379 A/&/J 3C3i THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF FIELD OF PRESENTATION AND CUEING DISSERTATION Presented to the Graduate Council of the University of North Texas in Partial Fulfillment of the Requirements For the Degree of DOCTOR OF PHILOSOPHY By Vicki Marlene Soukup Denton, Texas August, 1992
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379 A/&/J 3C3i
THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS
WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF
FIELD OF PRESENTATION AND CUEING
DISSERTATION
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
DOCTOR OF PHILOSOPHY
By
Vicki Marlene Soukup
Denton, Texas
August, 1992
379 A/&/J 3C3i
THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS
WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF
FIELD OF PRESENTATION AND CUEING
DISSERTATION
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
DOCTOR OF PHILOSOPHY
By
Vicki Marlene Soukup
Denton, Texas
August, 1992
Soukup, Vicki Marlene, The Assessment of Cognitive
Functioning among Patients with Unilateral Visual Neglect:
Effects of Field of Presentation and Cueing. Doctor of
correlations for the neglect measures and MFD scoring
systems were confirmed.
Results are interpreted in terms of increased
attentional demands and task complexity. These results
suggest that, despite the frequent clinical use of these
manipulations in the cognitive assessment of this
population, support for the efficacy of these procedures is
lacking.
TABLE OF CONTENTS
Page
LIST OF TABLES iv
LIST OF ILLUSTRATIONS V
Chapter
I. INTRODUCTION 1
Anatomical Correlates Animal Literature Theories of Neglect Incidence of Neglect Recovery of Function Assessment of Neglect Factors Affecting the Manifestation of Neglect Independent Deficit or Global Cognitive
Deterioration Defective Performance on the Raven's Coloured
Matrices Memory-for-Designs Test Summary and Statement of Hypotheses
II. METHOD 4 0
Subjects Procedure Instruments
III. RESULTS 50
IV. DISCUSSION 59
APPENDICES 68
REFERENCES 107
i l l
LIST OF TABLES
Table Page
1. Sample Characteristics and Group Performance
on Screening Measures 72
2. Clinical Data for Neglect Subjects 74
3. Clinical Data for RBD W/0 Neglect Subjects . . 75 4. Correlation Matrix for Subject Characteristics,
Screening Measures, and Dependent Variables . . 76
5. Group Means and Standard Deviations for the Raven's Coloured Progressive Matrices (RCPM) and the Memory-for-Designs (MFD) Tests . . . . 79
6. Tests for Equality and Compound Symmetry for the Dependent Variables 80
7. Analysis of Variance with Repeated Measures on One Factor for Raven's Coloured Progressive Matrices (RCPM) Scores 81
8. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Graham-Kendall Scoring) 82
9. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Modified Taylor Scoring System) 83
10. Components Found to Influence the Expression of Neglect 84
11. Comparison of RCPM Group Performance for RBD Patients and Controls 87
IV
LIST OF ILLUSTRATIONS
Figure Page
1. Raven's Coloured Progressive Matrices Group Means for Each Presentation 55
2. Memory-for-Designs Mean Error Scores (Graham-Kendall Scoring System) 56
3. Memory-for-Designs Mean Error Scores (Modified Taylor Scoring System 57
CHAPTER I
INTRODUCTION
Converging evidence from neurophysiological and
clinical studies points to the presence of a neuronal
apparatus in each hemisphere which functionally mediates the
shift of attention and of head and eye movements to the
contralateral space. This mechanism implements its scanning
as soon as a novel stimulus appears; however, if this
mechanism is disrupted by a unilateral lesion, the patient
is no longer aroused by events occurring in that space and
will not respond to them (De Renzi, Gentilini, Faglioni, &
Barbieri, 1989). This phenomenon is known as unilateral
neglect, but has also been referred to in the literature as
unilateral spatial neglect, hemispatial agnosia,
hemi-inattention or hemi-neglect (Fox, 1983).
Initially described by Oppenheimer (1883) and by Holmes
(1919), and then discussed in detail by Brain (1941),
unilateral spatial neglect was regarded as a disorder of
attention confined to one-half of space. In Brain's three
patients, large right parietal lesions were present. Brain
(1941) concluded that visual neglect was usually seen after
damage to the right hemisphere, and was thus encountered as
left visual neglect. He indicated that the symptom was not
due to visual-field or oculomotor abnormalities.
