Pros and Cons of Online Medical Education

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PROS & CONS OF ONLINE MEDICAL

EDUCATION

ACADEMIC YEAR: 2017-2022

BATCH: D

DEPARTMENT OF COMMUNITY MEDICINE

CMH KHARIAN MEDICAL COLLEGE, KHARIAN CANTT.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

APPROVAL SHEET

Head of Department:

Prof. Dr. Abrar Hussain Syed

Supervising Faculty:

Dr. Iffat Noor

Dr. Tehreem Afza


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

CERTIFICATE

Batch D has completed this SRP titled ‘Pros & Cons of Online Medical Education’ as a

university requirement of experiential research training in the subject of community

medicine, under immediate supervision of the batch in charge, supervising faculty and head

of the department. All work is genuine and original data has been deposited and is an asset of

the department.

Sr.
No Roll no. Student’s Name Contribution Signature
1. 17-MC-081 Fareena Yasin Questionnaire, Data
collection, Literature
review.
2. 17-MC-086 Nimra Noor Questionnaire, Data
collection, Literature
review.
3. 17-MC-088 Hajirah Bibi Questionnaire, Data
collection, Literature
review.
4. 17-MC-089 Ahmed Naeem Data Collection.
5. 17-MC-091 Usman Ghani Questionnaire, Data
Mughal Collection.
6. 17-MC-094 Maryam Fatima Questionnaire, Data
Qumber collection, Abstract,
Literature review, Data
analysis, Methodology,
Results, Discussions,
References, Copy
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

editing, Proofreading,
Formatting.
7. 17-MC-097 Ayesha Ahmed Questionnaire, Google
form development, Data
collection.
8. 17-MC-099 Fizzah Arshed Questionnaire, Data
collection, Data
analysis, Results,
Discussion, References.
9. 17-MC-100 Fezan Fazal Sidhu Questionnaire,
Introduction, Data
Collection, Data entry.
10. 17-MC-103 Mohsin Riaz Questionnaire, Data
collection, Data Entry,
Conclusions,
Recommendations.
11. 17-MC-104 Mishal Ahmed Questionnaire,
Introduction.

Batch incharge: Mohsin Riaz


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

TABLE OF CONTENTS

Serial No. Title Page No.

1. Abstract 6

2. Introduction 8

3. Literature review 10

4. Materials and Methods 14

5. Questionnaire 16

6. Results 19

7. Discussion 22

8. Conclusions 24

9. Recommendations 26

10. References 27
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

ABSTRACT

ABSTRACT… Objective: To evaluate


the pros and cons of an online course
from medical
students’ standpoint. Study Design:
Cross Sectional study. Setting: At Al-
Tibri Medical College
and Hospital. Period: January 2020 to
May 2020. Material & Methods: After
taking ethical
approval, 200 students were equally
divided into basic medical sciences and
clinical sciences
based on convenient sampling. The
participants, after taken verbal consent,
lled a self-
designed questionnaire. The data were
analyzed through SPSS version 21.0 and
presented
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

in the form of frequency and percentage.


The Chi-square test was applied, and the
level of
signicance was taken P=<0.05.
Results: Both medical and clinical
medical science students
were well-motivated in learning online
through online courses. However, the
lack of internet
facility, poor IT skills, and improper
facilitation by the faculty hindered their
progress towards
achieving good online education.
Conclusion: Improvement in the way
online courses are
delivered and taught by the faculty is
crucial in increasing student motivation
towards online
learning, but issues such as poor IT skills
and lack of internet facility must be
addressed to
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

provide an equal form of e-learning for


students.
ABSTRACT… Objective: To evaluate
the pros and cons of an online course
from medical
students’ standpoint. Study Design:
Cross Sectional study. Setting: At Al-
Tibri Medical College
and Hospital. Period: January 2020 to
May 2020. Material & Methods: After
taking ethical
approval, 200 students were equally
divided into basic medical sciences and
clinical sciences
based on convenient sampling. The
participants, after taken verbal consent,
lled a self-
designed questionnaire. The data were
analyzed through SPSS version 21.0 and
presented
9
PROS AND CONS OF ONLINE MEDICAL EDUCATION

in the form of frequency and percentage.


