Post-discharge compliance to venous thromboembolism prophylaxis in high-risk orthopaedic surgery

2012 ◽  
Vol 107 (02) ◽  
pp. 280-287 ◽  
Author(s):  
Juan Arcelus ◽  
Paulo Felicissimo ◽  
David Bergqvist ◽  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Patient Education ◽  
Patient Compliance ◽  
Orthopaedic Surgery ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Access To Treatment ◽  
Good Compliance ◽  
Vte Prophylaxis

SummaryVenous thromboembolism (VTE) risk persists for several weeks following high-risk orthopaedic surgery (HROS). The ETHOS registry evaluated post-operative VTE prophylaxis prescribed, and actual VTE prophylaxis received, compared with the 2004 American College of Chest Physicians (ACCP) guidelines in HROS patients. We performed a subanalysis of ETHOS to assess patient compliance with ACCP-adherent prophylaxis after discharge and the factors predicting poor compliance. Consecutive patients undergoing hip fracture surgery, total hip arthroplasty, or knee arthroplasty were enrolled at discharge from 161 centres in 17 European countries if they had received adequate in-hospital VTE prophylaxis. Data on prescribed and actual prophylaxis received were obtained from hospital charts and patient post-discharge diaries. Good compliance was defined as percentage treatment intake ≥80% with no more than two consecutive days without treatment. A total of 3,484 patients (79.4%) received ACCP-adherent anticoagulant prescription at discharge and 2,999 (86.0%) had an evaluable patient diary. In total, 87.7% of evaluable patients were compliant with prescribed treatment after discharge. The most common reason for non-compliance (33.4%) was “drug was not bought”. Injection of treatment was not a barrier to good compliance. Main factors affecting compliance related to purchase of and access to treatment, patient education, the person responsible for administering injections, country, and type of hospital ward at discharge. Within our study population, patient compliance with ACCP-adherent thromboprophylaxis prescribed at discharge was good. Improvements in patient education and prescribing practices at discharge may be important in further raising compliance levels in high-risk orthopaedic surgery patients.

Post-discharge venous thromboembolism prophylaxis for surgical oncology patients.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 79-79
Author(s):  
Ashlie Nadler ◽  
Mary Ellen Morba ◽  
Jesse Pezzella ◽  
Jeffrey M. Farma
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Compliance Rate ◽  
Surgical Oncology ◽  
Pelvic Surgery ◽  
Cancer Center ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Oncology Patients ◽  
Vte Prophylaxis

79 Background: A number of guidelines have been proposed for prolonged venous thromboembolism (VTE) prophylaxis following hospital discharge for cancer patients undergoing major abdominal or pelvic surgery. However, there is disparity in how closely these guidelines are followed. The purpose of this study was to examine the administration and complications of post-discharge chemical VTE prophylaxis (pdVTE) at an institutional level among surgical oncology patients to help inform policy creation. Methods: A retrospective study at a tertiary referral cancer center was performed. Data was analyzed for patients undergoing surgery in 2015. Chi-square tests were performed. Results: Of 566 colorectal, urologic, and gynecologic surgical oncology procedures performed in 2015, 24% (137) were discharged with a prescription for enoxaparin for pdVTE. An additional 24 patients were already on another form of anticoagulation at the time of discharge. Of the patients discharged on pdVTE, 77% (105) had the prescriptions filled. The compliance rate of those patients was 96% (101). The rate of VTE was 3.5% for all patients. There was a significantly greater rate of VTE amongst patients that received pdVTE (10.4%) compared to those who did not (1.6%) (OR 7.20, CI 2.80-18.46, p < 0.001). For each subspecialty, there was also a significantly greater rate of VTE amongst patients that received pdVTE (p < 0.001). Conclusions: There is a very low rate of pdVTE administration despite current guidelines. Identifying patients who received pdVTE appears to identify patients at high risk for VTE rather than the benefits of pdVTE. Institutional policies regarding prolonged VTE prophylaxis should be implemented to target high-risk patients and to ensure appropriate prescribing practices. [Table: see text]

Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery

2009 ◽  
Vol 102 (07) ◽  
pp. 56-61 ◽  
Author(s):  
Klaus-Arno Siebenrock ◽  
Urs Metzger ◽  
Philipp Tuor ◽  
Daniel Sterzing ◽  
Kurt Oehy ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Knee Replacement ◽  
Hip Replacement ◽  
Orthopaedic Surgery ◽  
Cancer Surgery ◽  
Interquartile Range ◽  
Major Surgery ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis

SummaryExtended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p <0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%),gastrointestinal (19%),and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylax is was longer in patients with orthopaedic surgery (32 days, interquartile range 14–40 days) than in patients with cancer surgery (23 days, interquartile range 11–30 days; p<0.001).Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

Implementation of extended prolonged venous thromboembolism prophylaxis with rivaroxaban after major abdominal and pelvic surgery safety and early outcomes.