1
Brain damaged patients demonstrating neglect are
unaware of body side or extrapersonal space contralateral to
the site of the lesion. In severe cases, the affected
individual persistently lacks awareness of sensory stimuli
in the affected hemifield (Critchley, 1966). In other
cases, lack of awareness is manifest episodically, only when
there are simultaneous competing sensory stimuli in the
normal hemifield (eg., Heilman & Valenstein, 1972b).
Typical behavioral manifestations have been described in
terms of failure to complete the left side of drawings
(Colombo, De Renzi, & Faglioni, 197 6), to respond to oral
commands from the left side of space (Heilman & Valenstein,
1979), to eat food from the left side of the plate, and to
recognize the limbs on the left side as his/her own
(Friedland & Weinstein, 1977).
Neglect can occur for stimuli presented in the visual,
auditory, or tactile modalities, but Riddoch and Humphreys
(1983) contend that patients rarely demonstrate neglect in
all of these modalities. Conceptual neglect has been
documented in the studies by Bisiach and Luzzatti (1978) and
a distinct, nonsensory form of motor neglect has been
described by Laplane and Degos (1983). Halsband, Gruhn, and
Ettlinger (1985) identified 30 individuals as having neglect
from a sample of 84 unilaterally injured patients, with 20
of these patients showing only one form of neglect and 10
subjects revealing various combinations of neglect.
Analysis of patient performance indicated that mixed neglect
seems to differ qualitatively from unimodal neglect. Mixed
neglect, tactile, and motor neglect were reported as easy to
discriminate from other kinds of neglect; whereas, visual
and auditory neglect were less easy to discriminate,
particularly from patients without neglect.
Anatomical Correlates
Instances of neglect have traditionally been considered
to occur following lesions in the right parietal lobe
(Brain, 1941; Critchley, 1966). More recent case studies,
however, have reported virtually identical and in certain
instances, more persistent and severe inattention to the
left extrapersonal space after right hemisphere lesions in
the frontal lobe (Heilman & Valenstein, 1972b; Stein &
Volpe, 1983), the thalamus (Watson & Heilman, 1979; Watson,
Valenstein, & Heilman, 1981) and the basal ganglia (Damasio,
Damasio, & Chui, 1980). These findings are consistent with
models that propose multiple cerebral structures, including
the posterior parietal and the frontal cortex, are involved
in a neural network responsible for the modulation of
directed spatial attention (Mesulam, 1981).
The data presented by Vallar and Perani (1986), using
CT-scans of 110 right hemisphere stroke patients, has
provided support for the traditional view that neglect is
more frequently associated with retrorolandic damage. Their
results indicated that the inferior parietal lobule was the
area most frequently involved in patients with cortical
lesions showing signs of neglect. In their analysis,
frontal lesions and damage confined to the subcortical white
matter were rarely found to be associated with neglect.
When the lesion was confined to deep structures, neglect
occurred much more frequently when grey nuclei such as the
thalamus and basal ganglia were damaged.
On the other hand, evidence presented by Spiers and
colleagues (1990) lends support for the role of frontal
activity in neglect symptomatology. These researchers
examined hemispheric asymmetries in the spatial distribution
of attention using a rather unique paradigm involving the
artificial induction of neglect via intracarotid sodium
amobarbital tests. Scanning performance was correlated with
EEG activity, in an effort to identify the anatomic locus of
control for directed attention to extrapersonal space. The
results indicated that disruption of scanning and
contralateral neglect occurred only after right hemisphere
suppression and seemed specifically related to changes in
right frontal lobe EEG activity. The resolution of neglect
appeared to coincide most closely with the resumption of
normal electrophysiological activity in the frontal areas.
This pattern of performance was revealed for right handed
and left handed subjects, as well as those who had right
hemisphere language dominance. While this study provides
strong support for the presence of a lateralized attentional
network, further investigation with a nonCNS impaired
sample, as opposed to epileptic patients, is warranted.
