Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE.

“A study to assess the effectiveness of self instructional module on knowledge regarding prevention of upper limb lymphedema following breast cancer treatment among breast cancer patients in a selected hospital at Bangalore

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mrs .Reena Roy

First year Msc nursing

(Obstetrics and gynaecological nursing)

2012-2014 batch

Harsha College of Nursing.

193/4, NH-4

Nelamangala BY PASS

Bangalore-562123

KARNATAKA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

PERFORMA FOR REGISTRATION OF SUBJECT

FOR DESERTATION

| | |

| |Mrs .Reena Roy |

| |First year Msc nursing |

|NAME OF THE CANDIDATE AND ADDRESS |2012-2014 batch |

| |Harsha College of Nursing |

| |Nelamangala BY PASS |

| |Bangalore-5621 |

| | |

| | |

| | |

| | |

| |Harsha College of Nursing. |

| |193/4, NH-4 |

|NAME OF THE INSTITUTION |Nelamangala BY PASS |

| |Bangalore-562123 |

| | |

| | |

|COURSE OF STUDY AND SUBJECT |Msc nursing.(obstetrics and gynecological nursing) |

| | |

|DATE OF ADMISSION OF THE COURSE |11-07-2012 |

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| |“A study to assess the effectiveness of self instructional |

| |module on knowledge regarding prevention of upper limb |

| |lymphedema following breast cancer treatment among breast |

|TITLE OF THE TOPIC |cancer patients in a selected hospital at Bangalore |

| | |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Make everything as simple as possible, but not simpler”

-Albert Einstein.

Breast cancer is the top cancer in women both in developed and developing world. The incidence of breast cancer is increasing in developing world due to increase life expectancy, increase urbanization and adoption of western life styles. Presently a wide range of treatment options are available to both the patients and the health care providers attempting to make critical decisions about what treatment to select. Mastectomy (surgical removal of a breast) is one of the standards of care.1

One issue challenging women’s quality of life following breast cancer treatment is lymphedema, a condition characterised by chronic and abnormal swelling of the arm, chest, neck or back that results from breast cancer treatment that involve the removal of or damage to lymph nodes located under the arms and chest. Studies estimates that 40% of breast cancer survivors experience upper limb lymphedema.2

A normal lymphatic system consists of blind-end vessels which collect the fluid that bathes and nourish the tissues. In a normal system, this fluid, called lymph, is derived from the arterial side of capillaries, and is returned to the circulation via veins near the neck. Nearly 90% of the water-component in our blood is consistently filtered through the lymphatic system while the remaining 10% is found in the tissues. The purpose of the lymphatic system is to help the body to maintain fluid balance while filtering out waste products. White blood cells and other immune cells congregate in lymph nodes in various parts of the body, notably the armpit and groin region. They help to destroy bacteria, cancerous cells or other wastes that make their way into this lymph fluid.2

Patients undergoing axillary surgery or axillary radiation therapy for breast cancer are higher risk for developing lymphedema of the arm.partial or total mastectomy followed by full axillary lymph node dissection significantly increases patient’s risk for developing arm lymphedema.among all breast cancer patient being obese or over weight may predisposing women to develop lymphedema after treatment of breast cancer treatment.

Other risk factors include delayed wound healing ,tumor causing obstruction of anterior cervical ,thoracic , axillary ,or pelvic lymphnodes ,scarring of right or left subclavian lymphatic ducts by either surgery or radiation.

The patient may experience heaviness, pain, impaired motor function in the arm, numbness and paresthesia of the fingers as a result from lymphedema. Although lymphedema is not always preventable, it can be controlled somewhat after surgery or radiation3.

Lymphedema results difficulty or inability to lift heavy object such as groceries, as well as difficulty in performing activities that require repetitive motions with the upper body or arms 4in addition to limitation, women with lymphedema are subject to potential psychosocial problems including depression ,anxiety ,poor adjustment to illness ,and low self esteem5.

The diagnostic evaluation include history and physical examination ,soft tissue imaging ,lymph vessel and lymph node imaging, measures of volume ,changes in electrical conductance ,changes in biochemical properties ,genetic testing, magnetic resonance imaging, computed tomography, ultra sound other vascular imaging and blood tests4.

