����JFIFXX�����    $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222����"��4�� ���,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu���#ډb���_�N�?��wQ���5-�~�I���8����TK<5o�Iv-�����k�_U_�����~b�M��d����Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F�?_�'ϔ��_�Ջt��=||I ��6�έ"�����D���/[�k�9���Y�8ds|\���Ҿp6�Ҵ���]��.����6�z<�v��@]�i%��$j��~�g��J>��no����pM[me�i$[����s�o�ᘨ�˸ nɜG-�ĨU�ycP�3.DB�li�;��hj���x7Z^�N�h������N3u{�:j�x�힞��#M&��jL P@_���� P��&��o8������9�����@Sz6�t7#O�ߋ �s}Yf�T���lmr����Z)'N��k�۞p����w\�Tȯ?�8`�O��i{wﭹW�[�r�� ��Q4F�׊���3m&L�=��h3����z~��#�\�l :�F,j@�� ʱ�wQT����8�"kJO���6�֚l����}���R�>ډK���]��y����&����p�}b��;N�1�m�r$�|��7�>e�@B�TM*-iH��g�D�)� E�m�|�ؘbҗ�a��Ҿ����t4���o���G��*oCN�rP���Q��@z,|?W[0�����:�n,jWiE��W��$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S����VN;�}�s?.����� w�9��˟<���Mq4�Wv'��{)0�1mB��V����W[�����8�/<� �%���wT^�5���b��)iM� pg�N�&ݝ��VO~�q���u���9� ����!��J27����$O-���! �:�%H��� ـ����y�ΠM=t{!S�� oK8������t<����è:a������[�����ա�H���~��w��Qz`�po�^ ����Q��n� �,uu�C�$ ^���,������8�#��:�6��e�|~���!�3�3.�\0��q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�<���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y�|�y��� ~�6�@c��1vOp�Ig����4��l�OD���L����� R���c���j�_�uX6��3?nk��Wy�f;^*B� ��@�~a�`��Eu������+���6�L��.ü>��}y���}_�O�6�͐�:�YrG�X��kG�����l^w���~㒶sy��Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2��#I/�׍qz��^t�̔���b�Yz4x���t�){ OH��+(E��A&�N�������XT��o��"�XC��'���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�|Lp�d�H��}�(�.|����k��c4^�"�����Z?ȕ ��a<�L�!039C� �Eu�C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf���M}7����]����s2tcS{�\icTx;�\��7K���P���ʇ Z O-��~��c>"��?�������P��E��O�8��@�8��G��Q�g�a�Վ���󁶠�䧘��_%#r�>�1�z�a��eb��qcPѵ��n���#L��� =��׀t� L�7�`��V���A{�C:�g���e@�w1 Xp3�c3�ġ����p��M"'-�@n4���fG��B3�DJ�8[Jo�ߐ���gK)ƛ��$���� ���8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`���?��K����QK�d����B`�s}�>���`��*�>��,*@J�d�oF*����弝��O}�k��s��]��y�ߘ��c1G�V���<=�7��7����6�q�PT��tXԀ�!9*4�4Tހ3XΛex�46���Y��D ����� �BdemDa����\�_l,��G�/���֌7���Y�](�xTt^%�GE�����4�}bT���ڹ�����;Y)���B�Q��u��>J/J �⮶.�XԄ��j�ݳ�+E��d ��r�5�_D�1 ��o�� �B�x�΢�#���<��W�����8���R6�@g�M�.��� dr�D��>(otU��@x=��~v���2� ӣ�d�oBd��3�eO�6�㣷�����ݜ6��6Y��Qz`��S��{���\P�~z m5{J/L��1������<�e�ͅPu�b�]�ϔ���'������f�b� Zpw��c`"��i���BD@:)ִ�:�]��hv�E�w���T�l��P���"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u�)]կ�����7x���s�M�-<ɯ�c��r�v�����@��$�ޮ}lk���a���'����>x��O\�ZFu>�����ck#��&:��`�$�ai�>2Δ����l���oF[h��lE�ܺ�Πk:)���`�� $[6�����9�����kOw�\|���8}������ބ:��񶐕��I�A1/�=�2[�,�!��.}gN#�u����b��� ~��݊��}34q����d�E��Lc��$��"�[q�U�硬g^��%B �z���r�pJ�ru%v\h1Y�ne`ǥ:g���pQM~�^�Xi� ��`S�:V29.�P���V�?B�k�� AEvw%�_�9C�Q����wKekPؠ�\�;Io d�{ ߞo�c1eP����\� `����E=���@K<�Y���eڼ�J���w����{av�F�'�M�@/J��+9p���|]�����Iw &`��8���&M�hg��[�{��Xj��%��Ӓ�$��(����ʹN���<>�I���RY���K2�NPlL�ɀ)��&e����B+ь����( � �JTx���_?EZ� }@ 6�U���뙢ط�z��dWI�n` D����噥�[��uV��"�G&Ú����2g�}&m��?ċ�"����Om#��������� ��{�ON��"S�X��Ne��ysQ���@Fn��Vg���dX�~nj�]J�<�K]:��FW��b�������62�=��5f����JKw��bf�X�55��~J �%^����:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v���g�8�1��f24;�V���ǔ�)����9���1\��c��v�/'Ƞ�w�������$�4�R-��t���� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃������A��20�c#��@ 0!1@AP"#2Q`$3V�%45a6�FRUq��� ����^7ׅ,$n�������+��F�`��2X'��0vM��p�L=������5��8������u�p~���.�`r�����\���O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;������S�T���1���i[U�ɵz�]��U)V�S6���3$K{�ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u�!��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� ���D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v�����멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$�JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4�[�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ�dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il��d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J��oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.���3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R=X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N�����#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%���JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$���L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����)�H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>�dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\�y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~������Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7��ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz��)�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!)'��8Ϣ�ٔ��ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'�L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���(}��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3�������QT��a����x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3�,#c�co��q�a)*Pt����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O���������m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l�O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m���PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q������~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~�|,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)`7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ����}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i����>J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q��nxҍ!U�f�!eh�i�2�m���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{/ �?