Also, consistent findings revealed via PET neuroimaging
would provide strong confirmatory evidence to resolve these
anatomical foci disputes.
Animal Literature
The experimental evidence provided by ablation studies
in animals has yielded some interesting findings concerning
the lesion site controversy. In monkeys, contralateral
multimodal sensory neglect has often been produced by
concerning the screening measures and the relationship
between the two scoring systems for the MFD were
investigated. The two measures employed for detection of
neglect (i.e., the Bells Test and the SLB) yielded
substantial correlations, ranging from .65 to .90. These
results not only confirm the predictions generated in this
study, but also provide additional validation data for the
recently introduced Bells Test. According to the test
developers, this measure is sensitive for detection of mild
and moderate neglect and is more suitable for use during the
rehabilitation period of recovery (Gauthier et al., 1989).
In contrast, the less complex visual scene, like Albert's
Test (Albert, 1973) is routinely used to elicit striking
neglect in severe cases and more commonly employed during
acute stage assessment. Results from the present study
suggest that, in spite of apparent differences in task
requirements or level of perceived difficulty, the two
measures demonstrate marked agreement in their ability to
tap manifestations of neglect. Furthermore, the congruence
between the two instruments exists not only for those
66
patients examined at different stages of recovery, but also
for those patients exhibiting varying degrees of severity.
Similarly, a secondary concern of this study predicted
significant correlations between the two MFD scoring
systems. The findings support the proposed relationship,
revealing correlations ranging from .68 to 90. Contrary to
speculations concerning the deficiencies of the initial
system, these results suggest that the two scoring systems
provide a relatively consistent picture of the perceptual,
motor, and memory deficits associated with brain
dysfunction. Furthermore, these similarities are revealed
in samples that have traditionally been characterized as
exhibiting inconsistent performance (i.e., the RBD
patients), pronounced variability within the sample (i.e.,
the elderly control subjects), and substantial dysfunction
in this cognitive domain (i.e., the neglect group).
There are several limitations of the study that deserve
mention. Due to time constraints, no formal estimates of
premorbid IQ were obtained. More importantly, considerable
neglect group variability characterized the current neglect
sample. While the overall RBD severity level of the neglect
sample was in the moderate to severe range of impairment,
all levels of severity were represented in the neglect
group. On the other hand, the nonneglecting group revealed
an average RBD impairment rating of mild to moderate, and by
definition, represented a less impaired RBD group. The
67
failure to equate the RBD groups on degree of impairment and
premorbid intellectual factors may have posed limitations in
interpretation. Also, since admissions were screened for
participation in the study, there may have been a selection
factor in operation. Attempts were made, however, to
procure a representative sample, since patients were
selected from both a full-service medical facility as well
as a rehabilitation hospital. Finally, data pertaining to
lesion location and extent of damage were relatively crude
and nonspecific, restricting speculations about anatomical
correlates.
At the present time, replication studies designed to
confirm these initial findings are warranted. Future
studies that address the extent and course of recovery
following stroke, according to levels of severity, are
recommended.
APPENDIX A
INFORMED CONSENT
68
69
Informed Consent Form
I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.
I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.
I have been informed that any information obtained in this study will be recorded with a code number to ensure that all information remains anonymous. At the completion of the study, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. Under this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.
I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to me on the rehabilitation unit at St. Joseph's Hospital.
If I have any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).
Date Participant
Date Investigator
Date Witness
THIS PROJECT HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.
70
Informed Consent Form
I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.
I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.
I have been informed that any information obtained in this study will be recorded with a code number to ensure that all infprmation remains anonymous. At the completion of the study;, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. U;nder this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.
I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to( me at the Baylor Institute for Rehabilitation.
If I haye any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).
Date ; Participant
Date Investigator
Date ; Witness
THIS PROJECT! HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.
