Student Learning and Perceptions in A Flipped Linear Algebra Course

You might also like

Download as pdf or txt
Download as pdf or txt
You are on page 1of 9

International Journal of Mathematical Education in

Science and Technology

ISSN: 0020-739X (Print) 1464-5211 (Online) Journal homepage: http://www.tandfonline.com/loi/tmes20

Student learning and perceptions in a flipped


linear algebra course
Betty Love, Angie Hodge, Neal Grandgenett & Andrew W. Swift
To cite this article: Betty Love, Angie Hodge, Neal Grandgenett & Andrew W. Swift
(2014) Student learning and perceptions in a flipped linear algebra course, International
Journal of Mathematical Education in Science and Technology, 45:3, 317-324, DOI:
10.1080/0020739X.2013.822582
To link to this article: http://dx.doi.org/10.1080/0020739X.2013.822582

Published online: 06 Sep 2013.

Submit your article to this journal

Article views: 2434

View related articles

View Crossmark data

Citing articles: 7 View citing articles

Full Terms & Conditions of access and use can be found at


http://www.tandfonline.com/action/journalInformation?journalCode=tmes20
Download by: [University of Malaya]

Date: 04 October 2015, At: 02:53

International Journal of Mathematical Education in Science and Technology, 2014


Vol. 45, No. 3, 317324, http://dx.doi.org/10.1080/0020739X.2013.822582

Student learning and perceptions in a flipped linear algebra course


Betty Love,a Angie Hodge,a Neal Grandgenettb and Andrew W. Swifta
a

Department of Mathematics, University of Nebraska at Omaha, 6001 Dodge Street, Omaha,


NE 68182, USA; b Department of Teacher Education, University of Nebraska at Omaha,
6001 Dodge Street, Omaha, NE 68182, USA

Downloaded by [University of Malaya] at 02:53 04 October 2015

(Received 13 January 2013)


The traditional lecture style of teaching has long been the norm in college science,
technology, engineering, and mathematics (STEM) courses, but an innovative teaching
model, facilitated by recent advances in technology, is gaining popularity across college
campuses. This new model inverts or flips the usual classroom paradigm, in that
students learn initial course concepts outside of the classroom, while class time is
reserved for more active problem-based learning and practice activities. While the
flipped classroom model shows promise for improving STEM learning and increasing
student interest in STEM fields, discussions to date of the model and its impact are
more anecdotal than data driven very little research has been undertaken to rigorously
assess the potential effects on student learning that can result from the flipped classroom
environment. This study involved 55 students in 2 sections of an applied linear algebra
course, using the traditional lecture format in one section and the flipped classroom
model in another. In the latter, students were expected to prepare for the class in some
way, such as watching screencasts prepared by the instructor, or reading the textbook
or the instructors notes. Student content understanding and course perceptions were
examined. Content understanding was measured by the performance on course exams,
and students in the flipped classroom environment had a more significant increase
between the sequential exams compared to the students in the traditional lecture section,
while performing similarly in the final exam. Course perceptions were represented by
an end-of-semester survey that indicated that the flipped classroom students were very
positive about their experience in the course, and particularly appreciated the student
collaboration and instructional video components.
Keywords: flipped classroom; linear algebra; teaching with technology; inquiry-based
learning; student perceptions of instruction

1. Introduction
As identified in numerous reports from across the world, educational institutions are continually challenged to establish a strong conceptual foundation in introductory science, technology, engineering, and mathematics (STEM) courses while keeping students interested
in learning so that they can advance to higher level and more specialized courses.[16] The
traditional lecture style of teaching remains the norm in college courses across the world,
and particularly in the USA.[7] Students are familiar with this method and are generally
comfortable in the traditional classroom. For many, it is a method that yields positive results.
However, it certainly is not the best approach for everyone, both in terms of learning style
and flexibility.