The treatment of lymphedema include manual lymph drainage ,multi layer-short stretch compression bandage ,lymphatic exercises ,skin care ,health education regarding the prevention of lymphedema5.

Once lymphedema develops, it tends to be chronic, so preventive strategies are vital. The patient is instructed to follow these guidelines for the rest of her life. She is also instructed to contact the physician or a nurse immediately if she suspects that she has lymphedema, because early intervention provides the best chance for control. If allowed to progress without treatment, the swelling can become more difficult to manage.6

Exercise is an essential component of lymphedema treatment; because the movement of muscles and joints increases the lymph flow up to 15 times above the resting rate5.prevention is better than cure. So it is important to give knowledge regarding the prevention of lymphedema. this study concentrate to provide some lymphedema exercises in a view to prevent the development of upper arm lymphedema.

6.1 NEED FOR THE STUDY

“Obstacles are those frightful things you see when you take your eyes off your goal”

-Henry Ford.

Breast cancer cases at present are estimated to reach 1.2 million worldwide. The world wide breast cancer mortality rate shows in United States 14.7/100,000 deaths, Brazil 12.3/100,000 deaths, UK 18.6/100, 000, India 12/100,000 deaths and in Pakistan 18/100,000 deaths. The incidence of breast cancer in India is on the rise and is rapidly7.

A 2005 study conducted by the International Association of Cancer Research projected that there would be 250,000 cases of breast cancer in India by 2015, a 3% increase per year8. Currently India reports roughly 120,000 new cases annually.

In India the lymphedema incidence shows that 10% of patients develop severe lymphedema, 6.5% develops moderate lymphedema and 33.8% develops mild lymphedema after breast cancer therapy8.in Karnataka the incidence of development of severe arm lymphedema is 12%.moderate and mild development is 5.5% and 32% respectively.3% of post mastectomy patients develops arm lymphedema in Bangalore.

After modified radical mastectomy the rates of wound infections range from 2.8% to 15%.Infection of the mastectomy wound arm may represent serious morbidity in the postoperative patient and produces disability that may progress to late postoperative lymphedema of the arm.

Lymphedema symptoms can arise between hours and years after breast cancer treatment.9 A study reported in the journal of clinical oncology says that, breast cancer survivors who develop lymphedema report a lower quality of life and higher levels of anxiety and depression.mon breast cancer treatment damage and potentially weaken the lymphnodes and the vessels carrying lymph fluids, and they can compromise the effectiveness of valve in lymph vessels11.the result is accumulation of lymph fluid in tissue of arms ,hand ,back and neck12.

Persons with lymphedema are especially at risk of cellulitis and skin breakdown.because the presence of stagnant lymph fluid in the limbs creating ideal condition for bacteria to thrive infection related to lymphedema.13

Lymphedema results difficulty or inability to performing activites4.in addition to limitation,women with lymphedema are subject to potential psychosocial problems including depression ,anxiety ,poor adjustment to illness and low self-esteem5.

The purpose of the a study was to evaluate the influence of a mixed exercise program, including Greek traditional dances and upper body training, in physical function, strength and psychological condition of breast cancer survivors. Twenty-seven women (N = 36), who had been diagnosed and surgically treated for breast cancer, volunteered to participate in this study. The experimental group consisted of 24 women with mean age 59.6 (3) years. They attended supervised Greek traditional dance courses and upper body training (1 h, 3 sessions/week) for 24 weeks. The control group consisted of 13 sedentary women with mean age 59 years. Blood pressure, heart rate, physical function (6-min walking test), handgrip strength, arm volume and psychological condition (Life Satisfaction Inventory and Beck Depression Inventory) were evaluated before and after the exercise program. The results showed significant increases of 13.9% for physical function, 34.3% for right handgrip strength, 20.1% for left handgrip strength, 36.3% for life satisfaction and also a decrease of 25% for depressive symptoms in the experimental group after the training program. Significant reductions of 19% for left hand and 18% for right hand arm volume were also found in the experimental group. Consequently, aerobic exercise with Greek traditional dances and upper body training could be an alternative choice of physical activity for breast cancer survivors, thus promoting benefits in physical function, strength and psychological condition5.