APPENDIX B
TABLES
71
72
Table 1
Sample Characteristics and Group Performance on Screening
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Table 5
Group Means and Standard Deviations for the Raven's Coloured
Progressive Matrices (RCPM^ and the Memorv-for-Desian fMFDl
Tests
Neglect RBD w/o Neglect
Controls
RCPM (Mean number correct on 12 items)
Standard* M 4.67 7.89 8. 06
SD 1.41 2 . 63 2 . 01
RH** M 5. 39 7.72 8.11
SD 2 .17 1.96 2.25
RH + L*** M 5.11 7.94 8 . 00
SD 1.78 2.46 2 . 28
MFD Errors (Graham-Kendall Scoring)
Standard* M 6.83 2.83 2 . 61
SD 3.31 3.15 2 . 09
RH** M 6.72 3 . 11 2.67
SD 3.46 2.85 2.77
RH + L*** M 6.33 3 .72 2.50
SD 4.23 3.49 2 . 01
MFD Errors (Modified Taylor Scoring)
Standard* M 8 .17 3 . 83 3.44
SD 3.11 2.46 2 . 01
RH M 8.28 3.56 3.22
SD 3 . 08 2.73 2.37
RH + L M 7.78 4.44 3 .17
SD 4 .49 3 .11 1.72
Note. =
Condition;
Standard Presentation; ***
* * = Right Hemispace
Right Hemispace Plus Left Cue Condition,
80
Table 6
Tests for Equality and Compound Symmetry for the Dependent
Variables
Dependent Variables
RCPM MFD-GK MFD-MT"
Test for Equality
Chi Square* 9.07
df 12
Test for Compound Symmetry
Chi Square** 4.31
df 4
24.75
12
2 .18
4
18 . 61
12
6.83
4
1
Raven's Coloured Progressive Matrices
^Memory-for-Designs Test (Graham-Kendall Scoring)
3Memory-for-Designs Test (Modified Taylor Scoring) *Critical value (.99) = 26.2 ** Critical value (.99) = 13.3
81
Table 7
Analysis of Variance with Repeated Measures on One Factor
for Raven's Coloured Progressive Matrices (RCPM} Scores
Source Sum of Squares
df MS F E
A (group) 303.49 2 151.75 18.29* <.001
Subjects Within Group 423.15 51 8.30
B (condition) o CM •
rH 2 . 60 . 22 .80
AB 4 .17 4 1. 04 . 39 .82
B X Subjects Within Group 273.96 102 2 . 69
82
Table 8
Analysis of Vciriance with Repeated Measures on One Factor
for Memory-for-Designs CMFD) Test (Graham-Kendall Scoring)
Source Sum of Squares
df MS F E
A (group) 509.48 2 254.74 11.82* <.001
Subjects Within Group 1098.96 51 21. 55
B (condition) .26 2 . 13 . 03 .97
AB 9.93 4 2.48 . 66 . 62
B X Subjects Within Group 381.81 102 3 . 74
83
Table 9
Analysis of Variance with Repeated Measures on One Factor
for Memory-for—Designs (MFD) Test (Modified Tavlor Scoring
System
Source Sum of Squares
df MS £ P
A (group) 729.05 2 364.52 20.15* <.001
Subjects Within Group 922.70 51 18.09
B (condition) .53 2 .27 . 08 .93
AB 10.17 4 2 . 54 . 73 . 57
B X Subjects Within Group 353.96 102 3 . 47
84
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APPENDIX C
SCHENKENBERG LINE BISECTION TEST
88
89
APPENDIX D
THE BELLS TEST
90
91
4
• *
* •
92
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APPENDIX E
RAVEN'S COLOURED PROGRESSIVE MATRICES (RCPM)
SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION
94
B 8 95
W)
r -
I -
i
5
J
96
1) 3 CM CO
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00 00
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APPENDIX F
MODIFIED TAYLOR SCORING INSTRUCTIONS
MEMORY-FOR-DESIGNS (MFD) TEST
97
98
Memory-for Designs Test
(Modified Taylor Scoring System)
General Instructions
Judging the figures one at a time, tally the appropriate
number of points for each error. Note that any individual
figure may score in several of the error categories. Points
may be given to a single figure for errors of rotation and
omission and distortion, etc., or any figure may be found to
score in only one category, or in no category.
After scoring all figures for each of the first six
categories, then score for Organization.
Total the number of tallies in each of the seven
categories and sum them. This grand total is the subject's
Total score.
Omission:
Distortion:
Scoring Categories Defined
If half or more of the figure is omitted,
score 2 points. If any part or line (but
less than half the figure) is omitted,
score 1 point.
