Via Research Recognition Day 2024 VCOM-Carolinas

Educational Reports

RETROSPECTIVE ANALYSIS OPTIMIZING OPHTHALMOLOGY IN MEDICAL STUDENT EDUCATION Nicholas Minner OMS-III, Jordan Paugh, OMS-III, Christopher Jue OMS-III, Yash Patel, OMS-III, Michael Parks, MPA, Stacey

Stokes, Dr. Raymond Romano DO, Dr. Tom Lindsey, DO . Edward Via College of Osteopathic Medicine, Spartanburg, SC. .

Introduction

Results

Results

dŚĞƌĞ ǁĂƐ Ă ϯϴй ŝŵƉƌŽǀĞŵĞŶƚ ŝŶ ƐƚƵĚĞŶƚ ĐŽŶĨŝĚĞŶĐĞ ĂŶĚ ĐŽŵƉĞƚĞŶĐLJ ŝŶ ƵƐŝŶŐ ŽĐƵůĂƌ ĞƋƵŝƉŵĞŶƚ ƚŽ ĚŝĂŐŶŽƐĞ ĂŶĚ ŵĂŶĂŐĞ ŽĐƵůĂƌ ŝŶũƵƌŝĞƐ͘ dŚĞ ƉŽƐƚͲƚĞƐƚ ƐĐŽƌĞƐ ΀ϮϬ͘ ϭϮ͖ ƐƚĂŶĚĂƌĚ ĚĞǀŝĂƚŝŽŶ ;^ Ϳ ϯ͘ ϯϴ΁ ƐŚŽǁĞĚ ƐŝŐŶŝĨŝĐĂŶƚ ŝŵƉƌŽǀĞŵĞŶƚ ĨƌŽŵ ƚŚĞ ƉƌĞͲƚĞƐƚ ƐĐŽƌĞƐ ΀ϭϬ͘ ϲϱ͖ ϵϱй ^ ϰ͘ Ϯϭ΁ ǁŝƚŚ W ф Ϭ͘ ϬϬϬϭ ;dĂďůĞ ϭ͕ &ŝŐƵƌĞ ϭͿ͘ dŚĞ <ƌƵƐŬĂů tĂůůŝƐ ĐŚŝͲƐƋƵĂƌĞĚ ǀĂůƵĞ ǁĂƐ ϭϯϴ͘ ϱϯ ǁŝƚŚ ŽŶĞ ĚĞŐƌĞĞ ŽĨ ĨƌĞĞĚŽŵ ŐĞŶĞƌĂƚĞĚ Ă ƉͲǀĂůƵĞ ф Ϭ͘ ϬϬϬϭ ƐƵƉƉŽƌƚŝŶŐ ƐŝŐŶŝĨŝĐĂŶƚ ĐŚĂŶŐĞ ďĞƚǁĞĞŶ ƉƌĞƚĞƐƚ ĂŶĚ ƉŽƐƚƚĞƐƚ ;dĂďůĞ ϭͿ͘ dŚĞ dd ^d ƉƌŽĐĞĚƵƌĞ ĚĞŵŽŶƐƚƌĂƚĞĚ Ă Ɖ ǀĂůƵĞ фϬ͘ ϬϬϬϭ ǁŚŝĐŚ ŝƐ ůĞƐƐ ƚŚĂŶ ƚŚĞ ƐŝŐŶŝĨŝĐĂŶĐĞ ůĞǀĞů ŽĨ Ϭ͘ ϬϬϭ͕ ǁĞ ƌĞũĞĐƚ ƚŚĞ ŶƵůů ŚLJƉŽƚŚĞƐŝƐ ĂŶĚ ĂĐĐĞƉƚ ƚŚĂƚ ŝŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐ ĚŽĞƐ ŝŵƉƌŽǀĞ ƐƚƵĚĞŶƚ ĐŽŶĨŝĚĞŶĐĞ ĂŶĚ ŬŶŽǁůĞĚŐĞ ƌĞŐĂƌĚŝŶŐ ĚŝĂŐŶŽƐŝŶŐ ĂŶĚ ŵĂŶĂŐŝŶŐ ŽƉŚƚŚĂůŵŝĐ ŝŶũƵƌLJ͘