�͟��|1�:�#g��W�>$����d��J��d�B��=��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H����O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l����l�cGs�ځ�������y�Ac�����\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6����N6�q������N ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td�� ?���N����a��3��m���C���w��������xA�m�q�m���m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4���r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0������u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ����V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�����Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q�(v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9��3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M����A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#yw��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa����Q�#� WeF��ŮNj�p�J* mQ�N����*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]��陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv:��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WPw���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp�BGv[]�u�Ov���0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R��� ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`(�>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG��{+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�>e]�����Q�r�:����g�,i"�����ԩA�*M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f�����֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ���˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)��h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~������ G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W�I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��BS�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c���]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪�\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W�����6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}�����6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@�P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6�����m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw�k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ����mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e��R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1[y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN��ĕ��0 !01@Q"2AaPq3BR������?���@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j�ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^���ԯ̾9Z��F��������n��1��� ��]�[��)�'������:�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0��;_��3 !01"@AQa2Pq#3BR������?��ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6����������4B>��o��](��$B���m�����a�!=��?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)����I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a�84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b��$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7��k�� 403WebShell
403Webshell
Server IP : 172.67.215.126  /  Your IP : 172.69.214.108
Web Server : Apache/2.4.52 (Ubuntu)
System : Linux ip-172-31-19-221 6.8.0-1029-aws #31~22.04.1-Ubuntu SMP Thu Apr 24 21:16:18 UTC 2025 x86_64
User : www-data ( 33)
PHP Version : 8.1.28
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : OFF  |  Sudo : ON  |  Pkexec : ON
Directory :  /efsdata/scitechnol.com/httpdocs/submission/uploads/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :


[ Back ]     

Current File : /efsdata/scitechnol.com/httpdocs/submission/uploads/2566-0-Manuscript-2015-02-12.doc
��ࡱ�>��	_b����^��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	���9bjbjs�s�	7`���1�������DD�������������d�<�K#�;QQQQ@Vb�"�"�"�"�"�"�"$%��'P�"�j@@jj�"��QQ�#HHHjn�Q�Q�"Hj�"HH( t Q������C�F����@ �"#0K#H ,(�v(t t &(�� jjHjjjjj�"�"HjjjK#jjjj��������������������������������������������������������������������(jjjjjjjjjD	M:	Title: Regional Prevalence of Congenital CMV
First Author: 	Stephanie Warrington, BS
Louisiana State University-Health Science Center
533 Bolivar Street Suite 566, New Orleans, LA 70112
Second Author: Jovanny Zabaleta, PhD
Department of Pediatrics and Stanley S. Scott Cancer Center
Louisiana State University-Health Science Center
1700 Tulane Ave., Room 909; New Orleans, LA 70112
Third Author: Lorna Seybolt, MD
Louisiana State University-Health Science Center
533 Bolivar Street Suite 566, New Orleans, LA 70112
Fourth Author & Corresponding Author: Anita Jeyakumar, MD, MS, FACS
Department of Otorhinolaryngology
Louisiana State University-Health Science Center
200 Henry Clay ave, Ste 4119, New Orleans, LA 70118
		Phone:� 504-896-9832		Fax:� 504-896-9296
		Email:�		  HYPERLINK "mailto:ajeyak@lsuhsc.edu" \t "_blank" ajeyak@lsuhsc.edu
Work was done at Louisiana State University and Children�s Hospital, New Orleans
Some of the data was presented in a poster at AAO-HNS September 2014, Orlando, Florida
Keywords
Congenital cytomegalovirus, congenital CMV, blood spots
Abbreviations
CMV: Cytomegalovirus
PCR: polymerase chain reaction
SNHL: sensorineural hearing loss
DNA: Deoxyribonucleic acid
Financial Disclosure: All the authors have no financial disclosures
Funding: The work was supported in part by The Department of Pediatrics, Louisiana State University, and by NIGMS grant P20GM103501. All genomic analyses were done at the LCRC Translational Genomics Core from the Stanley Scott S. Cancer Center, Louisiana State University Health Sciences Center.
Conflict of Interest: All the authors have no conflict of interest
Word Count: 1049Contributors� Statement PageAnita Jeyakumar: Conceptualized and designed the study, and reviewed and revised the manuscript.
Jovanny Zabaleta: Carried out the initial analyses, and reviewed and revised the manuscript.
Lorna Seybolt: Conceptualized and designed the study, and reviewed the manuscript.
Stephanie Warrington: Carried out the initial analyses, and drafted the initial manuscript.All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
ABSTRACT
Background: Congenital Cytomegalovirus (CMV) is the most common cause of newborn infections in the developed countries, affecting up to 1% of newborn babies. Symptomatic CMV can occur in up to 10% of viral positive babies, including manifestations ranging from sensorineural hearing loss, microcephaly, developmental delays and others. 
Methods: Basic Science study in newborn infants to evaluate the incidence of congenital CMV in a general population of newborn babies. De-identified randomly selected newborn blood spots were obtained. The blood spots were evaluated using quantitative real time polymerase chain reaction (PCR) for CMV. The PCR primers and probes were purchased from Life Technologies and based on the sequences published by Schovoerer et al (2005). A CMV standard curve was generated for each PCR run with a Human Cytomegalovirus (AD169) and a quantitated Viral DNA�PCR control (Advanced Biotechnologies, Inc). The DNA was serially diluted to obtain a quantitative curve.
Results: 600 blood spots were analyzed. 50% were male; 50% were Caucasian; 50% were African American. One female African-American baby was found to have CMV.  
Conclusions: Our local data suggests a smaller incidence of CMV than the general population. The study is a small study and the implications are unclear. Further study is needed.


INTRODUCTION 
Cytomegalovirus (CMV) infection is a leading cause of congenital infections in the developed world1,2,3,4.  Congenital CMV infections affect about 1% of newborn babies4,5.  At birth, approximately 12.7% of infected infants will be symptomatic2.  Symptomatic manifestations include sensorineural hearing loss, microcephaly, development delays, epilepsy and visual deficits6,7,8.  The most common symptom is sensorineural hearing loss (SNHL), which is present in 10-15% of children at birth2,6.  Children infected with congenital CMV may be asymptomatic at birth, but will develop late onset hearing loss2.
Barbi et al.  has demonstrated that dried blood spots could be used as a reliable tool for detecting congenital CMV infections4.  Also, Barkai et al. have shown real-time polymerase chain reaction (PCR) to be a possible tool for detecting congenital CMV1. 
The objective of this study was to evaluate the incidence of congenital CMV in a general population of newborn babies from dried blood spots utilizing quantitative real-time PCR.

PATIENTS AND METHODS
Institutional review board approval was obtained. Using an assumption of 1% incidence, a power calculation was done to ensure there was adequate power to the study. Randomized dried blood spots were collected from newborns.  The blood spots were de-identified.  The only information available was the gender and ethnicity/race of the blood spots. The blood spots were screened with a quantitative real time PCR for CMV.  The real time PCR reaction was based off the Schoevoerer et al. study which developed a sensitive method for low viremia levels of CMV in blood9.  The Deoxyribonucleic acid (DNA) was extracted using DNA-zol.   The primer sequences were antisense primer sequence 5�-GAATACAGACACTTAGAGCTCGGGGt-3�, sense primer 5�-AAGCGCTGGATACACGGTACA-3�, and FAM-5�-CTGGCCAGCACGTATCCCAACAGCA-3�-TAMRA that targeted the HXFL4 gene.  The primers were mixed with 5.0�L of the 2X Taqman universal PCR master mix, 1�L of DNA, and water up to 10�L.  The PCR amplification program consisted of 95�C for 10 minutes, 50 cycles of 95 �C for 15 seconds and 60 �C for 1 minute.  A CMV standard curve (figure 1) was generated for each PCR run with a Human Cytomegalovirus (AD169) Quantitated Viral DNA PCR control (Advanced Biotechnologies INC).  The DNA was serially diluted (DNA copy number): 1/3X104, 103, 102, 101 to obtain a quantification curve (figure 2).

RESULTS
Randomized dried blood spots were obtained from 600 newborns in 2006.  Each spot was screened via quantitative real time PCR for the presence of CMV.  Of the 600 blood spots, 50% were male infants, 50% were Caucasian, and 50% were African American, which represented a general population of newborns in our area.  After all blood spots were screened, only one female African American baby was found to be positive for a congenital CMV infection (Table 1).  The incidence of CMV in our population was 0.16%. 