The Chi-square test was applied, and the
level of
signicance was taken P=<0.05.
Results: Both medical and clinical
medical science students
were well-motivated in learning online
through online courses. However, the
lack of internet
facility, poor IT skills, and improper
facilitation by the faculty hindered their
progress towards
achieving good online education.
Conclusion: Improvement in the way
online courses are
delivered and taught by the faculty is
crucial in increasing student motivation
towards online
learning, but issues such as poor IT skills
and lack of internet facility must be
addressed to
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

provide an equal form of e-learning for


students.
Background: In December 2019, the first case of COVID was reported in Wuhan, China. It

was declared a global pandemic by WHO in March 2020, and all countries individually

imposed a lockdown for prevention of spread of disease. Due to this effective lockdown, all

educational institutes shifted their instruction to online mediums.

Objective: To assess the advantages and disadvantages of online medium of learning from

the perspective of medical students.

Study Design: Cross Sectional study with convenient sampling.

Setting: CMH Kharian Medical College.

Period: July 2021 to August 2021.

Material & Methods: After the concerned committee’s approval, gave their informed

consent and filled a self-developed questionnaire. The data was analyzed through SPSS

version 20.0 and Chi-square test was applied, and the level of significance was taken P<.0.05.

The data was finally presented in the form of percentages.

Results: After the emergence of the pandemic and application of an effective lockdown, the

medical students anticipated learning well through online classes. However, the lack of

proper training in software usage, stable internet connection, poor IT skills and, improper

management of the curriculum by the concerned faculty greatly hindered the learning process

for the students, as well as reduced concept building and development of practical skills.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

Conclusion: Improvement in the instructive aspect of online education by the faculty is

crucial in potentiating student response and their adaption to online learning, but problems

such as diminished IT skills, mismanagement of the curriculum, and unavailability of the

internet facility must be addressed to provide effective and sufficing e-learning for students.

Key Words: COVID-19, Online learning, Medical Students, Pros and cons, Barriers, Need

of Improvement in instruction.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

INTRODUCTION

On 31 December 2019, WHO was informed of cases of pneumonia of unknown origin in

Wuhan City, China. A novel coronavirus was identified as the only cause by the Chinese

authorities on January 7, 2020, and was temporarily named “2019-nCoV”. It was declared as

a global "pandemic" by WHO on March 11, 2020, and was labeled as an "airborne virus".

Considering the field of medicine, Covid-19 has deeply affected all the aspects of medical

education as well as profession. The online medium of education can be a highly effective

alternative method of education for the students who are at a mature age, self-disciplined,

motivated, well organized, and have a high degree of time management skills, but it is an ill-

suited method of learning for more dependent learners who have difficulty assuming

responsibilities required by the online courses.

The pandemic has crippled the socioeconomic and educational system of the whole world. In

Pakistan, where having access to learning facilities is considered a privilege, Covid-19 has

challenged the old ways of learning and made it extremely crucial for students to learn

effectively. The typical on-campus classes were suspended during the spring of 2020 to

ensure the safety of the students, instructors, and patients. All the educational institutions had

to switch their academic programs to E-learning. In Pakistan, medical schools specially had

not anticipated and were not prepared for such a massive transition of the learning medium.

Although students have already been familiarized with online textbooks, study guides, digital

lectures, and online-based exams in the preliminary stages, most of the institutions lacked

appropriate strategies for application of E-learning which affected the learning process to a
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

great scale. It has been accredited that online institutional methods are effective tools for

learning however it can be potentially challenging for students because of the restricted two-

way communication. The system used by different institutions, including CMH Kharian

Medical College comprised of online lectures, online case-based learning (CBLs), YouTube

video links, and dry labs (online lab demonstrations). After 9 to 11 months of online learning

we, the research team of CMH Kharian Medical College, decided to analyze the pros and

cons of this system. The major goal of this research study is to determine the level of

students’ satisfaction regarding E-learning, raising the question of whether the education

should be switched to E-learning permanently.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

LITERATURE REVIEW

The following subdivision presents a reflection on the antecedent studies conducted regarding

E-learning during the COVID-19 pandemic, and some reflect challenges and educational

technology during online learning. It is centered on the findings of previously conducted

researches and the topics of online medical education, the challenges faced by the teaching

faculty, and the perspective of medical students on this conundrum.

