lesson plan on mucour

1. 61
ANNEXURE-7
LESSON PLAN ON MUCORMYCOSIS
 General objectives:
The group might gain adequate knowledge regarding mucormycosis after the teaching-learning programme.
 Specific objectives:
At the end of the teaching learning session group will be able,
 To introduce and define mucormycosis.
 To explain in detail about types of mucormycosis
 To describe about etiology and risk- factors.
 To explain about pathophysiology.
 To enumerate and explain sign and symptoms in brief.
 To discuss about diagnostic tests.
 To brief about treatment and management.
 To discuss and enumerate preventive measures.
 To conclude and summarize the topic.

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SR
NO.
TIME SPECIFIC
OBJECTIVE
S
CONTENT TEACHER-
LEARNER
ACTIVITIES
AV-
AIDS
EVALUATI
ON
1. 5min To introduce
and define
mucormycosis
 INTRODUCTION
Mucormycosis (previously called zygomycosis) is a serious but rare fungal
infection caused by a group of molds called mucormycetes. These molds
live throughout the environment. Mucormycosis mainly affects people who
have health problems or take medicines that lower the body’s ability to
fight germs and sickness. It most commonly affects the sinuses or the lungs
after inhaling fungal spores from the air. It can also occur on the skin after
a cut, burn, or other type of skin injury.
 DEFINITION
Mucormycosis (sometimes called zygomycosis) is a serious but rare fungal
infection caused by a group of molds called mucormycetes. These fungi
live throughout the environment. They live in soil and in decaying organic
matter, such as leaves, compost piles, or rotten wood.
People get mucormycosis by coming in contact with the fungal spores in
the environment. For example, infections involving the lung or sinus can
occur after someone breathes in spores. These forms of mucormycosis
usually occur in people who have health problems or take medicines that
lower the body’s ability to fight germs and sickness.
 Mucormycosis Statistics
 How common is mucormycosis?
Mucormycosis is rare, but the exact number of cases is difficult to
determine because no national surveillance exists in the United States.
Population-based incidence estimates for mucormycosis were obtained
from laboratory surveillance in the San Francisco Bay Area during 1992–
Teacher will
explain and
group will
listen and
understand.
By
using
PPT
Group will
be able to
define
mucormyco
sis

3. 63
1993 and suggested a yearly rate of 1.7 cases per 1 million population.
Prospective surveillance among 16,808 transplant recipients performed in
23 institutions during 2001–2006 found that mucormycosis was the third
most common type of invasive fungal infection in stem cell transplant
recipients and accounted for 8% of all invasive fungal infections (77
mucormycete cases occurred among 983 stem cell transplant recipients
who developed any fungal infection). Among solid organ transplant
recipients, mucormycosis accounted for 2% of all invasive fungal
infections (28 mucormycete cases occurred among 1,208 solid organ
transplant recipients who developed any fungal infection). The number of
cases varied widely across participating institutions.
 Mucormycosis outbreaks
Healthcare providers who are concerned about an unusual number of new
cases should contact their state or local public health agency.
Although most cases of mucormycosis are sporadic (not part of an
outbreak), outbreaks of mucormycosis have occured. In healthcare settings,
it can be difficult to determine whether mucormycosis is healthcare-
associated or whether the infections were acquired somewhere else. Some
examples of sources implicated in healthcare-associated mucormycosis
outbreaks include adhesive bandages, wooden tongue depressors, hospital
linens, negative pressure rooms, water leaks, poor air filtration, non-sterile
medical devices, and building construction.
 Deaths due to mucormycosis
Mucormycosis is frequently a life-threatening infection. A review of
published mucormycosis cases found an overall all-cause mortality rate of
54%. The mortality rate varied depending on underlying patient condition,
type of fungus, and body site affected (for example, the mortality rate was
46% among people with sinus infections, 76% for pulmonary infections,
and 96% for disseminated mucormycosis.

4. 64
2. 5min To explain in
detail about
types of
mucormycosis
.
 TYPES OF MUCORMYCOSIS
 Rhinocerebral (sinus and brain) mucormycosis is an infection in the
sinuses that can spread to the brain. This is most common in people
with uncontrolled diabetes and in people who have had a kidney
transplant.
Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Group will
able to
differentiate
types of
mucornycos
is.

