The Effect of Duration of Antibiotic Prophylaxis on Infections Following Open Reduction and Internal Fixation of Mandibular Fractures: A Prospective Randomized Clinical Trial Risimati E. Rikhotso, PhD and Gontse P. Mohotlhoane, MDent Aim: To evaluate the benefits of a long-term prophylactic an- tibiotic regimen following treatment of fractured mandibles with open reduction and internal fixation. Material and Methods: A prospective, randomized controlled trial was undertaken at Wits Oral Health Centre. Patients with mandibular fractures who were managed with open reduction and internal fixation using miniplates were randomized into 2 groups. The control group, the perioperative antibiotic (POA) group, was composed of patients who received intravenous (IV) antibiotic cover intraoperatively and a further 3 IV doses 24 hours postoperatively. The study group, the extended post- operative antibiotic (EPOA), was composed of patients who received similar doses as the control group but with an addi- tional 5 days of oral antibiotics upon discharge. The patients were then evaluated for evidence of infection 1, 4, and 6 weeks postoperatively. Results: A total of 77 patients were included in the study, 41 in the POA and 36 in the EPOA groups. Fourteen patients had evidence of infection noted within the 6-week follow-up period (10 in the POA and 4 in the EPOA groups). Statistical analysis with the Pearson Chi-square and Student t test showed no sta- tistically significant difference (P= 0.399) between POA and EPOA groups. There were no significant differences between the groups with respect to site and etiology of fracture, duration of operation, and presence of infection (P> 0.05) during the 6-week review period. Conclusions: The extended use of antibiotic prophylaxis when managing mandibular fractures with open reduction and in- ternal fixation offers no additional benefit in reducing post- operative infections. Key Words: Antibiotics, duration, fractures, infection, mandible (J Craniofac Surg 2024;35: 185–188) Although the efficacy of prophylactic antibiotics in the management of facial fractures has been demonstrated in several studies, there is, however, great variability in practice.1,2 The practices vary from using antibiotics preoperatively, in- traoperatively, and postoperatively or in combination. In par- ticular, the appropriate duration of prophylactic antibiotics remains a controversial subject in the management of traumatic mandibular fractures.3 Despite the long-standing evidence that perioperative pre- scription is not required for more than 24 hours postoperatively, many units anecdotally still prescribe longer courses3–10 (Sup- plemental Digital Content, Table 1, http://links.lww.com/SCS/ F556). Because the most common reason for misuse of pro- phylactic antibiotics is the excessive duration, we conceived this prospective, randomized-controlled clinical study to assess whether extended postoperative course of oral antibiotics in addition to perioperative intravenous antibiotics offer better prevention of postoperative infections than perioperative anti- biotics (POA) in patients with mandibular fractures. MATERIALS AND METHODS Study Population To answer the research question, we designed and im- plemented a prospective randomized-controlled study whose sample consisted of patients treated by open reduction and in- ternal fixation (ORIF) for compound mandibular fractures at the University of the Witwatersrand Oral Health Centre in Johannesburg, South Africa, between January 1, 2019, and December 31, 2019. The study was approved by the institution’s Human Research Ethics Committee (clearance number M181035). All the participants were given an explanation about the study and signed an agreement of informed consent. To be included in the study, patients needed to have been at least 18 years of age, with isolated compound mandibular fractures treated by ORIF via a transoral approach. Also, a minimum of 6-week follow-up data post-treatment was required for inclusion in the study. Compound fractures were defined as fractures communi- cating with the oral cavity through a periodontal ligament space or intraoral laceration. Patients were excluded if they presented with fractures older than 2 weeks, associated fractures (zygoma From the Department of Maxillofacial and Oral Surgery, School of Oral Health Science, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Received June 17, 2023. Accepted for publication August 25, 2023. Address correspondence and reprint requests to Risimati E. Rikhotso, PhD, Department of Maxillofacial and Oral Surgery, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; E-mail: risimati.rikhotso@wits.ac.za This randomized study was approved by the University’s Human Re- search Ethics Committee; (clearance number M181035) and written informed consent was obtained from all patients. The authors report no conflicts of interest. Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.jcraniofacialsurgery.com. Copyright © 2023 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000009784 CLINICAL STUDY The Journal of Craniofacial Surgery � Volume 35, Number 1, January/February 2024 185 Copyright © 2023 Mutaz B. Habal, MD. All rights reserved. D ow nloaded from http://journals.lw w .com /jcraniofacialsurgery by B hD M f5eP H K av1zE oum 1tQ fN 4a+ kJLhE Z gbsI H o4X M i0hC yw C X 1A W nY Q p/IlQ rH D 3i3D 0O dR yi7T vS F l4C f3V C 4/O A V pD D a8K 2+ Y a6H 515kE = on 07/22/2024 http://links.lww.com/SCS/F556 http://links.lww.com/SCS/F556 mailto:risimati.rikhotso@wits.ac.za http://www.jcraniofacialsurgery.com or maxillary fractures), complex mandibular fractures requiring transcervical approach, gunshot wounds, pathological fractures, fracture site infections present at the time of initial presentation, closed mandibular fractures, compromised host defenses (im- munosuppression, uncontrolled diabetes), or received anti- biotics for any other indication. The enrolled patients were randomly allotted into 2 groups representing those who were to receive POA only or those to receive extended postoperative antibiotics (EPOA). A research assistant balloted for the first patient into one of the 2 groups and allotted subsequent consecutive patients to the opposite group in alternation until exhaustion of patients who met the inclusion criteria. Group 1 or control group was composed of patients who received an intravenous (IV) antibiotic cover in- traoperatively and further 3 doses postoperatively (8 hourly) before being discharged. Group 1 patients received POA only and was also called POA group. Group II or study group was composed of patients who received similar doses as the control group but with an additional 5 days of oral antibiotics following discharge. Group II patients received EPOA and was also called the EPOA group. The antibiotics for the purpose of the study given were as follows: Patients in the POA group received Amoxicillin/clavulanic acid 1.2 g IV intraoperatively and then 3 intravenous doses postoperatively (no>24 hours) while they were still in the hos- pital. Patients in the EPOA were given Amoxicillin/clavulanic acid 1.2 g IV intra-operatively and then 3 intravenous doses postoperatively plus Amoxil 500 mg capsules 3 times a day orally for an additional 5 days. Patients allergic to penicillin received Clindamycin 600 mg IV intraoperatively and the 3 doses postoperatively, and Clin- damycin 300 mg orally 6 hourly for 5 days. Surgical Procedure All patients were managed under general anesthesia with nasotracheal intubation. Sterile protocols were observed. A prophylactic dose of Amoxicillin/clavulanic acid 1.2 g stat was administered intravenously before the incision was made, and patients allergic to penicillin were given Clindamycin 600 mg. Local anesthetic was administered, followed by placement of eyelet wires or arch bars. The fracture sites were exposed through intraoral incisions. Fractures were mobilized and debrided under direct vision. To establish proper occlusion, maxillomandibular fixation was es- tablished by fixing the mandible against the maxilla with stainless steel wires around the extensions of the arch bars or eyelet wires. The fractured segments were then reduced and fixated with 2.0 mm standard titanium miniplates according to the Champy principle. Two miniplates were fixated in the symphysis and parasymphyseal regions, whereas fractures in the angle and body regions were fixated with single plates. The miniplates were secured with monocortical titanium screws, with at least 2 screws on either side of the fracture. Adequacy of fixation and occlusion were verified after placement of the miniplates. Maxillomandibular fixation was released after fixation of the fracture segments and after copious irrigation with saline and achievement of adequate hemostasis, the incisions were closed in layers with 3-0 chromic. Guiding elastics were used post- operatively for occlusal guidance. Patients were discharged from the hospital after receiving a further 3 intravenous doses of antibiotics 24 hours post- operatively and were reviewed during 1-, 4-, and 6-week follow- up visits from date of discharge, or as needed. At each