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l -1.493 1.139 l -1.574 .643 -1.498 .426 -1.26 .426 c -.763 .426 -.206 1.667 -.081 2.449 c .032 3.162 l .508 3.162 l 0 0 l f Q q 1 0 0 1 538.313 727.089 cm 0 0 m -.73 0 l -.995 -1.654 l -1.071 -2.144 -1.017 -2.278 -.752 -2.278 c -.6 -2.278 -.487 -2.259 -.379 -2.227 c -.411 -2.704 l -.568 -2.742 -.757 -2.767 -.914 -2.767 c -1.466 -2.767 -1.607 -2.462 -1.493 -1.743 c -1.206 0 l -1.753 0 l -1.677 .445 l -1.136 .445 l -.968 1.47 l -.465 1.603 l -.655 .445 l .076 .445 l 0 0 l f Q q 1 0 0 1 540.287 727.039 cm 0 0 m -.498 .165 -1.028 -1.075 -1.168 -1.953 c -1.282 -2.666 l -1.758 -2.666 l -1.25 .496 l -.784 .496 l -.828 .222 -.903 -.115 -1.06 -.668 c -1.049 -.674 l -.746 .095 -.422 .655 .097 .553 c 0 0 l f Q q 1 0 0 1 541.293 728.056 cm 0 0 m -.179 0 -.308 .166 -.297 .363 c -.292 .579 -.135 .744 .043 .744 c .216 .744 .352 .585 .341 .388 c .33 .172 .173 0 0 0 c h -.4 -3.684 m -.876 -3.684 l -.362 -.522 l .114 -.522 l -.4 -3.684 l f Q q 1 0 0 1 543.543 727.089 cm 0 0 m -.73 0 l -.995 -1.654 l -1.071 -2.144 -1.017 -2.278 -.752 -2.278 c -.6 -2.278 -.487 -2.259 -.379 -2.227 c -.411 -2.704 l -.568 -2.742 -.757 -2.767 -.914 -2.767 c -1.466 -2.767 -1.607 -2.462 -1.493 -1.743 c -1.206 0 l -1.753 0 l -1.677 .445 l -1.136 .445 l -.968 1.47 l -.465 1.603 l -.654 .445 l .076 .445 l 0 0 l f Q q 1 0 0 1 544.635 728.056 cm 0 0 m -.178 0 -.308 .166 -.297 .363 c -.292 .579 -.135 .744 .043 .744 c .216 .744 .352 .585 .341 .388 c .33 .172 .173 0 0 0 c h -.4 -3.684 m -.876 -3.684 l -.362 -.522 l .114 -.522 l -.4 -3.684 l f Q q 1 0 0 1 546.61 727.109 cm 0 0 m -.59 0 -.985 -.776 -.985 -1.572 c -.985 -2.042 -.822 -2.303 -.417 -2.303 c .108 -2.303 .568 -1.642 .568 -.719 c .568 -.255 .389 0 0 0 c h -.498 -2.793 m -1.174 -2.793 -1.482 -2.392 -1.482 -1.667 c -1.482 -.407 -.801 .483 .076 .483 c .784 .483 1.076 .013 1.076 -.655 c 1.076 -1.96 .314 -2.793 -.498 -2.793 c f Q q 1 0 0 1 550.196 724.373 cm 0 0 m -.476 0 l -.146 2.023 l -.065 2.519 -.14 2.736 -.384 2.736 c -.882 2.736 -1.433 1.495 -1.558 .713 c -1.671 0 l -2.147 0 l -1.877 1.654 l -1.807 2.106 -1.709 2.698 -1.639 3.162 c -1.168 3.162 l -1.201 2.952 -1.276 2.589 -1.466 1.915 c -1.455 1.915 l -1.201 2.583 -.773 3.225 -.211 3.225 c .287 3.225 .454 2.812 .352 2.15 c 0 0 l f Q q 1 0 0 1 552.684 727.134 cm 0 0 m -.801 0 -1.114 -.973 -1.114 -1.756 c -1.114 -2.169 -1.006 -2.335 -.838 -2.335 c -.33 -2.335 .222 -1.069 .346 -.312 c .384 -.057 l .276 -.025 .151 0 0 0 c h .427 -2.761 m -.054 -2.761 l -.005 -2.487 .097 -2.068 .26 -1.476 c .249 -1.469 l .054 -1.959 -.352 -2.825 -1.006 -2.825 c -1.396 -2.825 -1.607 -2.532 -1.607 -1.864 c -1.607 -.699 -1.093 .452 .081 .452 c .389 .452 .676 .414 .925 .357 c .638 -1.412 .541 -2.004 .427 -2.761 c f Q q 1 0 0 1 554.479 724.373 cm 0 0 m -.476 0 l .276 4.645 l .752 4.645 l 0 0 l f Q q 1 0 0 1 558.547 726.994 cm 0 0 m -.146 .077 -.303 .121 -.492 .121 c -1.174 .121 -1.493 -.782 -1.493 -1.501 c -1.493 -1.832 -1.401 -2.169 -.931 -2.169 c -.72 -2.169 -.492 -2.112 -.325 -2.017 c -.357 -2.519 l -.546 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m -.914 -1.489 -.925 -1.648 -.925 -1.762 c -.925 -2.252 -.779 -2.379 -.346 -2.379 c -.092 -2.379 .179 -2.309 .411 -2.195 c .411 -2.653 l .152 -2.774 -.162 -2.844 -.514 -2.844 c -1.13 -2.844 -1.417 -2.532 -1.417 -1.819 c -1.417 -.592 -.838 .433 .054 .433 c .628 .433 .844 .089 .844 -.286 c .844 -.967 .254 -1.342 -.898 -1.393 c f Q EMC /Artifact <>BDC q 0 841.89 595.276 -841.89 re 297.66 421.02 m W n .059998 841.98 595.32 -841.92 re W n 1 .89 0 0 k q 1 0 0 1 297.525 498.902 cm 0 0 m 272.013 0 l 273.579 0 274.848 -1.269 274.848 -2.835 c 274.848 -256.692 l 274.848 -258.258 273.579 -259.527 272.013 -259.527 c -272.013 -259.527 l -273.579 -259.527 -274.848 -258.258 -274.848 -256.692 c -274.848 -2.835 l -274.848 -1.269 -273.579 0 -272.013 0 c h f* Q EMC /P <>BDC BT /F1 1 Tf 11 0 0 11 46.993 469.9203 Tm 0 0 0 0 k .01 Tc .0838 Tw (Advanced malignancy is considered when cure is no longer possible, or where treatment has been)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 453.9203 Tm .1512 Tw (declined by the patient or is not viable due to comorbidities. Intestinal failure \(IF\) in patients with)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 437.9203 Tm 0 Tc .0593 Tw (malignancy is most often caused by bowel obstruction, which may be partial, intermittent or complete.)