5. 65
3. 2min To describe
about etiology
and risk-
factors.
 Pulmonary (lung) mucormycosis is the most common type of
mucormycosis in people with cancer and in people who have had an
organ transplant or a stem cell transplant.
 Gastrointestinal mucormycosis is more common among young
children than adults. Premature and low-birth-weight infants less than 1
month of age are at risk if they have had antibiotics, surgery, or
medications that lower the body’s ability to fight germs and sickness.
 Cutaneous (skin) mucormycosis occurs after the fungi enter the body
through a break in the skin. This type of infection might occur after a
burn, scrape, cut, surgery, or other types of skin trauma. This is the
most common form of mucormycosis among people who do not have
weakened immune systems.
 Disseminated mucormycosis occurs when the infection spreads
through the bloodstream to affect another part of the body. The
infection most commonly affects the brain, but also can affect other
organs such as the spleen, heart, and skin.
 CAUSATIVE AGENTS ,ETIOLOGY AND RISK FACTORS
Mucormycosis is rare, but it’s more common among people who have
health problems or take medicines that lower the body’s ability to fight
germs and sickness. Certain groups of people are more likely to get
mucormycosis, including people with:
Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Learner will
be able to
enlist the
causes and
risk factors.

6. 66
 Diabetes, especially with diabetic ketoacidosis
 Cancer
 Organ transplant
 Stem cell transplant (low number of white blood cells)
 Long-term corticosteroid use
 Injection drug use
 Too much iron in the body (iron overload or hemochromatosis)
 Skin injury due to surgery, burns, or wounds
 Prematurity and low birthweight (for neonatal gastrointestinal
mucormycosis)
 Rhizopus species, Mucor species, Rhizomucor species, Syncephalastru
m species, Cunninghamella bertholletia, Apophysomyces species, and
Lichtheimia species.

7. 67
4. 2
min
To explain
about
pathophysiolo
gy.
 PATHOPHYSIOLOGY Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Group will
understand
the
pathogenesi
s of
diseases.

8. 68
 Reservoir
Mucormycetes are thermotolerant molds that are found in the environment.
Environmental sampling studies indicate that Mucormycetes are commonly
found in soil, but are rarely found in air samples targeting fungal
spores. Specific environmental niches vary among genera and species.
 Pathogenesis
Mucormycetes, the group of fungi that cause mucormycosis, are present
throughout the environment, particularly in soil and in association with
decaying organic matter, such as leaves, compost piles, and animal
dung. 1
They are more common in soil than in air, and in summer and fall
than in winter or spring. Most people come in contact with microscopic
fungal spores every day, so it’s probably impossible to completely avoid
coming in contact with mucormycetes. These fungi aren’t harmful to most
people. However, for people who have weakened immune systems,
breathing in mucormycete spores can cause an infection in the lungs or
sinuses which can spread to other parts of the body.
People get mucormycosis through contact with fungal spores in the
environment. For example, the lung or sinus forms of the infection can
occur after someone inhales the spores from the air. A skin infection can
occur after the fungus enters the skin through a scrape, burn, or other type
of skin injury.
 Transmission
Transmission occurs through inhalation, inoculation, or ingestion of spores
from the environment. Although most cases are sporadic, healthcare-
associated outbreaks have been linked to adhesive bandages, wooden
tongue depressors, hospital linens, negative pressure rooms, water leaks,
poor air filtration, non-sterile medical devices, and building construction.
Community-onset outbreaks have been associated with trauma sustained
during natural disasters.

9. 69

10. 70
5. 3min To enumerate
and explain
sign and
symptoms in
brief.
 SIGN AND SYMPTOMS Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Students
will enlist
sign and
symptoms
of mucor
mycosis.

11. 71
The symptoms of mucormycosis depend on where in the body the fungus is
growing. Contact your healthcare provider if you have symptoms that you
think are related to mucormycosis.
 Symptoms of rhinocerebral (sinus and brain)
mucormycosis include:
 One-sided facial swelling
 Headache
 congestion
 Black lesions on nasal bridge or upper inside of mouth that quickly
become more severe
 Fever
 Symptoms of pulmonary (lung) mucormycosis include:
 Fever
 Cough
 Chest pain
 Shortness of breath
 Cutaneous (skin) mucormycosis
 can look like blisters or ulcers, and the infected area may turn black.
Other symptoms include pain, warmth, excessive redness, or swelling
around a wound.
 Symptoms of gastrointestinal mucormycosis include:
 Abdominal pain
 Nausea and vomiting
 Gastrointestinal bleeding
 Disseminated mucormycosis
 Patients with disseminated infection in the brain can develop mental
status changes or coma.

