b2404412d8808f64ade47cad878!}{!LANG-10efa34a632dd752571e1a8fe95c4f7b!}
{!LANG-54a61289439e3f2f3b128d67def44477!}{!LANG-70cfc56840c24bc7278452bf213ce0da!}
{!LANG-c6f087f7f0a0334971b885a1d32d74f9!}{!LANG-fe99017969ef4e5cc53c60a66afa6d3b!}
{!LANG-95160c46119edb5259e0da95a55570a7!}{!LANG-75b7d0c7780e0c3f4e7eb250ce68dc39!}
{!LANG-68946285e38cfade4b5428576af48b57!}{!LANG-1175d1573221525376df672030163b2c!}

{!LANG-e5dfcdc9623f49d4000d2e3ad4b06dd1!}

{!LANG-1a2b2e67b77331ceebbe43b087b3bfcb!}

{!LANG-cc20662a0bf0078351f4367907ddc874!}

{!LANG-4e345ad2f35f6428dcfe152eb42256ec!}

{!LANG-4a3c6f52ae2e2a3fa08354a557c95d7f!}
{!LANG-16379dd3c4207ec30b6ae86291dcfeaf!}
{!LANG-b74746938930156c5498b89b85b82a1e!}
{!LANG-2b84f9eed0b731f0534d3e290daab45d!}
{!LANG-bdf09ad55e422e30074aee1467515c7b!}

{!LANG-e9563fe4101554fd104a745940df83dd!}{!LANG-09af8368fca4926ed39eb98492ed7d33!}
{!LANG-77ba2b722db720715e430bb4e1fb67ec!}{!LANG-2a29c5e1a392df45f2a5d7ac8807b753!}
{!LANG-243f0d64558dc042412de4016d1e3440!}
{!LANG-f44a518ab5c3b31a489e683d0a676ea6!}{!LANG-ed8793dfa0fa4cae9715b15e0e7ba892!}
{!LANG-0f6f8568b1fc669509ac125b9a80d357!}{!LANG-4275b23adb57f02f3facc77e6f7cce43!}
{!LANG-1bd7598a2f10b93182de65c8c95135e1!}{!LANG-dc262728fb7d45a5e4639d2e49e9447c!}

{!LANG-c07ae1b3ccb114c516d5b842db313f85!}

{!LANG-ccee7ce80405b534543627ea830e6761!}
{!LANG-c4a1e5e86a6477320e2c141fdc44ead3!}

{!LANG-f3dd473be78d8a690917ffd86350d44c!}{!LANG-66b681c2c4586ba5a162806942de8b1d!}
{!LANG-2ca327978b4c76b11371c6b84a534063!}{!LANG-634aace52c338150711121419765f6a1!}
{!LANG-8512449c290efddb665c71958fd96086!}{!LANG-b27db806711ac3f414363ec1a1fcdee1!}
{!LANG-5790f719ee78bd9f386aa4394a2ff72a!}{!LANG-b5a9dd891b8dba560a8fa773d2b39df4!}
{!LANG-614cffd309193795eecfbf33f10215f0!}{!LANG-fd65e2d37102f58205d73dd6cbeca25b!}

{!LANG-d969429e46b9668faeec9caa0e58385c!}

{!LANG-64d3233384d9167b8d981526b32f92ff!}

{!LANG-1592a0253c7b8b804a158a6353653eef!}
{!LANG-83636a936d9074a5e525be57585f7ec3!}
{!LANG-034cdcd46983632fe6545d26c3cfbd1c!}
{!LANG-23b5b019177757a1c617b8d639f0b513!}
{!LANG-2ed8f24d710672ff2d947a8b82840eb6!}
{!LANG-e9af44b535c19f555d45ff0120635e4a!}