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 421.9203 Tm .0072 Tc .0622 Tw (IF can also be due to an enterocutaneous fistula, short bowel \(resulting from surgery\), dysmotility or)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 405.9203 Tm .01 Tc .0884 Tw (severe mucosal disease \(often following chemotherapy or radiotherapy\). If the obstruction is partial)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 389.9203 Tm 0 Tc 0 Tw (or intermittent an oral/enteral regimen may be possible but rarely is the case if complete obstruction.)Tj ET EMC /P <>BDC BT 11 0 0 11 61.1663 373.9203 Tm .0085 Tc .0609 Tw [(Home parenteral support \(HPS\) includes home parenteral nutrition \(HPN\) and/or fluids and is the)]TJ ET EMC /P <>BDC BT 11 0 0 11 46.993 357.9203 Tm -.0053 Tc -.0364 Tw [(treatment for patients with )18.1(T)55.2(ype 3 intestinal failure \(IF\) requiring long-term nutrition/fluid. When to consider)]TJ ET EMC /P <>BDC BT 11 0 0 11 46.993 341.9203 Tm .01 Tc .1069 Tw [(HPS in patients with advanced abdominal malignancy is already covered in a BIF)55.2(A)55.2( position paper)55.2(.)]TJ ET EMC /P <>BDC BT 11 0 0 11 46.993 325.9203 Tm 0 Tc .0528 Tw [(However)55.2(, the COVID-19 pandemic has had a significant impact on HPN services. )18(This has resulted in)]TJ ET EMC /P <>BDC BT 11 0 0 11 46.993 309.9203 Tm .0097 Tc .0597 Tw (delays in discharging all new HPS patients from hospital; this situation may deteriorate further if the)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 293.9203 Tm 0 Tc 0 Tw [(COVID-19 pandemic continues to impact partly due to increased staf)18.1(f sickness. )]TJ ET EMC /P <>BDC BT 11 0 0 11 61.1663 277.9203 Tm -.0018 Tc -.0399 Tw (This document contains logistics of organising HPN in England, but the other included principles apply)Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 261.9203 Tm 0 Tc 0 Tw (to all four nations, including optimising oral/enteral nutrition in this cohort of patients. )Tj ET EMC /P <>BDC BT /F2 1 Tf 12 0 0 12 22.6771 220.7314 Tm 1 .89 0 0 k (Key points)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 22.6771 203.062 Tm 0 0 0 .8 k (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 203.062 Tm (Prior to discharge HPN patient requiring a compounded regimen will )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 191.062 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 191.062 Tm -.01 Tc [(need to be authorised by NHS England. )18.1(T)37.1(rusts can contact HPN suppliers)]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 179.062 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 179.062 Tm (directly for new patients requiring a multi-chamber bag \(MCB\) and/or )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 167.062 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 167.062 Tm (intravenous fluids.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 155.062 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 155.062 Tm [(All Nutrition Support )18.1(T)110.9(eams \(NST)110.9(s\) may be asked to review patient)]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 143.062 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 33.4037 143.062 Tm [(suitability for 24-hour HPN with one connection daily)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 22.6771 131.062 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 131.062 Tm (Establish how long it is likely to take to set a patient up on HPN.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 119.062 Tm -.025 Tc (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 29.1583 119.062 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 119.062 Tm -.025 Tc (Optimise the enteral route especially in those with intermittent or partial small)Tj ET EMC /P <>BDC BT 8 0 0 8 24.7529 107.062 Tm -.01 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 107.062 Tm (bowel obstruction. Low fibre/liquid diets may reduce obstructive episodes.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 95.062 Tm 0 Tc (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 95.062 Tm -.01 Tc (Consider insertion of a nasogastric draining tube or a venting gastrostomy)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 83.062 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 83.062 Tm (to help manage nausea/vomiting.