Corresponding author. Email: blove@unomaha.edu


C 2013 Taylor & Francis

Downloaded by [University of Malaya] at 02:53 04 October 2015

318

B. Love et al.

Recently an innovative teaching model, facilitated by recent advances in technology, has


been gaining popularity. This new model inverts or flips the usual classroom paradigm
online educational tools, primarily screencasts and recorded videos, allow students to learn
course concepts outside of the classroom, while class time is reserved for more active,
problem-based learning and practice activities.[8,9] Although instructors may implement
this new instructional approach in many ways, the basic idea is to move the basic knowledge
out of the classroom and then use class time for activities that deepen that knowledge. In
class, students may engage in group activities, lab work, or other active types of learning.
Claimed advantages of the new model include self-paced learning outside of the classroom, where students can view the online materials on their own schedule as frequently as
needed, and focused instructional support within the classroom, where both the instructor
and classmates are available to help when students most need it as they apply newly
acquired knowledge to relevant problems and tasks.[10] While the flipped classroom model
shows promise for improving STEM learning and increasing student interest in STEM
fields,[11,12] little research has been undertaken to rigorously assess the actual effects on
learning that can result from this new approach.[13] The utility and educational impact
of the flipped classroom model needs to be well researched and documented in specific
content areas and courses so that faculty members and administrators can make informed
decisions when considering changing instructional strategies in such a significant way.
The purpose of this study was to compare the effectiveness of two teaching methods
(a traditional lecture and a flipped style) in a sophomore-level linear algebra course at a
mid-sized metropolitan university. Current technology allows instructors to provide course
learning materials in a variety of electronic forms, which are available to students on
demand. In addition to the rapidly increasing collection of free online instructional videos,
tools for creating ones own screencasts are accessible to anyone with a personal computer,
making the results of this study applicable to all mathematics educators regardless of the
type of institution or where they are located. The results of this study could also easily be
extended to the instruction of other STEM disciplines.

2. Perspectives on a flipped classroom


The traditional lecture is obviously well entrenched in university instruction and has long
been the norm in college classrooms. It is how most of todays faculty members were taught
and therefore, how most teach. This is true despite the notion that not all faculty necessarily
think it is the best approach; it is simply the teaching method with which they are most
familiar. Lord and Camacho,[14] in reporting on a survey of teaching-oriented engineering
faculty (those who were attending an engineering education conference), found that while
only 36% of respondents think traditional lecture is a good teaching approach, 60% of them
still teach that way. Many faculty members recognize the need for a more active learning
environment and seek ways to incorporate that, to varying degrees, in their classes. One
obstacle is the need to adequately cover the material specified in the course syllabus. The
(passive) conveyance of basic knowledge competes with the (active) application of that
knowledge for class time. Students need both, so the question is how to best provide both
passive and active learning opportunities.
Various researchers and instructional designers have sought to leverage advances in
technology to address the need for more active learning. By recording lecture content in
the form of videos or screencasts and making it available on the Internet, they have moved
the lecture component, in part or whole, outside the classroom. This flipped, or inverted,

Downloaded by [University of Malaya] at 02:53 04 October 2015

International Journal of Mathematical Education in Science and Technology

319

model of instruction pushes passive learning out of the classroom while correspondingly
pulling in active learning, in the time previously used for instructor lectures.
There is no single model for implementing the flipped classroom approach,[15] and
our review of the literature indicates that the approach is still in a stage of innovation.
Research has also shown that students of the new millennium believe that doing is more
important than knowing and that learning is a trial-and-error process.[16] The hands-on,
in-class strategies associated with the flipped classroom may better accommodate this type
of learner since the instructor is available to guide the process and to provide help to
students while they are engaged in the learning activities. In contrast, students in traditional
lecture courses typically encounter the difficult and frustrating parts outside of class where
they likely do not have access to such instructional help. As a result, the flipped classroom
approach has started to surface in many STEM learning discussions. To date, however,
discussions of the flipped classroom model and its impact on student learning are more
anecdotal than data driven.
Lage, Platt, and Tregalia,[9] who claim to be the first to have implemented the flipped
(inverted) approach, reported that students in their economics course felt that they learned
more in the flipped environment than in a lecture course. They enjoyed the hands-on
approach as well as the group work and interaction with peers and felt more comfortable
asking questions in the less formal flipped classroom. Kaner and Fiedler [17] used the
flipped approach in a software testing course. Lectures were posted online and class time
was used for various coached activities, such as group discussions, presentations, or problem
solving. The use of the term coached is appropriate, since students in a flipped classroom
environment are typically expected to become more independent and active learners.
In another study, Day and Foley [18] implemented the flipped classroom approach in two
sections of a humancomputer interaction course. Using a small-scale quasi-experimental
design, they taught one section using traditional lectures and one section using the flipped
approach. They found that students in the flipped section performed better on every course
assignment.
In a large-enrolment physics course, Deslauriers, Schelew, and Wieman [11] compared
learning achieved using a traditional lecture approach to that achieved using a deliberate
practice approach that had characteristics of the flipped methodology. In the latter approach,
class time was spent with a series of challenging questions and tasks that required students
to practice physicist-like reasoning and problem solving with frequent feedback. The
goal was to have students spend class time engaged in activities designed to give them
individualized and group practice at thinking scientifically. They formed hypotheses and
tested them, solved problems, and critiqued their own reasoning and that of their peers.
The study found increased student attendance and higher engagement in the non-lecture
section. Students in the non-lecture section also did more than twice as well on the given
test compared to those in the lecture section.
Carlisle [19] used the flipped classroom approach in an introductory computer programming course. Students indicated that the instructional videos he had developed for the
course helped them learn the material, and they liked having more time to do hands-on
programming work in class.
Other researchers have examined specific strategies that, while not unique to the flipped
approach, are frequently associated with it. Peer instruction [20] was used by Gannod, Burge,
and Helmick [10] in an implementation of the flipped approach in a software engineering
course. They reported a number of potential benefits associated with active in-class learning
and peer instruction (students benefit from having to explain concepts to each other and
from having direct access to the instructor and peers while engaged in problem solving), in