12. 72
6. 2min To describe
about
diagnosis.
 Diagnosis and testing for Mucormycosis.
 Healthcare providers consider,
 Past and present medical history,
 sign and symptoms,
 physical examinations,
 complete laboratory tests.
 CSF examinations
 Oropharyngeal and nasopharyngeal swabs.
 collect a sample of fluid.
 tissue biopsy, in which a small sample of affected tissue is analyzed in
a laboratory for evidence of mucormycosis under a microscope or in a
fungal culture.
 imaging tests such as a CT scan of your lungs, sinuses, or other parts of
your body, depending on the location of the suspected infection.
Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Group will
enumerate
diagmostic
tests.

13. 73
7. 2min To brief about
treatment and
management.
 TREATMENT FOR MUCORMYCOSIS
 Median treatment duration was 102 days for patients with primary
mucormycosis, 33 days for those with refractory mucormycosis, and 85
days for those with intolerance to other antifungal therapy.
 Mucormycosis is a serious infection and needs to be treated with:
prescription antifungal medicine, usually amphotericin B,
posaconazole, or isavuconazole.
 These medicines are given through a vein (amphotericin B,
posaconazole, isavuconazole) or by mouth (posaconazole,
isavuconazole).
 Other medicines, including fluconazole, voriconazole, and
echinocandins, do not work against fungi that cause mucormycosis.
 Often, mucormycosis requires surgery to cut away the infected tissue.
 Patients with immunosuppression from corticosteroids, such as patients
with autoimmune diseases should be tapered or transitioned to
alternative non-steroidal therapy, if possible.
 Patients with HIV/AIDS should be started on anti-retroviral therapy, in
order to restore their immunity.
 Aggressive glycemic control is paramount for patients with
uncontrolled diabetes and/or ketoacidosis.
 Reversal of acidemia by administration of sodium bicarbonate is able to
partially block the ability of Rhizopus oryzae to invade endothelial
cells, and to restore host iron chelation and neutrophil function .
Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Learner will
able to enlist
the drugs
used in
treatment of
mucormyco
sis.

14. 74

15. 75
8. 5min To discuss
preventive
measures
from
mucormycosis
 PREVENTION
It’s difficult to avoid breathing in fungal spores because the fungi that
cause mucormycosis are common in the environment. There is no vaccine
to prevent mucormycosis. For people who have weakened immune
systems, there may be some ways to lower the chances of developing
mucormycosis.
 Protect yourself from the environment.
 Try to avoid areas with a lot of dust like construction or excavation
sites.
 Wear an N95 respirator if dust is unavoidable.
 Avoid direct contact with water-damaged buildings and flood water
after hurricanes and natural disasters.
 Avoid activities that involve close contact to soil or dust, such as yard
work or gardening. If this isn’t possible,
 Wear shoes, long pants, and a long-sleeved shirt when doing outdoor
activities such as gardening, yard work, or visiting wooded areas.
 Wear gloves when handling materials such as soil, moss, or manure.
 To reduce the chances of developing a skin infection, clean skin
injuries well with soap and water, especially if they have been exposed
to soil or dust.
 Antifungal medication.if at high risk for developing mucormycosis,
healthcare provider may prescribe medication to prevent mucormycosis
and other mold infections.
Teacher will
explain using
PPT and group
will listen and
understand.
By
using
PPT
Students
will discuss
about
different
measures to
prevent
mucor
mycosis.

16. 76

17. 77
 SUMMARY.
Mucormycosis (previously called zygomycosis) is a serious but rare fungal
infection caused by a group of molds called mucormycetes. Diagnostic
options are limited with variable results . No specific clinical or
radiological features making diagnosis more difficult and challenging
Suspected in patients already on anti-aspergillus treatment .More common
in immunocompromised .Adjunctive therapies need to proved in large trials
and standardized. Posaconazole, Isuvaconazole can also be tried  Duration
of treatment is highly individualized . Reversal of underlying factors,
Surgery and Liposomal amphotericin B increases cure rates . Early
diagnosis means early treatment and leading to less mortality rates.
 REFERENCES.
 CDC guidelines on mucornycosis,
 https://www.cdc.gov/fungal/diseases/mucormycosis/index.html
 Mucormycosis and entomophthoramycosis: a review of the clinical
manifestations, diagnosis and treatment, R. M. Prabhu and R.
 Patel,Mayo clinic of medicine, Clin Microbiol Infect 200
 ESCMID and ECMM joint clinical guidelines for the diagnosis and
management of mucormycosis 2013, Clin Microbiol Infect 2014
Challenges in the diagnosis and treatment of mucormycosis A. Skiada.
Medical Mycology, 2018
 Pilmis B, Lanternier F. Recent advances in understanding and
management of mucormycosis 2018, F1000 research
 Fishman's Pulmonary Diseases and Disorders, 5th edition