  
DISCUSSION
Cytomegalovirus (CMV) is the most common congenital infection of the developed world, affecting  approximately 1% of all infants born in the USA and slightly less of all infants born worldwide1,2,3,4. It is the leading viral cause of mental retardation and the most frequent non-hereditary cause of sensorineural hearing loss worldwide. Virus can be isolated from urine, saliva, cervical and vaginal secretions, semen, breast milk, tears, blood products and transplanted organs10. Soetens et al. found real time PCR screening of dried blood spots to have a sensitivity of up to 82%11, while Grosse et al. reports specificities of PCR based studies on dried blood spots close to 100%8.  The 0.16% incidence of congenital CMV that we observed is much lower that what has been previously reported at approximately 1%4,5.  The lower incidence could be due to a sampling error.  The limitation could be rectified with a bigger sample size and more demographic information such as described by Kharrazi et al12.

As of now there is no standard, validated screening assay for congenital CMV on dried blood spots8,12.  Soetens et al. suggested real time PCR to be the most sensitive screening tool for detecting CMV11.  Here we proposed screening for CMV with a real time PCR assay that detected the HXFL4 gene.  Screening for this gene had not been used in previous studies to detect CMV from dried blood spots.  It is a reasonable option for a screening assay because it was designed for detection of CMV in low viremic states9.  Our study suggests it is another viable screening assay to consider in determining a standardized screening method for congenital CMV.

Other studies have proposed using newborn urine or saliva samples to screen for congenital CMV1,3,13. This was suggested because of the high levels of CMV in newborn urine and saliva8,12,14.  However, screening with newborn urine and saliva is potentially labor-consuming and no current method exists to store the samples5,14,15.  For these reasons, it makes using urine and saliva as a large screening tool undesirable5,14,15.  Blood spots are routinely collected from all newborns at birth for the U.S. newborn screening program12.  Therefore, using dried blood spots to screen for congenital CMV appears to be the most viable option.  

CONCLUSIONS
Overall, screening for congenital CMV on dried blood spots with PCR is a reasonable detection method.  Addition of CMV to the newborn screening would be the end goal.  However, the incidence of congenital CMV detected in our study suggests a smaller incidence of CMV than the general population.  The study is a small study and the implications are unclear, showing the need for further studies.
References
Barkai G, Barzilai A, Mendelson E, et al. Newborn Screening for Congenital Cytomegalovirus Using Real-time Polymerase Chain Reaction in Umbilical Cord Blood. IMAJ 2013; 15:279-283.
Dollard S, Grosse S, Ross D. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Rev. Med. Virol. 2007; 17:355-363.
Schlesinger Y, Reich D, Eidelman A, et al. Congenital Cytomegalovirus Infection in Israel: Screening in Different Subpopulations. IMAJ 2005; 7:237-240.
Barbi M, Binda S, Primache V et al. Cytomegalovirus DNA detection in Guthrie cards: a powerful tool for diagnosing congenital infection. Journal of Clinical Virology 2000; 17:159-165.
Yamagishi Y, Miyagawa H, Wada K, et al. CMV DNA Detection in Dried Blood Spots for Diagnosing Congenital CMV Infection in Japan. Journal of Medical Virology 2006; 78:923-925.
Boppana S, Fowler K, Pass R, et al. Congenital Cytomegalovirus Infection: Association Between Virus Burden in Infancy and Hearing Loss. J Pediatr 2005; 146:817-23.
Albanna E, El-latif R, Sharaf H et al. Diagnosis of Congenital Cytomegalovirus Infection in High Risk Neonates. Mediterr J Hematol Infect Dis 2013; 5.
Grosse S, Dollard S, Ross D, et al. Newborn screening for congenital cytomegalovirus: Options for hospital-based and public health programs. Journal of Clinical Virology 2009; 46S:S32-S36.
Schvoerer E, Henriot S, Zachary P, et al. Monitoring Low Cytomegalovirus Viremia in Transplanted Patients by a Real-Time PCR on Plasma. Journal of Medical Virology 2005; 76:76-81.
Nassetta L, D Kimberlin, R Whitley. Treatment of congenital cytomegalovirus infection: implications for future therapeutic strategies. Journal of Antimicrobial Chemotherapy (2009) 63, 862�867.
Soetens O, Vauloup-Fellous C, Foulon I, et al. Evaluation of Different Cytomegalovirus (CMV) DNA PCR Protocols for Analysis of Dried Blood Spots from Consecutive Cases of Neonates with Congenital CMV Infections. Journal Of Clinical Microbiology 2008; 46(3):943-946.
Kharrazi M, Hyde T, Young S, et al. Use of Screening Dried Blood Spots for Estimation of Prevalence, Risk Factors, and Birth Outcomes of Congenital Cytomegalovirus Infection. The Journal of Pediatrics 2010; 157(2):191-197.
De Vries J, van der Eijk A, Wolthers K, et al. Real-time PCR versus viral culture on urine as a gold standard in the diagnosis of congenital cytomegalovirus infection. Journal of Clinical Virology 2012; 53:167-170.
Kadambari S, Williams E.J., Luck S, et al. Evidence based management guidelines for the detection and treatment of congenital CMV. Early Human Development 2011; 87:723-728.