Downloaded by [University of Malaya] at 02:53 04 October 2015

320

B. Love et al.

addition to those associated with asynchronous learning (students can view online content
as frequently as they want to and at their own pace).
Another strategy frequently seen implemented in a flipped classroom approach is just-intime teaching (JiTT).[21] When using a JiTT approach, the instructor reviews assessments
of student readiness before or at the beginning of the class and adjusts the in-class activities
to address any deficiencies reflected in the assessments. Carter [22] incorporated both
peer instruction and JiTT in a flipped introductory programming course. Clicker questions,
using mobile response devices, were used at the beginning of the class to assess student
comprehension of information contained in screencasts, which students viewed before class.
Mini lectures and peer instruction were used when there was significant disagreement on the
correct answer to a clicker question. The remaining class time was spent in active-learning
group activities. Survey data from this particular study indicated that students strongly
favoured the flipped approach over a traditional lecture style of instruction. Since the flipped
classroom approach shows great promise but data-driven research within this context is
relatively sparse, we undertook a very focused investigation of the flipped classroom model
on a specific course with a comparison section.
3. Methods and results
Our study was conducted in the Spring 2012 semester and contrasted two specific instructional models traditional lecture and a flipped model in a sophomore-level applied linear
algebra course. This course serves primarily mathematics, computer science, and various
engineering majors. There were 32 students in each of the flipped and traditional classes.
Of the 55 students who agreed to participate in the study, 27 were in the flipped section and
28 were in the traditional section. Students were not given a choice regarding the method
of instruction. The instructor was teaching two sections of the course and arbitrarily chose
one to be flipped and the other to be traditional. The students selected the time slot that
fit into their schedules and were unaware of the method of instruction until the first day
of class. All the students in the course completed the same work for the course with the
exception of a researcher-developed post-course survey that was administered via SurveyMonkey to study the participants. The survey was used to obtain data regarding student
perceptions of the way the course was taught. It included a set of common questions for
students in both sections as well as additional questions specific to each section. The time
required to complete the survey was approximately 515 minutes. The major findings of
this survey are discussed here, if the reader would like to see the full survey, please contact
the corresponding author.
In addition, the applied linear algebra students were compared across sections on three
common midterm exams and a comprehensive final exam. Students in the flipped section
were encouraged to review course materials, including online screencasts, prior to coming
to the class. The topics of the screencasts mirrored those of the lectures that were delivered
in the traditional section of the course, and were also made available to the students in
the traditional section. The screencasts were developed specifically for this course. The
instructor created the presentations using the LaTeX beamer package. The screencasts
were recorded on the instructors computer and consisted primarily of the instructor talking
while going through the presentation slides. Occasionally the instructor would switch to a
Maple session to illustrate concepts graphically, particularly the three-dimensional concepts
in the course such as a plane spanned by a set of vectors. In the flipped section, class time was
reserved for engaging students in organized, interactive, hands-on activities. Specifically,
students in the flipped classroom section spent most of their class time working problems