DĞĚŝĐĂů ĞĚƵĐĂƚŝŽŶ ĂŝŵƐ ƚŽ ƐĞƌǀĞ ƚŚĞ ŐƌŽǁŝŶŐ ŶĞĞĚƐ ŽĨ ƉĂƚŝĞŶƚ ƉŽƉƵůĂƚŝŽŶƐ͘ ĂĐŚ LJĞĂƌ͕ ĂŶ ĞƐƚŝŵĂƚĞĚ Ϯ͘ ϰ ŵŝůůŝŽŶ ĐĂƐĞƐ ŽĨ ďůŝŶĚŶĞƐƐ ĚƵĞ ƚŽ ĞLJĞ ŝŶũƵƌŝĞƐ ŽĐĐƵƌ ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ͘ ϭ͕ Ϯ dŚŝƐ ƌĞƉƌĞƐĞŶƚƐ Ă ĚĞĨŝŶŝƚĞ ŶĞĞĚ ĨŽƌ ƐƚƵĚĞŶƚ ƚƌĂŝŶŝŶŐ ŝŶ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ĐŽŵŵŽŶ ŝŶũƵƌŝĞƐ͘ dŚĞ ĨƵƚƵƌĞ ŽĨ ĞLJĞ ĐĂƌĞ ŝŶ ďŽƚŚ ƉƌŝŵĂƌLJ ĐĂƌĞ ĂŶĚ ƐƵďƐƉĞĐŝĂůŝƚŝĞƐ ŝƐ ĚĞƉĞŶĚĞŶƚ ŽŶ ƚŚĞ ĞĚƵĐĂƚŝŽŶĂů ĨŽƵŶĚĂƚŝŽŶ ŝŶ ŵĞĚŝĐĂů ƐĐŚŽŽů͘ KƉŚƚŚĂůŵŽůŽŐŝĐ ĞdžƉŽƐƵƌĞ ŝŶ ƚŚĞ ĚŝĚĂĐƚŝĐ LJĞĂƌƐ ŽĨ ŵĞĚŝĐĂů ƐĐŚŽŽů ŝƐ ůŝŵŝƚĞĚ͕ ĂǀĞƌĂŐŝŶŐ Ăƚ ϭϮ͘ ϱ ŚŽƵƌƐ͘ ϯ ĚĚŝƚŝŽŶĂůůLJ͕ ůĞƐƐ ƚŚĂŶ Ă ĨŝĨƚŚ ŽĨ ŵĞĚŝĐĂů ƐĐŚŽŽůƐ ƌĞƋƵŝƌĞ ŽƉŚƚŚĂůŵŽůŽŐLJ ĂƐ Ă ƌĞƋƵŝƌĞĚ ĐůŝŶŝĐĂů ƌŽƚĂƚŝŽŶ͘ ϰ ƐLJƐƚĞŵĂƚŝĐ ƌĞǀŝĞǁ ŽĨ ďĞƐƚ ƉƌĂĐƚŝĐĞƐ ŝŶ ƚĞĂĐŚŝŶŐ ŽƉŚƚŚĂůŵŽůŽŐLJ ƚŽ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ĐĂůůĞĚ ĨŽƌ ƚŚĞ ŽƉƚŝŵŝnjŝŶŐ ŽĨ ůĞĂƌŶŝŶŐ ŝŶŶŽǀĂƚŝŽŶƐ ĂŶĚ ƌĞƐŽƵƌĐĞ ĞĨĨĞĐƚŝǀĞ ŵŽĚĞůƐ ĨŽƌ ŝŶƚĞƌĂĐƚŝǀĞ ůĞĂƌŶŝŶŐ͘ ϱ KƉƚŝŵŝnjŝŶŐ ƚŚĞ ĐƵƌƌŝĐƵůĂ ĂŝŵƐ ƚŽ ŝŶĐƌĞĂƐĞ ƌĞƚĞŶƚŝŽŶ ĂŶĚ ĐŽŵƉĞƚĞŶĐLJ ŝŶ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ŽƉŚƚŚĂůŵŽůŽŐŝĐ ƉĂƚŚŽůŽŐLJ ǁŝƚŚŽƵƚ ĂĚĚŝŶŐ ůĞĂƌŶŝŶŐ ŚŽƵƌƐ Žƌ ŝŶĐƌĞĂƐŝŶŐ ƚŚĞ ƐƚƵĚLJŝŶŐ ďƵƌĚĞŶ ŽŶ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ͘ ϲ͕ ϳ dŚĞƌĞ ŝƐ ĂŶ ĞǀŝĚĞŶƚ ƚƌĂŝŶŝŶŐ ŐĂƉ ŝŶ ƚŚĞ ĞĚƵĐĂƚŝŽŶ ŽĨ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ĐŽŶĐĞƌŶŝŶŐ ŽƉŚƚŚĂůŵŝĐ ĚŝĂŐŶŽƐŝƐ ĂŶĚ ƚƌĞĂƚŵĞŶƚ ŵĂŶĂŐĞŵĞŶƚ͘ ϴ͕ ϵ /ŶĐŽƌƉŽƌĂƚŝŶŐ ĐŽƌĞ ŶƚƌƵƐƚĂďůĞ WƌŽĨĞƐƐŝŽŶĂů ĐƚŝǀŝƚŝĞƐ ŝŶ ŵĞĚŝĐĂƚŝŽŶ ĞĚƵĐĂƚŝŽŶ ĐĂŶ ŽǀĞƌĐŽŵĞ ƚŚŝƐ ďĂƌƌŝĞƌ ĂŶĚ ďĞƚƚĞƌ ƉƌĞƉĂƌĞ ƐƚƵĚĞŶƚƐ ĨŽƌ ƌĞƐŝĚĞŶĐLJ ĂŶĚ ƚŚĞŝƌ ĨƵƚƵƌĞ ĐĂƌĞĞƌƐ͘ dŚŝƐ ŝŶĐůƵĚĞƐ ƚŚĞ ĂďŝůŝƚLJ ƚŽ ŐĂƚŚĞƌ Ă ƚŚŽƌŽƵŐŚ ŚŝƐƚŽƌLJ͕ ƉĞƌĨŽƌŵ ĂŶ ŽĐƵůĂƌ ĞdžĂŵŝŶĂƚŝŽŶ͕ ĂŶĚ ƵƚŝůŝnjĞ ĐŽŵŵŽŶ ŽƉŚƚŚĂůŵŝĐ ĞƋƵŝƉŵĞŶƚ ĨŽƌ ĂƐƐĞƐƐŵĞŶƚ͘ ϭϬ KďũĞĐƚŝǀĞ͗ tĞ ŚLJƉŽƚŚĞƐŝnjĞ ƚŚĂƚ ƐƚƵĚĞŶƚƐ ǁŚŽ ƉĂƌƚŝĐŝƉĂƚĞ ŝŶ ƚŚĞ ŝŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐͲƐŝŵƵůĂƚŝŽŶ ƚƌĂŝŶŝŶŐ ƐĞƐƐŝŽŶ ǁŝůů ďĞ ŵŽƌĞ ĐŽŶĨŝĚĞŶƚ ƚŽ ƵƐĞ ĞLJĞ ĂƐƐĞƐƐŵĞŶƚ ĞƋƵŝƉŵĞŶƚ ĂŶĚ ďĞƚƚĞƌ ƉƌĞƉĂƌĞĚ ƚŽ ĚŝĂŐŶŽƐĞ ĂŶĚ ƚƌĞĂƚ ŽĐƵůĂƌ ŝŶũƵƌŝĞƐ͘ ƋƵĂůŝƚLJ ĂƐƐƵƌĂŶĐĞ ĂŶĚ ƋƵĂůŝƚLJ ŝŵƉƌŽǀĞŵĞŶƚ ƌĞƚƌŽƐƉĞĐƚŝǀĞ ĂŶĂůLJƐŝƐ ǁĂƐ ĐŽŶĚƵĐƚĞĚ͕ ĞŵƉůŽLJŝŶŐ Ă ϯ ͲƉƌŝŶƚĞĚ ŽƉŚƚŚĂůŵŽůŽŐŝĐ ƚƌĂŝŶĞƌ ĨŽƌ ĞLJĞ ĞdžĂŵŝŶĂƚŝŽŶ ĂŶĚ ƚƌĞĂƚŵĞŶƚ ŵĂŶĂŐĞŵĞŶƚ ;&ŝŐƵƌĞ ϮͿ͘ dŚĞ ŝŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐͲƐŝŵƵůĂƚŝŽŶ ƚƌĂŝŶŝŶŐ ƐĞƐƐŝŽŶ ŝŶĐůƵĚĞĚ Ă ƚĞĂĐŚŝŶŐ ƐĞƐƐŝŽŶ ĂŶĚ ŚĂŶĚƐͲŽŶ ůĞĂƌŶŝŶŐ͘ ^ƚƵĚĞŶƚƐ ǁĞƌĞ ƚĂƵŐŚƚ ŝŶĚŝĐĂƚŝŽŶƐ͕ ĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͕ ĂŶĚ ĐŽŵƉůŝĐĂƚŝŽŶƐ ĨŽƌ ƚŚĞ ƵƐĞ ŽĨ ĨůƵŽƌĞƐĐĞŝŶ ĚLJĞ ǁŝƚŚ tŽŽĚƐ ůĂŵƉ͕ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ĐŽƌŶĞĂů ĂďƌĂƐŝŽŶƐ͕ ƚŽŶŽŵĞƚƌLJ͕ ĂŶĚ ĨŽƌĞŝŐŶ ďŽĚLJ ƌĞŵŽǀĂů͘ dŚĞ ƉƌĞ ĂŶĚ ƉŽƐƚ ƚĞƐƚ ƋƵĞƐƚŝŽŶŶĂŝƌĞƐ ǁĞƌĞ ŝĚĞŶƚŝĐĂů ĂŶĚ ŝŶĐůƵĚĞĚ ƚŚĞ ĨŽůůŽǁŝŶŐ ƐƚĂƚĞŵĞŶƚƐ ƌĂƚĞĚ ŽŶ Ă ϱͲƉŽŝŶƚ >ŝŬĞƌƚ ƐĐĂůĞ͗ / Ăŵ ĐŽŶĨŝĚĞŶƚ ŝŶ ŵLJ ĂďŝůŝƚLJ ƚŽ ƌĞŵŽǀĞ Ă ĨŽƌĞŝŐŶ ďŽĚLJ ĨƌŽŵ ƚŚĞ ĞLJĞ͘ / Ăŵ ĐŽŵƉĞƚĞŶƚ ŝŶ ƵƚŝůŝnjŝŶŐ Ă ŚŽůůŽǁ ďŽƌĞ ŶĞĞĚůĞ ĨŽƌ ƌĞŵŽǀĂů ŽĨ Ă ĨŽƌĞŝŐŶ ŽďũĞĐƚ ĨƌŽŵ ƚŚĞ ĞLJĞ͘ / Ăŵ ĐŽŶĨŝĚĞŶƚ ŝŶ ŵLJ ĂďŝůŝƚLJ ƚŽ ŝĚĞŶƚŝĨLJ ŝŶĚŝĐĂƚŝŽŶƐ͕ ĐŽŶƚƌĂŝŶĚŝĐĂƚŝŽŶƐ͕ ĂŶĚ ĐŽŵƉůŝĐĂƚŝŽŶƐ ŽĨ ĨŽƌĞŝŐŶ ďŽĚLJ ƌĞŵŽǀĂů͘ / Ăŵ ĐŽŵƉĞƚĞŶƚ ŝŶ ƵƚŝůŝnjŝŶŐ ĨůƵŽƌĞƐĐĞŝŶ ĚLJĞ ǁŝƚŚ ƉƌŽƉĞƌ ĂĚŵŝŶŝƐƚƌĂƚŝŽŶ͘ / Ăŵ ĐŽŵƉĞƚĞŶƚ ŝŶ ƵƚŝůŝnjŝŶŐ Ă ǁŽŽĚƐ ůĂŵƉ ƚŽ ĚŝĂŐŶŽƐĞ ĐŽƌŶĞĂů ĂďƌĂƐŝŽŶ͘ WƌĞ ĂŶĚ ƉŽƐƚ ƚĞƐƚ ƋƵĂŶƚŝƚĂƚŝǀĞ ĞǀĂůƵĂƚŝŽŶ ǁĂƐ ƉĞƌĨŽƌŵĞĚ ǁŝƚŚ ϱͲŝƚĞŵ ŵƵůƚŝƉůĞ ĐŚŽŝĐĞ ƋƵĞƐƚŝŽŶƐ ƌĞŐĂƌĚŝŶŐ ĚŝĂŐŶŽƐŝƐ ĂŶĚ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ŽƉŚƚŚĂůŵŝĐ ŝŶũƵƌŝĞƐ͘ Methods