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 71.062 Tm (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 71.062 Tm [(Arrange )18.1(T)110.9(elemedicine or outpatient clinic follow up within 2-4 weeks )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 59.062 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 59.062 Tm (from discharge. )Tj ET EMC /P <>BDC BT /F2 1 Tf 12 0 0 12 303.5263 220.7314 Tm 1 .89 0 0 k (Explanations)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 303.5263 205.7467 Tm 0 0 0 .8 k -.015 Tc (1.)Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 314.865 205.7467 Tm 0 Tc (Authorisation: )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 371.7477 205.7467 Tm [(A)55.2( multi-professional group of clinicians and )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 193.5967 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 193.5967 Tm (commissioners meet twice a week to review all requests, including )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 181.4468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 181.4468 Tm [(sterile fluids and homecare nursing support. )18.1(This NHSE HPN Clinical )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 169.2968 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 169.2968 Tm (Cell has been reviewing new patient applications for compounded slots )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 157.1468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 157.1468 Tm [(since September 2019, and multi-chamber bags \(MCBs\) since )55.2(April )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 144.9967 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 144.9967 Tm (2020, as the supply of MCBs across the whole market is now more )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 132.8468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 132.8468 Tm (stable this has been revised and NHSE clinical cell will only review )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 120.6968 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 120.6968 Tm (requests for compounded HPN regimens. From 1 June 2020, trusts )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 108.5468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 108.5468 Tm (can contact HPN suppliers directly for new patients requiring MCBs. )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 96.3968 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 96.3968 Tm (Compounded slots for all patients will continue to be allocated by the )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 84.2468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 84.2468 Tm [(HPN Clinical Cell. )18.1(The application form to the HPN Clinical Cell for a )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 72.0968 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 72.0968 Tm (compounded slot for a HPN patient and supporting documents are on )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 59.9468 Tm ( )Tj ET EMC /P <>BDC BT /F3 1 Tf 8 0 0 8 314.865 59.9468 Tm [(Our FutureNHS Parenteral Nutrition W)18.1(orkspace)]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 499.1969 59.9468 Tm (. )Tj ET EMC /P <>BDC BT /F2 1 Tf 9 0 0 9 22.6772 814.1643 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .059998 806.78 595.32 1.417 re f EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 22.6772 14.3571 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 191.2006 14.3571 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 22.277 511.2451 Tm 0 0 0 .8 k [(Lucy Eldridge, Kirstine Farrer)55.2(, Loraine Gillespie, Jessica Bower)55.2(, Clare Shaw and the BIF)55.2(A)55.2( Committee)]TJ ET EMC /P <>BDC BT 6 0 0 6 510.4381 41.029 Tm (Continued over page...)Tj ET EMC Q endstream endobj 58 0 obj <>/ExtGState<>>> endobj 65 0 obj <> endobj 108 0 obj <>stream /Figure <>BDC q 1 i -15.701 670.23 625.343 -662.486 re 297.66 421.02 m W* n 0 841.89 595.276 -841.89 re 297.66 421.02 m W n .059998 841.98 595.32 -841.92 re W n /GS3 gs q 681.786 103.07 71.77 -474.746 -59.267 392.947 cm /Im1 Do Q EMC /P <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.66 421.02 m W n .059998 