International Journal of Mathematical Education in Science and Technology

321

Downloaded by [University of Malaya] at 02:53 04 October 2015

on the board in pairs.[23] Students in each pair rotated the roles as writer and helper and
then one student in each pair rotated to the next pair. Students in the flipped section were
also required to complete pre-class daily readiness assessments, which were designed to
assess learning and to provide students an opportunity to ask for more explanation about
certain topics in class.
Each daily readiness assessment was administered via the testing mechanism within
our learning management system (LMS), in this case blackboard, and consisted of three
questions. The first two questions always related specifically to the current content and
were designed to engage students and to promote their thinking rather than just repeating a
definition or something similarly passive. Following are the two questions from the section
on spanning sets.
(1) Suppose you have two nonzero vectors, say u and v. How many linear combinations of u
and v exist? Explain. Suppose u is the zero vector. Then how many linear combinations of
u and v exist? Explain.
(2) If you have two vectors, say u and v where v is a multiple of u, how is span {u} related to
span {u,v}? Explain.

The third question was always the same; it was:


(3) What did you find difficult or confusing about this section? If nothing was difficult or
confusing, what did you find most interesting? Please be as specific as possible.

The answers to the third question were used to guide the instructor in the JiTT approach
regarding what to discuss and cover in the upcoming class.
Students were encouraged to be thoughtful when answering the questions. Each question
was worth two points, and the points were awarded so that even wrong answers, when
presented with evidence of thoughtfulness, were given full credit. Generally any answer to
question 3 was given full credit.
The flipped section of the course met at 4 pm on Mondays and Wednesdays. Students
were required to submit their daily readiness test responses by 2 pm on those days, so the
instructor had two hours to read through the answers to question 3 and determine what to
focus upon in the upcoming class.
Each of the two sections met for two 75-minute classes each week. Each class meeting
for the traditional section typically was divided roughly in half; in the first half the instructor
would answer questions from students and work some of the homework problems on the
board. Most sections of our text had 810 true/false questions and individual students would
be asked to read and answer these in class. In the second half of the class, the instructor
overviewed or lectured on new material and worked through some example problems.
Students in the flipped class were expected to prepare for class, not necessarily to watch
the videos. This is an important distinction. The average length of a class video was around
30 minutes. Some students replayed all or part of the videos, so the actual time each student
spent watching a video for a particular class was variable.
The first 15 minutes or so of each flipped class were spent in instructor-led discussion
with students. The instructor discussed the daily readiness test questions and addressed
student questions including both those posed before class and during class. The instructor
and class also typically went through the true/false questions together just as the traditional
class did. For the remainder of the class, students typically worked on some even-numbered
problems from the textbook. Students in the traditional class did not work on problems in
class per se. However, the instructor worked some even-numbered textbook problems on