18. 78
MASTER DATA SHEET SHOWING DEMOGRAPHIC DATA OF SAMPLE
SECTION-1 PRE-TEST
SAMPLE AGE(INYEARS) SEX RELIGION
EDUCATIONAL
QUALIFICATIO
N
PREVIOUSKNOWLE
DGEREGARDING
OBSERVED ANY
PATIENT OF
MUCORMYCOSIS
PREVIOUSLY
ATTENDED
TRAINING ON
MUCORMYCOSIS
MOCORMYCOSIS
1 b b a b b b b
2 b b a b b b b
3 c c a b c c b
4 b b a b b b b
5 b b b b b b b
6 a a a b a a b
7 c c a b c c b
8 b b a b b b a
9 b b a b b b b
10 a a c b a a b
11 b b c b b b b
12 b b a b b b b
13 b b c b b b b
14 b b a b b b b
15 a a a a a a a
16 b b c b b b b
17 b b a b b b b

19. 79
18 b b a b b b b
19 a a a b a a b
20 a a a b a a b
21 a a a b a a b
22 a a a b a a b
23 b b a b b b b
24 b b a b b b b
25 a a a b a a b
26 a a a b a a b
27 b b a b b b b
28 c c a b c c b
29 b b a b b b b
30 b b a b b b b
31 b b a b b b b
32 b b a b b b b
33 a a a b a a b
34 a a a b a a b
35 b b a b b b b
36 b b a b b b b
37 a a c b a a b
38 b b a b b b b
39 a a c b a a b
40 a a a b a a b
41 c c a b c c b
42 a a a b a a b

20. 80
43 a a a b a a b
44 b b a b b b b
45 b b a a b b a
46 b b a a b b a
47 a a a a a a b
48 c c a a c c a
49 a a a a a a b
50 d d a a d d b
51 b b a a b b b
52 a a a a a a b
53 b b a a b b b
54 a a a a a a b
55 a a a a a a b
56 a a a a a a b
57 a a a a a a b
58 b b a a b b b
59 a a a a a a b
60 a a a a a a b

21. 81
ANNEXURE-10
MASTER DATA SHEET SHOWING PRE-TEST OF SAMPLE
SECTION-2
Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total
1 1 1 1 1 1 0 1 1 1 0 1 0 0 0 0 0 1 0 1 1 1 0 1 0 1 14
2 0 1 0 1 0 1 1 1 0 0 1 1 1 1 0 0 0 1 1 1 0 0 1 1 1 15
3 0 1 1 1 0 1 0 1 1 0 0 1 1 1 0 0 0 0 1 1 1 0 1 1 1 15
4 0 1 1 1 0 1 0 1 1 0 0 1 1 1 0 0 0 0 1 1 1 0 1 1 1 15
5 1 1 1 1 1 1 0 1 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 1 1 14
6 1 1 0 1 0 1 0 1 0 1 0 1 1 0 0 0 0 1 1 1 1 1 1 1 0 15
7 0 1 0 1 0 1 1 1 0 0 0 1 1 0 1 0 0 1 0 1 0 0 1 1 1 13
8 1 1 1 1 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 1 14
9 0 1 1 1 1 1 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 1 14
10 0 1 1 0 0 1 1 0 0 0 1 0 1 0 1 0 0 1 1 1 0 0 1 0 0 11
11 1 1 0 1 0 1 0 1 0 0 0 1 1 1 0 0 0 1 0 1 1 1 1 0 1 11
12 0 1 1 1 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 1 1 0 1 10
13 0 1 1 0 1 0 0 1 0 0 0 1 1 0 1 1 0 1 1 1 1 0 1 1 1 15
14 0 1 1 0 1 0 1 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 1 1 15
15 0 1 1 0 1 1 1 0 1 0 1 0 1 0 0 0 0 1 1 1 0 1 1 0 1 12
16 0 1 1 0 0 1 1 1 0 0 1 1 0 0 0 0 0 1 0 1 1 1 0 0 1 13
17 0 1 1 0 0 1 1 1 0 1 1 0 1 1 0 1 0 1 0 1 0 1 1 0 1 14
18 1 1 0 1 1 0 1 1 0 1 0 1 1 0 0 0 1 1 0 1 0 1 0 1 0 14
19 0 1 0 1 0 1 1 0 0 0 0 1 1 0 1 0 0 1 0 0 1 0 1 1 1 13
20 1 1 1 1 1 0 0 0 0 1 1 0 1 0 1 0 0 1 1 1 1 1 1 1 1 17
21 0 1 1 1 0 1 1 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 0 0 0 14
22 1 1 1 1 0 1 1 1 0 0 0 1 1 1 1 0 0 1 0 1 0 0 0 1 0 14
23 0 1 1 1 0 1 1 0 0 1 1 0 1 0 0 1 0 0 1 1 1 0 1 1 1 14
24 0 1 0 0 1 1 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 0 0 1 0 14
25 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 12
26 0 0 1 1 0 0 1 1 1 0 0 0 1 1 0 0 0 0 0 1 1 0 0 1 1 10
27 0 0 1 1 0 0 1 1 0 0 0 1 1 1 1 0 1 1 1 1 0 0 1 1 0 14
28 0 1 0 1 0 0 1 1 0 0 0 1 0 0 1 1 0 1 0 1 1 1 0 1 0 12