Rahemsl Etal (2009) assessed the safety of a graduated exercise programme on 200 survivors with breast cancer and recommends that individuals who are at risk for lymphedema or who have lymphedema can participate in exercise, provided it is progressed slowly and their limbs are assessed for any signs of increased or developing swelling throughout the programme and the programme is modified accordingly14.

The researcher had come across many cases of lymphedema during her clinical experience. Knowing about the unawareness of clients, researcher felt the need to make clients aware of lymphedema its causes signs and symptoms prevention and management for better life. Education of patients regarding the importance of prevention of lymphedema is the need of the hour; primary prevention of lymphedema is relatively simple and should be practical as established part of good medical care. Efforts to ensure primary prevention of lymphedema should focus on the education of the patients on importance of measures to avoid occurrence of lymphedema.

6.2 REVIEW OF LITERATURE

The review of literature in a research report is a summary of current knowledge about a particular problem, to provide a basis for conducting the study.

Literature review is one of the major components of the research process. According to Polit & Hungler (1999), literature review to the activities involved in identifying & searching for information.

It provides essential information to assist in critiquing the literature review section. An extensive review was done to gain insight into the selected problem.

The literature reviewed for the present study has been organized under the following headings.

I. Literature related to incidence of upper limb lymphedema after breast cancer treatment.

II. Literature related to prevention of upper limb lymphedema after breast cancer treatment.

III. Literature related to assessment of knowledge on prevention of upper limb lymphedema among patient undergoing breast cancer treatment.

IV. Literature related to effectiveness of self instructional module on prevention of lymphedema.

I. Literature related to incidence of upper limb lymphedema after breast cancer treatment.

A study conducted a study on incidence and risk factors of arm edema following treatment for breast cancer: a two year follow up study was carried out on 161 samples who had surgical treatment for breast cancer. Measurements of limbs were carried out preoperatively and postoperatively. According to the researcher 46 patients (28.5%) had developed lymphedema. The risk factors identified were age type of surgery, and radiotherapy.15

A study conducted in 2006 on incidence of lymphedema and associated risk factors in women with invasive breast cancer following surgery. The follow up interview was conducted sample was 125. The findings of the study stated 43% incidence of lymphedema, the risk factors being age, axillary node dissection, received chemotherapy, radiation therapy.16

A study conducted in 2008 studied the incidence of lymphedema in the first year after mastectomy. It included 65 samples that underwent mastectomy. The data was collected by means of postoperative follow-up .Edema was detected in 24 women, 12of which were in mild level and 6 in moderate level.17

A study on incidence and risk factors of breast cancer lymphedema among women with breast cancer(2008). A descriptive design with structured questionnaire as a tool was used. It included a sample size of 280 patients who underwent mastectomy. The findings of the study revealed that 27.8% had developed lymphedema .18

II. Literature related to prevention of upper limb lymphedema after breast cancer treatment.

A study to determine the effectiveness of arm exercise and preventive strategies in reducing the risk of lymphedema after breast cancer treatment. A randomized clinical trial was conducted on 145 women who had undergone surgery and after radiation therapy. The experimental group received exercise training and education on prevention of lymphedema. The findings revealed 6% lymphedema in the experimental group and 35% in the control group19.

A study to find the effectiveness of early rehabilitation in patients with modified radical mastectomy. Fifty-seven patients were included who underwent 15 sessions of individual rehabilitation programme. The findings stated that early onset rehabilitation programme after mastectomy provides improvement in arm movement and functional capacity without causing adverse effect in postoperative period.20

A study conducted on prospective evaluation of a preventive strategy for lymphedema following breast cancer surgery. 78 women who had modified radical mastectomy were included. The preventive strategy included exercises and general activities to minimise the risk. The findings of the study suggested that the preventive strategy help to minimise the risk of developing lymphedema among post operative patients.21

III. Literature related to assessment of knowledge on prevention of upper limb lymphedema among patients undergoing breast cancer treatment.