Barkai G, Roth D, Barzilai A, et al. Universal neonatal cytomegalovirus screening using saliva-Report of clinical experience. Journal of Clinical Virology 2014; 60:361-366.
Table 1
African AmericanCaucasianMale150 (0)150 (0)Female150 (1)150 (0)
(#)=Number of dried blood spots screened positive for congenital CMV
Table 1: This table demonstrates the gender and ethnicity of the 600 dried blood spots.  The distribution between gender and ethnicity was 50%.  The number in the parenthesis represents the number of dried blood spots that screened positive for congenital CMV.  Only one blood spot, an African American female, screened positive for congenital CMV.

Figure 1. CMV Standard Curve Plot
Figure 2. Amplification curve demonstrating serial dilutions of DNA (S1-S5) and the one positive congenital CMV infant (unknown).

-TU��K	L	�	�	�
�
89JK��5C�
rs���lmnw�����MO�����������������������������桑���r�rh6�h�+CJOJQJaJh6�h�+5�CJOJQJaJh6�h6�5�CJOJQJaJh6�h�1CJOJQJaJhP�5�CJOJQJ\�aJhP�6�CJOJQJaJhP�0JCJOJQJaJjhP�UhP�hP�CJOJQJaJhP�5�CJOJQJaJ)-U���	L	~	�	�	
G
i
�
�
�
L���5�����������������������[$\$gdP�d�7$8$H$gdP�����d�7$8$H$^��`��gdP�����d�^��`��gdP�d�gdP�5CXw���b�N�mw�X�����������������������������d�gdO.�
$d�a$gd�}�$a$gd6�d�gd6�gdP�d�gdP�O]op!&X_��������%cf���������Ӵӥ�Ӝ���uhYhJ>hJh��CJOJQJaJh�5�h>^CJOJQJaJh�5�h�	FCJOJQJaJh{&CJH*OJQJaJh�5�h�U�CJOJQJaJh�5�h�1aJ
h�}�aJh6�h�}�aJh6�h�1aJh6�h6�CJOJQJaJh6�h�15�CJOJQJaJh6�h�fCJOJQJaJh6�h�1CJOJQJaJh6�h�+CJOJQJaJh6�hMa`CJOJQJaJ���/4������&B�������������غɺ��غ��}�n�n_O�_h�5�h�7-6�CJOJQJaJh�5�h�7-CJOJQJaJh�5�hS[�CJOJQJaJh�5�h2�6�CJOJQJaJh�5�h2�CJOJQJaJh�5�h�1CJOJQJaJh�5�h�$CJOJQJaJh�5�hcCJOJQJaJh�5�h�W�CJOJQJaJh{&CJH*OJQJaJh{&CJOJQJaJh�5�hTBCJOJQJaJ�����������������������ƺ��ӫӜ���xl�]NBN�Nh�fCJOJQJaJh�5�h�iNCJOJQJaJh�5�h�CJOJQJaJh�0@CJOJQJaJhMa`CJOJQJaJh6�CJOJQJaJh�h�CJOJQJaJh�5�h�w2CJOJQJaJh�5�h�b�CJOJQJaJh{&CJOJQJaJh{&CJH*OJQJaJh�5�h�XQCJOJQJaJh�5�h�7-CJOJQJaJh�5�h�$ICJOJQJaJ���-.62!5!@!.%/%�'�';*<*H*�+�+�,^-�-��������������������
&Fd�gd6�d�gd6�	d��gd7"�	d��gd�5�	d��gd��d��7$8$H$gd��	d��gdF1�	d��gd�XQ>z}�����4569:XZ���'����Ƿ�����}��֨h�֨YNJNJNJNJh�5�h�p8CJOJQJaJ)h�5�h�$I0JB*CJOJQJaJphDDDh{&CJH*OJQJaJh�5�hw6SCJOJQJaJh�5�h�<jCJOJQJaJh�5�h<tCJOJQJaJh�5�h�#6�CJOJQJaJh�5�h�#CJOJQJaJh�5�h�$ICJOJQJaJh�5�h�CJOJQJaJh�0@CJOJQJaJ�'2�������� +,-.6Brs{}�����������ⷫ����ufWHfh�5�h�$ICJOJQJaJh�5�hq�CJOJQJaJh�5�hQ!�CJOJQJaJh�UCJOJQJaJh�5�h�^�CJOJQJaJh�h�CJOJQJaJh�5�h�CJOJQJaJh�tqCJOJQJaJh�5�hCJOJQJaJh�5�h�p8CJH*OJQJaJh�vCJOJQJaJh�5�h�p8CJOJQJaJh�5�h�&�CJOJQJaJ}��- m n � � � � !