2020 ◽  
Vol 92 (5) ◽  
pp. 1-5
Author(s):  
Volodymyr Tyselskyi ◽  
Vitaliy Poylin ◽  
Daniel Wong ◽  
Yegor Tryliskyy ◽  
Andrey Kebkalo
Keyword(s):  
Venous Thromboembolism ◽  
Colorectal Surgery ◽  
Factor Xa ◽  
Pelvic Surgery ◽  
Minor Bleeding ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Vte Prophylaxis ◽  
Abdominal Bleeding ◽  
Patient Reported

Abstract Purpose: Venous thromboembolism (VTE) after colorectal surgery is a well-documented complication, resulting in a general recommendation of extended post discharge prophylaxis. Rivaroxaban, a factor Xa inhibitor, is a daily tablet approved for treatment of VTE and prophylaxis after orthopedic surgery. The purpose of this study is to evaluate the safety of rivaroxaban for extended prophylaxis after major abdominal and pelvic surgery. Methods: This is a retrospective review of patients undergoing major colorectal surgery at a regional hospital in Kiev, Ukraine. Patients received peri-operative VTE prophylaxis with subcutaneous heparin and then transitioned to rivaroxaban for a total of 30 days. Occurrences of major or minor bleeding, blood transfusion, and a need for re-intervention were noted. Phone surveys were administered on post-operative day 30 to assess compliance and satisfaction with the regimen. Results A total of 51 patients were included in the study with an average age of 62.4 years old. Seventy-one percent of the cases were abdominal cases, 29% were pelvic cases and 59% were done laparoscopically. There was one episode of major intra-abdominal bleeding requiring return to the operating room. There were 2 minor bleeding episodes not requiring intervention. There were no VTE events in the group. The phone survey response rate was 100%. All but one patient reported completing the full course of rivaroxaban. Patients reported that oral prophylaxis was easy to adhere to and preferable compared to injections. Conclusion Implementation of extended prophylaxis with rivaroxaban is easy, safe and does not increase rates of post-operative bleeding.

scholarly journals Quality Improvement at an Academic Cancer Center: Venous Thromboembolism Prophylaxis in Patients With Multiple Myeloma

2020 ◽  
Vol 27 (2) ◽  
pp. 107327482093020
Author(s):  
Rachid Baz ◽  
Roy Furman ◽  
Katherine Simondsen ◽  
Christine Stone
Keyword(s):  
Multiple Myeloma ◽  
Quality Improvement ◽  
Venous Thromboembolism ◽  
Patient Education ◽  
Tertiary Care ◽  
Cancer Center ◽  
Prior History ◽  
Thromboembolism Prophylaxis ◽  
Practice Improvement ◽  
Vte Prophylaxis

Patients with multiple myeloma are at elevated risk of venous thromboembolism (VTE), the second leading cause of death in patients with cancer, but physician adherence to VTE prevention guidelines is low. Several organizations partnered in designing and implementing a 2-year quality improvement (QI) program in a tertiary care/academic cancer center, to increase awareness of VTE prophylaxis for patients with multiple myeloma and thus improve adherence to prophylaxis guidelines and protocols. The QI arm included 2 chart audits, conducted 2 years apart, of unmatched cohorts of 100 patients with multiple myeloma. An Education arm included 2 grand rounds presentations, 3 web-based case discussions, and a patient education module. Twenty providers took part in the continuous QI arm. More than 1100 learners participated in the online cases; the patient education curriculum reached 112 multiple myeloma patients. The initiative proved helpful in defining barriers to guideline adherence and identifying data-driven practice improvement strategies for VTE prophylaxis. It also increased learner awareness of VTE guidelines, patient risk stratification, and optimal thromboprophylaxis strategies. There was a reduction in VTE events (primary clinical outcome) from 10% at baseline to 4% in the follow-up cohort, although this was not statistically significant. Higher rates of guideline-based prophylaxis were observed in low-risk patients, and a lower incidence of VTE was observed in multiple myeloma patients with a prior history of VTE. Additional research is needed to refine prophylaxis guidelines. With appropriate institutional support, this type of QI program can be readily adopted by other organizations to address practice improvement needs.