visit, a surgeon who was blinded to the antibiotic schedule ad- ministered reviewed the patients. Patients were evaluated for presence or absence of postoperative infection. Criteria for infection included purulent discharge (with or without microbiologic confirmation), abscess formation, or de- liberate opening of the wound by a surgeon in the presence of signs and symptoms of infection such as localized pain, ten- derness, or fever (> 38°C). Sample Size The estimated sample size was calculated based on a pre- vious study, using obtained prevalence of infection rates in the intervention (36%) and control groups (64%).9 We estimated that a sample size of 49 in each group would be adequate for a power of 80% and type 1 error of 5% (2-tailed). Data Analysis The data were collected and tabulated in Microsoft Excel worksheets (Microsoft Office 2013; Microsoft Corporation, Redmond, WA). Statistical analysis of results was performed using SPSS v.25 (IBM Corporation, Armonk, NY). Descriptive statistics of median and interquartile range was used to sum- marize the continuous variables (age, date of injury— presentation and date of injury-operation) and percentage and frequency was used to report the categorical variables (gender, site of fracture, and presence of infection). The significant dif- ference between the continuous variables was measured by us- ing the Mann–Whitney U test for nonparametric data and the measure of association between the categorical variables was determined by using the 2-tailed Fisher exact test. A P value ≤ 0.05 was considered significant. RESULTS A total of 98 patients were enrolled in the study, of which 77 patients with isolated mandibular fractures met the inclusion criteria. The median age was 32, ranging from 26 to 38 years, and the majority (92.2%) of the participants were males. The etiology of the fracture was alleged assault in 57 patients (74%), motor vehicle accident in 11, and pedestrian vehicle accident in 5. The most common site of fracture was the angle (35.1%), followed by angle and body (26%) and parasymphysis and angle (10.4%) fractures. Of the 77 patients, 41 were randomized into the POA group and 36 into the EPOA group. The difference between POA and EPOA 2 at baseline is summarized in Table 2 (Supplemental Digital Content, http://links.lww.com/SCS/F557). There were no significant differences between the groups at baseline in all the variables except for the days between injury and pre- sentation and the duration of surgery. Patients in the EPOA group had a significantly higher number of days before pre- sentation compared to the patients in the POA group (P= 0.04). The mean duration of surgery was 70 minutes (range 55–90 min) and 82 minutes (range 65–124 min) for the POA and EPOA groups, respectively (P= 0.04). Comparison of Presence of Infection Between the POA and EPOA Groups The number of infections at weeks 1, 4, and 6 in the POA group was 4, 10, and 4, respectively. In the EPOA group, the figures at weeks 1, 4, and 6 were 4, 4, and 1, respectively. As shown in Figure 1, there was an equal number of patients with infection at week 1 in both groups. In the POA group, the number of patients with infection increased to 10 (24.39%) by week 4, and the number of patients with infection in the EPOA group remained at 4. At 6 weeks, the number of patients with infection in the POA and the EPOA groups had reduced to 4 Rikhotso and Mohotlhoane The Journal of Craniofacial Surgery � Volume 35, Number 1, January/February 2024 186 Copyright © 2023 by Mutaz B. Habal, MD Copyright © 2023 Mutaz B. Habal, MD. All rights reserved. D ow nloaded from http://journals.lw w .com /jcraniofacialsurgery by B hD M f5eP H K av1zE oum 1tQ fN 4a+ kJLhE Z gbsI H o4X M i0hC yw C X 1A W nY Q p/IlQ rH D 3i3D 0O dR yi7T vS F l4C f3V C 4/O A V pD D a8K 2+ Y a6H 515kE = on 07/22/2024 http://links.lww.com/SCS/F557 (9.76%) and 1 (2.78%), respectively. Using Fisher exact test, there was no significant association between the presence of infection and the 2 groups (P> 0.05). The differences between the number of infections in both groups at weeks 1, 4, and 6 were not statistically significant (P= 1, P= 0.15, and P= 0.36, respectively) (Fig. 1 and Supplemental Digital Content, Table 3, http://links.lww.com/ SCS/F558). There was no significant difference between these groups with respect to age and gender. The mean delay in time from injury to receiving treatment was 9 days (range 6–11 d) and 10 days (range 8–13) for POA and EPOA, respectively. There was also no significant difference between delay in treatment, site of fracture, etiology