scholarly journals Early emergency readmission frequency as an indicator of short-, medium- and long-term mortality post-discharge from hospital

2020 ◽  
Author(s):  
David Fluck ◽  
Paul Murray ◽  
Jonathan Robin ◽  
Christopher Henry Fry ◽  
Thang Sieu Han
Keyword(s):  
Event Rate ◽  
Age Groups ◽  
Hazard Ratio ◽  
Hospital Length Of Stay ◽  
Post Discharge ◽  
Increased Risk ◽  
Discharge From Hospital ◽  
Age And Sex ◽  
Long Term Mortality

AbstractFrequent emergency readmissions, an indicator of quality of care, has been rising in England but the underlying reasons remain unclear. We examined the association of early readmissions with subsequent mortality in adults, taking into account the underlying presenting diagnoses and hospital length of stay (LOS). Data of alive-discharge episodes were prospectively collected between 01/04/2017 and 31/03/2019 in an National Health Service hospital, comprising 32,270 patients (46.1% men) aged 18–107 years (mean = 64.0, ± SD = 20.5 years). The associations of readmission frequency within 28 days of discharge and mortality within 30 days and 6 months of hospital discharge, and over a 2-year period were evaluated, adjusted for presenting diagnoses, LOS, age and sex during the first admission. Analysis of all patients 18–107 years (reference: no readmission) showed mortality within 30 days was increased for 1 readmission: event rate = 9.2%, odds ratio (OR) = 3.4 (95% confidence interval (CI) = 2.9–4.0), and ≥ 2 readmissions: event rate = 10.0%, OR = 2.6 (95%CI = 2.0–3.3), and within 6 months for 1 readmission: event rate = 19.6%, OR = 3.0 (95%CI = 2.7–3.4), and ≥ 2 readmissions: event rate = 27.4%, OR = 3.4 (95%CI = 2.9–4.0), and over a 2-year period for 1 readmission: event rate = 25.5%, hazard ratio = 2.2 (95%CI = 2.0–2.4), and ≥ 2 readmissions: event rate = 36.1%, hazard ratio = 2.5 (95%CI = 2.2–2.8). Within the age groups 18–49, 50–59, 60–69, 70–79 and ≥ 80 years, readmissions were also associated with increased risk of mortality within 3 months and 6 months of discharge, and over 2-year period. In conclusion, early hospital readmission predicts short-, medium- and long-term mortality post-discharge from hospital in adults aged 18–107 years, independent of underlying presenting conditions, LOS, age and sex. Further research focussing on safe discharge and follow-up patient care may help reduce preventable readmissions and post-discharge mortality.

Abstract 14588: Post-discharge Readmission and Survival After Percutaneous Coronary Intervention Among Patients With a History of Recent Gastrointestinal Bleeding: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Chelsea Meloche ◽  
Milan Seth ◽  
Ryan D MADDER ◽  
Jacob Kurlander ◽  
Jessica Yaser ◽  
...  
Keyword(s):  
Gastrointestinal Bleeding ◽  
Recent History ◽  
Bleeding Complications ◽  
Post Discharge ◽  
Clinical Registry ◽  
Increased Risk ◽  
Significant Difference ◽  
History Of ◽  
Long Term Mortality

Introduction: Given the use of potent antithrombotic agents during and after PCI, patients (pts) are at an increased risk of gastrointestinal bleeding (GIB). Hypothesis: We hypothesize that pts with a history of recent GIB have a higher risk of post-discharge readmission and mortality compared with those without a history of GIB. Methods: We linked clinical registry data from PCIs performed between 1/1/2013 and 3/31/2018 at 48 Michigan hospitals to Medicare claims. A recent history of GIB prior to PCI was defined in the clinical PCI registry as any occurrence of melena or hematemesis in the last 30 days or any history of GIB including peptic ulcer disease that may influence clinical management during this hospitalization. Primary outcomes of interest were 90-day readmission after PCI and long-term mortality. We used 1:5 propensity-matching to adjust for differences in characteristics between pts with and without a history of recent GIB. Log-rank testing was used to evaluate survival at 1 and 5 years. Fisher's exact testing was used to compare the rates of 90-day readmission after PCI. Results: Of 30,206 pts, 1.1% had a history of GIB. Pts with a history of GIB were more likely to be older, female, black, and have more cardiovascular comorbidities. After matching 1896 pts, those with a history of GIB (n=316) appeared to have decreased survival early after PCI (Fig); however, the differences in survival were not statistically significant at 1 yr (76.%3 vs. 80.1%; p=0.11) or 5 yrs (52.5% vs. 52.2%; p=0.50) (Fig). There was no significant difference in readmission rates among those with and without a history of GIB (33.5% vs. 30.2%; p=0.26). Conclusions: Pts with and without a history of recent GIB had similar risks of readmission and long-term mortality after PCI. Although a history of GIB has previously been shown to be associated with increased post-PCI bleeding complications, a recent history of GIB was not associated with long-term post-PCI outcomes.

