PK 'B\_rels/PK 'B\:S$11 _rels/.rels PK 'B\pp[Content_Types].xml PK 'B\ppt/PK 'B\ppt/slideMasters/PK 'B\ppt/slideMasters/_rels/PK 'B\2Ԩ::,ppt/slideMasters/_rels/slideMaster1.xml.rels PK 'B\#Vcc!ppt/slideMasters/slideMaster1.xml PK 'B\ppt/slideLayouts/PK 'B\ppt/slideLayouts/_rels/PK 'B\::,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK 'B\jFCC!ppt/slideLayouts/slideLayout1.xml PK 'B\ ppt/slides/PK 'B\=7] ppt/slides/slide1.xml بِسْمِ اللَّهِ الرَّحْمَنِ الرَّحِيمِIn the name of Allah, the Most Gracious, the Most Merciful 1 / 45 PK 'B\ppt/slides/_rels/PK 'B\2Ԩ:: ppt/slides/_rels/slide1.xml.rels PK 'B\pHffppt/slides/slide2.xml PILONIDAL SINUSDisease of the Natal Cleft Presented byProf. Zahid MahmoodProfessor of SurgeryLahore Medical and Dental College 2 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide2.xml.rels PK 'B\F:ppt/slides/slide3.xml DID YOU KNOW?(Surprise for Students) Pilonidal = 'Nest of Hair' — Latin originFirst described by Anderson in 1847Called 'Jeep Driver's Disease' in WW2Hair DRILLS into skin — does not grow from itMore common than appendicitis in some studies 📸 Suggested: Wartime jeep photo or hair tuft in pit 3 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide3.xml.rels PK 'B\oppt/slides/slide4.xml LEARNING OUTCOMES Define pilonidal sinus and its aetiologyDescribe anatomy of natal cleftList clinical features and presentationsOutline investigations requiredDiscuss surgical and non-surgical treatmentManage recurrence and complications 4 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide4.xml.rels PK 'B\ Kppt/slides/slide5.xml DEFINITION & TERMINOLOGY Latin: pilus = hair, nidus = nestAcquired epithelium-lined sinus tractContains loose hair in natal cleftSacrococcygeal region — most common siteNot congenital — acquired in young adults 📸 Insert: Diagram of pit with hair tuft 5 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide5.xml.rels PK 'B\=Yppt/slides/slide6.xml EPIDEMIOLOGY Affects young adults aged 15–30 yearsMale : Female ratio = 3–4 : 1Incidence: 26 per 100,000 populationRare after age 40 yearsHigher in Mediterranean and Middle Eastern races 6 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide6.xml.rels PK 'B\ߚppt/slides/slide7.xml AETIOLOGY — THE MECHANISM Hair follicle distension and ruptureLoose hair penetrates skin via suctionGluteal movement draws hair inwardHair acts as foreign body → abscessInfection → chronic sinus tract formation 📸 Insert: Bailey & Love — hair penetration mechanism 7 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide7.xml.rels PK 'B\ſppt/slides/slide8.xml PREDISPOSING FACTORS Hirsutism — excessive body hairObesity — deep natal cleft createdSedentary occupation / prolonged sittingPoor hygiene in natal cleftRepeated trauma or friction to cleft 8 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide8.xml.rels PK 'B\)ttppt/slides/slide9.xml PATHOLOGY Primary pit: midline hair follicle openingSecondary opening: lateral to midlineSinus lined with granulation tissueHair tufts visible in 50% of casesAbscess cavity develops in acute phase 📸 Insert: Operative photo of sinus tract 9 / 45 PK 'B\2Ԩ:: ppt/slides/_rels/slide9.xml.rels PK 'B\.