841.98 595.32 -841.92 re W n /GS2 gs BT /F1 1 Tf 8 0 0 8 24.5131 774.0668 Tm 0 0 0 .8 k 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 774.0668 Tm (The HPN centre /IF centre will need to be registered to complete this )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 761.9168 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 761.9168 Tm (submission \()Tj ET EMC /P <>BDC BT 8 0 0 8 78.9181 761.9168 Tm 1 .89 0 0 k (https://future.nhs.uk/system/login?nextURL=%2Fconnect% )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 749.7668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 749.7668 Tm (2Eti%2Fsystem%2Fuserhome)Tj ET EMC /P <>BDC BT 8 0 0 8 141.6095 749.7668 Tm 0 0 0 .8 k (\). Local HPN/IF centres are informed )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 737.6169 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 737.6169 Tm -.005 Tc (within 2 working days of the outcome. Following allocation of a homecare)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 725.4669 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 725.4669 Tm [(company)74.2(, the local HPN centre will submit a final HPN prescription to)]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 713.3169 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 33.4037 713.3169 Tm (the homecare company and a discharge date agreed with the patient. )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 701.1669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 701.1669 Tm (This is usually within 5 working days but may be longer during the )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 689.0168 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 689.0168 Tm (pandemic and the current challenges within the provision of home PN.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 671.3776 Tm (2. )Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 34.0157 671.3776 Tm (Once daily connections:)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 128.7032 671.3776 Tm (Where training would delay discharge, )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 659.4076 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 659.4076 Tm (community nursing care should be utilised, either via homecare or in )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 647.4376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 647.4376 Tm [(some regions via district nursing teams. )18.1(T)37.1(raining of patients/families can )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 635.4676 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 635.4676 Tm (then be completed at home following discharge if appropriate. Discharge)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 623.4976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 623.4976 Tm (should not be delayed for training. It is envisaged that most advanced )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 611.5276 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 611.5276 Tm (malignancy HPN patients will be )Tj ET EMC /P <>BDC BT 8 0 0 8 150.5117 611.5276 Tm -.01 Tc (supported with home community nursing)Tj ET EMC /P <>BDC BT 8 0 0 8 24.753 599.5576 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 599.5576 Tm (care, except in Northern Ireland,)Tj ET EMC /P <>BDC BT 8 0 0 8 147.8811 599.5576 Tm 0 Tc (North East of England and Scotland )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 587.5876 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 587.5876 Tm (where no homecare nursing provision is available and district nurse )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 575.6176 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 575.6176 Tm (training may be required. )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 557.9783 Tm (3.)Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 34.0157 557.9783 Tm [(T)18.1(ime to set up HPN:)]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 112.0977 557.9783 Tm (Speak to your local HPN/IF service as they will )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 546.0083 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 546.0083 Tm (have an idea of the national situation with respect to the provision of )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 534.0383 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 534.0383 Tm [(HPN. )18.1(The COVID-19 pandemic has impacted the supply of HPN, the )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 522.0683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 522.0683 Tm (availability of nursing support and the work being undertaken by hospital)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 510.0983 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 510.0983 Tm -.005 Tc (IF teams. Each IF team will be able to outline whether they are accepting)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 498.1283 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 498.1283 Tm (referrals, the service they are able to provide and possible timeframe. )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 486.1583 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 486.1583 Tm (The whole referral process may take weeks to set up, requiring transfer )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 474.1883 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 474.1883 Tm [(of the patient or may be supported remotely)74.2(. If the referral is made, then )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 462.2183 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 462.2183 Tm (it is advisable for the patient to have an appointment with the HPN or )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 450.2483 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 450.2483 Tm -.005 Tc (integrated IF centre through telephone or a virtual clinic before discharge.)Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 432.579 Tm 0 Tc (4.)Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 34.0157 432.579 Tm (Optimise oral/enteral feeding:)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 149.0079 432.579 Tm (There is an urgency to frequently )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 420.579 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 420.579 Tm -.005 Tc [(review and optimise the enteral route in those with advanced malignancy)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 408.579 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 408.579 Tm (These may include the following:)Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 393.7443 Tm ( )Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 34.0157 393.7443 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 393.7443 Tm (Oral liquids, including whole protein or peptide sip feeds)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 257.9272 393.7443 Tm ( In the )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 381.7443 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 381.7443 Tm (case of bowel obstruction these may be considered if nasogastric or )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 369.7443 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 369.7443 Tm (gastrostomy outputs indicate that some absorption may be taking )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 357.7443 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 357.7443 Tm [(place. )18.1(This may be established with monitoring of fluid balance and )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 345.7443 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 345.7443 Tm [(blood biochemistry)74.2(.)]TJ ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 24.5131 330.9097 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 330.9097 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 330.9097 Tm (Low fibre liquids/textures)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 138.8101 330.9097 Tm (could be considered for patients with )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 318.9097 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.6851 318.9097 Tm (a drainage tube. Guidance must be sought from the dietitian. )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 774.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 774.0668 Tm [(The Dietetic Departments at )18.1(The Christie NHS Foundation )18.1(T)37.1(rust, )18.1(The )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 762.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 762.0668 Tm [(Royal Marsden NHS Foundation )18.1(T)37.1(rust and )18.1(The Royal Surrey County )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 750.