If the overall gestalt of the figure does
not agree with the stimulus figure, or if
any portion of a figure is out of
proportion by more than about 50%, score
1 point. Do not score this category if
the discrepancy between reproduction and
99
3. Rotation:
4. Reversal:
Perseveration:
stimulus is caused solely by omission,
rotation, or reversal, etc.
Score 1 point in this category when the
figure as it is reproduced represents the
stimulus as though it were rotated about
its central axis. Rotation must be 45
degrees or more to be scored.
Score 1 point for reversal if the figure
or a proportion of the figure is drawn as
though the stimulus had been "flopped
over," either horizontally or vertically.
Note. Rotation represents the
figure as having been "spun around"—
reversal as though it had been "flopped
over." Generally there are fewer
possibilities of reversal, and reversal
must not be scored on Figures 1, 2, 7, or
8. When in doubt, check the illustrated
sample errors, and remember that the same
reproduction may contain both rotation
and reversal errors.
This might be called "carry-over effect"
and is scored for uncalled for
reproduction or partial reproduction of
any previous stimulus figure. No
perseveration score may be given on Figure
100
#1, as it represents the initial
stimulus.
6. Embellishment: Score 1 point for any addition of
uncalled for lines, loops, flags, boxes,
etc. to the figure, except where such
additions are clearly preservations from
previous figures.
Note. Distortion changes the
gestalt of the figure from that of the
stimulus; Embellishment maintains the
general gestalt, but adds extra frills or
adornments.
7. Organization: This category is based on the arrangement
of the figures on the paper relative to
numerical order of presentation. Only
scores of 0, 3, or 6 may be given in this
category.
For figures in orderly column or row
sequence with no more than one deviation,
score zero (0) points. For irregular
arrangement in which there is some order
but the figures do deviate more than once
from sequential column or row
presentation, score three (3) points.
For confused presentation score six (6)
points. This is for helter-skelter
101
distribution in which there appears no
pattern or sequential order of
presentation.
8. Total: This is the grand total of all points
scored in each of the preceeding seven
categories.
Bradford, D. C. (1978). Differences between groups of brain
damaged patients on the Memory-for-Designs test: A
comparison of two scoring systems. Unpublished doctoral
dissertation, University of Utah.
APPENDIX G
MEMORY-FOR-DESIGNS (MFD) TEST
SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION
102
103
104
APPENDIX H
RAW DATA
105
106
X LS_ O X H- <*O o O ( ^ ^ c c ^ r O T a 3 a ? w < j D C s i 0 ^ c n ^ o o ^ ( r j 0 ^ c D C > / ^ c ^ r \ j c n ^ ( o c n u n o ^ ^ < N c o r ) r o i j r ) i n c N j r ) , < c r u ^ o - H ( N i * - f r ) f s ! i n c \ j < j D L n *-4 «-4 *-4 —4 -H