Downloaded by [University of Malaya] at 02:53 04 October 2015

322

B. Love et al.

the board and actively involved the class in discussing strategies for addressing the problem
and the overall solution process.
Both sections were assigned the same homework problems from the book, which
generally consisted of odd-numbered problems for which the answers were provided in
the back of the book.
Each Friday a quiz was posted on our LMS. Students had to turn in a paper copy of
their solutions or upload their solutions to the LMS by the following Monday evening.
No attempts were made to proctor the quizzes and students were allowed to use available
resources. However, they were cautioned that the quizzes should be viewed as a preparation
for the exams, which would be proctored and that these would be undertaken with closedbook/closed-notes restrictions.
At the end of the semester, scores on the three course exams were analysed for all
the students. Of particular interest is the analysis of how the students progressed between
exams, since the benefit of the flipped class approach may not be evident early in the
course but should increase as the course progresses. When looking at the performance
on the second exam relative to the first exam, the average change in score for those students in the flipped classroom environment was significantly greater than for those in
the traditional lecture section (p < 0.034). Similarly, when comparing the third exam
to the first exam, the average change in score for those in the flipped classroom section was again significantly greater than for those in the traditional section (p < 0.012).
The analysis was done using the non-parametric MannWhitney U test, since the nonnormality of the data precluded the use of the traditional two-sample t-test. Students in
both the flipped and traditional sections performed similarly in the final exam, with an
average raw score in the flipped section of 89.5 compared to 87.4 in the traditional lecture
section.
A survey administered at the end of the semester also captured students perceptions
about teaching methods. Results showed that 74% of students in the flipped section had a
positive attitude about the flipped classroom approach. Students also had generally positive
views of the paired in-class work. Over 74% agreed that working problems on the board
helped them remember the course material better and was more fun than a traditional lecture
course. This perception was also reflected in student comments the more interactive
environment of the course held my attention and helped me stay focused and this style
of teaching kept my attention. . .it is more fun to work with others on the board than it is
working by yourself on paper.
While many students were quite hesitant to do the board work early in the semester,
by the end of the course, over 81% of students were comfortable with working problems
on the board. Almost 78% agreed that the group work helped them to become socially
more comfortable with their classmates, and over 70% agreed that explaining a problem or
idea to their partner helped them to develop a deeper understanding of it. Again, this was
reflected in student comments this format is so much more fun. . .you get to get to know
your classmates much better. I feel like I learned better too.
Students were asked if they were more comfortable talking with classmates in this class
than other mathematics courses they had taken. Almost 56% of students in the flipped
classroom section agreed with this statement, while only 21% of students in the lecture
section agreed. Using a MannWhitney U test on the 5-point Likert scale with the alternative
hypothesis that students in the flipped classroom section tend to be more comfortable talking
to classmates in this class than in other mathematics courses compared to those students
in the lecture section yields a p value of 0.00294, which indicates significant support for
the alternative hypothesis. This shows that the peer interaction in the flipped section may

Downloaded by [University of Malaya] at 02:53 04 October 2015

International Journal of Mathematical Education in Science and Technology

323

contribute significantly toward the development of a social network for students, something
particularly important for the retention of women and minority students.[24]
The instructional videos proved to be popular among students in the flipped sections,
suggesting that this may be a key element of flipped classroom interventions. About 96%
of students in the flipped section believed that the videos helped them learn the material.
Students in the flipped classroom section found the instructors videos significantly more
helpful (p < 0.001) than those in the lecture section. As one student commented, Many
times I have wished to pause or rewind a live lecture. You can do that with a video without
disrupting the flow of the class. Also, watching a second time really reinforces the concepts.
The survey also found that of the students who watched the videos, about one-third watched
them multiple times.
The students in the flipped classroom section seem to have completed the course with a
greater perception that linear algebra is relevant to their career, in comparison to the students
in the lecture section. When asked on a 5-point Likert scale whether they agreed with the
statement that linear algebra is likely to be relevant to my career, testing the alternative
hypothesis that in general, flipped classroom students agreed with this statement more than
lecture section students, yielded a p value of 0.089, which is reasonably significant.
4. Summary
Our review of the literature and results from our own experimentation with a flipped
classroom indicate that this approach holds significant promise for successful implementation in introductory courses in STEM disciplines and may support improved student
outcomes in STEM courses that are typically considered very challenging by students. In
our study, we found that students within a flipped classroom still performed as well as
their peers in a traditional classroom on the final exam, representing conceptual understanding. This result is important since the students in the flipped classroom not only did
still learn the necessary mathematical skills from their linear algebra course work, but also
enjoyed the classes more. Sparking and retaining student interest in mathematics is important with the worldwide demand for more STEM majors.
We do recognize, however, that the promise of a flipped classroom instructional environment has not yet been well researched and documented, especially within the context of
introductory courses, which frequently involve numerous students and multiple sections.
Our study by itself cannot establish that a flipped classroom environment is preferable for
student instruction in STEM learning, but with the growing research supporting the flipped
classroom approach there is an increasing endorsement for this instructional approach in
STEM courses. These courses are critical gatekeepers in potential STEM career pathways
and are often very influential in student decisions about whether or not to pursue a STEMrelated major. Before a significant number of university faculty will be willing to undertake
such a dramatic change in instructional practices, as that represented by flipped classroom
strategies, it will be critical to continue to build a foundation of systematic research that
investigates the nature, utility, and effectiveness of flipped classroom models. Hence, further research is needed in other disciplines, instructional contexts and by additional STEM
educators, to more fully contribute to the instructional decision making being undertaken
on college campuses today related to the use of flipped classroom environments.
References
[1] European Schoolnet. Science, technology, engineering, and mathematics: defining the challenges. Brussels, Belgium: European Unions Framework Programme for Research and Development; 2011.