{!LANG-11ae7974299008fd8914cf9b75a4e125!}

{!LANG-8fd15932f2ff0d8851f760879e66df4b!}{!LANG-574cb8533246c701b9848086eb24edb6!}
{!LANG-cf526a0d4d7f3be10ca92c9a716e5fcd!}{!LANG-1ece03d3741814ec0432b6b6a2b09e21!}
{!LANG-def8d208f265a82b3912284879289ae1!}{!LANG-c1fc92dc02e2e5af81c027890711f97b!}
{!LANG-0a4362919d79320bf25ac0dd30d10d40!}{!LANG-8704d2534e2108250b0a48cd08ec80e2!}
{!LANG-a32e2fb0017de793612e4e7cbdfb34c1!}
{!LANG-fe989ace12d6c9ac82b715456257b2a6!}
{!LANG-46dba10ce8067b519903af2fea921c2c!}
{!LANG-d86fdb9d80bb18501bd066fcbd54927d!}
{!LANG-e9f0719cda062549adfde473b07d2afc!}
{!LANG-f749c9af7f0dbd2ae127408effae0114!}
{!LANG-56d79ab6291d457476329eccc4b060c3!}
{!LANG-5f52e8f2886703ac3ee8553b3dc52db8!}{!LANG-75dc105883cf5a93848386587df2b3b9!}
{!LANG-14384cbe4c0343a314e7314caf6874ee!}
{!LANG-440c7e6d2eea6afb73c9bbd2571d6197!}
{!LANG-e2f301d49852f3955db60d1ec716fc02!}
{!LANG-2c7ac0cf9b8ab092a96ae6ea3b5f549a!}{!LANG-cb34dc8b069e41a51f373478ecece728!}

{!LANG-d9bcee76f86bfb7303f76522b6ee9d74!}

{!LANG-afe142b25e2e4f5bf45beb3ce00ab92c!}{!LANG-999cb914a2a7f40f43fb184e7c79f8c6!}
{!LANG-0f6b176a48c637c706fbd82bd7063d47!}{!LANG-a6b7a09674a2e80772e63e59f6a6d6bb!}
{!LANG-87c20e33afacc628a1c1a912002a606f!}
{!LANG-2e4d24589256b59a0608e94a529146fb!}{!LANG-86627cc2f01b7b53bcc0e08112e9641e!}
{!LANG-6ef7d92f93afd460199068022103eff8!}{!LANG-80e2d5cdf24908a32f21eeeb77b92dca!}
{!LANG-ce93f68028b1002feb7e30889fb93b95!}
{!LANG-35569c8ed6929b7c82dc6ec6c571b297!}
{!LANG-1d90765568826f3fa0d47b513e000c13!}
{!LANG-bf637a02ddfebf7cf051edfefb1af39c!}

{!LANG-71bf04f8057a555252333e3b0adb86e0!}

{!LANG-3196c845043d7c820bd321b59f2955f5!}
{!LANG-107d494db10496089a17b46e01c16040!}
{!LANG-e32513323c87e34f2160613781a73967!}
{!LANG-1aea6a034f885888e38739a22abc2eb5!}
{!LANG-878e13ded3c16fc43d773685a1bc9978!}
{!LANG-c32f7fe7b0a543ad8c876304e4fd395c!}
{!LANG-d6a88be8ffa714d1ccb9b01aa77acac7!}

{!LANG-57d97b4417f04072f76834e13eabb60d!}{!LANG-c7f517d62ea2b41d54d3b36d9cdda9b5!}
{!LANG-0352b50551c0c4d0fb8e0810948c463e!}
{!LANG-612874e7c2c30243312d5023bd11530f!}
{!LANG-e2571878d21e4152f49ce8348fcef733!}{!LANG-6d2dbda3473a051acb04f932f2c3864b!}
{!LANG-4b78984863bd2fd09c8b447b40c51276!}
{!LANG-d248c69bea4bbd604547553b99b2fe2c!}
{!LANG-ab0a40785110361e01bcecbbe35ae898!}{!LANG-e06ab46bf34053f4eea25f35d2acf7e3!}
{!LANG-d65b72ce10aca258ea4bded3f5415577!}
{!LANG-ddb41f5aaabedac266ae9e66cbf7b9db!}{!LANG-76e94e7d6ba494ac10b834474a15af92!}
{!LANG-aa824c332ffc49c296e4d55a47ee575c!}{!LANG-9fdb6113c1e67781b06770bd12938cef!}
{!LANG-69043ff9bd3bc244a4b1e5558cb43b7c!}{!LANG-39cf16d54db9ea29d97f8b156e14f200!}
{!LANG-fec2a8b49bc2bfa5ca8b2c0bc5e75e74!}
{!LANG-6f2e3702a04eb9f13b3ea3bd4308c3de!}{!LANG-2efc85ba2b60e6b0560008334343d5bf!}
{!LANG-14384cbe4c0343a314e7314caf6874ee!}
{!LANG-5df57aa5679c3ffc159e2d780ae019a7!}
{!LANG-521effa78022b0b0c2cbc4581544546b!}
{!LANG-c77a9bbbcdddc450f9c93134a96dcd0d!}{!LANG-dc64f326a592183485d00eaf55d0926a!}