<6ppt/slides/slide10.xml CLINICAL FEATURES — SYMPTOMS Intermittent pain in natal cleftSwelling and purulent dischargeAcute abscess: severe throbbing painChronic sinus: recurrent dischargeAsymptomatic pits found incidentally 10 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide10.xml.rels PK 'B\Ns~~ppt/slides/slide11.xml CLINICAL FEATURES — SIGNS Pit(s) visible in midline natal cleft1–2 cm above anal verge typicallyLateral secondary openings may existTender indurated swelling if abscessHair visible protruding from pit 📸 Insert: Clinical photo of pilonidal pit 11 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide11.xml.rels PK 'B\O20ppt/slides/slide12.xml CLINICAL PRESENTATIONS 1. Acute pilonidal abscess — most common2. Chronic sinus with recurrent discharge3. Asymptomatic midline pit4. Recurrent disease after surgery5. Rarely: squamous cell carcinoma 12 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide12.xml.rels PK 'B\=kAeeppt/slides/slide13.xml DIFFERENTIAL DIAGNOSIS Anal fistula — ano-cutaneous tractCrohn's disease perianal abscessFuruncle / carbuncle of skinHydradenitis suppurativaSacral dermoid cyst 📊 Insert: Table — Pilonidal Sinus vs Fistula-in-ano 13 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide13.xml.rels PK 'B\Sf/ppt/slides/slide14.xml INVESTIGATIONS Mostly a clinical diagnosisProbe to assess tract directionMRI for complex or recurrent diseaseUltrasound for deep abscessBiopsy if malignancy suspected 14 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide14.xml.rels PK 'B\N6^ɴppt/slides/slide15.xml TREATMENT — ACUTE ABSCESS Incision and drainage (I&D) under LALateral incision — NOT midlineRemove visible hair from cavityPack wound — secondary intention healingDefinitive surgery after 6–8 weeks 15 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide15.xml.rels PK 'B\GMZ||ppt/slides/slide16.xml TREATMENT — CHRONIC SINUS Lay open — excision + marsupializationExcision and primary closureKarydakis flap — off-midline closureLimberg rhomboid rotation flapBascom cleft lift procedure 📸 Insert: Bailey & Love — Karydakis flap steps 16 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide16.xml.rels PK 'B\ˠppt/slides/slide17.xml LAY OPEN TECHNIQUE Excise all sinus tracts completelyWound left open to granulateSimple technique — recurrence 4–8%Slow healing — 6 to 10 weeksSuitable for primary uncomplicated sinus 17 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide17.xml.rels PK 'B\8{{ppt/slides/slide18.xml FLAP TECHNIQUES Karydakis: oblique off-midline closureLimberg: rhomboid rotation flapCleft Lift: flattens natal cleft depthFaster healing than open techniquesRecurrence rate reduced to 1–3% 📸 Insert: Bailey & Love — Limberg flap figure 18 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide18.xml.rels PK 'B\FDppt/slides/slide19.xml MINIMALLY INVASIVE OPTIONS Phenol injection — sclerosant therapyLaser ablation: SiLaT techniqueVideo-assisted ablation (VAAPS)Suitable for simple sinus tracts onlyNot for complex or recurrent disease 19 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide19.xml.rels PK 'B\03ppt/slides/slide20.xml POST-OPERATIVE ADVICE Regular shaving of natal cleftDaily wound irrigation essentialAvoid prolonged sitting for 4 weeksHigh-fibre diet — avoid constipationLong-term hair removal cream use 20 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide20.xml.rels PK 'B\xYppt/slides/slide21.xml COMPLICATIONS Wound infection and dehiscenceRecurrence — commonest complicationChronic non-healing woundFistula to rectum — rareMalignant change: squamous carcinoma 21 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide21.xml.rels PK 'B\ppt/slides/slide22.xml RECURRENCE — KEY POINTS Recurrence: 5–40% depending on techniqueCauses: incomplete excision, midline scarOngoing hirsutism and poor hygieneOff-midline closure reduces recurrenceFlap repair preferred for recurrent cases 22 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide22.xml.rels PK 'B\%Bppt/slides/slide23.xml MALIGNANT TRANSFORMATION Rare but well-recognised complicationSquamous cell carcinoma in chronic sinusSuspect: non-healing, bleeding, massBiopsy all suspicious chronic sinusesWide excision ± radiotherapy required 23 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide23.xml.rels PK 'B\K0ppt/slides/slide24.xml TAKE HOME MESSAGE Acquired disease — not congenitalYoung hirsute men most at riskAcute phase: drain first, then definitive surgeryOff-midline closure = best recurrence preventionHair removal is key to preventionAlways biopsy chronic non-healing wounds 24 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide24.xml.rels PK 'B\;Dppt/slides/slide25.xml MCQ 1 The most common site of pilonidal sinus is: A. AxillaB. Natal cleft / sacrococcygeal region ✓ KEYC. ScalpD. UmbilicusE. Web of fingers 25 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide25.xml.rels PK 'B\_ݴppt/slides/slide26.xml MCQ 2 Pilonidal sinus is best described as: A. Acquired epithelium-lined sinus with hair ✓ KEYB. Anal fistula variantC. Congenital sinus from spinal defectD. Infected sebaceous cystE. Sacral dermoid cyst 26 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide26.xml.rels PK 'B\\ ppt/slides/slide27.xml MCQ 3 Pilonidal sinus is also known as: A. Barber's diseaseB. Cook's abscessC. Jeep driver's disease ✓ KEYD. Miner's diseaseE. Shepherd's disease 27 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide27.xml.rels PK 'B\ dppt/slides/slide28.xml MCQ 4 The primary pit of pilonidal sinus is located: A. Anterior to coccyx onlyB. In the ischiorectal fossaC. In the midline natal cleft ✓ KEYD. Inside the anal canalE. Lateral to anal verge 28 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide28.xml.rels PK 'B\p&ppt/slides/slide29.xml MCQ 5 Immediate treatment of acute pilonidal abscess is: A. Antibiotics aloneB. Incision and drainage ✓ KEYC. Karydakis flap repairD. MarsupializationE. Wide excision and primary closure 29 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide29.xml.rels PK 'B\زppt/slides/slide30.xml MCQ 6 Off-midline closure to reduce recurrence is: A. Bascom I techniqueB. Goodsall's procedureC. Karydakis flap ✓ KEYD. Milligan-Morgan procedureE. Parks' operation 30 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide30.xml.rels PK 'B\ppt/slides/slide31.xml MCQ 7 Malignant change in chronic pilonidal sinus is: A. AdenocarcinomaB. Basal cell carcinomaC. LymphomaD. MelanomaE. Squamous cell carcinoma ✓ KEY 31 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide31.xml.rels PK 'B\ppt/slides/slide32.xml MCQ 8 Which group is most commonly affected by pilonidal sinus? A. Children under 10 yearsB. Elderly women over 60C. Infants under 2 yearsD. Post-menopausal womenE. Young men aged 15–30 years ✓ KEY 32 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide32.xml.rels PK 'B\[ppt/slides/slide33.xml MCQ 9 Recurrence after surgery is highest with: A. Cleft lift procedureB. Karydakis off-midline closureC. Laser ablationD. Limberg flap techniqueE. Simple midline excision and closure ✓ KEY 33 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide33.xml.rels PK 'B\{t@ppt/slides/slide34.xml MCQ 10 The term 'pilonidal' derives from Latin meaning: A. Deep abscessB. Infected follicleC. Midline cleftD. Nest of hair ✓ KEYE. Subcutaneous sinus 34 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide34.xml.rels PK 'B\ ppt/slides/slide35.xml MCQ 11 — Clinical Vignette A 22-year-old male student presents with 3-day history of severe throbbing pain and swelling in the natal cleft. He is obese, hirsute, and sits 8 hours daily. Examination shows a tense, fluctuant, tender swelling 2 cm above the anal verge in