Downloaded by [University of Malaya] at 02:53 04 October 2015

324

B. Love et al.

[2] Asia Science Educator Academy. Action plans for Asia STEAM education. Paper presented at:
Asia Science Educator Conference; 2011; Seoul, Korea.
[3] Australian Council for Educational Research. Participation in science, mathematics and technology in Australian education. Camberwell, Australia: Australian Council for Educational
Research; 2008.
[4] National Academy of Sciences, Institute of Medicine, and National Academy of Engineering.
Rising above the gathering storm, revisited: rapidly approaching category 5. Written by Members of the 2005 Rising Above the Gathering Storm Committee. Washington, DC: National
Academies Press; 2010 .
[5] National Science Board. National Science Board STEM Education recommendations for the
president-elect Obama administration, NSB-0901. Arlington, VA: National Science Foundation;
2009.
[6] Royal Academy of Engineering. Jobs and growth: the importance of engineering skills to the UK
economy. London: Royal Academy of Engineering econometrics of engineering skills project;
2012.
[7] National Governors Association Center for Best Practices. Building a science, technology,
engineering and math education agenda: an update of state actions. Washington, DC: National
Governors Association Center for Best Practices; 2012.
[8] Bergmann J, Sams A. Flip your classroom: reach every student in every class every day. Eugene,
OR: International Society for Technology in Education; 2012.
[9] Lage MJ, Platt G, Treglia M. Inverting the classroom: a gateway to creating an inclusive learning
environment. J Econ Educ. 2000;31:3043.
[10] Gannod GC, Burge JE, Helmick MT. Using the inverted classroom to teach software engineering. Proceedings of the 30th International Conference on Software Engineering (ICSE 08),
Leipzig, Germany. New York, NY: ACM; 2008; p. 777786.
[11] Deslauriers L, Schelew E, Wieman C. Improved learning in a large-enrollment physics class .
Science. 2011;332:862864.
[12] Bates S, Galloway R. The inverted classroom in a large enrollment introductory physics course:
a case study. Paper presented at: Proceedings of the 1st International Conference on the Aiming
for Excellence in STEM Learning and Teaching; 2012; London.
[13] Moravec M, Williams A, Aguilar-Roca N, ODowd DK. Learn before lecture: a strategy that improves learning outcomes in a large introductory biology class. CBE Life Sci Educ. 2010;9:473
481.
[14] Lord S, Camacho M. Effective teaching practices: preliminary analysis of engineering educators.
Paper presented at: Proceedings of the 37th ASEE/IEEE Frontiers in Education Conference;
2007 Oct 103; Milwaukee, WI.
[15] Tucker B. The flipped classroom. Educ Next. 2012;12:8283.
[16] Frand JL. The information-age mindset: changes in students and implications for higher education. EDUCAUSE Rev. 2000;35:1425.
[17] Kaner C, Fiedler RL. Inside out: a computer science course gets a makeover. Paper presented at:
Proceedings of the Association for Educational Communication and Technology International
Conference; 2005; Orlando, FL.
[18] Day J, Foley J. Evaluating a web lecture intervention in a humancomputer interaction course.
IEEE Trans Educ. 2006;49:420431.
[19] Carlisle MC. Using you tube to enhance student class preparation in an introductory Java course.
Paper presented at: Proceedings of the 41st ACM Technical Symposium on Computer science
Education; 2010 Mar 1013; Milwaukee, WI.
[20] Mazur E. Peer instruction: a users manual. Upper Saddle River, NJ: Addison-Wesley; 1996.
[21] Novak G, Gavrin A, Christian W, Patterson E. Just-in-time teaching: blending active learning
with web technology. Upper Saddle River, NJ: Addison-Wesley; 1999.
[22] Carter P. An experience report: on the use of multimedia pre-instruction and just-in-time teaching in a CS1 course. Paper presented at: Proceedings of the 43rd ACM Technical Symposium
on Computer Science Education; 2012 Feb 29March 3; Raleigh, NC.
[23] Andersen M. Back to the board. NISOD Innovation Abstracts XXVIII. Austin, TX: University
of Texas College of Education; 2006.
[24] Barker LJ, McDowell C, Kalahar K. Exploring factors that influence computer science introductory course students to persist in the major. ACM SIGCSE Bull. 2009;41:153157.

You might also like