{!LANG-ad006bb5cab7944252fce0e2ba024bd1!}

{!LANG-4f26c0f8692f2a72df7bd30235d9cb6d!}{!LANG-ec042b6a883ce66348c69be29dc09e7f!}
{!LANG-ea4945445e9d49dd08d27d9f5e109774!}{!LANG-aaddd15e35637b9ef2e73710365a1d27!}
{!LANG-9cf391f901271ab78ec1ae96e4a07b42!}{!LANG-540557dae5912a9bcda8fca38075d475!}
{!LANG-f1311e95b8195910eb841116d8665001!}{!LANG-855d245dbcb937ced61399c7d01c0ffd!}

{!LANG-e4dc28f8e4d9576ff80e23d52ba11983!}

{!LANG-90c85776e5aea89d7d6314a60468a567!}
{!LANG-6bf348b7621a09ff290ca2efefbb6732!}
{!LANG-6326177992658031cc21923da396206d!}
{!LANG-e5ae3022b9c773c275fce2fc29bce02c!}

{!LANG-30a4d23e03da15ef19db4cc64816e645!}{!LANG-73662eea8e0af3b5659d68fe5a67f034!}
{!LANG-3a51e12e0f615c0bbe3f6fcbdd85967c!}
{!LANG-eb852618175e8c3d7ddbf4a22ea49257!}
{!LANG-4369e32d018ebcc1911a7545ab80853d!}
{!LANG-ed0abc8ed89911c4c73faf71d723d29e!}
{!LANG-46c3f5dcbbfad01d3f576ae452873046!}
{!LANG-246c24b30b9f74702e937a2f6bfd01ab!}
{!LANG-178ab1c64d0908865a5297a856d445df!}
{!LANG-63954915ce75475ce779008764a5f953!}
{!LANG-3a2ee5b670859d749c69c20991344c72!}
{!LANG-ec9425c6809f4da3d486ac047709b269!}
{!LANG-721dc3cb87d5cdbdce79ca454f7ddab3!}{!LANG-a6da0b0d4ba24ec9f4260f9f903a6381!}
{!LANG-a7e86271ddd3c0365af52a9c69f86e1e!}
{!LANG-1ec646577d57bb3585beca322e52227c!}{!LANG-0e30ebb57d5ed7470f0d0b1954a0b8c4!}
{!LANG-979df7a071a0715acd8853411b1d410f!}{!LANG-d57ddda7fb8821acd3446a38c7acd6dd!}
{!LANG-1359314662a05d23b2b2c8d772cc35f7!}
{!LANG-d820689fe37e05b74c2614a122ebd465!}
{!LANG-2dc41f81627563878e8dd297e0306a2e!}{!LANG-720cc3e31ec427bf4a26852bdce43cc9!}
{!LANG-01037795f3f16574f90bbd9fa4b3a018!}
{!LANG-37b6dda72bb01b97fe913b99e4ab91d7!}
{!LANG-28fb689f7ba9f10ff43aa29b4e1aefaf!}
{!LANG-c8ac396836c685ac04bd5f6d3a9d0a22!}
{!LANG-f68283c6d56ee96394992e056f189266!}
{!LANG-8c7a49614df806f65bee0a263d20b903!}
{!LANG-165d818a4148bb6db20d7326f9cf4c6f!}{!LANG-59d6997565d2b9962bc4c6ea11bb39f2!}
{!LANG-e8053224b0243a8a7de4ae2581aba74d!}
{!LANG-4f1080abd4ce39ac6ce9c46055717c4f!}{!LANG-123312c591497b7f3474aebb78f70ce5!}

{!LANG-582c89d495df041082358c51e25a696a!}

{!LANG-4ea4bfab1369bd21a49b4afb0bb4ee4b!}
{!LANG-de2f0b5afbb6a2df0f8721e9e7da47e6!}