scholarly journals Exploring Factors Contributing to Race Differences in Poststroke Disability

Stroke ◽  
2020 ◽  
Vol 51 (6) ◽  
pp. 1813-1819
Author(s):  
Lesli E. Skolarus ◽  
Chunyang Feng ◽  
James F. Burke
Keyword(s):  
Nursing Home ◽  
Race Differences ◽  
Hazard Ratio ◽  
Nursing Home Placement ◽  
Stroke Survivors ◽  
Postacute Care ◽  
Home Placement ◽  
Age And Sex ◽  
Long Term Mortality

Background and Purpose— Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods— A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009–2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0–7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results— There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7–2.2]; P =0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2–2.4]; P =0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0–3.2] in blacks versus 1.4 [1.0–1.8] in whites, mean difference, 1.2 [0.5–1.9], P <0.001) and immediately poststroke (2.6 [2.0–3.3] in blacks versus 1.7 [1.2–2.1] in whites, mean difference, 1.0 [0.2–1.7], P <0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions— Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.

scholarly journals Associations between Subsequent Hospitalizations and Primary Ambulatory Services Utilization within the First Year after Acute Myocardial Infarction and Long-Term Mortality

2020 ◽  
Vol 9 (8) ◽  
pp. 2528
Author(s):  
Ygal Plakht ◽  
Dan Greenberg ◽  
Harel Gilutz ◽  
Jonathan Eli Arbelle ◽  
Arthur Shiyovich
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Multivariable Analysis ◽  
First Year ◽  
Post Discharge ◽  
Services Utilization ◽  
Increased Risk ◽  
Ambulatory Services ◽  
Long Term Mortality

Healthcare resource utilization peaks throughout the first year following acute myocardial infarction (AMI). Data linking the former and outcomes are sparse. We evaluated the associations between subsequent length of in-hospital stay (SLOS) and primary ambulatory visits (PAV) within the first year after AMI and long-term mortality. This retrospective analysis included patients who were discharged following an AMI. Study groups: low (0–1 days), intermediate (2–7) and high (≥8 days) SLOS; low (<10) and high (≥10 visits) PAV, throughout the first post-AMI year. All-cause mortality was set as the primary outcome. Overall, 8112 patients were included: 55.2%, 23.4% and 21.4% in low, intermediate and high SLOS groups respectively; 26.0% and 74.0% in low and high-PAV groups. Throughout the follow-up period (up to 18 years), 49.6% patients died. Multivariable analysis showed that an increased SLOS (Hazard ratio (HR) = 1.313 and HR = 1.714 for intermediate and high vs. low groups respectively) and a reduced number of PAV (HR = 1.24 for low vs. high groups) were independently associated with an increased risk for mortality (p < 0.001 for each). Long-term mortality following AMI is associated with high hospital and low primary ambulatory services utilization throughout the first-year post-discharge. Measures focusing on patients with increased SLOS and reduced PAV should be considered to improve patient outcomes.

Lymphopenia and risk for long-term mortality among patients undergoing coronary angiography

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
B Zafrir ◽  
R Jaffe ◽  
H Sliman ◽  
O Barnett-Griness ◽  
W Saliba
Keyword(s):  
Coronary Angiography ◽  
Mortality Risk ◽  
Predictive Accuracy ◽  
Cohort Analysis ◽  
Cox Proportional Hazards ◽  
Cross Sectional ◽  
Distribution Width ◽  
Increased Risk ◽  
Long Term Mortality

Abstract Background Lymphopenia has been shown to be associated with adverse prognosis in chronic disease states that are related to immune dysregulation. Purpose We aimed to determine the association between lymphopenia and all-cause mortality in patients presenting to coronary angiography with or without acute coronary syndromes (ACS). We also investigated whether elevated red blood cell distribution width (RDW), an established cardiovascular prognostic marker, further refines risk stratification and improves predictive accuracy beyond lymphocytes count. Methods Retrospective cohort analysis of patients undergoing coronary angiography for evaluation or treatment of coronary artery disease between 2003 and 2018. Long-term mortality risk associated with relative (1000–1500 /μL) or severe (&lt;1000 /μL) lymphopenia was analyzed using Cox proportional hazards regression models, adjusting for comorbidities, ACS and RDW. Results Overall, 15179 patients underwent coronary angiography, at a mean age of 65±12 years. On cross-sectional analysis, lymphopenia was associated with kidney disease, cancer, heart failure and presentation with ACS, but lower rates of smoking and obesity. During a median follow-up of 7 (IQR 3.5–11.5) years, 4253 patients died. Compared to normal lymphocytes count (1500–5000 /μL), the multivariable adjusted hazard ratio (HR) (95% confidence interval) for mortality was 1.31 (1.21–1.41) and 1.97 (1.75–2.22) for relative and severe lymphopenia, respectively. The increase in mortality associated with severe lymphopenia was significant in patients presenting with non-ACS [HR 2.18 (1.74–2.73)], ST-segment elevation myocardial infarction (STEMI) [HR 1.59 (1.15–2.21)], or unstable angina/non-STEMI [HR 2.00 (1.70–2.34)]; p-for-interaction 0.626. The association of lymphopenia with mortality remained significant after additional adjustment to RDW. High RDW (&gt;14.5%) was associated with increased mortality risk in each of the lymphocytes count groups, and improved the predictive accuracy with AUC increase from 0.609 (0.601–0.616) to 0.646 (0.639–0.654) (p&lt;0.001). Conclusions Lymphopenia is associated with increased risk for long-term mortality in patients undergoing coronary angiography, regardless of coronary presentation. High RDW may enhance the predictive ability of lymphopenia. Lymphocyte count and mortality risk Funding Acknowledgement Type of funding source: None

scholarly journals Role of diuretics on long-term mortality may differ in volume status in patients with acute myocardial infarction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Kawai ◽  
D Nakatani ◽  
T Yamada ◽  
T Watanabe ◽  
T Morita ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Propensity Score ◽  
Plasma Volume ◽  
Cox Regression ◽  
Volume Status ◽  
Increased Risk ◽  
Long Term Mortality

Abstract Background Diuretics has been reported to have a potential for an activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system, leading to a possibility of poor clinical outcome in patients with cardiovascular disease. However, few data are available on clinical impact of diuretics on long-term outcome in patients with acute myocardial infarction (AMI) based on plasma volume status. Methods To address the issue, a total of 3,416 survived patients with AMI who were registered to a large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed with the estimated plasma volume status (ePVS) that was calculated at discharge as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females), and ePVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). Multivariable Cox regression analysis and propensity score matching were performed to account for imbalances in covariates. The endpoint was all-cause of death (ACD) within 5 years. Results During a median follow-up period of 855±656 days, 193 patients had ACD. In whole population, there was no significant difference in long-term mortality risk between patients with and without diuretics in both multivariate cox regression model and propensity score matching population. When patients were divided into 2 groups according to ePVS with a median value of 4.2%, 46 and 147 patients had ACD in groups with low ePVS and high ePVS, respectively. Multivariate Cox analysis showed that use of diuretics was independently associated with an increased risk of ACD in low ePVS group, (HR: 2.63, 95% confidence interval [CI]: 1.22–5.63, p=0.01), but not in high ePVS group (HR: 0.70, 95% CI: 0.44–1.10, p=0.12). These observations were consistent in the propensity-score matched cohorts; the 5-year mortality rate was significantly higher in patients with diuretics than those without among low ePVS group (4.7% vs 1.7%, p=0.041), but not among high ePVS group (8.0% vs 10.3%, p=0.247). Conclusion Prescription of diuretics at discharge was associated with increased risk of 5-year mortality in patients with AMI without PV expansion, but not with PV expansion. The role of diuretics on long-term mortality may differ in plasma volume status. Therefore, prescription of diuretics after AMI may be considered based on plasma volume status. Funding Acknowledgement Type of funding source: None

Long-term mortality rates and associated risk factors following primary and revision knee arthroplasty

2022 ◽  
Vol 104-B (1) ◽  
pp. 45-52
Author(s):  
Liam Zen Yapp ◽  
Nick D. Clement ◽  
Matthew Moran ◽  
Jon V. Clarke ◽  
A. Hamish R. W. Simpson ◽  
...  
Keyword(s):  
General Population ◽  
Knee Arthroplasty ◽  
Mortality Rates ◽  
Factors Associated ◽  
Revision Knee Arthroplasty ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Male Sex ◽  
Long Term Mortality