!!1!2!4!5!@!}!����ӵ������sdUF1)h��h��B*CJOJPJQJaJph# h�5�hF1�CJOJQJaJh�5�ho�CJOJQJaJh�5�h�Q�CJOJQJaJh�5�CJOJQJaJh��CJOJQJaJh�5�h�5�CJOJQJaJh�5�h��CJOJQJaJh�tqCJOJQJaJh�5�h�CJOJQJaJh�5�h�.SCJOJQJaJh�5�h�5$CJOJQJaJh�5�h}\CJOJQJaJh�5�hfjeCJOJQJaJ}!~!�!�!�!�!""""R"S"�"�"## #!#)#0#�#�#�#�#�#�#�����ع����ا�~�o`P`�`P`Ah{&h�5�CJOJQJaJh��h�5�6�CJOJQJaJh��h�5�CJOJQJaJh��h��CJOJQJaJ&h{&B*CJH*OJPJQJaJph# )h��h��B*CJOJPJQJaJph# #h{&B*CJOJPJQJaJph# h{&CJH*OJQJaJ#h��B*CJOJPJQJaJph# )h��h��B*CJOJPJQJaJph# #h��B*CJOJPJQJaJph# �#�#�#�#�#m$p$s$�$�$�$%%*%,%-%.%b%�%�%�%�%�%�%0'1'�'�'�'����ѵѦѦі�с�r�rbr�r�rVGh�5�h�5�CJOJQJaJh�vCJOJQJaJh�vh�v6�CJOJQJaJh�vh�vCJOJQJaJ)h��h�5�B*CJOJPJQJaJph# h��h�5�6�CJOJQJaJh��h�vCJOJQJaJh{&CJH*OJQJaJh��h��CJOJQJaJh��h�5�CJOJQJaJh{&h�5�CJOJQJaJh{&h{&CJH*OJQJaJ�'�'�'( ("(r(y(�(�(�(�(�(�()_)f)g)i)x)�)�)�)�)�)�)�)
**0*:*;*��������⽱���բⓢ��u�u�ufZfZh�vCJOJQJaJh�5�h\]CJOJQJaJh�5�h6fCJOJQJaJh�5�hm{CJOJQJaJh�5�hfHCJOJQJaJh�5�hlU)CJOJQJaJh�fCJOJQJaJh��CJOJQJaJh{&CJOJQJaJh{&CJH*OJQJaJh�5�hyoCJOJQJaJh�5�h�f6CJOJQJaJ;*G*H*/+n+o+�+�+�+�+�+�+0x0�0�0	2�276�6�6�����ʻʬ���sdsdSdD5h�}�h�5�CJOJQJaJh]�h�.CJOJQJaJ h]�h]�CJOJPJQJaJh]�h]�CJOJQJaJh]�hRcyCJOJQJaJh]�h{&CJOJQJaJh�w2CJOJQJaJh�5�h�5�CJOJQJaJhs�h�-XCJOJQJaJh�5�h:�CJOJQJaJh�5�h�)�CJOJQJaJh�5�h7"�CJOJQJaJh�V�CJOJQJaJh�h�CJOJQJaJ�-�.]/0�0U1	2�2�3�4�576�6�6�6�6	7����������������$d��$Ifa$gdY@$a$gd�5�
&Fd�gd6��6�6	7
777 7'7778797~7�728W8�8�8
9
9*9�9�9�9�����������w�wh�h�5�h�tqCJOJQJaJh�tqh�tqCJOJQJaJh�tqCJOJQJaJh :ACJOJQJaJh�5�h�5�5�CJOJQJaJh�5�CJOJQJaJhY@h�5�%hY@h�5�B*CJOJQJaJphhY@h�}�+hY@h�5�5�B*CJOJQJ\�aJphh�5�h�5�CJOJQJaJ	7
7777hWWW$d��$Ifa$gdY@�kd$$IfT�l��g�F��W$'
f���������F���������f���������
t��0K���K������|6��K��K��K����������������K��K��K���������������4�4�
lB�a�ytY@�T7 7'7/777B111$d��$Ifa$gdY@�kd�$$IfT�l��,�F��W$'
f���������f���������f���������	�
t���������������0K���K������|6�����������������������������������4�4�
lB�a�p�������������ytY@�T778797~7�8�8�8�9�9h^^^\^^\	d��gd�5��kd�$$IfT�l��;�F��W$'
f�f�f�
t��0K���K������|6�����������������4�4�
lB�a�ytY@�T501�h:p�?���/ ��=!��"��#��$��%��������$$If�!vh5��5��5�#v�#v�#v:V�l�g
t��0K���K������|65��5��9�9�/�K��/�
��������B�ytY@�T$$If�!vh5��5��5�#v�#v�#v:V�l�,	�
t���������������0K���K������|65��5��9�/�
��������B�p�������������ytY@�T�$$If�!vh5��5��5�#v�#v�#v:V�l�;
t��0K���K������|65��5��9�B�ytY@�Tj���������666666666vvvvvvvvv666666>666666666666666666666666666�6666666666�666666666666hH6666666666666666666666666666666666666666666666666666666666666666�62���� 0@P`p������2(�� 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p��8X�V~ OJPJQJ_HmH	nH	sH	tH	N`�N�1Normald��CJPJ_HaJmH	sH	tH	DA`�D
Default Paragraph FontRi@�R0Table Normal�4�
l4�a�(k �(
0No Listd�o��d�1imported-Normal)B*CJOJPJQJ_HmH	phsH	tH	B' �B	50Comment ReferenceCJaJN`N	50Comment Textd�CJaJmHsHtHF�/�!F50Comment Text CharCJPJaJ@j @	50Comment Subject5�\�R�/�AR50Comment Subject Char5�CJPJ\�aJZ� RZ	50Balloon Textd��CJOJQJaJmHsHtHR�/�aR50Balloon Text CharCJOJPJQJ^JaJ6U`�q6�$I0	Hyperlink>*B*ph�\^@�\�$INormal (Web)d��d�d[$\$CJOJQJ^JaJ�O���$Ist1������5��Light Shading - Accent 5G:V�0K���K������4�4j�;@������������������������������������������
����j�;������������������������������������������
����j�D�K����K������������������������������������������j�D�K����K������������������������������������������2d��f�d���f�d���5B*ph1����5\��5\��5\��5\@�@�@]� List Paragraph	^��m$.(��.	xG�0Line NumberPK!����[Content_Types].xml���j�0E����ж�r�(��΢Iw},��-j��4	��w�P�-t#bΙ{U�����T�U^h�d}㨫��)��*1P�'��	�^��W��0)��T�9<�l�#��$yi}��;�~@��(��H����u�*Dנz��/0�ǰ��$��X��3aZ����,�D0j~�3߶�b��~i>���3�\`�?�/�[���G��\�!�-�Rk.�s�Ի�..���a濭?��PK!�֧�6_rels/.rels���j�0���}Q��%v/��C/�}�(h"���O�
����=������ ����C?�h�v=��Ʌ��%[xp��{۵_�Pѣ<�1�H�0���O�R�Bd���JE�4b$��q_����6L�R�7`������0̞O��,�En7�Li�b��/�S���e��е�����PK!ky���theme/theme/themeManager.xml�M
� @�}�w��7c�(Eb�ˮ��C�AǠҟ����7��՛K
Y,�
�e�.���|,���H�,l����xɴ��I�sQ}#Ր���� ֵ+�!�,�^�$j=�GW��)�E�+&
8���PK!����Ptheme/theme/theme1.xml�YOo�6��w toc'vu�ر�-M�n�i���P�@�I}��úa��m�a[�إ�4�:lЯ�GR��X^�6؊�>$�������!)O�^�r�C$�y@�����/�yH*��񄴽)�޵��߻��UDb�`}"�qۋ�Jח���X^�)I`n�E���p)���li�V[]�1M<������O�P��6r�=���z�gb�Ig��u��S�eb��O������R�D۫����qu	�g��Z����o~ٺlAp�lx�pT0���+[}`j���zA��V�2�F���i�@�q�v�֬5\|��ʜ̭N��le�X�ds���jcs���7���f����
��W��+�Ն�7����`���g�Ș��J���j|��h(�K��D-����
dX��iJ�؇(��x$(��:��;�˹!�I_�T��S1�����?E��?�����?ZBΪm���U/������?�~����xY���'���y5�g&΋/����ɋ�>���G�M�Ge���D�����3Vq%'#q�����$�8��K�����)f�w9:ĵ��
x}r�x����w���r�:\TZaG�*�y8I�j�bR��c|XŻ�ǿ�I
u3KG�nD1�NIB�s���
��R��u���K>V�.EL+M2�#'�f��i~�V��vl�{u8��z��H�
�*���:�(W�☕
~��J�T�e\O*�tHG��HY��}KN�P�*ݾ˦���TѼ�9/#��A7�qZ��$*c?���qU��n��w�N��%��O��i�4=3ڗP��
����1�P�m\\9���������Mؓ�2a�D�]�;Yt�\��[x����]�}Wr��|�]��g-���
eW�
�)6-r��CS�j��
i�d	�DЇA�ΜIqbJ#x�꺃6k���#��A�Sh��&ʌt(Q�%��p%m��&]�caSl=�X�����\P�1�Mh�9�M��V�dDA��aV�B��[݈fJ�íP|8�քA�V^��f
�H��n���-��"�d>�z��n��NJ�	�ة�>�b���&����2��v����Kyϼ��D:����,AGm��\nz��i�Ù��.uχYC�6�OMf��3o�r��$��5�����NH�T[XF64�T,ќ���M0�E)`#�5�XY�`�פ;��%�1�U�٥m;���R>QD����D�cp�U�'��&LE�/p���m���%]�����8fi��r�S4�d7y\�`�J�n���ί�I�R��3U�~7+���׸#��m�q�BiD���������i*�L6�9�m�Y&���i���HE��=(K&�N!V�.K�e�LD�ĕ�{D	����vEꦚde��NƟ��e�(�MN9ߜR�6����&3(��a���/D��U�z�<�{ˊ�Y��ȳ����V���)�9�Z[��4^n��5���!J��?��Q�3�eBo�C����M����m<�.�vp�����IY�f���Z�Y_p�[�=al-�Y�}Nc͙���ŋ4vfa��vl����'S��A�8�|�*u�{��-�ߟ0%M0�7%����<���ҍ���PK!