{!LANG-9819724cf47974ed295f0b4d86738501!}{!LANG-f1305eec5bbad3e1af064a9e65984943!}
{!LANG-3a51e12e0f615c0bbe3f6fcbdd85967c!}
{!LANG-510440641d8e00aeca8cbfe850995ac0!}
{!LANG-fec588733b979ffa9dbc1385415e375e!}
{!LANG-e565ea7c0d03a58960eda10a2b7064a1!}
... NOS
{!LANG-8047cdc2713bb950656df3a3b6477f61!}
{!LANG-a487cd717c78175b7a2ce86d8ab7ab0b!}
{!LANG-65b921d7efc296afc5fff62a49ad7d0c!}{!LANG-b8ecc4467f09a133da9bb409d848f02f!}
{!LANG-284b20cd24ba90a5ec5e30987d948ab5!}
... NOS
{!LANG-51374be597767e19a64eae3075f73217!}
{!LANG-45dd63cd5abe9e162776ebffc8def7bc!}
{!LANG-9890994631ef4268c042d0d2e5b47fd5!}
{!LANG-f5cf50d7958eb0fde98f30e1e4bd7792!}{!LANG-2263f648f7bc13acab71d4a7de5ed1cd!}
{!LANG-3a51e12e0f615c0bbe3f6fcbdd85967c!}
{!LANG-bd5dcecd6ed9bd8f8d05dfd86ca55d27!}
{!LANG-17bbe7c6ebd02af5446f09171a3dcabd!}
{!LANG-6dde77d405c034dadfa73636f9fe7e93!}
{!LANG-46a21a1eb65a7ebbf109e1eb97571688!}
{!LANG-e0af726d49c888ab23635658b9101a3c!}
{!LANG-ea10c4c96ab7f4954cb2d5f6877ca4b2!}
{!LANG-b23765955c57f6083da543c6abd53c3b!}{!LANG-3783b73a4aa80a486930518f410232f2!}
{!LANG-fbcda97c68b8ea9a8985168e8a7728ae!}{!LANG-1188449944708a7a038685688c734429!}
{!LANG-3a51e12e0f615c0bbe3f6fcbdd85967c!}
{!LANG-d87bfe1cb02d749c3785789112740ca0!}
{!LANG-f48fbff48a0647114ed50ac14d1934bd!}
{!LANG-3d4e0c3c9c5fac36832590f2461bcef7!}
{!LANG-b776d800758578245658c410eb7e5897!}
{!LANG-1ce114d8a988392a3974228ba021fce1!}{!LANG-da885f9125c9bf949c5c72b222140572!}
{!LANG-dfb404b9b4565d753a054d203fdf0eb1!}{!LANG-1b5032dfcd6ae21a8492b0bf15bacdeb!}

{!LANG-c3debc1deb7e60b47ef327dbedf041ee!}

{!LANG-563038329287345707e0c2ea89f10c6a!}{!LANG-44496b266f8c4149dacd00462cef42dd!}
{!LANG-fbcb0af3eaf71c64f8bc5c3360ed617a!}
{!LANG-6b080768acb395a55805925e72c7966f!}
{!LANG-dbce8ea2429054e47dabe49661aef8b3!}
{!LANG-b1c64513e0e829f7b76a030daf6528b0!}
{!LANG-d4ff170cf1b60eb27cc79809ff823dc4!}{!LANG-73467f3245feebafcdff0c6ec66e3815!}
{!LANG-bc3f26f122a4553ff984a7f086fc81d6!}{!LANG-8a6ea1052cb4a53d420311a9a8bd8366!}
{!LANG-d86fdb9d80bb18501bd066fcbd54927d!}
{!LANG-2619f67cad1bdb014d35e4ea20771e8e!}
{!LANG-3fb0a67aab7be31158e9cc93d21b10b8!}
{!LANG-0650cf1ce602f9d40c9a32817a2cf221!}
{!LANG-9ad6bce6860d2a5e636511db3ff6cdec!}{!LANG-ceb770b842530e8edb0db83c1e41e9c7!}
{!LANG-2f2e5201de77b17f060a17fec5cb11c7!}{!LANG-2027e78964d0a2430d362c1666b33d49!}
{!LANG-2d9129ef575ec800c1f83466d9c62048!}{!LANG-27feca63b59846e2985ec1f90b52a86c!}