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 750.0668 Tm (Hospital have developed a staged best practice clinical approach )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 738.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 738.0668 Tm (\(unfortunately there is little research evidence\), which can be shared )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 726.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 726.0668 Tm (with other Dietetic Departments on request from )Tj ET EMC /P <>BDC BT 8 0 0 8 492.6084 726.0668 Tm 1 .89 0 0 k (NutritionandDietetic@)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 714.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 714.0668 Tm (christie.nhs.uk )Tj ET EMC /P <>BDC BT 8 0 0 8 373.8897 714.0668 Tm 0 0 0 .8 k (and )Tj ET EMC /P <>BDC BT 8 0 0 8 389.4601 714.0668 Tm 1 .89 0 0 k (rmdieteticschelsea@nhs.net)Tj ET EMC /P <>BDC BT 8 0 0 8 492.2958 714.0668 Tm 0 0 0 .8 k (or )Tj ET EMC /P <>BDC BT 8 0 0 8 501.6318 714.0668 Tm 1 .89 0 0 k (rsch.oncology)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 702.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 702.0668 Tm (dietitians@nhs.net)Tj ET EMC /P <>BDC BT 8 0 0 8 386.4717 702.0668 Tm 0 0 0 .8 k [(. )18.1(There is limited evidence on the use of elemental )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 690.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 690.0668 Tm [(diets in obstruction, however)55.2(, there is currently a clinical trial being )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 678.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 678.0668 Tm [(undertaken \(NCT)18.1( 03150992\). )55.2(At present we do not recommend them.)]TJ ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 305.3623 663.2322 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 663.2322 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 663.2322 Tm (Enteral tube feeding)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 399.6553 663.2322 Tm [( )18.1(The administration of fluids and or enteral )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 651.2322 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 651.2322 Tm (feeds \(whole or peptide\) via an enteral tube feed such as nasogastric, )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 639.2322 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 639.2322 Tm [(gastrostomy or jejunostomy)74.2(. Enteral tube feeding should only be )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 627.2322 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 627.2322 Tm (considered when obstruction is sub-acute or intermittent.)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 612.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 612.3976 Tm [(A)55.2( double lumen tube should be considered for drainage and feeding )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 600.3976 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 320.5342 600.3976 Tm (particularly in the case of upper gastro-intestinal obstruction. )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 582.7282 Tm (5. )Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 312.4209 582.7282 Tm (Draining/venting tubes:)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 403.9795 582.7282 Tm (Patients may require a venting nasogastric )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 570.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 570.7282 Tm (tube or gastrostomy to help manage the symptoms of obstruction and)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 558.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 558.7282 Tm [(reduce vomiting. For a venting tube to be ef)18.1(fective it must be suf)18.1(ficiently )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 546.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 546.7282 Tm (large to enable free flow or aspiration of gastric contents. Patients must )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 534.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 534.7282 Tm (be taught how to care for the tube, aspirate gastric contents and have )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 522.