22. 82
29 1 1 1 1 1 0 1 1 0 0 0 0 1 1 0 1 0 0 0 1 1 0 0 1 0 13
30 1 1 1 0 1 1 1 1 0 0 0 1 1 1 0 0 0 1 0 1 0 1 0 0 1 14
31 0 1 1 0 1 0 1 0 0 0 1 1 0 0 0 0 1 1 1 1 1 0 1 0 0 12
31 1 1 1 0 1 0 1 1 0 1 1 0 0 0 1 0 1 0 1 1 1 0 0 0 0 13
32 1 1 1 1 1 0 0 1 1 1 0 1 0 1 1 1 0 0 0 0 1 1 0 0 0 14
33 1 1 1 1 0 0 0 1 1 1 0 0 1 0 1 1 0 1 0 0 0 0 0 1 0 12
34 1 1 1 0 0 0 0 1 1 1 1 1 1 1 0 0 0 0 1 1 0 0 0 0 0 12
35 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 13
36 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 0 1 0 1 0 1 1 0 0 14
37 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 14
38 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 1 1 13
39 0 0 1 1 1 1 0 1 0 0 1 0 0 1 0 1 0 1 0 1 1 1 1 1 0 14
40 1 1 0 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 14
41 1 0 1 1 1 1 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 1 0 14
42 1 1 1 0 0 0 0 1 1 1 1 0 1 1 1 0 0 0 0 0 1 0 1 1 1 13
43 1 1 1 0 0 0 0 0 1 1 0 1 0 1 1 0 1 1 1 1 0 0 1 1 1 15
44 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 0 0 0 0 1 0 1 0 1 1 14
45 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 0 0 1 1 1 1 0 0 0 0 15
46 1 1 1 1 1 0 0 0 0 1 1 1 0 0 0 0 1 1 1 1 1 1 1 0 0 14
47 1 1 1 1 1 1 1 1 0 0 0 1 1 0 1 1 0 1 1 1 0 0 0 0 1 15
48 1 1 1 1 1 1 0 1 0 1 0 1 0 1 1 1 1 0 0 1 0 0 1 1 1 14
49 1 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 0 0 1 1 1 1 0 0 14
50 1 0 0 1 0 0 1 1 1 1 1 1 0 1 0 1 1 0 1 0 0 0 1 1 0 14
51 0 1 1 1 1 0 0 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 0 0 0 15
52 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 1 14
53 0 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 0 1 1 0 1 0 1 1 1 15
54 1 0 1 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 15
55 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 13
56 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 0 0 1 1 1 0 0 1 1 1 13
57 0 1 1 0 1 1 0 1 1 0 0 1 1 1 0 1 0 1 1 1 1 1 1 1 1 16
58 1 1 1 1 1 1 0 1 0 1 0 1 0 1 1 1 1 0 0 1 0 0 1 1 1 14
59 1 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 0 0 1 1 1 1 0 0 14
60 1 0 0 1 0 0 1 1 1 1 1 1 0 1 0 1 1 0 1 0 0 0 1 1 0 14

23. 83
MASTER DATA SHEET SHOWING POST-TEST OF SAMPLE
SECTION-2
Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
6 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
7 1 1 1 1 0 0 0 1 1 1 1 0 0 1 0 1 1 1 1 1 1 1 1 1 1 19
8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
10 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
11 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
12 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
13 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
14 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
15 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
16 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
17 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 23
18 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
19 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
21 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 23
22 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
23 1 1 1 1 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 23
24 1 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
25 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
26 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
27 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
28 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19
29 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24

24. 84
30 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
31 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
32 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
33 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
34 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
35 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
37 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
38 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 22
39 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
40 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
41 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
42 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
43 1 1 1 1 1 0 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 22
44 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
45 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
46 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
47 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
48 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
49 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
50 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24
51 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
52 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
53 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
54 1 1 1 1 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 22
55 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
56 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
58 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
59 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
60 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25

25. 85