{!LANG-99782111d73e81260c5e9e512c5a76fd!}

{!LANG-bce246522998e650a02b3d940ba07d9c!}{!LANG-ca7aaf77da2a83dc8db424b2e7c22fab!}
{!LANG-7840316f3354d977879406317a281f72!}
{!LANG-bd6d3b353fd4fd492c5a20c83de64a26!}{!LANG-f42dd59d111ca754e8532b634a78ef18!}
{!LANG-c27f332eccfb8e1881aa8374ce8b0ce4!}{!LANG-f8e260fb6e0dd6310da1e2258ebc0076!}
{!LANG-8ac95c04803eca702e37bc78cc93128e!}{!LANG-d464cf286e6d6d341d966686e7ab4a59!}

{!LANG-183c1144ecfa0fe0e8e3bdd6ac9a10a9!}

{!LANG-6728ea9e2b422719ce675df16dce83b6!}
{!LANG-9797a7a3ecdd9ee306002ff849120565!}{!LANG-e5e1aade7e140df92268a9d71ae37ad4!}
{!LANG-e55770a81969de10fe5eff20294f6e68!}
{!LANG-2b29fc234c46a01ec5d8a93f44fdc699!}{!LANG-93929bbabc3fa4ac1f1da890d390d1fb!}
{!LANG-7009e0d19cce0f83e971812f441d15ea!}
{!LANG-156645fea3d579b8306a28861e68586d!}
{!LANG-398b3e4d4f1634ea1131b5afa23b4ac0!}{!LANG-24e6e42e47f3fbd4c231d1a836f4e986!}
{!LANG-1f54a5b64db99bbc1d1e25397d4a966e!}
{!LANG-a07bb49b372487908dcb77cd0800b522!}
{!LANG-4b85c57a11765c96eb3013528c613ecb!}
{!LANG-01bcbfd0ccb8f79c487010db1a6f032f!}
{!LANG-9e3f203e4dcecb4ef80ca01068f2f86a!}{!LANG-f4e925807fa2f46e7285f99de4733444!}
{!LANG-c66aad67f5d54d4051b315bdbd045331!}
{!LANG-7d1a1407be48b76260983d7d1a52927f!}{!LANG-a8ac63da5540ff8aca1014946e998675!}
{!LANG-c527b6ac679a6d072bd4bfe3862023a8!}{!LANG-0511ce6fb0ddef00cbcec62269c63b0e!}
{!LANG-364c6ad1159986cb4e5c8c37e6b24e4f!}{!LANG-20215f38d5fcd32dec48594d65272a88!}
{!LANG-58c047dcf3589935b8dbd61b0510582f!}
{!LANG-598e3a15ca87a72b241d6942099f61e7!}{!LANG-46a83af5af16394c1da95bbda508f255!}
{!LANG-ee9cd60bf88b622d0a9fc6a9c1eeebb2!}{!LANG-a1f9a3cb24845f4773646f259ff5c37c!}

{!LANG-7a4f4d16990e136613ef02e43be1c48c!}

{!LANG-3f98c93bb73ef8cd6fbf4c679fe9cf2f!}
{!LANG-aac9ef88d32c93f98bd91f21a78f0046!}
{!LANG-d6a88be8ffa714d1ccb9b01aa77acac7!}
{!LANG-8013d661c9d0ac9c250b1a822e50e279!}
{!LANG-07fd056a94255cb4e3b2aedc0ebe94df!}

{!LANG-737526334f41132e275d6bded37c7a40!}{!LANG-a531c38a9efd02a9bf706bedd90e2cf5!}
{!LANG-2609621826a84500b048e8b4375ad948!}{!LANG-49db8a2d1aee2f9ae6b03072a0f2d23e!}
{!LANG-dfb1f7afd5e41ff822183748d0198c36!}{!LANG-90663b62fc8b8de633115eb1e4166448!}
{!LANG-706d4c7971541ec6eed65e7142fd4f23!}{!LANG-77f7c17e4aaaba53736d3a25ee6c4a25!}