A study was conducted at Al-Faisal University, College of Medicine in Riyadh (Saudi

Arabia) that constituted a sample size of 208 participants. It investigated the learning

challenges faced due to remote learning in medical education during global lockdown(Rajab,

Gazal et al. 2020). The challenges relayed were regarding communication, assessments, e-

learning experience, time management, use of information technology, and COVID-19 stress.

However, students showed a positive response towards the efficacy of online learning during

the lockdown. A meta-analysis study was conducted (Yildiz, Cengel et al. 2020) regarding

the modern developments in educational technology during 2015-2020 which divulged

several significant factors in the field. One such article published by the editorial board

(Liguori and Winkler 2020) about the impact of this global crisis on remote learning,

analyzed the significance of online learning and investigated the strengths, challenges,

weaknesses and prospects of online education in the duration of effective lockdown (Dhawan

2020). The study also presented basic guidelines for dealing with challenges that arise with e-

learning during pandemics and other natural disasters.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

A study conducted on the students of both British and Helena universities in Egypt showed

the discrepancy in student motivation and engagement in online e-learning however there was

a clear difference between the basic medical sciences students and students of clinical

sciences who require more clinical and bedside training to develop skills of examination, to

infer a diagnosis, and to treat the condition. In contrast, the basic medical sciences students

currently studying theoretical aspects of medicine don’t require hands-on patients dealing for

learning the subject during this global emergency. Therefore, students studying theoretical

subjects preferred the online medium of instruction and didn’t provide the researchers with a

clear understanding (Yeni Absah and Harahap 2021). This can also be seen in a study

conducted on first-year medical students of a medical school in Denmark who were in favor

of replacing on-campus learning with e-learning. However, student groups failed to fully

commit to online learning and realized that online learning was neither stimulating nor

nondescript and it made it difficult for students to learn the allocated subjects properly.

Students’ motivation is an integral part of online learning even though the online courses are

not up to the mark or even if they have poor internet access. Students from both groups also

highlighted a reduction in instructors’ motivation and reported improper and incoherent

communication between the facilitator and the students. This is one of the many reasons why

students have not been able to commit to online courses completely. If this communication

gap prevails among the students, and there is no significant improvement in online teaching

then the students will suffer significantly which in result would impact their examinations

and their careers in the future as clinical practitioners. A study conducted on 214

undergraduates and graduate students showed instructors that ‘verbal immediacy’ is a

significant predictor of frequency of online and highlighted that they must develop a different

approach towards the development of communication skills that reduces the social and

psychological distance during online learning. Therefore, faculty must develop a way to
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

provide effective online education to their students and create a motivational style of teaching

to ensure student participation to the fullest. There is also an integral lack of IT skills among

basic and clinical medical science students as well as the instructors. Another similar study

displayed similar results when conducted among 171 first-year medical students at the

University of Jordan, indicating that most students had an average or somewhat advanced

knowledge of using the computer and internet. Furthermore, the study also found that

connectivity issues, lack of time and resources are still notable constraints for students.

Another study was done at the University of Edinburgh in which 144 third-year students were

assessed for their degree of computing skills and the level of aplomb in carrying out tasks and

it signified that the students did not have the confidence to carry out simple tasks. Therefore,

a special course must be incorporated into the curriculum of medical education to acquire

necessary IT skills. Furthermore, three previously conducted studies were found that were in

staunch favor of online learning from Pakistan. Two studies at Lahore medical and dental

college and the University of Health Sciences Karachi reported higher degrees of students’

satisfaction in regards to e-learning technology. The study from Khyber Pakhtunkhwa

investigated the feasibility of online learning among students, trainees, and faculty members

they reported a good technology assessment, IT skills, preparedness for online discussions

among participants across the medical education nexus (Khan, Zulfiqar et al. 2021).