Aims The aim of this study was to determine the long-term mortality rate, and to identify factors associated with this, following primary and revision knee arthroplasty (KA). Methods Data from the Scottish Arthroplasty Project (1998 to 2019) were retrospectively analyzed. Patient mortality data were linked from the National Records of Scotland. Analyses were performed separately for the primary and revised KA cohorts. The standardized mortality ratio (SMR) with 95% confidence intervals (CIs) was calculated for the population at risk. Multivariable Cox proportional hazards were used to identify predictors and estimate relative mortality risks. Results At a median 7.4 years (interquartile range (IQR) 4.0 to 11.6) follow-up, 27.8% of primary (n = 27,474/98,778) and 31.3% of revision (n = 2,611/8,343) KA patients had died. Both primary and revision cohorts had lower mortality rates than the general population (SMR 0.74 (95% CI 0.73 to 0.74); p < 0.001; SMR 0.83 (95% CI 0.80 to 0.86); p < 0.001, respectively), which persisted for 12 and eighteight years after surgery, respectively. Factors associated with increased risk of mortality after primary KA included male sex (hazard ratio (HR) 1.40 (95% CI 1.36 to 1.45)), increasing socioeconomic deprivation (HR 1.43 (95% CI 1.36 to 1.50)), inflammatory polyarthropathy (HR 1.79 (95% CI 1.68 to 1.90)), greater number of comorbidities (HR 1.59 (95% CI 1.51 to 1.68)), and periprosthetic joint infection (PJI) requiring revision (HR 1.92 (95% CI 1.57 to 2.36)) when adjusting for age. Similarly, male sex (HR 1.36 (95% CI 1.24 to 1.49)), increasing socioeconomic deprivation (HR 1.31 (95% CI 1.12 to 1.52)), inflammatory polyarthropathy (HR 1.24 (95% CI 1.12 to 1.37)), greater number of comorbidities (HR 1.64 (95% CI 1.33 to 2.01)), and revision for PJI (HR 1.35 (95% 1.18 to 1.55)) were independently associated with an increased risk of mortality following revision KA when adjusting for age. Conclusion The SMR of patients undergoing primary and revision KA was lower than that of the general population and remained so for several years post-surgery. However, approximately one in four patients undergoing primary and one in three patients undergoing revision KA died within tenten years of surgery. Several patient and surgical factors, including PJI, were associated with the risk of mortality within ten years of primary and revision surgery. Cite this article: Bone Joint J 2022;104-B(1):45–52.

Abstract 87: Assessment of Stroke Caregiver Readiness: A Primary Prevention Strategy

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Barbara J Lutz ◽  
Mary Ellen Young
Keyword(s):  
Primary Prevention ◽  
Family Caregivers ◽  
Family Members ◽  
Inpatient Rehabilitation ◽  
Stroke Survivors ◽  
Post Discharge ◽  
Readiness Assessment ◽  
Increased Risk ◽  
Transition Home

Introduction: More than 3.5 million family caregivers provide assistance with activities and instrumental activities of daily living for stroke survivors living at home. Studies consistently indicate that stroke family caregivers are inadequately assessed and under prepared for their new caregiver roles and responsibilities as stroke survivors transition home from inpatient rehabilitation. Several tools exist to assess caregivers once they have assumed the caregiving role, however, there are no tools assess stroke caregiver readiness prior to discharge. Research has indicated the need for a thorough and systematic pre-discharge assessment of the caregiver’s ability to assume the caregiving role. The purpose of this presentation is to describe ten critical stroke caregiver readiness assessment domains and to discuss their relevance for long-term outcomes for stroke survivors and family caregivers. Methods: In this grounded theory study, data were collected from19 persons with stroke and 19 family caregivers. Semi-structured interviews were conducted during inpatient rehabilitation and within 6 months post-discharge. First interviews focused on expectations for recovery and caregiving needs post-discharge. Follow-up interviews focused on how families managed the transition from rehabilitation to home and how their initial expectations matched the reality of their post-discharge experience. Interviews were analyzed using dimensional analysis and coded in NVivo data management software. Findings: Participants indicated that stroke was an overwhelming, life changing crisis event. Family members felt abandoned, isolated, and under prepared to assume the fulltime caregiving role as stroke survivors transitioned home. They described using ineffective or risky caregiving strategies that resulted in safety and health issues for both stroke survivors and caregivers. Ten pre-discharge caregiver readiness assessment domains were identified in the interviews and a corresponding stroke caregiver readiness assessment interview guide was developed. Conclusion: Stroke survivors and family caregivers are extremely vulnerable as they transition home from inpatient rehabilitation leaving them at risk for poorer health, depression, and increased risk for injury. In order to prevent these deleterious outcomes, caregivers should be assessed, and potential areas of risk identified and addressed prior to discharge from inpatient rehabilitation. As new interventions are developed to improve survival rates for persons with stroke, we must also develop and implement primary prevention strategies for family members who are called upon to provide care following discharge to protect their health and improve the long-term recovery outcomes for the stroke survivor.