X u . O X •— f \ f c n ^ c n u ^ c ^ ^ r c o r ^ — i r v j i / ^ c o a s r s j — 4 < X J O 3 C \ I — i O O ~ H i n i n c o ^ o c o ^ c g c o c s j c g c \ j c 0 L n ^ r ' ^ ( \ j r o - H ( o r s J t v ( o c o » - 4 O < * O c o O <-H *H »H »—I <—4 ^ —4
l u - Q S t - H * t c n ^ Q i j n c o < D i x » c N j c r r c s i a > ^ ^ O i n — i t n — i r o r s j c o - < c N j c » c N ^ c \ m a > c o < o c o c o — < c o c \ j ^ ^ o n c o c o L n — l O c o i n L n c g u o c s j c o — i W - H - 4 - H —I - H
l u - D O ^ n Q — < ^ « j n < T i C v j u i < 0 c o ^ — < o r s J t o r ^ c » r g 0 D O O 0 0 O - 4 O ~ 4 — 4 r 0 — 4 C o r ^ c o n c \ j H < x > < N J u ^ c ^ « f O H ^ c o O O t \ i c w O t f " > c o t o i , s r *>H W *H H H *-4
X L i - O O ^ f N i c & u ^ c 0 ^ o ^ ^ ^ c o < n c o e o n ^ c o c \ i t 0 i n u o - < o a o o c o c o e o c ^ o r ^ c o ( s j i / > — i c o c N h ^ o i ^ r ^ c \ i w o u " ) O O r o c o < \ i a » - t o r x . c > *-4 *-4 *-H
I i l O O ^ H « > ^ c o a ) Q L n o ^ r \ i c o c o c n O h - c s / < o o r o — < — < q c o o ^ W — t — < r \ i r o u 3 * t c o O — i - H L r t c o u " ) u - > c s i r \ i r N i C N j u " > o o < C N J C D O ^ O I / I O *H «-H •—( «H *—*
o c O CL X <*> u > c o ' * t ' t * L n c v ) h - ( r > o > ' * f t D * f c o « « 3 ' * t < o o , > f < > . o o - - - t ^ - i ^ . c D O ( D * H O * H < D t n o o i n i n ' H ' H L n o o o r ^ . i n i n O ( o o c ^ c w c n c r i L n c o o o f ^ o j c o *-4 —4 <-H »-4 •—4 —( —4 —» •—4 *H - H —4
O C Q C U X C S J tf>c^t^^i/jOO<Dknir)cv)<DootDi^,**tDtoinoo«-ttDtno),*toocooor^.oTir^-N>i,-»*-<oojtDN-f^{DUDoo»-^cooc3,)tDrvjLr)OcocvOf^ *H —< — 4 W —I «-* —1 —I —« —»
a : o c l X *—* tf>oinr^co"«Jincoh--iri<oroir)C,>in,**CDCDh«.*HcniftLnc?>'«j''Heo(McDi«3,r-CDOo>csir^Oh»«3meioooocn o o — < u n c r ) *H '<-4 i-H »H »H *—I «H *—4 •—I
O o < D » < » c N ^ o o O N u ^ ^ O i n ^ t n v n r v i r a a ) 0 0 r w o ^ a > i t N O « H 0 > c s i O O 0 5 r , ) r 0 i r j O - H 0 > < c f « E t ^ r c s < r , > i n ( v > f - * ' C n c r > * f - H O « 5 t ' - < c u O C N < » i n c r > < o c t t c o ^ r \ i c s j T f c ^ c o o > ^ r o i n C T > r \ i c v c r > ^ ^ - 4 i » o c \ j — i r ^ e o — i — < — 4 r ^ ^ t o e o c o ^ u 5 r ) c o w o — < u n O r ^ < ^ u o i j - > o o
h - t D C O a j O h - O O C O C O ? - - f < 0 — < f M t O ( N ( O r - » * e J ' - - 4 —i —I «-< f-» I CM r - O -H CN CO *H CMtD i n u i i d h c m »-«"a - C\J o —• W i f ) r s j —4 <M —I I * t ( CO t D —« «H —4 —4 <—I I | ! I t I I ( I f r-4
c t - t o o o o i n o o m i n o a i O ) N 0 0 5 ( o ^ * J H C o e o i n N n f M o e o i / i N W i n O ' - t t D < t f < D t \ i o o ^ N < » 0 ( o o ) c o H O ( D 0 3 N H ^ m r ) * t O c o c o o ^ c r > ( o < o ( 0 ^ c \ i ^ o c » a > < ^ r ^ ^ o o — 4 ^ — i r o o r ^ ^ ' t f i / i ^ r g o ^ t t o o " ' ? } ' — < « " H O c \ t , < a i ' C O ( o i n o , i > ^ c n c N j O r g L n c \ j ' * t o D — < o o
< t n o o ' t j f - ^ o r o m r N j i o n c o r s i o ^ t r s j c o — i c o t o r - - l o —< r - . u o <» c o r-- r - - i o o m r o c \ j c o o o i i n M h h h i c c o i o u n I <NI »H - H CO UO —4 I •—I i —4 CO "*t I "H 1 -H I I l i t I t I —i