A cross-sectional study was conducted (Khan, Zulfiqar et al. 2021) in which a sample

of 100 students from basic Medical Sciences and 100 students of clinical Medical Sciences

was selected for the study based on the convenient sampling technique and data was collected

through an online process. They were then asked to fill the questionnaire after giving

informed consent, in which they needed to answer the formulated questions for the study. It

concluded that students are well motivated to take online sources for learning medical

education. However, many hindrances when it comes to delivering efficient online instruction
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

to students of Medical Sciences. A survey was conducted by the International Association of

Universities 2020 about the global impact of COVID-19 on the higher education institutes the

findings of the study indicated that all the activities of the participants have been affected by

the COVID-19 crisis. There was also a study conducted that focused on student’s and

faculty’s satisfaction in the online learning model at Al-Qassim University Saudi Arabia, that

concluded that electronic learning mode is an advancement in education, but significant

modifications are needed to improve online learning. This review also identified various

challenges posed by online education on the current medical curriculum faced by both faculty

members and students and various solutions were given for the resolution of these challenges

(Khalil, Mansour et al. 2020).


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

METHODOLOGY

After the concerned committee’s approval, a cross-sectional study was conducted at CMH

Kharian Medical College from July 2021 to August 2021. A total of 152 students from

MBBS (150) and BDS (2) participated in the study, and data was collected via an online

medium. The students were then asked to fill an online questionnaire after giving their

informed consent in which they had to answer questions by selecting their preferred choices.

The questionnaire was then collected, and the data was analyzed using SPSS version 20.0.

The chi-square test was applied, and the level of P significance was kept at <.05. The data

once analyzed using SPSS, was then tabulated and presented in frequency and percentage

form.

STUDY DESIGN: It is a descriptive cross-sectional study.

SETTING: The study is conducted among MBBS and BDS students of various medical

colleges.

DURATION: July 2021 to August 2021.

SAMPLING TECHNIQUE: Probability convenient sampling.

SAMPLE SIZE: 152 students.

SAMPLING SUBJECTS:

Sampling procedure is done based on inclusion and exclusion criteria’s.

 Exclusion criteria: Non-medical students.

 Inclusion criteria: All years of study in MBBS and BDS.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

No gender specification, both boys and girls took part in the research.

DATA COLLECTION TOOL:

 Questionnaire was communicated through a Google form link.

 The data was collected through by self-assessment questionnaire.

 The participants were asked to fill out the questionnaire which was proceeded

by demographic details providing information about the (a) age (b) gender and year of

study.

 The questionnaire comprised of 21 close-ended questions.

DATA ANALYSIS PLAN: Data analysis was performed using IBM Statistical Package for

Social Science (SPSS) software.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

QUESTIONNAIRE

SECTION 1

Age: _________

Gender: __________

Email address: ______________

Residence: __________

Name of Institution: __________

Education: ____________

Academic year: ___________

Informed consent:

You are being invited to take part in a research study. This survey is being carried out by a

research team in CMH Kharian Medical College, aimed at providing information about ‘Pros

& Cons’ of online system of Medical Education. All data will be kept confidential by the

team, as your privacy is our priority. You are free to fill out this survey anonymously &

voluntarily.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

SECTION 2

PROS AND CONS OF MEDICAL EDUCATION


YES NO
QUESTIONS
1. Are you a Male or Female?

2. Residence

3. Have you taken online classes?

4. Did you find online lectures troublesome for your eyes?

5. Did reduced interaction with your teacher play a role in low

grades?

6. Was it stressful for you being taught remotely during COVID-

19 pandemic?

7. Did you face any problem regarding the use of

software/applications required for online learning?

8. Was attending online classes an issue to students due to

unavailability of internet?