Abstract P36: Venous Thromboembolism Prophylaxis in Hospitalized Medically Ill Patients

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Trudy Pendergraft ◽  
Montserrat Vera-Llonch ◽  
Alex Kartashov ◽  
Xianchen C Liu ◽  
Hemant Phatak ◽  
...  
Keyword(s):  
High Risk ◽  
Venous Catheter ◽  
Intermittent Pneumatic Compression ◽  
Nursing Home Admission ◽  
Thromboembolism Prophylaxis ◽  
Post Discharge ◽  
Vte Prophylaxis ◽  
Medically Ill ◽  
C Statistic ◽  
Medically Ill Patients

Background: Many hospitalized medically ill patients are at risk of VTE, during admission and after discharge. Risk factors include prior VTE, older age, immobility, obesity, heart or respiratory failure, and cancer. ACCP guidelines recommend use of low-molecular weight heparin (LMWH) or unfractionated heparin (UFH), and mechanical prophylaxis otherwise, in high-risk patients. VTE prophylaxis may be underutilized, however. Methods: Using a database linking admission records from >150 US hospitals to health insurance claims, we identified all persons, aged >=40 years, hospitalized from 2003 to 2008 and at high risk of VTE (based on ACCP guidelines). We excluded patients who: (1) underwent surgery; (2) were hospitalized in prior 30 days; (3) were treated for VTE in prior 30 days; (4) had hypercoagulability at admission; and (5) received LMWH, UFH, or fondaparinux (FOND) at therapeutic dosages on hospital day 1 or 2. We examined use of VTE prophylaxis during hospital admission and post-discharge. Results: We identified 35,606 patients who met all study entry criteria. Mean age was 67 years. Only 17.9% of study subjects received in-hospital VTE prophylaxis, most frequently LMWH (10.1%), intermittent pneumatic compression (4.5%), warfarin (2.9%), and/or stockings (2.0%). Prophylaxis use exceeded 25% only in patients with history (>30 days) of VTE and those admitted from nursing homes. Very few patients (1.7%) received post-discharge VTE prophylaxis; use was limited to LMWH. While there were several significant predictors of VTE prophylaxis (nursing home admission [odds ratio, 2.15; 95% confidence interval 1.91-2.42], central venous catheter placement [1.76; 1.60-1.94], ischemic stroke [1.68; 1.54-1.84] obesity [1.58; 1.47-1.70], and prior VTE [1.57; 1.24-1.99]), model discrimination was relatively poor (c statistic = 0.61). Conclusion: VTE prophylaxis is under-utilized in high-risk hospitalized medically ill patients, during initial admission and following hospital discharge.

512 Single Center Experience with Venous Thromboembolism Prophylaxis for Obese Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S93-S93
Author(s):  
Brian McKinzie ◽  
Rabia Nizamani ◽  
Samuel W Jones ◽  
Felicia N Williams
Keyword(s):  
Body Weight ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Peak Plasma ◽  
Total Body Surface Area ◽  
Retrospective Chart Review ◽  
Burn Patients ◽  
Thromboembolic Complications ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis

Abstract Introduction Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases risk for thromboembolic complications. Recent evidence supports the use of anti-Xa guided enoxaparin dosing for the prevention of venous thromboembolism (VTE) in high risk populations. Our objective was to evaluate the efficacy of enoxaparin 40mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. Methods A retrospective chart review of an ABA-verified burn center from November 2018 until September 2019 identified patients who were either ≥100 kilograms (kg) or had a body mass index (BMI) ≥ 30 kg/m2 and were initiated on enoxaparin 40 mg twice daily for VTE prophylaxis. Patients were included if they were at least 18 years of age and received at least three sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. Patient demographics were analyzed, as well as body weight, BMI, and total body surface area (TBSA) burn. Statistical analysis was performed with student’s t-test for continuous data and Fischer’s exact test for categorical data. Results During the study period, 148 patients were screened with 44 patients included for analysis. Forty-one percent of the patients evaluated did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/mL) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (p&lt; 0.05) and have an increased body weight (129 +/- 24 kg versus 112 +/- 17 kg, p&lt; 0.05). Eleven out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional four patients required further dosage adjustment to meet goal peak plasma levels. Conclusions Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for VTE prophylaxis is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target peak plasma anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated. Applicability of Research to Practice This study demonstrates the need for more accurate dosing and evaluation of our dosing practices for VTE prevention. It also demonstrates the importance of having a Burn dedicated pharmacist in facilitating appropriate care.