<£ H < D ( N < 0 O n O H N f 0 0 0 < - t t / l L O h - 0O CO CO < I ( I S C J I I O H H l/"> i/> t CM "<t CM —I I LO —4 CO CO 0 0 f \ l *—5 *-4 C\! CO CO CO CD CO ! I LO I f - . - H — I I - H I ) I I I | I I I I [ H
X O O O O O O O O ^ O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O o CO - J CO
a CO t—I
X h o - t o o r o - H o r s i o — t T f O — " t o r o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o
0 0
X f O N ^ i / ) ( C N n N H H i n H H ( C l t f f M M O O O O O H O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O
CO
O ( v 5 « - H L O r ^ o ) f * - - t j ( 5 i x j * 3 - r ^ t o c o r o — l O t o o a x M O - H r j c s i c N — i — i c s j — i m n - H t j - — - i ^ i n ^ O O M N H O O i N M H ^ N H O O ' - J C J ' - t CNf CM CM - H N H ( \ l - t - H n fNJ f \ )
_ i U J CD > U J CO n c g < ' o ^ r i « e r < « c j ' L r ) r j * t T f ' 5 f ' d ' L n f O ' 5 3 - L n t o m c o c \ f c o - H c o — ( - > t L A - H C s i — t m L n c o * 3 - - H C s ( * H * j CO
X
X *—< e d CO t-H CK: —i i n ( j D t o r s j c y ) f o r ^ - f ^ . r o f o i r j c \ i u i 0 4 C v > c o L n * t m t o o o < x i a ) < » c \ f O i N ^ c o - H * i - t o i r > c o o r ) c n r ^
Z H Q ; £ D H I - O H M , « j ' 0 ) f f l h . * J O O O i D c r i i r ) ( 0 t » a ) N ^ ^ M ) 0 ( D ( N « a ' N t D ^ r j r v * j r v j ( M i n ( D i n O t D O •I«HO")C\JCNJ—«—<—4(NJ—i — 4 — i r s i C N t r s t r o c - j c o c o — < t " o c s i c o " - H ' — i r s i — I C O C O C O C N J
< Q X Q X t — l - H - H
X < 2 ! O
- t c o r o r o r o f o c o , < j p T « ^ - > t j c o c o c o ' ^ " < ? c o c o c o
Q - O O O - t o i - H c o r - c o ^ c o O T r s i C N J c o t o c o - H t o c o - H i o i - H c o o c n C T m — < c o < x i u ^ t o r o c ^ o o r o C T > 0 ( O L n , < 3 - c o a w < » c o u " > c r > C D O , « j f ' ^ C M * H c r i - 4 » H - H O - H { N C N I C O i r ) CM CO iTS t O •—(*J O O l N J —t CM —<—t —l CM —< — i n n •—( CO "H CO •—t *H *—4 *—i >—4 CM —< •—( «—4 •—< — K M - H C N J C O - h
< O U J ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ » ^ ^ o ^ o ^ r - ^ c n r o ^ r - H u ^ c s i r ^ r - - O c r i O c g r - - o < t c o o o o r g ( o c o r o a ) c o t o c o ^ O r ^ c » t o L r > 0 - - t O c o ( i > u ^ r ^ < o r ^ i X ) ^ c o t O { £ j L n u i u n r ^ r ^ c o o " > t o c i D r i ^ i ^ i ^ ^ u 5 ^ o o u ? o c x j o D c o c j D c o c r 5 w o o o r - - r - c o f - . h > h v f ^ f > > c n r - - r ~ . t O ( X 3 f ^ o o r -
CO 3 o a i—< Q ^ r J ^ ^ ^ f ^ ' ^ T O c ^ o ^ r ^ i c ^ ^ L ^ ) c o ^ - ^ ^ c s J r ; ^ u o u ^ ^ ^ c u c ^ ) 0 * - ^ c ^ J ^ O ' ^ r ^ u n o ^ ^ c o • - ^ r s ( f o ^ ^ L r ) t o ^ « . c o c r ^ o • - ^ c ^ J c o ' s J ' L A ^ x > ^ - o o
CD c c O Z3 cl- ^ h h - i ~ i h - h h w ^ m ^ r j r j r g r \ i r j c j o j ( \ i r j : j - \ j f \ .--j < \ (M n n c o r - ' s r o n c o c o c o r o c o f o r o r o c o r o c o t o
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