of fracture, duration of operation, and presence of infection (P> 0.05) during the 6-week review period. Further analysis using binary logistic regression showed that the odds of presenting with infection is 19.2 times higher in the patients with comorbidities than in patients without co- morbidities. Patients who developed infections were treated differently depending on their signs and symptoms. Five of the infections resolved with oral antibiotics alone, 8 required an incision and drainage procedure (either intraoral or extraoral depending on the presentation) as well as oral antibiotics, and 8 required hardware removal with concomitant antibiotic administration. The remaining infection, presented as a nonunion requiring hardware removal, incision and drainage, and treatment with oral antibiotics. DISCUSSION We designed this study to evaluate the benefit of an EPOA regimen following ORIF of the fractured mandible as compared to a POA regimen. We hypothesized that there is no significant difference between patients receiving short-term antibiotics and those that received an extended antibiotic regimen. After a 6- week follow-up, we found that the extended use of antibiotic prophylaxis when managing mandibular fractures with ORIF offers no additional benefit in reducing postoperative infection. The findings of this study that there is no significant differ- ence between POA and EPOA confirm our hypothesis of no difference between a short and extended antibiotic regimen and correspond with the findings of Miles et al.9 The limitation to the study by Miles et al9 was that the duration of postoperative antibiotics was not consistent and that patients received un- known preoperative antibiotics (not mandated by the study protocol) until the day of surgery. This is a common problem in that most patients with mandibular fractures receive antibiotics prophylaxis at the initial consultation. Gaal et al6 have, how- ever, shown that there is no increase in surgical site infections secondary to a lack of preoperative antibiotics from the time of consultation to when surgery is performed. Unless there is an infection noted, preoperative antibiotic prophylaxis is not deemed necessary.11 Studies by Schaller et al,3 Lovato et al,8 Abubaker and Rollert,10 and Andreasen et al12 have also concluded that the use of extended postoperative oral antibiotics in the manage- ment of mandibular fractures has no benefit in reducing post- operative surgical site infections. A similar study design by Dogra et al,13 which analyzed 39 patients with mandibular fractures undergoing ORIF, con- cluded that there was no significant difference between the short and extended antibiotic groups (P= 0.58). The study, however, was more focused on the surgical site infection and assessing microbial load at the suture site, which was analyzed at 3- and 7-day reviews. There was no record of further follow-up on the patients. A bigger sample size would have strengthened the findings of this study. Systematic review and meta-analyses have also reported that there is no significant difference in infection at the surgical site between patients who were given antimicrobials for 24 hours postoperatively and those who take them for longer.14–16 Miles et al9 also reported a statistically significant (P= 0.021) increase in the risk of postoperative infections in patients who abused tobacco and alcohol simultaneously, citing local and systemic effects of alcohol and tobacco on soft tissue/bone healing, poor nutrition, and poor compliance with post- operative instructions. Our study did not investigate the rela- tionship between the independent or combined use of alcohol and smoking and the infection rate. Early treatment of mandibular fractures is reported to be associated with a decreased risk of postoperative infections.17 Both Champy et al18 and Cawood et al19 recommended that ORIF must be performed within 12 to 24 hours after the injury to minimize the risk of postoperative infection. Many of our patients, however, did not present for treatment for several days after the injury. Similar to the findings by Gaal et al6 and Dillon et al,20 delay in treatment was not significantly associated with an increased risk of infection between the groups. Sundheep- kumar et al21 also prospectively evaluated infectious compli- cations in 83 patients who underwent delayed (defined as ORIF beyond 72 h) ORIF (median 8, range 4–19 d) for mandibular fractures. They also concluded that delay to definitive surgical intervention was not an independent attributing factor in postoperative infectious