A study to compare the surgical patients knowledge regarding mastectomy and prevention of lymphedema.A descriptive and comparative design was with a structured questionnaire was used on 205 samples. The findings stated that mastectomy patients received less knowledge than they felt they expected.22

A study conducted on lymphedema care of breast cancer patients in a breast cancer clinic: a survey on knowledge and health practice. 224 patients were included. self administered questionnaire was administered. The findings revealed that 79.5% of patients knew that they were at risk of developing lymphedema.23

A study to assess the knowledge and practice on control and prevention of lymphedema following breast cancer treatment. They included 72 samples and structured questionnaire. The findings stated that the level of knowledge was inadequate among the patients, only 5% had adequate level of knowledge regarding control and prevention of lymphedema24.

A study to find the knowledge and attitude of mastectomy patients regarding the lymphedema.a structured interview was used to assess the knowledge level and attitude questions to check the attitude .the study report revealed that only 2% of the patient have adequate knowledge regarding the development of lymphedema.25

IV. Literature related to effectiveness of self instructional module on prevention of lymphedema.

A study conducted on breast cancer related lymphedema: information, symptoms and risk reduction behaviors using self instructional module. The purpose was toprovide information regarding lymphedema.. Self instructional module was administered to 186 patients. A cross sectional design was used; data was collected through questionnaire and checklist. The findings of the study stated that there was 82% increase in knowledge prevention of lymphedema by using self instructional module.26

A study to determine patient’s recall of lymphedma pre-treatment education between breast cancer related lymphedema. 132 breast cancer survivors were included; data collection was done through interview schedule. The result suggested that individuals with lymphedema had less education and a decline in risk reduction to those who get adequate education. 27

A study to assess the effectiveness of self instructional module on preventive strategies of lymphedema following mastectomy and radiation therapy. The study was done on 85 samples, there was 85% increase in the knowledge of the patients following mastectomy and radiation therapy.28

SUMMARY

This chapter dealt with a representation of review of literature related to knowledge on prevention of lymphedema. The review helped the researcher to prepare a structured questionnaire to assess the patient knowledge and provide self instructional module on prevention of lymphedema

6.3 Statement of the problem

A study to assess the effectiveness of self instructional module on knowledge regarding prevention of upper limb lymphedema following breast cancer treatment among breast cancer patients in a selected hospital at Bangalore

6.4 Objectives of the study

➢ To assess the pre-test knowledge regarding prevention of upper limb lymphedema.

➢ To determine the effectiveness of self instructional module on prevention of upper limb lymphedema.

➢ To assess the post-test knowledge of regarding prevention of upper limb lymphedema.

➢ To find out the association between knowledge of selected demographic variables of breast cancer patients regarding prevention of upper limb lymphedema.

6.5 Operational definitions

1. Assess

It refers to the act of estimation of the effectiveness of self instructional module on knowledge regarding prevention of upper limb lymphedema among breast cancer patients who are posted for various breast cancer treatments.

2. Effectiveness

It means a change produced by an action or a cause or a result, or an outcome. In this study it refers to the extent to which the self instructtional module has achieved the desired objectives, knowledge by using structured knowledge questionnaire.

3. Self instructional module

It refers to the learning material prepared in Kannada and English language, by the researcher to provide information regarding prevention of upper limb lymphedema.

4. Knowledge:

In this study knowledge refers to the awareness or understanding of breast cancer patients regarding prevention of upper limb lymphedema in response to structured knowledge questionnaire.

5. Prevention

It refers to the intervention prior to the onset of a disease.

6. Lymphedema

It refers to the arm or leg swelling which is caused by building up of extra lymph fluid in tissues. It occurs when the lymph vessels are blocked, damaged or removed by surgery.

6. Assumptions.

1. Breast cancer patients may have some knowledge regarding the prevention of lymphedema.

2. Self instructional module is an accepted strategy in improving knowledge.

6.7 Limitations

1. This study is limited to patients at selected hospitals, Bangalore.

2. Sample size is limited to 60.

3. The study did not use a control group. The investigator had no control of the events that took place between pre test and post test.