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 522.7282 Tm (clear guidance on the actions to be taken if the tube is blocked or )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 510.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 510.7282 Tm -.01 Tc [(displaced. )55.2(All equipment and connectors must be checked for compatibility)]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 498.7282 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 498.7282 Tm [(to ensure that the drainage system is ef)18.1(fective and manageable.)]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 481.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 481.059 Tm (Patients should be given clear written advice on oral intake too, after )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 469.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 469.059 Tm (discussion with the medical/surgical team and the dietitians. Patients )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 457.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 457.059 Tm (may wish to take fluids/foods for taste and comfort. Patients and teams )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 445.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 445.059 Tm (should be aware that any information provided is guidance and that oral )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 433.059 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 433.059 Tm (intake may make symptoms worse.)Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 415.3897 Tm (6. )Tj ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 312.4209 415.3897 Tm (Follow up/monitoring:)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 398.624 415.3897 Tm (Follow up should be arranged on a case-by-case)Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 403.3897 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 403.3897 Tm (basis, but it is envisaged that for patients discharged home that an )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 391.3897 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 391.3897 Tm (out-patient appointment is made within 2-4 weeks. For those patients )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 379.3897 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 379.3897 Tm (discharged to a hospice, liaison with the palliative care team is likely to )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 367.3897 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 367.3897 Tm [(be enough to meet patient)18.1(s ongoing follow up needs. In the case of )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 355.3896 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 355.3896 Tm (longer surviving patients \(>3 months\) follow up should be made based )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 343.3896 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 343.3896 Tm [(upon clinical requirements and will depend upon the patient)18.1(s condition. )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3623 331.3896 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 331.3896 Tm (The standard HPN monitoring tests are recommended as defined by the )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3623 319.3896 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.0302 319.3896 Tm (HPN centre. )Tj ET EMC /P <>BDC BT /F2 1 Tf 9 0 0 9 22.6772 814.1656 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .059998 806.781 595.32 1.4171 re f EMC /Artifact <>BDC 0 0 0 .08 k 22.677 182.222 549.698 125.152 re f EMC /P <>BDC BT 9 0 0 9 37.1472 285.5097 Tm 1 .89 0 0 k (Suggested reading:)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 37.1472 273.5097 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 273.5097 Tm [(Naghibi M, W)18.1(oodward J, Neild P)18.1( and the BIF)55.2(A)55.2( Committee. Palliative parenteral nutrition \(HPN\) for patients with malignancy)74.2(. Brit)]TJ 56.3027 0 TD (ish Intestinal )Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 261.5097 Tm [(Failure )55.2(Alliance \(BIF)55.2(A\) Position Statement )55.2(April 2020: www)55.2(.bapen.org.uk/pdfs/bifa/position-statements/position-statement-on-pal)]TJ 56.6406 0 TD (liative-hpn-for-)Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 249.5097 Tm [(patients-with-malignancy)74.2(.pdf)]TJ ET EMC /P <>BDC BT 8 0 0 8 37.1472 237.5097 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 237.5097 Tm (Information for home parenteral nutrition \(HPN\) patients Updated 27 March 2020 with the latest government adviceon keeping your)Tj 57.9209 0 TD (self safe. )Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 225.5097 Tm [(Accessed on PINNT)18.1( website 28th May 2020: https://pinnt.com/News/News/Non-Members/NHS.aspx )]TJ ET EMC /P <>BDC BT 8 0 0 8 37.1472 213.5097 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 213.5097 Tm [(Farrer K, CawleyC, Page )55.2(A, )18.1(T)110.9(aylor M and the BIF)55.2(A)55.2( Committee. )18.1(T)110.9(op )18.1(T)37.1(ips for Discharging a Patient on Home Parenteral Support in En)]TJ 58.4912 0 TD (gland: )Tj ET EMC /P <>BDC BT 8 0 0 8 45.6512 201.5097 Tm [(www)55.2(.bapen.org.uk/pdfs/bifa/bifa-top-tips-series-8.pdf)]TJ ET EMC /Artifact <>BDC 1 .1 0 .1 k .059998 .059998 595.32 31.422 re f EMC /P <>BDC BT 8 0 0 8 22.6772 14.3583 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /F2 1 Tf 8 0 0 8 191.2007 14.3583 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 535.0078 14.3583 Tm (June 2020)Tj ET EMC Q endstream endobj 109 0 obj <>/XObject<>/ExtGState<>>> endobj 6 0 obj <> endobj 5 0 obj <> endobj 110 0 obj <>stream Adobed         #"""#''''''''''     !! !!''''''''''""  s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjzm!1AQa"q2#BRbr3$4CS%cs5DT &6E'dtU7()󄔤euFVfvGWgw8HXhx9IYiy*:JZjz?lٳ_ |6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳd>FO O hl=;u3j<O]g>).P9Wf͖=2;4/R.VJCn#|{8pe_76V?ҚH; Ѭap NT ;u7GN#=1f ㎥:g8MKcH4&$xFDgbH4徻]IޣNg_ټ2ŦGclB{め(P ygF͛6lٳb͛6lٳb͛6lٳb͛6lٳb͛6lٳb͛6lٳb͛6lٲ5o?yO(ߦ(gnj%XWj|Qsjr8ID|J6l@.5}/Dk^+e,yϰ<ȭR=V#P/n,xB=kZtouٯ[; *el{_ ٸ67?TCޭ/Ayr#I-|fڌa{r+qRǴ#o<җ5&KD>j9<ߵ~&:A#Gb>U1+6lٳf]6lٳf]6lٱʬ*ƊrIu$~Ey> hcQ0KɍvaCYևs;D{ٳc9z~k%ܦ ch:_mZM(.~OīM#:ߖ|(YKBKp@g?ґYoA =Wh|:1fF1/;q|r^#kkkco)om(DET1lٳD͛6lٳaWf͛6lٱWf͛6lt"}kUԀOOZfP~ӝ5:\3jrG,b9A]6Q aֱ6ܥHiUYeWާi_M}ᶭ$G*zw6|yϺzvђ-,#'хO?sȶx׵~>=g`򔾜6׹[q2f$ٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6ly_6k~NU'YzS%kʕSal|2> d:۳ٞA'/U@Ǵ͛6ٞ͛6ٳ͛6ٳ͛6ٳ͛6ٳ͛6ٳ͛6ٳ͛6|Z!uD>1)̿ӿ8<DA𫟖i;SnT*=;YؖfcRIܒN76p:xFLg+yDyl9Yf͛6af͛6lثf͛6lyG^t~)gZ>qXz= r<]&W84$B2]6XS'~K_\E-:ҕVL{413y/CY5E֦>P^"Ӏ6sN؏ݓ({V“ ;!K򯒂\ZQGũ]_WRrq6znEaG1ǔ`(_y>ܳ(f͛6嫳͛6ثf͛6ثf͛+ᚮѩj1Y+$ܞnߞZhT/f4$?G7Զ?ŖB??;+f·ӦݰyǨ#וn?黤5I5>vı槲ٳf͛4*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳfj]6_Wң-x%*=gll+Ǭ'Y<3g2ao0y떟'4Ι1>uޟ>zg{1}LF9G>cϒ ,Hgȯ0 5\͋ Bfyf͗f͛6lثf͛6lثfͅaƅ#aYGy I?GC?XK)HuK1)(H?)-==/4}eO媎|~DW4?6xx'bxf)Am!+ #Jt@+=Ϟs?}[~+K_ߕ;+eXp=KynHjIQ>̇eai+?pO/Np_7~u& G؉ͳg׷\XA#y>}WXnl%XzrfM]6lٳf]6lٳf]6lٳd^l"Ņ4}B[AG}.Q\S͒\&Rvl`LS^r ŚڼdvYTg|'Cߘ^ D?.ubb08UQ `39c/~"%O&ËeOLpQ|vr'~BoB1M_D[)^Fu(cTD*cgod;7z.sϪ_Bٳf͛3ٳf͛6lUٳf͛6lUٳf͛6u/|tvp4UT2d8K&IBRb9O ͛65xNT||Եa&}6^OҢ%>1#Hg5$$'mϩua5j}{U>[o7҅3yYv߱Y2b3j2'qgZ*4"$B6 g[9꺃oFґO'pg=K)MSHQ]3{k^,<_PXU,ءPqH_$UԕeaB؂;cs岭͛6lٳ`Wf͛6lٱWf͛6lٱWf͛6lٱWf͛6lٱWf͛6lٱWf͛6lٱWf͛6lٱWf͛6^ tCXNvlO="|Qma?뛾w{c7cŏ.#uvl9K?;2]:vOŨΧ[DZ=1!yo6j>IKeh&ETUDU@ P:2}G{#$#MzwqФ^lٳfΙ]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٱ14؀3M4&WV3k{Wtf`7ɐ3ٱ3zzQYZ۾;|!m8M#r/5/oVr[Yu5-bK۹~ҵM;* Gvhq`^Nv>̫dӮ4;I#w%Ԓw$6q ٳf͛6vlٳf͛vlٳfJ^G!UI;ΗO8ƣ,[s%ڟ\-jW3 O<Loy͛lY6GcPQiO+O3>SgxN-Ij C$!coӗO;gӗ3_<[xP2yK/>ܱ:VɷS̶tD4ʈ*1ٳѻ?==ҪUs>2:㳴͛6W͛6ٱ´͛6ٱ´͛6ٱ´͛6F$ƶ$ڶ<$Ʊ*+j;xWm{#Nuܜ7|r #uWf͍-?ihE# e5G=|ߛ<>U?᰿wO%̯4;1ܳ3Ա_30ս40k[,0rf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf͛6*ٳf.<3wV]!%J$ 6 f͞1hvd4Hup!o;2 VЂ3Yҿ.85&4znQkO6ݿ;xq랗gGr30!.}x,g3a^ tztvm~7tČ<gbˏ.88eD aU3ff͛&͛6lٳb͛6lٳb͛6lٳb͛6Dq8>`xʷ𫶪`ᆱ6AFudҳ٠˕Y폻x.8ıʱ-͵Ŝ[$2G,<6tWL#II>5;/"sR7?3&ѼÜS Ӫyi24=N<4LS͖L ,UٳeNDIHaFYTff&@s/ZQ/+hmF[E U[Fvo$~XygPkT+Iu; qĜNB:ڗ>cO8&7=8) c>КٱRy'.R+&͛=:Î<"Lٳf͛.Wf͛6lٱWf͛6lٱWf͛6lٱWf͛6lٱWf͛6k:]WYKK8~ԎzȊ7f= 0t?"XzҩG^~>q}H~*-lҢTE=~}I805mF+,r3]HI뒏̏WΏ&h-ᗷo6lN-_he\yDtc1[-_76lٳf%vlٳf͛vlٳf͛vlٳf͛vlٳf͛vlٳf͛vlٳf͛vlٳf͆Zfk'_%QH@'`-]6l-͝MhKqh4Vi?rUa8 )OYQnG-4@vٳf%=g8ע_.=wm8G(ѡy=+f͞V͞? ^Sec{?@EOWf͛xC.]U^a@͛6z 6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf_3E&aMo$8éfŃfq 9#$f$ceZMΖ)y'<}/[E=j]n܎ּxDmtX=5; &?%;jojͭvTMg˜u@^oZ2͛6lvlٳf͛vlٳf͛vlٳbC5̩ooK48RM 9u8+vg;TC ە(O`sԿ[Zeڌ*kΗdNDmc],zcw{XEHC_-m㴳-PCDQUV W6{_cvgFE@-=Z6lٳf]6lٳf]6lٳf]6lٳf]6lٳf]6lٳe$͛6lwM#H{(Rڿ5:}X=o/*nSo޲]RЎ'o|wy;jI=I'<~AxiA+%QLE1rvx?ʼWf͛<5=o+)CyORky:Y|վy|_5yI4`VynIh} &.?;w»6l͛6R͛6lٳb͛6lٳb͛6lٳb͛6lٳb͛6lٳb͛6^v ZN-6KnK:q,ٲV:N #j /. 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