&ŝŐƵƌĞ Ϯ͘ >ĞĨƚ ĂŶĚ DŝĚĚůĞ͗ ϯ ͲƉƌŝŶƚĞĚ ŽƉŚƚŚĂůŵŽůŽŐŝĐ ƚƌĂŝŶĞƌ ĨŽƌ ĨŽƌĞŝŐŶ ďŽĚLJ ĂƐƐĞƐƐŵĞŶƚ ĂŶĚ ƌĞŵŽǀĂů͘ ZŝŐŚƚ͗ dŚĞ ƐLJŶƚŚĞƚŝĐ ĞLJĞďĂůů ƵƐŝŶŐ ƐŝŵƵůĂƚĞĚ ĨůƵŽƌĞƐĐĞŝŶ ĚLJĞ ǀŝƐƵĂůŝnjĞĚ ƵŶĚĞƌ Ă tŽŽĚƐ >ĂŵƉ͘

Analysis Variable : Score Test N Observed Mean Std Dev Min Max Pre 138 10.65 4.21 4 25 Post 108 20.12 3.83 5 25

Kruskal-Wallis Test Chi-Square DF Pr > ChiSq 138.53 1 <0.0001

Conclusion

The TTEST Procedure

The authors of this poster would like to acknowledge and thank the VCOM Carolinas Campus Simulation Center staff for their assistance and guidance in developing this simulation.This is a quality improvement study. 1. Li C, Fu Y, Liu S, et al. The global incidence and disability of eye injury: an analysis from the Global Burden of Disease Study 2019. EClinicalMedicine. 2023;62:102134. doi:10.1016/j.eclinm.2023.102134 2. Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998;5(3):143-169. doi:10.1076/opep.5.3.143.8364 3. Moxon NR, Goyal A, Giaconi JA, et al. The state of ophthalmology medical student education in the united states: an update. Ophthalmology. 2020;127(11):1451-1453. doi:10.1016/j.ophtha.2020.05.001 4. Shah M, Knoch D, Waxman E. The state of ophthalmology medical student education in the United States and Canada, 2012 through 2013. Ophthalmology. 2014;121(6):1160-1163. doi:10.1016/j.ophtha.2013.12.025 5. Succar T, Grigg J, Beaver HA, Lee AG. A systematic review of best practices in teaching ophthalmology to medical students. Surv Ophthalmol. 2016;61(1):83-94. doi:10.1016/j.survophthal.2015.09.001 6. Graubart EB, Waxman EL, Forster SH, et al. Ophthalmology objectives for medical students: revisiting what every graduating medical student should know. Ophthalmology. 2018;125(12):1842-1843. doi:10.1016/j.ophtha.2018.08.032 7. Succar T, Grigg J, Beaver HA, Lee AG. Advancing ophthalmology medical student education: International insights and strategies for enhanced teaching. Surv Ophthalmol. 