the midline. Temperature is 38.2°C. What is the most appropriate immediate management? A. Broad-spectrum antibiotics onlyB. Excision and primary closure todayC. Incision and drainage under local anaesthesia ✓ KEYD. Karydakis flap repairE. MRI pelvis first then surgery 35 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide35.xml.rels PK 'B\/Wppt/slides/slide36.xml MCQ 12 — Clinical Vignette A 25-year-old male army officer has recurrent natal cleft discharge for 8 months after abscess drainage 10 months ago. Examination reveals two lateral secondary openings with hair and a midline pit. There is no active abscess or cellulitis. He requests definitive surgery to prevent further recurrence. Which surgical option gives the lowest recurrence rate? A. Excision with midline primary closureB. Incision and drainage aloneC. Karydakis off-midline flap closure ✓ KEYD. Lay open and packE. Phenol injection sclerotherapy 36 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide36.xml.rels PK 'B\r`ppt/slides/slide37.xml MCQ 13 — Clinical Vignette A 28-year-old truck driver presents with a discharging natal cleft sinus for 2 years. He has had three previous operations at another hospital, each time with midline closure, with recurrence within 12 months each time. Examination shows a midline pit with granulation tissue and two lateral openings. What is the most likely reason for recurrent disease? A. Failure to remove all hair folliclesB. Inadequate antibiotic therapyC. Insufficient wound irrigationD. Midline closure used previously ✓ KEYE. Use of general anaesthesia 37 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide37.xml.rels PK 'B\ MCQ 14 — Clinical Vignette A 30-year-old male has a non-healing natal cleft wound for 18 months after pilonidal sinus excision. He reports increasing pain, contact bleeding, and foul-smelling discharge. Examination shows a 3 cm indurated ulcerating lesion at the operative site with surrounding chronic inflammation. Malignant transformation is suspected. What is the most appropriate next investigation? A. CT scan of pelvisB. Full blood countC. MRI lumbosacral spineD. Tissue biopsy of lesion ✓ KEYE. Wound swab for culture 38 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide38.xml.rels PK 'B\|["ppt/slides/slide39.xml MCQ 15 — Clinical Vignette A 19-year-old female college student is referred after routine examination revealed a small midline pit in the natal cleft, 2 cm above the anal verge. She has no pain, discharge, or swelling. The pit is non-tender and clean with no hair protruding. She is not overweight and has mild body hair only. What is the most appropriate management at this stage? A. Excision under general anaesthesiaB. Immediate Karydakis flap repairC. Observation with hygiene advice and hair removal ✓ KEYD. Phenol injection into pitE. Urgent MRI to assess sinus extent 39 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide39.xml.rels PK 'B\< ,,ppt/slides/slide40.xml MCQ 16 — Clinical Vignette A 24-year-old male is reviewed 3 weeks after excision and lay open of a pilonidal sinus. The wound is healing slowly with granulation tissue. He is hirsute, moderately overweight, and works as a computer programmer sitting for long hours daily. He asks the single most important step to prevent disease recurrence. Which measure is MOST important to prevent recurrence? A. Avoiding all physical activityB. Daily wound dressing by a nurse onlyC. High-protein diet supplementationD. Long-term regular hair removal from natal cleft ✓ KEYE. Oral antibiotic prophylaxis for 6 months 40 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide40.xml.rels