{!LANG-7060accf8e0f350fafd6da11264aec44!}

{!LANG-1d0e7c2e36852af7bb0203fa5a4d3cbb!}

{!LANG-41a88bd42846f05d9faebe228e1993c8!}{!LANG-61e004b7dad9a2d0cddb1f3440c0a942!}
{!LANG-b58e2f2d5e35c9c53220946ae474ebee!}
{!LANG-84359da32ef2fe3b68c2543278074961!}{!LANG-21a72bc19cc13e954d797d0b5626c619!}
{!LANG-02155e2636ae6230710ecb8a141d78f0!}{!LANG-b0a2101bbe27cb4fad6a69a8c6d2ba05!}
{!LANG-f9872d3e800df7268f3bc6e9a843ea90!}
... NOS
{!LANG-7a924a050b12ea28a6a0ff4828b58942!}
{!LANG-be139764cac01d902ea40ae3d8ba65ff!}
{!LANG-a624111d0290cf0ebecb6a51a8c4c0f9!}{!LANG-302fa5314909f2a8a71b9cd05fe944f4!}
{!LANG-eb3b790751181cc926234a390c17185b!}{!LANG-98ea6092a519459c25ec86c69c63fb6a!}
{!LANG-ecde92f422a8ff3b835834b65664dc13!}{!LANG-38a551d69fd5a82ed55c69d1c4a71bbe!}
{!LANG-578b86e76485daddf55f1b89b0b8f352!}{!LANG-9a3ef84d1268dbc0ad1adf6c661a50e9!}
{!LANG-842949d9f9bad2348b2dae7292e82781!}{!LANG-b3ce8f3ef10781b680a0c45e519673e6!}

{!LANG-0b4a28836f8f3e37a411090b87cd49c3!}

{!LANG-2bc7bc6193f8906f6c2d7e42457917ec!}
{!LANG-7b61b48bd809f7270637f8e942760662!}
{!LANG-0be4dd0eae1b1b56b31f8a14807e1a18!}

{!LANG-9d0e97d00f4cb3cec7a588929f99bbb9!}{!LANG-b8762ed82f1415bec42b68667b3b8c8b!}
{!LANG-3c2e7cf95770188d5d4c46b41e2538ad!}{!LANG-10591a4c96c98cabbe266ac03564064b!}
{!LANG-fe08c33fabf7d52a60a4a9ed51bc1612!}
{!LANG-1efb0deda0cf6eac7d1e7f2197c66c51!}
{!LANG-ed1119d591475fdff3147f7eb63a36d9!}
{!LANG-2371870ef2801119c1d9324c32fe5086!}{!LANG-f2d2164e4c268593449344a2f5fc15c4!}
{!LANG-8af0c7004860c3fbeed368c51d13ef74!}{!LANG-8cba13e636c83830a2d35e1309df6807!}
{!LANG-a02cb9d731678d413c5058a6bb214625!}
{!LANG-e3455a8f2f6ad7b556196e5b475f5349!}
{!LANG-0d2fbac85988c96c01852bf379a9ec03!}
{!LANG-9b425fb97b8235e39a00b0cf41c7f116!}
{!LANG-cb507dcf6e9f95630d7b03021bfba771!}
{!LANG-e8c14230c515ef392657dc22267ca8f1!}{!LANG-748bff8fb1c3c77d16bf6657d331be88!}
{!LANG-36fbd646cdebe47a4a14163d977de7d0!}{!LANG-f630dc922977fdf4eeecdab9cf335dd9!}
{!LANG-f768063c872dc715ddd1519f75050f4b!}
{!LANG-ee609be6aa70c9226d95001e3f0d0d93!}
{!LANG-a0d2dadf1c447b4047c15914e12e5fca!}{!LANG-26b027d7dce6774c8d1dfefd73503f82!}
{!LANG-3da57dddacaa1f2259f28f8833ac0573!}{!LANG-e0bc0cc4388be5730ae8e7d1fe845f68!}

{!LANG-a56db6c6aa767bd94bc76131905e81db!}

{!LANG-b6b9b48e0a5e00d52b093a49ae4cee8a!}

{!LANG-a506fada7b177aef1f61627f17be0640!}{!LANG-1e4706f9383472ba8a6eafb7e1f5cbc9!}
{!LANG-94430ee58b0788158e1a5f68d45d51aa!}{!LANG-fab1b477047502daaaa58e0396706475!}
{!LANG-76378172dc56d3e774a0279198e54560!}{!LANG-c7a46312b08d59c39699172af3b3f854!}
{!LANG-8cf7efa047efd9c6f293c642c16cc88d!}{!LANG-015f3ba049536ce70ee60aa8506d8f71!}