6.8 Hypothesis

H1.There will be significant difference between pre-test and post-test level of knowledge of the breast cancer patients after administration of self instructional module on prevention of upper limb lymphedema.

H2. There will be is a significant association between the post-test levels of knowledge of breast cancer patients with selected demographic variable

7. MATERIALS AND METHODS

Research methodology is a way to systematically solve the research problem. It may be understood as a science of studying how research is done scientifically. This chapter includes a description of research approach, research design, variables, and setting of the study, population, sampling, research tool, data collection and plan for data analysis

7.1. Source of Data

Data will be collected from breast cancer patients who are posted for breast cancer treatment in a selected hospital, Bangalore.

7.1.1 Research Design

Pre-experimental, one group pre-test – post-test design was adopted for this study.

One group pre-test post-test design

|Subjects |Pre-test |Treatment |Post-test after 5 days |

|Breast cancer patients |O1 |X |O2 |

O1: Administration of structured questionnaire to assess the knowledge of breast cancer patients regarding prevention of upper limb lymphedema.

X: self instructional module regarding prevention of upper limb lymphedema after breast cancer treatment.

O2: Administration of structured questionnaire after self instructional module.

7.1.2 Setting of the study

Study is planned to conduct in a selected hospital at Bangalore.

7.1.3 Population

The population for the study are the patients those who are posted for breast cancer treatment and admitted in pre operative wards at, Bangalore.

7. 2methods of data collection

7.2.1Sampling technique

Non probability convenient sampling technique.

7.2.2 Sample size

The sample of the present study comprised of 60 breast cancer patients posted for breast cancer treatment and are admitted in pre operative wards at hospital at Bangalore.

Criteria for sample selection

3. Inclusion criteria

1. Breast cancer Patients who are posted for breast cancer treatment.

2. Patients who are willing to participate in the study.

3. Patients who can read and write either Kannada or English.

7.2.4 Exclusion criteria

1. Who are not present during the period of data collection

2. Pre operative patients who are critically ill.

4. Selection and development of the tool

• Self prepared & structured questionnaire.

Section A-Socio-demographic data

Breast cancer patients profile consisted of items such as age, religion, residence, type of family, dietary pattern, education level, occupation, source of information regarding lymphedema and family history of breast cancer.

Section B-Knowledge questionnaire regarding prevention of lymphedema

Content area was classified under different aspects such as Knowledge on general aspects of Breast cancer, Knowledge on general aspects of upper limb lymphedema, Knowledge on prevention of upper limb lymphedema and Knowledge on treatment of lymphedema.

Development of SIM

SIM was developed on prevention of lymphedema,which was based on literature review and suggestion from experts.

The SIM consists of the following sub-topics:

General aspects of breast cancer, General aspects of lymphedema, Prevention of lymphedema, Treatment of lymphedema.

5. Data collection method

A formal written permission will be obtained from the concerned authorities before data collection. The structured questionnaire will administer to assess the knowledge on breast cancer treatment and prevention of upper limb lymphedema respectively after giving the necessary instruction to breast cancer patients. On the same day self instructional module will be administered. A post-test will conduct on the 7th day using the same tools.

6. Data analysis

|No; |Data analysis |Statistical methods |Remarks |

| | | | |

|1. |Descriptive |Frequency & |To analyze the demographic variables |

| |Analysis |Percentage | |

| | | | |

|2. |Inferential |1.Mean score and standard |To assess the pre-test and post-test knowledge of |

| |Analysis |deviation |patients regarding prevention of lymphedema. |

| | | | |

| | | |To compare the pre-test and post test knowledge of|

| | |2.Paired ‘t’ test |patients regarding prevention of lymphedema. |

| | | | |

| | | |To associate the post test knowledge of patients |

| | | |regarding prevention of lymphedema. |

| | | |With selected demographic variables. |

| | |3.Chi-square test | |

7.3. Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly?

NO.

7.4 Has ethical clearance been obtained from your institution?

YES. The ethical clearance is obtained before study.

8. Bibliography.

1. Basavanthappa B.T. (2003), “medical surgical nursing”, 1st edition, Jaypee brother’s medical publishers: New Delhi: Pg no.788 – 792.