PK 'B\ppt/slides/slide41.xml MCQ 17 — Clinical Vignette A 26-year-old Pakistani male presents with a painful natal cleft swelling. A similar episode 6 months ago resolved with antibiotics. Examination shows a 4 cm tense abscess in the midline above the anus with surrounding cellulitis. He is a known type 2 diabetic on insulin. You decide to perform incision and drainage today. Where should the incision be placed? A. Directly over the midline pitB. In the gluteal crease bilaterallyC. Lateral to the midline ✓ KEYD. Over the coccyx posteriorlyE. Through the anal canal 41 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide41.xml.rels PK 'B\<ppt/slides/slide42.xml MCQ 18 — Clinical Vignette A 35-year-old male with Crohn's disease presents with perianal discomfort and two discharging openings near the natal cleft. Chronic loose stools are present. Examination shows two lateral sinus openings with granulation tissue. A probe passes toward the anal canal on the right. There is no midline pit visible on careful examination. This presentation most likely represents: A. Anal fistula related to Crohn's disease ✓ KEYB. Carbuncle of natal cleftC. Hidradenitis suppurativaD. Pilonidal sinus with lateral openingsE. Sacral dermoid cyst abscess 42 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide42.xml.rels PK 'B\hQ*ppt/slides/slide43.xml MCQ 19 — Clinical Vignette A final year MBBS student is asked in a surgery viva about the Limberg flap for pilonidal sinus. He correctly states it is used for definitive treatment. The examiner then asks what anatomical principle makes the Limberg flap superior to simple midline closure in reducing recurrence rates in pilonidal sinus disease. The Limberg flap reduces recurrence primarily by: A. Creating a deeper natal cleftB. Eliminating the natal cleft depthC. Increasing blood supply to midlineD. Moving the scar away from the midline ✓ KEYE. Removing all hair follicles surgically 43 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide43.xml.rels PK 'B\Bu?Hppt/slides/slide44.xml MCQ 20 — Clinical Vignette A 23-year-old male presents with his second episode of pilonidal abscess in one year. After drainage of the acute abscess today, he is counselled about definitive surgery in 6–8 weeks. He requests the procedure that gives the quickest return to work, least wound care burden, and the permanently lowest chance of disease recurrence. The most appropriate definitive procedure is: A. Bascom I — pit picking procedureB. Excision and lay open techniqueC. Karydakis or Limberg flap repair ✓ KEYD. Phenol injection sclerotherapyE. Wide excision without closure 44 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide44.xml.rels PK 'B\g99ppt/slides/slide45.xml THANK YOUJazakAllah Khair — جزاک اللہ خیر Moral Lesson for a Surgeon:"The art of surgery is not just in the hands —it lives in the heart, the mind, and the conscience.Treat every wound as if it were your own."A surgeon who operates with compassion heals far more than the body alone.— Prof. Zahid Mahmood | 0300-4130159 45 / 45 PK 'B\2Ԩ::!ppt/slides/_rels/slide45.xml.rels PK 'B\ ppt/_rels/PK 'B\Wiippt/_rels/presentation.xml.rels PK 'B\`ٗppt/presentation.xml PK 'B\_rels/PK 'B\:S$11 $_rels/.relsPK 'B\pp~[Content_Types].xmlPK 'B\ppt/PK 'B\Appt/slideMasters/PK 'B\pppt/slideMasters/_rels/PK 'B\2Ԩ::,ppt/slideMasters/_rels/slideMaster1.xml.relsPK 'B\#Vcc!)ppt/slideMasters/slideMaster1.xmlPK 'B\!ppt/slideLayouts/PK 'B\!ppt/slideLayouts/_rels/PK 'B\::,/"ppt/slideLayouts/_rels/slideLayout1.xml.relsPK 'B\jFCC!