scholarly journals The effectiveness and safety of the use of antithrombotic therapy in COVID-19

2021 ◽  
Vol 18 (2) ◽  
pp. 17-30
Author(s):  
K. V. Lobastov ◽  
O. Ya. Porembskay ◽  
I. V. Schastlivtsev
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Increased Risk ◽  
Severe Infections ◽  
Thrombotic Complications ◽  
Risk Of Disease ◽  
Anticoagulant Prophylaxis ◽  
Discharge From Hospital ◽  
Outpatient Settings

The article is a non-systematic review of the literature, addressing the effectiveness, safety and appropriateness of antithrombotic drugs for COVID-19 in patients undergoing treatment in different settings: in the hospital phase, including the intensive care unit, in the outpatient phase after discharge from hospital, in primary outpatient treatment. The issues of thrombotic complications during vaccination and the necessity of their prevention are discussed. The studies confirm the importance of prophylactic doses of anticoagulants in all hospitalized patients. The use of increased doses has proven ineffective in patients with a severe course of the disease who are being treated in the intensive care unit. In moderately severe infections, there is a clear benefit of increased doses of anticoagulants in reducing the risk of organ failure, but definitive conclusions can only be drawn after the final results of the studies have been published. Prolonged pharmacological prophylaxis after hospital discharge may be useful in individual patients, but the overall risk of thrombotic complications in the long-term period does not appear to be high. The available data do not support the use of anticoagulants in the treatment of coronavirus disease in the outpatient settings, since the risk of thrombotic complications is not increased in such patients, and the safety of anticoagulant use has not been evaluated. Sulodexide may be useful in selected outpatients at increased risk of disease progression. Vaccination may provoke the development of atypical localized thrombosis by immune mechanisms, but the risk of such complications is lower in the coronavirus disease itself. Anticoagulant prophylaxis during vaccine administration is not indicated.

scholarly journals Long-Term Health Outcomes of Korean Adults With Classic Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency

2021 ◽  
Vol 12 ◽  
Author(s):  
Seung Gyun Lim ◽  
Young Ah Lee ◽  
Han Na Jang ◽  
Sung Hye Kong ◽  
Chang Ho Ahn ◽  
...  
Keyword(s):  
Dehydroepiandrosterone Sulfate ◽  
Metabolic Risk ◽  
Menstrual Irregularity ◽  
Adrenal Hyperplasia ◽  
Hydroxylase Deficiency ◽  
Classic Congenital Adrenal Hyperplasia ◽  
Increased Risk ◽  
21 Hydroxylase Deficiency ◽  
Age And Sex

There is a lack of studies regarding the long-term outcomes of Asian adults with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. We hypothesized that adults with CAH are at higher metabolic risk than their age-, and sex-matched controls. We further investigated the long-term health outcome-related factors in adults with CAH. We compared metabolic risk between adults with CAH (71 men, 93 women) and age-, and sex-matched controls (190 men, 261 women) from the Korean National Health and Nutrition Examination Survey data. The presence of obesity, testicular adrenal rest tumors (TARTs), and menstrual irregularity was assessed. Hormone status and treatment regimens were compared according to the presence of adverse outcomes. The median age was 27.0 y and 28.0 y for men and women, respectively. Adults with CAH had a higher waist circumference (88.0 vs. 82.3 cm in men, and 83.5 vs. 72.3 cm in women), and blood pressure (125.0 vs. 113.0 mmHg in men, and 120.0 vs. 104.0 mmHg in women) than age- and sex-matched controls (P&lt;0.05 for all). The 2.7-fold increased risk for hypertension (men) and 2.0-fold increased risk for obesity (women) was significant in patients with CAH (P&lt;0.05 for both). Obese adults with CAH showed significantly higher adrenal limb thicknesses (men) and 17-hydroxyprogesterone and dehydroepiandrosterone sulfate levels (women) (P&lt;0.05 for both). TARTs occurred in 58.1% of men and did not differ by hormone or treatment regimen. Irregular menstruation was observed in 57.1% of women, with higher dehydroepiandrosterone sulfate levels in those with irregular periods. Adults with CAH had a higher metabolic risk than the general population. Poor disease control may increase their risk of metabolic morbidity and menstrual irregularity.

Sign in / Sign up

Export Citation Format

Share Document