Rates of venous thromboembolism occurrence in medical patients among the insured population

2009 ◽  
Vol 102 (11) ◽  
pp. 951-957 ◽  
Author(s):  
Mohamed Hussein ◽  
Jay Lin ◽  
David Battleman ◽  
Alex Spyropoulos
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Multivariate Logistic Regression Analysis ◽  
The United States ◽  
Primary Diagnosis ◽  
Severe Form ◽  
World Population ◽  
Medical Patients ◽  
Post Discharge ◽  
Vte Prophylaxis

SummaryThe burden of venous thromboembolism (VTE) remains high in the United States (US). This study assesses the rate of VTE prophylaxis in a large real-world population of medically ill patients and identifies factors which confer VTE risk to this population. Discharges from the PharMetrics database were included if they were aged ≥40 years and had a hospitalisation claim (Jan 2001-Dec 2005) for cancer, congestive heart failure (CHF), severe infectious disease (SID), or lung disease. Discharges with incomplete records in the prior year to the index hospitalisation claim date were excluded. VTE rate, type (deep venous thrombosis [DVT] or pulmonary embolism [PE]), and time to VTE were compared between groups. Multivariate logistic regression analysis was used to identify independent predictors of VTE occurrence. A total of 158,325 patients were included in the study. Cancer patients had the highest incidence of VTE (7.6%), with the average for all patients being 5.6% (1.5% PE).VTE occurred most frequently post discharge, with the median time being 74 days. Post-discharge prophylaxis was provided to 13.1% of CHF patients and < 5% of all other patients. Independent predictors of VTE included a pre-index VTE (odds ratio [OR] 9.06, 95% confidence interval [CI] 8.28–9.91) and a primary diagnosis of cancer compared with a diagnosis of SID (OR 1.34, 95% CI 1.24–1.46). In conclusion, commercially insured medical patients in the US are at high risk of VTE following hospital discharge. One-quarter of medical patients who developed a VTE are at high risk of developing the more severe form of the disease, namely PE, with independent predictors of VTE in the postdischarge period including previous VTE and cancer.

scholarly journals Evaluation of the duration of thromboembolic prophylaxis after high-risk orthopaedic surgery: The ETHOS observational study

2012 ◽  
Vol 107 (02) ◽  
pp. 270-279 ◽  
Author(s):  
Juan Arcelus ◽  
Paulo Felicissimo ◽  
David Bergqvist ◽  
Keyword(s):  
High Risk ◽  
Orthopaedic Surgery ◽  
Real Life ◽  
Post Discharge ◽  
Thromboembolic Prophylaxis ◽  
Pharmacological Prophylaxis ◽  
Vte Prophylaxis ◽  
Hip Fracture Surgery ◽  
Real Life Data ◽  
Fracture Surgery

SummaryReal-life data on post-discharge venous thromboembolism (VTE) prophylaxis practices and treatments are lacking. We assessed post-operative VTE prophylaxis prescribed and received in a prospective registry, compared with the 2004 American College of Chest Physicians (ACCP) guidelines in high-risk orthopaedic surgery patients. Consecutive patients undergoing total hip arthroplasty (THA), hip fracture surgery (HFS), or knee arthroplasty (KA) were enrolled at discharge from 161 centres in 17 European countries if they had received in-hospital VTE prophylaxis that was considered in accordance with the ACCP guidelines by the treating physician. Data on prescribed and actual prophylaxis were obtained from hospital charts and patient post-discharge diaries. Post-operative prophylaxis prescribed and actual prophylaxis received were considered adherent or adequate, respectively, if recommended therapies were used for ≥28 days (HFS and THA) or ≥10 days (KA). Among 4,388 patients, 69.9% were prescribed ACCP-adherent VTE prophylaxis (THA: 1,411/2,217 [63.6%]; HFS: 701/1,112 [63.0%]; KA: 955/1,059 [90.2%]). Actual prophylaxis received was described in 3,939 patients with an available diary after discharge (non-evaluability rate of 10%). Mean actual durations of pharmacological prophylaxis from surgery were: 28.4 ± 13.7 (THA), 29.3 ± 13.9 (HFS), and 28.7 ± 14.1 days (KA). ACCP-adequate VTE prophylaxis was received by 66.5% of patients (60.9% THA, 55.4% HFS, and 88.7% KA). Prophylaxis inadequacies were mainly due to inadequate prescription, non-recommended prophylaxis prescription at discharge, or too short prophylaxis prescribed. In high-risk orthopaedic surgery patients with hospital-initiated prophylaxis, there is a gap between ACCP recommendations, prescribed and actual prophylaxis received, mainly due to inadequate prescription at discharge.