ѐ��'theme/theme/_rels/themeManager.xml.rels��M
�0���wooӺ�&݈Э���5
6?$Q��
�,.�a��i����c2�1h�:�q��m��@RN��;d�`��o7�g�K(M&$R(.1�r'J��ЊT���8��V�"��AȻ�H�u}��|�$�b{��P����8�g/]�QAsم(����#��L�[������PK-!����[Content_Types].xmlPK-!�֧�6+_rels/.relsPK-!ky���theme/theme/themeManager.xmlPK-!����P�theme/theme/theme1.xmlPK-!
ѐ��'�	theme/theme/_rels/themeManager.xml.relsPK]�
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>�1`����O���}}!�#�';*�6�9 !"$%&'()*,5��-	7777�9#+-./8J�1X���L�#����@�����������0�(	�
��B
�S����	?���_GoBack�#�1�#�1������/8Uh��}������T[`j�����SVSY!(��")�#�#�#�#�#�#�$�$E%J%v%~%�%�%�%&&&�&�&�'�'((((((q(y(|(�(U)^)b)i)�)�)	*** *�*�*�*�*�*�*�,�,�,�,�,�,�-�-7.=.I.Q.�1��%df04��%'*Pr����np%'��   s y � !`!f!�+�+�0�0�01�133333333333333333333nw��	�	�	�	M
O
]
o
�������1�1yD�=��H.��������������^��`���.������^��`���.��p�L�^�p`�L�.��@���^�@`���.�����^�`���.����L�^��`�L�.������^��`���.������^��`���.��P�L�^�P`�L�.yD�=��������									DNKB�\��
�+c\O	g^�.fH�$TB5�>^�	yo.%�#*N}\.w�5${&�E)lU)-^*�7-Zf/�1�1�w2�f6�p8%N=Y@�0@ :A�	F�$I�	L�iN�XQ�.Sw6S�U�V�-X�!\\]�u^Ma`�]b�ycfje6f�f#f�vi�<jIm{moDbp�fq�tq<t�vRcym{E{+q�=���7"��Y��t��V���o�F1��2��W�O.��'�2��{�)~��-���s���)��I�`D�s�/��l��?�Q!�4d��T�S[��5�xG��}�-3��^��B��m�w����6��?��z�:��&�1��h�N=�q��b�%I�P�W��U��r�]�(s��Q��1�1�@w�
(�ww�1X@��Unknown������������G��*�Ax�	�Times New Roman5��Symbol3.��*�Cx�	�Arial7.���@	�Calibric��0�0�0�0҉�0 Pro W3Times New Roman5.��.�[`�)�TahomaA���$B�Cambria Math"q���h#�*�+b2�.Z)�c*�Yc*Y���n���20i1i1:����HX	�	$P�����������������������12!xx���
Administratorajeyak����Oh��+'��0p�������	�
 ,8
DPX`h�AdministratorNormalajeyak4Microsoft Office Word@�Ik@�I���@�P
���@r�2�F�c*����՜.��+,��D��՜.��+,��,�hp|�������
���HPYi1Title� 8@_PID_HLINKS�Al/mailto:ajeyak@lsuhsc.edu�	

 !"#$%&'()*+,-./0����2345678����:;<=>?@ABCDEFGHIJKLM����OPQRSTU����WXYZ[\]��������`a��������d����������������������������������������������������������������������������������������������������������������Root Entry��������	�Fp��C�F�cData
������������11Table��������9(WordDocument
����7`SummaryInformation(������������NDocumentSummaryInformation8��������VMsoDataStore���������]�C�F���C�F�J����3L��UW��P1A���45�==2���������]�C�F���C�F�Item
����	�����Properties������������UCompObj����
y����������������	����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������<b:Sources SelectedStyle="\APA.XSL" StyleName="APA" xmlns:b="http://schemas.openxmlformats.org/officeDocument/2006/bibliography" xmlns="http://schemas.openxmlformats.org/officeDocument/2006/bibliography"></b:Sources>
<?xml version="1.0" encoding="UTF-8" standalone="no"?>
<ds:datastoreItem ds:itemID="{D5EA7B26-E9D2-45AD-B280-F6C0C70D1E7E}" xmlns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"><ds:schemaRefs><ds:schemaRef ds:uri="http://schemas.openxmlformats.org/officeDocument/2006/bibliography"/></ds:schemaRefs></ds:datastoreItem>��
����	�F'Microsoft Office Word 97-2003 Document
MSWordDocWord.Document.8�9�q

Youez - 2016 - github.com/yon3zu
LinuXploit