#ppt/slideLayouts/slideLayout1.xmlPK 'B\ 5&ppt/slides/PK 'B\=7] ^&ppt/slides/slide1.xmlPK 'B\W2ppt/slides/_rels/PK 'B\2Ԩ:: 2ppt/slides/_rels/slide1.xml.relsPK 'B\pHff3ppt/slides/slide2.xmlPK 'B\2Ԩ:: Dppt/slides/_rels/slide2.xml.relsPK 'B\F:Fppt/slides/slide3.xmlPK 'B\2Ԩ:: Zppt/slides/_rels/slide3.xml.relsPK 'B\or\ppt/slides/slide4.xmlPK 'B\2Ԩ:: {nppt/slides/_rels/slide4.xml.relsPK 'B\ Koppt/slides/slide5.xmlPK 'B\2Ԩ:: ppt/slides/_rels/slide5.xml.relsPK 'B\=Y'ppt/slides/slide6.xmlPK 'B\2Ԩ:: ppt/slides/_rels/slide6.xml.relsPK 'B\ߚrppt/slides/slide7.xmlPK 'B\2Ԩ:: ?ppt/slides/_rels/slide7.xml.relsPK 'B\ſppt/slides/slide8.xmlPK 'B\2Ԩ:: ppt/slides/_rels/slide8.xml.relsPK 'B\)ttppt/slides/slide9.xmlPK 'B\2Ԩ:: ppt/slides/_rels/slide9.xml.relsPK 'B\.<6$ppt/slides/slide10.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide10.xml.relsPK 'B\Ns~~|ppt/slides/slide11.xmlPK 'B\2Ԩ::!.ppt/slides/_rels/slide11.xml.relsPK 'B\O20ppt/slides/slide12.xmlPK 'B\2Ԩ::! ppt/slides/_rels/slide12.xml.relsPK 'B\=kAeeppt/slides/slide13.xmlPK 'B\2Ԩ::!!ppt/slides/_rels/slide13.xml.relsPK 'B\Sf/#ppt/slides/slide14.xmlPK 'B\2Ԩ::!3ppt/slides/_rels/slide14.xml.relsPK 'B\N6^ɴH5ppt/slides/slide15.xmlPK 'B\2Ԩ::!0Fppt/slides/_rels/slide15.xml.relsPK 'B\GMZ||Gppt/slides/slide16.xmlPK 'B\2Ԩ::!Y[ppt/slides/_rels/slide16.xml.relsPK 'B\ˠ\ppt/slides/slide17.xmlPK 'B\2Ԩ::!mppt/slides/_rels/slide17.xml.relsPK 'B\8{{oppt/slides/slide18.xmlPK 'B\2Ԩ::!΂ppt/slides/_rels/slide18.xml.relsPK 'B\FDGppt/slides/slide19.xmlPK 'B\2Ԩ::!'ppt/slides/_rels/slide19.xml.relsPK 'B\03ppt/slides/slide20.xmlPK 'B\2Ԩ::!tppt/slides/_rels/slide20.xml.relsPK 'B\xYppt/slides/slide21.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide21.xml.relsPK 'B\%ppt/slides/slide22.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide22.xml.relsPK 'B\%Bppt/slides/slide23.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide23.xml.relsPK 'B\K0ppt/slides/slide24.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide24.xml.relsPK 'B\;Dppt/slides/slide25.xmlPK 'B\2Ԩ::!uppt/slides/_rels/slide25.xml.relsPK 'B\_ݴppt/slides/slide26.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide26.xml.relsPK 'B\\ ppt/slides/slide27.xmlPK 'B\2Ԩ::!,ppt/slides/_rels/slide27.xml.relsPK 'B\ d.ppt/slides/slide28.xmlPK 'B\2Ԩ::!-@ppt/slides/_rels/slide28.xml.relsPK 'B\p&Appt/slides/slide29.xmlPK 'B\2Ԩ::!Sppt/slides/_rels/slide29.xml.relsPK 'B\ز7Uppt/slides/slide30.xmlPK 'B\2Ԩ::!Dgppt/slides/_rels/slide30.xml.relsPK 'B\hppt/slides/slide31.xmlPK 'B\2Ԩ::!zppt/slides/_rels/slide31.xml.relsPK 'B\(|ppt/slides/slide32.xmlPK 'B\2Ԩ::!Mppt/slides/_rels/slide32.xml.relsPK 'B\[Əppt/slides/slide33.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide33.xml.relsPK 'B\{t@Zppt/slides/slide34.xmlPK 'B\2Ԩ::!Wppt/slides/_rels/slide34.xml.relsPK 'B\ жppt/slides/slide35.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide35.xml.relsPK 'B\/Wgppt/slides/slide36.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide36.xml.relsPK 'B\r` ppt/slides/slide37.xmlPK 'B\2Ԩ::!;ppt/slides/_rels/slide37.xml.relsPK 'B\ppt/slides/slide39.xmlPK 'B\2Ԩ::!+ppt/slides/_rels/slide39.xml.relsPK 'B\< ,,,ppt/slides/slide40.xmlPK 'B\2Ԩ::!YCppt/slides/_rels/slide40.xml.relsPK 'B\Dppt/slides/slide41.xmlPK 'B\2Ԩ::!Zppt/slides/_rels/slide41.xml.relsPK 'B\<m\ppt/slides/slide42.xmlPK 'B\2Ԩ::!rppt/slides/_rels/slide42.xml.relsPK 'B\hQ*5tppt/slides/slide43.xmlPK 'B\2Ԩ::!ppt/slides/_rels/slide43.xml.relsPK 'B\Bu?Hppt/slides/slide44.xmlPK 'B\2Ԩ::!Jppt/slides/_rels/slide44.xml.relsPK 'B\g99ãppt/slides/slide45.xmlPK 'B\2Ԩ::!0ppt/slides/_rels/slide45.xml.relsPK 'B\ ppt/_rels/PK 'B\Wiiѹppt/_rels/presentation.xml.relsPK 'B\`ٗwppt/presentation.xmlPKkk>`