{!LANG-b6241d797054aa20ad81974d8d7e9dc4!}

{!LANG-0c46d3ac5c221e39d7c2a7e4f2826c68!}

{!LANG-614eb52a26be3bb87a6ac82bdd9a3fae!}{!LANG-83a24df4f4a51e368f87ba32d90170d9!}
{!LANG-4346fe742dd4f2b53d18667a5cb42775!}
{!LANG-d8a51b9ed3e07f0d1aa91703c2bd80a9!}{!LANG-c5ee7e6b748e735b76a57e36afc55c31!}
{!LANG-8f6784bf047b8b83a26e9c6e573860d6!}{!LANG-66ce03cadc80c0e052043fc708a04591!}
{!LANG-5a19f94f5e7a1bd1cc6f96140d54b2f3!}{!LANG-07a4e7b163fdcf493cbbe3f04ee50ae6!}
{!LANG-aa895227556f8b92ec71a11965100466!}{!LANG-b6ef4287e756f273f513f9824cdfc96f!}
{!LANG-0606d9eafff2a0e826d68ea559193de7!}{!LANG-de6afc26db0d6a847bc4bfb56fa1a69e!}
{!LANG-1f10c3479a589f8b03b2397456ea49a4!}{!LANG-9c46d48efacbb3fc62c8380333fc92a1!}

{!LANG-d1b3471c34912a4d58fec9f92250ec3c!}

{!LANG-8990e20a46a39364725c5d99505af3c8!}
{!LANG-b2720a1a6a737c6bcaa7512177763bed!}
{!LANG-a1225ffb63a6db47545794486d4681ef!}
{!LANG-4784743b41570c38c3b85aed71aa5cec!}
{!LANG-50a9d7e35530cee9c08ae294e354fea0!}
{!LANG-8ca9bf858f0041827105dd2f3f2cdbd5!}

{!LANG-ccaef9a64d8fd6e3792a32d055411e28!}

{!LANG-f7b3b5c3a8db67daeec760cb6f428524!}{!LANG-46570a639c431518ffd87a9f14f298aa!}
{!LANG-82bab15911ae9e5fe3d9ffa5d0d8dc2d!}{!LANG-b7dd97f7e46146402769dddc566ef3a4!}
{!LANG-3a0ab2eb9060ae50cd079f1206948b5a!}
{!LANG-3cebe0b165f8e8b8fbcc4a406701736d!}{!LANG-e192ce012e33bcc83cfc6692dd2bcd4a!}
{!LANG-a2f41ea8565de1b05e9e0049ecd71ca5!}
... NOS
{!LANG-32d722d4d0278674db6d66c3f9b7378d!}
{!LANG-38429ec8330f8369ef99cad734b981da!}
{!LANG-d44674d98996ae04aff3de7583c0211b!}
{!LANG-8214da7961f05787255bfd22a4ad89fa!}
{!LANG-01baa3dc78ab0ed3af20493d691cac02!}{!LANG-499d66bb1b2f28c85e5bac480f95fc58!}
{!LANG-741b4927b051c1be72319549b462d628!}
... NOS
{!LANG-38429ec8330f8369ef99cad734b981da!}
{!LANG-d44674d98996ae04aff3de7583c0211b!}
{!LANG-5f23623b1e58ebc663a7d62d05770749!}{!LANG-a47e914c1329d0b9ba51954196785826!}
{!LANG-350d4a8c2236838c9fcbd708e9b43b9b!}{!LANG-aa2d38fdfa8116071cbdef2f5f116d5c!}
{!LANG-1aedeb01f8177f84aca415c762b80a6b!}{!LANG-5105b310840675627fba3f01fc139c1a!}
{!LANG-1fd80888b95af9164dff8d912a492593!}{!LANG-59ac1beb05b581244d17295df7a6dac5!}
{!LANG-00556dbfff6d031e40a1a9911761b674!}
{!LANG-df4cdbbb249f88f4db52304db2306a7b!}{!LANG-c02cba4039b44aecc422d8ef7c8a0ff4!}
{!LANG-f722ad3acb1649d8cfbb9dd71d12c3b8!}