Multi-screen electronic alerts to augment venous thromboembolism prophylaxis

2010 ◽  
Vol 103 (02) ◽  
pp. 312-317 ◽  
Author(s):  
Karen Fiumara ◽  
Chiara Piovella ◽  
Shelley Hurwitz ◽  
Gregory Piazza ◽  
Clyde Niles ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Hospitalised Patients ◽  
Electronic Alerts ◽  
Significant Difference ◽  
Alert Program ◽  
Risk Patients ◽  
The One

SummaryVenous thromboembolism (VTE) prophylaxis in high-risk patients is frequently underutilised. We previously devised a one-screen computer alert program that identified hospitalised patients at high risk for VTE who were not receiving prophylaxis and advised their physicians to prescribe prophylaxis. While this strategy reduced the 90-day incidence of symptomatic VTE by 41%, the majority of electronic alerts were ignored. We have now developed a serial three-screen alert computer program designed to educate physicians who initially declined to order prophylaxis after a single screen alert. Of a total cohort of 880, the responsible physicians for 425 patients received a single electronic alert, whereas 455 who declined prophylaxis after the first screen received the second and third screens of the novel three-screen alert. Our enhanced serial three-screen alert program generated VTE prophylaxis orders for 58.4% of the 455 patients whose physicians initially declined to order prophylaxis following the one-screen alert. There was no significant difference in symptomatic 90-day VTE rates between the two cohorts (2.8% for the one-screen vs. 2.2% for the three-screen, p=0.55). We conclude that our three-screen computer alert program can markedly increase prophylaxis among physicians who decline an initial single screen alert.

Post Discharge Clinically Overt Venous Thromboembolism in Orthopaedic Surgery Patients with Negative Venography -an Overview Analysis

1996 ◽  
Vol 76 (06) ◽  
pp. 0887-0892 ◽  
Author(s):  
Serena Ricotta ◽  
Alfonso lorio ◽  
Pasquale Parise ◽  
Giuseppe G Nenci ◽  
Giancarlo Agnelli
Keyword(s):  
Venous Thromboembolism ◽  
Orthopaedic Surgery ◽  
Diagnostic Methods ◽  
Future Research ◽  
Post Discharge ◽  
Pharmacological Prophylaxis ◽  
Vein Thrombosis ◽  
Overview Analysis ◽  
Major Orthopaedic Surgery

SummaryA high incidence of post-discharge venous thromboembolism in orthopaedic surgery patients has been recently reported drawing further attention to the unresolved issue of the optimal duration of the pharmacological prophylaxis. We performed an overview analysis in order to evaluate the incidence of late occurring clinically overt venous thromboembolism in major orthopaedic surgery patients discharged from the hospital with a negative venography and without further pharmacological prophylaxis. We selected the studies published from January 1974 to December 1995 on the prophylaxis of venous thromboembolism after major orthopaedic surgery fulfilling the following criteria: 1) adoption of pharmacological prophylaxis, 2) performing of a bilateral venography before discharge, 3) interruption of pharmacological prophylaxis at discharge in patients with negative venography, and 4) post-discharge follow-up of the patients for at least four weeks. Out of 31 identified studies, 13 fulfilled the overview criteria. The total number of evaluated patients was 4120. An adequate venography was obtained in 3469 patients (84.1%). In the 2361 patients with negative venography (68.1%), 30 episodes of symptomatic venous thromboembolism after hospital discharge were reported with a resulting cumulative incidence of 1.27% (95% C.I. 0.82-1.72) and a weighted mean incidence of 1.52% (95% C.I. 1.05-1.95). Six cases of pulmonary embolism were reported. Our overview showed a low incidence of clinically overt venous thromboembolism at follow-up in major orthopaedic surgery patients discharged with negative venography. Extending pharmacological prophylaxis in these patients does not appear to be justified. Venous thrombi leading to hospital re-admission are likely to be present but asymptomatic at the time of discharge. Future research should be directed toward improving the accuracy of non invasive diagnostic methods in order to replace venography in the screening of asymptomatic post-operative deep vein thrombosis.

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