2. Clark.B,Sitzia .J et al(2005) incidence and risk of arm edema following treatment for breast cancer 3 year follow up study; international journal of medicine;vol 98;page no:343-348.

3. Logan V. etal (1995), “Incidence and prevalence of lymphedema, a literature review”, journal of clinical nursing. 4(2) 13-19.

4. Radina M.E,Armen J.M (2001) et al;post breast cancer lymphedema and family,a qualitative investigation of families coping with chronic illness;journal of family nursing;volume 7;page no:281-299.

5. Maunsell, Brisson et al (2005); arm problems and psychological distress after surgery for breast cancer; Canadian journal of surgery; volume 36;page no:315-320.

6. Smeltzer C. Suzanne, Bare G. Brenda etal(2008), “text book of medical surgical nursing”, 11 thedition, Lippincott publishers: Philadelphia; Pg no.1712 -1736.

7. WHO report on breast cancer mortality rate world wide;2012.

8. Samulena C, amilo B etal (2006), “Lymphedema after treatment of breast cancer: A literature review”, journal of clinical nursing. 4(2) 16-19.

9. Markowski j,Wilcox J.R (2007)et al;lymphedema incidence after specific post mastectomy therapy,rehabilitation;british journal of medicine;volume 63;page no:449-452.

10. voes waino et al (2009), “caring for patients after mastectomy”; volume 40 (5) page no:43-48 .

11. Smith R.A (2006);introduction; American cancer society workshop on breast cancer treatment related lymphedema; cancer; volume 83;page no:270-275.

12. Berne R.M,Levy M.N(2006);principles of physiology ;st.louis mo,mosby publications;page number:721-724.

13. Lymphnotes(2010),February 2008:article.php/id/10.

14. Bonnie B, Lasinski M. A. (2007), “Exercises for lymphedema benefits supported by studies”; 51(6) 364-380.

15. Wilcox etal (2005), “Study on incidence and risk factors of arm edema following treatment for breast cancer: a 2 year follow up study”, Oxford journals. 25(4) 100-106.

16. Levy M L. etal (2006) “Factors associated with arm swelling after breast cancer” journal of women’s health. 12(19) 921-930.

17. Smith.J.R etal (2008) “Complications and incidents associated with am edema in the first year after mastectomy”;volume 6;page 221-225.

18. Parilino. etal (2008) “Incidence and risk factors of breast cancer lymphedema”, journal of clinical nursing;volume 12;page no:63-69.

19. Pastello et al (2009) “Effectiveness of early exercise and preventive strategies in reducing the risk of lymphedema after surgery for breast cancer”;volume 30;page no:56-61.

20. Cinar N, Seckin U. etal (2008), “Effectiveness of early rehabilitation in patients with modified radical mastectomy”; volume 18;page no:237-242.

21. Bowanio A.M. etal (2009) “Prospective evaluation of a preventive protocol for lymphedema following surgery for breast cancer”, journal of clinical oncologyvolume 17;page no 21-28.

22. Salmetto etal (2008) “Expectations and received knowledge by surgical patients”; 29(2) 173-181.

23. Roxeno. etal (2008) “Lymphedema: care of breast cancer patients in a breast care clinic: A survey of knowledge and health practice”;volume 22;page no22-28.

24. Hemarto etal (2007) “knowledge and practice on control and prevention of lymphedema following mastectomy.” Journal of clinical nursing; 38(2)86-88

25. Nicholas et al (2004) The knowledge about preventing and managing lymphedema: a survey of recently diagnosed and treated breast cancer patients”; 19(3) 229-239.

26. Mariano et al (2006) “A study on present cancer related lymphedema: information, symptoms and risk reduction behaviors”, journal of nursing 46(4);page no:115-118.

27. Lister S. H. etal (2004) “Enhancing the importance of exercise of the survivors of breast cancer”; volume 18;page no:34-38.

28. Pastero. Et al (2005) “Effectiveness of self instructional module on preventive strategies of lymphedema following mastectomy”,volume 5;page no:22-27.

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