{!LANG-ef8995c2aa0352d85711017bd94e60a9!}

{!LANG-f9dc891a2340c4deff9bacc8bf34268a!}
{!LANG-c6c08439c77184143e9a7f1a6388ff8f!}

{!LANG-c05cd73c17b030ba5b66f79619302968!}{!LANG-fe5e586d50170a45e26f9e2bd44cc1bf!}
{!LANG-d35079ac24b6ad7cd9f26971eeaf07e1!}
{!LANG-f162698c19b17de5f8884c6f735e87e9!}
{!LANG-e9d21ce7c5f9d6a4df1a7e98049ac7d7!}
{!LANG-0ca12e363c4176879671082647f09277!}
{!LANG-3fd5979ae7970fb0e8cbe91b4600f6ab!}
{!LANG-5311f65107b3578abb1ea246fa5de17f!}{!LANG-63866df8058352af447aacdba8ae9c6d!}
{!LANG-8e7ada00591052679d575e5f18488ca7!}
{!LANG-a0710603bf2e6cafda54c19509af53c1!}{!LANG-35e733198abae1f8d31a3766ea370071!}
{!LANG-248f0d20ccfe4bd88fea24ac0e168c08!}
... NOS
{!LANG-74ae50a4f3eb02ed2193b003306663ec!}
{!LANG-d671f8db2cfad78de9ce10c91cb53fbf!}{!LANG-67cb00d2bc2f3bd2fddd7c2c5d378263!}
{!LANG-cf6eea74f76f79764e33881443eddb2d!}{!LANG-bb71b0cc01a63e4c9da35a75ebee08e6!}

{!LANG-4da5435bd24c9e14640e1dbeecf2df09!}

{!LANG-cd3daeb7b6c13936f05cfd10eb50ef8b!}{!LANG-29ca42c141b5f60cdf36c34966b5d46e!}
{!LANG-f8849f1ca3006f65e78a8b79d2f3dffb!}
{!LANG-eba3ae2b71486f060d5af08455adc605!}{!LANG-cf992b8203893de903bac3e43c96cc9b!}
{!LANG-adc63d6c792be7c5cf57ce3b4eb485d5!}
{!LANG-8aa2315ecff0c3b4154a14e118f70192!}{!LANG-92d892bfc2c39f4d0e59400fd995b152!}
{!LANG-9b030c932b26cd98665c7a21a5344ccb!}{!LANG-42423c09afb2544073693c297757602c!}
{!LANG-2bc9e18259df49bbbcf108a6862d1ee0!}{!LANG-0d65bb32174002dc24067865271f4d94!}
{!LANG-ca026d7a429326b62aee3e6d77aac204!}{!LANG-48a1f8abd8b4c5f5f4833690dff703f0!}
{!LANG-0b16e25abf8773c47a848200f2630db0!}{!LANG-7fd3d8e2dfeb3dcbdee0d58f9c013415!}
{!LANG-b77f7e728c1907d94976eeb41939b1d7!}{!LANG-f8784b75cc64684d9f0610ef172b9933!}
{!LANG-c30b81c3c4728462fb1b563b4d04d9de!}{!LANG-cca01098819d0a573d32a4d806e63a8b!}

{!LANG-0e1cdc5127ba12c1cefdbacff8452520!}{!LANG-2fbc1bed789522e24bd5fa3de2c8b713!}

{!LANG-62fbab7a0a2126a863c6792403ba741b!}

• {!LANG-193f79d5329c7cc69e5b5e106e9a34aa!}

{!LANG-435c23a394bd5036a3e686cf877ea5e5!}

{!LANG-30035861695c3c9b9cbf6cd004de25cf!}{!LANG-95c0ac6b99820ca0ff6aa37c6787be7d!}

{!LANG-4278bf0a75d892992988ec9f20b74172!}{!LANG-34519194471fbe2ec2099a05f5ddebad!}

Treatment

{!LANG-a272004fabb5573e7ce7a2af1653f514!}{!LANG-2a2b149a943de5c05b729659fed79b3b!}

{!LANG-bce71de0ef6ba3392ac1804da40df8c7!}{!LANG-ae527608651bed075d10e3268e089d09!}

{!LANG-b578bd1d9fc17af73341f71392b67e77!}