complications of compound man- dibular fractures. This finding seems to suggest that the time to actual surgical treatment does not influence the rate of in- fections at the surgical site, provided POA are administered when surgery is eventually performed. The rich blood supply in the head and neck region and the tolerance of the oral cavity to the normal oral flora are offered as possible reasons for this.6 Another possible explanation for this observation in our study is that fractures older than 2 weeks were excluded from the study. Fractures older than 2 weeks often require increased anesthetic and surgical time, which together with eburnation and increased mobility of the fragments may render them susceptible to in- fection, especially when no intermaxillary fixation is applied postoperatively. Our findings of lack of correlation between the duration of surgery and the infection rate is comparable to that of Miles et al9 who reported 119.5 minutes in the perioperative group and 166.6 minutes in the EPOA group, with no significant statistical difference between the groups. Contrary to our find- ing, Shigeishi et al22 reported an association between increased surgical time and risk of postoperative infections in patients who underwent head and neck surgeries. They, however, stated that this is dependent on the severity of the procedure and the surgeon’s skills. Studies have demonstrated that mandibular angle fractures, the left angle in particular, result in a greater complication rate than fractures in other locations in the mandible.23–25 Possible explanations for this include a more severe mechanism of injury from a right-hand-dominant assailant (“right hook concept”) and predominantly right-handed surgical registrars who may struggle to work on the left side of the patient early in their career. Dogra et al13 also found that a posterior location of the fracture in the mandible was a risk factor for the development of infection. Contrary to these studies, our study was unable to show any relationship between site of fracture and presence of infection. Although there were more angle fractures in both The Journal of Craniofacial Surgery � Volume 35, Number 1, January/February 2024 Effect of Duration of Antibiotic Copyright © 2023 by Mutaz B. Habal, MD 187 Copyright © 2023 Mutaz B. Habal, MD. All rights reserved. D ow nloaded from http://journals.lw w .com /jcraniofacialsurgery by B hD M f5eP H K av1zE oum 1tQ fN 4a+ kJLhE Z gbsI H o4X M i0hC yw C X 1A W nY Q p/IlQ rH D 3i3D 0O dR yi7T vS F l4C f3V C 4/O A V pD D a8K 2+ Y a6H 515kE = on 07/22/2024 http://links.lww.com/SCS/F558 http://links.lww.com/SCS/F558 groups, the rate of infection in the angle fractures was not sig- nificantly different from nonangle fractures. Also, we did not find that multiple or bilateral mandibular fractures resulted in an increase in the infection rate. Furthermore, the present study was unable to show any significant association between the cause of fracture and the presence of infection in both groups. This study has several limitations. First, the degree of fracture displacement was not quantified. Second, it was not possible to monitor compliance with regard to uptake of postoperative oral antibiotics. Third, confounding factors such as smoking, seniority of the surgeon, and alcohol use were also not investigated. Last, our sample size may not have been large enough to detect the differ- ences in infection rates necessary to reach statistical significance. Notwithstanding its limitations, this study has added valuable in- formation to the ongoing debate on the timing and duration for antibiotics in the management of mandibular fractures. CONCLUSION AND RECOMMENDATIONS From the findings of the present study, revealing no difference between the brief and extended us of antibiotics, we conclude that extended use of oral antibiotics offers no additional benefit in reducing postoperative infections of mandibular fractures. Future prospective randomized-controlled studies, involving a larger number of patients, as well as longer follow-up period that will include data on smoking and the use of alcohol, teeth in the line of fracture and the treatment approach (transoral or transbuccal) are recommended to further strengthen the findings of this study. REFERENCES 1. Dawoud BES, Kent S, Henry A, et al. Use of antibiotics in traumatic mandibular fractures: a systematic review and meta- analysis. Br J Oral Maxillofac Surg 2021;59:1140–1147 2. Tyler D, Wong JLY, Krishnan O, et al. Antimicrobial regimens used in the treatment of mandibular fractures in UK maxillofacial units: changes over 12 years. Br J Oral Maxillofac Surg 2020;58:89–91 3. Schaller B, Soong PL, Zix J, et al. The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomized, double-blind, placebo-controlled pilot clinical study. Part 2: mandibular fractures in 59 patients. Br J Oral Maxillofac Surg 2013;51:803–807 4. Zosa BM, Elliott CW, Kurlander DE, et al. Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less. J Trauma Acute Care Surg 2018;85:444–450 5. Perepa A, Sinha R, Agarwa A, et al. Protocol for antibiotic administration in mandibular trauma: a prospective clinical trial. J Maxillofac Oral Surg 2018;17:19–23 6. Gaal A, Bailey B, Patel Y, et al. Limiting antibiotics when managing mandibular fractures may not increase infection risk. J Oral Maxillofac Surg 2016;74:2008–2018 7. Mottini M, Wolf R, Soong PL, et al. The role of postoperative antibiotics in facial fractures: comparing the efficacy of a 1-day versus a prolonged regimen. J Trauma Acute Care Surg 2014;76:720–724 8. Lovato C, Wagner JD. Infection rates following perioperative prophylactic antibiotics versus postoperative extended regimen prophylactic antibiotics in surgical management of mandibular fractures. J Oral Maxillofac Surg 2009;67:827–832 9. Miles BA, Potter JK, Ellis E. The efficacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: a prospective randomized trial. Oral Maxillofac Surg 2006;64:576–582 10. Abubaker AO, Rollert MK. Postoperative antibiotic prophylaxis in mandibular fractures: a preliminary randomized, double-blind, and placebo-controlled clinical study. J Oral Maxillofac Surg 2001;59: 1415–1419 11. Salmeron-Escobar JI, de Velasco AD. Antibiotic prophylaxis in oral and maxillofacial surgery. Medicina Oral, Patologia Oral Y Cirugia Bucal 2006;11:E292–E296 12. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 2006;64:1664–1668 13. Dogra S, Bhutia O, Nagori SA, et al. A double-blind, randomized, placebo-controlled trial of short-and extended-regime antibiotics in infection rates after open reduction and internal fixation of uncomplicated single mandibular fractures. J Oral Maxillofac Surg Med Pathol 2015;27:318–322 14. Habib AM, Wong AD, Schreiner GC, et al. Postoperative prophylactic antibiotics for facial fractures: a systematic review and meta-analysis. Laryngoscope 2019;129:82–95 15. Domingo F, Dale E, Gao C, et al. A single-center retrospective review of postoperative infectious complications in the surgical management of mandibular fractures: postoperative antibiotics add no benefit. J Trauma Acute Care Surg 2016;81:1109–1114 16. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. J Cranio-Maxillofac Trauma Reconstr 2015;8:64–78 17. Abdelfadil E, Salem AS, Mourad SI, et al. Infected mandibular fractures: risk factors and management. J Oral Hyg Health 2013;1: 2332–0702 18. Champy M, Lodde JP, Schmitt R, et al. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg 1978;6:14–21 19. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985;23:77–91 20. Dillon JK, Christensen B, McDonald T, et al. The financial burden of mandibular trauma. J Oral Maxillofac Surg 2012;70:2124–2134 21. Sundheepkumar V, Saravanan R, Krishnan B. Infectious complications in compound mandibular fractures undergoing a delayed surgical intervention-a prospective observational study. Br J Oral Maxillofac Surg 2023;61:302–308 22. Shigeishi H, Ohta K, Takechi M. Risk factors for postoperative complications following oral surgery. J Appl Oral Sc 2015;23:419–423 23. Christensen BJ, Mercante DE, Neary JP, et al. Risk factors for severe complications of operative mandibular fractures. J Oral Maxillofac Surg 2017;75:787–e1 24. Gordon PE, Lawler ME, Kaban LB, et al. Mandibular fracture severity and patient health status are associated with postoperative inflammatory complications. J Oral Maxillofac Surg 2011;69:2191–2197 25. Shetty V, Atchison K, Der-Matirosian C, et al. The mandible injury severity score: development and validity. J Oral Maxillofac Surg 2007;65:663–670 FIGURE 1. Association of the presence of infection between POA and EPOA groups. EPOA indicates extended postoperative antibiotic; POA, perioperative antibiotic. Rikhotso and Mohotlhoane The Journal of Craniofacial Surgery � Volume 35, Number 1, January/February 2024 188 Copyright © 2023 by Mutaz B. Habal, MD Copyright © 2023 Mutaz B. Habal, MD. All rights reserved. D ow nloaded from http://journals.lw w .com /jcraniofacialsurgery by B hD M f5eP H K av1zE oum 1tQ fN 4a+ kJLhE Z gbsI H o4X M i0hC yw C X 1A W nY Q p/IlQ rH D 3i3D 0O dR yi7T vS F l4C f3V C 4/O A V pD D a8K 2+ Y a6H 515kE = on 07/22/2024