9. Was study discussion with friends a major problem during

online lectures?

10. Was non-availability of library a major issue during online

classes?

11. Were online videos on different topics a better source of

building concepts than online lectures?

12. Did you gain any practical experience regarding your


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

profession through online teaching?

13. Was it easy for you to do an effective case-based learning

online?

14. Did you have sufficient time to complete your assigned home

tasks?

15. Were online exams easier as compared to on-campus exams?

16. Do you think online learning proved to be more fruitful than

on campus learning?

17. Did online learning reduce your living costs?

18. Do you think online education contribute to the development

of student’s independence and skills of self-education?

19. Did teachers respond promptly to questions?

20. Do you think technology used for online classes was

appropriate?

21. Would you prefer online education in future?

Table 1.1
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

RESULTS

SECTION 3

Frequency and Percentile table of response

by the participants and level of YES NO P

significance after Chi-square test Value

1. Are you a male or female? MALE FEMALE 0.928

40.8% 9.2%

2. Residence URBAN RURAL 0.843

7.6% 22.4%

3. Have you taken online classes? 100% 0%

4. Did you find online lectures troublesome 89.2% 7.1% 0.641

for your eyes?

5. Did reduced interaction with your teacher 71.1% 28.9% 0.676

play a role in low grades?

6. Was it stressful for you being taught 81.6% 18.4% 0.713

remotely during COVID-19 pandemic?

7. Did you face any problem regarding the 62.5% 37.5% 0.741

use of software/applications required for

online learning?

8. Was attending online classes an issue to 69.1% 30.9% 0.270

students due to unavailability of internet?

9. Was study discussion with friends a major 71.7% 28.3% 0.593


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

problem during online lectures?

10. Was non-availability of library a major 48.0% 52.0% 0.118

issue during online classes?

11. Were online videos on different topics a 84.2% 15. 8% 0.511

better source of building concepts than

online lectures?

12. Did you gain any practical experience 15.8% 84.2% 0.737

regarding your profession through online

teaching?

13. Was it easy for you to do an effective case- 19.7% 80.3% 0.286

based learning online?

14. Did you have sufficient time to complete 66.4% 33.6% 0.262

your assigned home tasks?

15. Were online exams easier as compared to 60.5% 39.5% 0.826

on-campus exams?

16. Do you think online learning proved to be 19.1% 80.9% 0.157

more fruitful than on campus learning?

17. Did online learning reduce your living 71.1% 28.9% 0.699

costs?

18. Do you think online education contribute 38.2% 61.8% 0.961

to the development of student’s

independence and skills of self-education?

19. Did teachers respond promptly to 71.1% 28.9% 0.676

questions?

20. Do you think technology used for online 48.0% 52.0% 0.179
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

classes was appropriate?

21. Would you prefer online education in 22.4% 77.6% 0.285

future?

Table 1.2

As shown by the following chart, most of the students don’t prefer online education in the

future.

Would you prefer online education in future?


Yes No

22%

78%

Figure 1
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

DISCUSSION

The majority of the students of medical sciences are residents of the urban areas having

access to the basic amenities of life and a broadband internet connection. Despite the

availability of Wi-fi/ethernet, most of the students faced connectivity issues due to the

unavailability of a stable internet connection.

Moreover, more than half of the student population who filled the online questionnaire have

the opinion that the technology used for the commencement of online classes was

inappropriate and not suited to their educational needs.

The majority of the student population also report online mediums of education to be

troublesome for their eyes due to continuous and extended usage of digital screens. Digital

fatigue has been a common recurrence with remote learning. Most students also faced issues

regarding the operative usage of software/applications required for online learning.

The larger proportion of the student population has the opinion that they couldn't do effective

case-based learning online as there was no interaction with the patients or any room for group

discussion. As far as practical experience is concerned, most of the students find that they did

not develop basic bedside skills and techniques, as well as possessed reduced knowledge of

lab and practical work. A considerable percentage of students also believe that online

education did not contribute to the development of student independence and skills of self-

education.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

In the percentage results, it is clearly visible that a huge proportion of students found online

videos on various topics to be more helpful than the actual online classes and found online

learning to be sufficiently less fruitful than on-campus classes and prefer on-campus classes

instead of online learning.