2020;65(2):263-271. doi:10.1016/j.survophthal.2019.08.006 8. Succar T, McCluskey P, Grigg J. Enhancing Medical Student Education by Implementing a Competency Based Ophthalmology Curriculum. Asia Pac J Ophthalmol (Phila). 2017;6(1):59-63. doi:10.22608/APO.2016102 9. Gilmour G, McKivigan J. Evaluating medical students’ proficiency with a handheld ophthalmoscope: a pilot study. Adv Med Educ Pract. 2017;8:33-36. doi:10.2147/AMEP.S119440 10. Amiel J, Ryan MS, Andriole DA, Whelan AJ. Core Entrustable Professional Activities for Entering Residency: Summary of the 10-School Pilot, 2014-2021. AAMC. 2022. /ŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐͲƐŝŵƵůĂƚŝŽŶ ƚƌĂŝŶŝŶŐ ŝƐ ĂŶ ĞĨĨĞĐƚŝǀĞ ůĞĂƌŶŝŶŐ ŵĞƚŚŽĚ ƚŽ ĞĚƵĐĂƚĞ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ŽŶ ĚŝĂŐŶŽƐŝŶŐ ĂŶĚ ŵĂŶĂŐŝŶŐ ŽƉŚƚŚĂůŵŽůŽŐŝĐ ŝŶũƵƌŝĞƐ͘ 'ŝǀĞŶ ƚŚĞ ƉƌĞǀĂůĞŶĐĞ ŽĨ ŽƉŚƚŚĂůŵŝĐ ŝŶũƵƌLJ͕ ŝƚ ŝƐ ǀŝƚĂů ƚŚĂƚ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ůĞĂƌŶ ƚŽ ƵƐĞ ĐŽŵŵŽŶ ĚŝĂŐŶŽƐƚŝĐ ƚŽŽůƐ ĂŶĚ ƉĞƌĨŽƌŵ ďĂƐŝĐ ƚƌĞĂƚŵĞŶƚ ŽƉƚŝŽŶƐ ƐƵĐŚ ĂƐ ƚŽŶŽŵĞƚƌLJ ĂŶĚ ĨŽƌĞŝŐŶ ďŽĚLJ ƌĞŵŽǀĂů͘ dŚĞ ƵůƚŝŵĂƚĞ ŐŽĂů ŽĨ ŝŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐ ĨŽƌ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ŝƐ ƚŽ ĞĨĨĞĐƚŝǀĞůLJ ƉƌĞƉĂƌĞ ƐƚƵĚĞŶƚƐ ƚŽ ƉĞƌĨŽƌŵ ƚŚĞƐĞ ĐŽŵŵŽŶͲƉƌĂĐƚŝĐĞ ƉƌŽĐĞĚƵƌĞƐ͘ &ƵƚƵƌĞ ƌĞƐĞĂƌĐŚ ƐŚŽƵůĚ ĞdžĂŵŝŶĞ ƚŚĞ ďĞŶĞĨŝƚƐ ŽĨ ƚŚŝƐ ŝŶƚĞŐƌĂƚĞĚ ůĞĂƌŶŝŶŐ ŝŶ ƉƌŝŵĂƌLJ ĐĂƌĞ ƌĞƐŝĚĞŶƚ ƚƌĂŝŶŝŶŐ͘ Acknowledgements & References

Method Pooled

Variances DF t Value Pr> |t|

Equal

224 -18.18 <0.0001 238.61 -18.39 <0.0001

Satterthwaite

Unequal

dĂďůĞ ϭ͘ dŽƉ >ĞĨƚ ŶĂůLJƐŝƐ sĂƌŝĂďůĞ ƐĐŽƌĞ͘ dŽƉ ZŝŐŚƚ͗ <ƌƵƐŬĂůͲtĂůůŝƐ dĞƐƚ͘ ŽƚƚŽŵ͗ dd ^d ƉƌŽĐĞĚƵƌĞ͘

&ŝŐƵƌĞ ϭ͘ ŐƌĂƉŚ ƐŚŽǁŝŶŐ ƚŚĞ ŵĞĂŶƐ ƉƌŽĐĞĚƵƌĞ ĚŝƐƉůĂLJŝŶŐ ĂŶĂůLJƐŝƐ ǀĂƌŝĂďůĞ ƐĐŽƌĞ͘

102

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