A significant fraction of students also believes that reduced interaction with their professors

played a significant role in lower grades. It also presents with lack of group discussions

among students. Many students also found E-learning to be very stressful in reference to all

the discussed cons above.

Many students were in huge favor of the statement that online learning reduced their living

costs and found online exams to be easier than on-campus exams. Regardless of these two

factors, a considerable majority does not prefer to be taught online in the future and prefers

on-campus classes.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

CONCLUSIONS

The study was conducted to determine the advantages and disadvantages of the online mode

of medical education considering the viewpoint of medical students. Although the world had

already transferred to online system of education before covid-19, medical education also had

to be shifted to the online medium because of the prevailing conditions of lockdown imposed

by the Government. Considering the broader horizon, online education has been an absolute

disaster for medical education as this field involves a lot of practical work in labs and

hospitals. The same was observed by this study and the major conclusions were:

 The majority of the students felt the online system of medical education to be

at loss as compared to on-campus education. They were demotivated due to the

prevailing Covid-19 scare and lockdown had made the life increasingly excruciating

for them. Handling the pressure of medical education that too via online system was

very taxing for them.

 Availability of a steady internet connection was a major issue faced by the

students since Pakistan is still a developing country and the provision of a stable and

uninterrupted internet connection to every city and town is a big challenge.

 Reduced student-teacher interaction, separation anxiety, difficulty in using the

assigned software for attending lectures and lack of practical experience led the

students to believe that the online mode of medical education was ill-suited to their

educational needs.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

 The only plus point observed after analyzing the results was that the online

system of medical education reduced living costs for the students as they were

learning from their homes throughout the year.

 Due to all these liabilities, the majority of the students opted not to prefer the

online system of medical education in the future.


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PROS AND CONS OF ONLINE MEDICAL EDUCATION

RECOMMENDATIONS

The quality of the ‘online system of Medical Education’ can be improved by taking the

following measures:

 Provision of a stable internet connection to all students to minimize

connectivity issues.

 Selection of user-friendly, and efficient software/applications to deliver

lectures.

 Reduction of screen time by creating a schedule that incorporates breaks for

the students to avoid digital fatigue.

 Development of effective communication between the students and the

teaching faculty to abridge the communication gap between them.

 Lectures should be made more palatable, innovative, and easier to develop and

hold the interest of the students.

 Proper guidance supplemented with necessary training regarding the usage of

technology should be given to both teachers and students to enhance their IT skills.
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PROS AND CONS OF ONLINE MEDICAL EDUCATION

REFERENCES

Dhawan, S. (2020). "Online learning: A panacea in the time of COVID-19 crisis." Journal of
Educational Technology Systems 49(1): 5-22.

Khalil, R., et al. (2020). "The sudden transition to synchronized online learning during the COVID-19
pandemic in Saudi Arabia: a qualitative study exploring medical students’ perspectives." BMC
medical education 20(1): 1-10.

Khan, H., et al. (2021). "Pros and cons of online course from medical student’s standpoint." The
Professional Medical Journal 28(03): 387-391.

Liguori, E. and C. Winkler (2020). From offline to online: Challenges and opportunities for
entrepreneurship education following the COVID-19 pandemic, SAGE Publications Sage CA: Los
Angeles, CA.

Rajab, M. H., et al. (2020). "Challenges to online medical education during the COVID-19 pandemic."
Cureus 12(7).

Yeni Absah, B. K. and R. H. Harahap (2021). "Strategies to improve student satisfaction through the
quality of online learning facilities and infrastructure, characteristics of academic staff, lecturers
competence, and good university governance in Medan."

Yildiz, E. P., et al. (2020). "Current trends in education technologies research worldwide: Meta-
analysis of studies between 2015-2020." World Journal on Educational Technology: Current Issues
12(3): 192-206.

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