scholarly journals Postoperative Prescriptions and Corresponding Opioid Consumption After Septoplasty or Rhinoplasty

2019 ◽  
pp. 014556131986682 ◽  
Author(s):  
Alexander N. Rock ◽  
Kenneth Akakpo ◽  
Corey Cheresnick ◽  
Benjamin M. Zmistowksi ◽  
Garth F. Essig ◽  
...  
Keyword(s):  
Pain Control ◽  
Opioid Consumption ◽  
Prescribing Patterns ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Pain Medications ◽  
Control Regimen ◽  
Subjective Pain ◽  
The Mean ◽  
The Relationship

The objective of our study was to assess the relationship between postoperative opioid prescribing patterns and opioid consumption among patients who underwent septoplasty or rhinoplasty. A chart review of patients who underwent either septoplasty or rhinoplasty by 3 surgeons between July 2016 and June 2017 was performed, and pertinent clinical data were collected including the amount of narcotic pain medications prescribed. A telephone interview was then conducted to assess opioid usage and pain control regimen postoperatively. The number of opioid tablets prescribed and the number consumed were converted to total morphine milligram equivalent (MME) for uniform comparison. A total of 75 patients met the inclusion criteria, and 64 completed the telephone survey. Among these 64 patients, the mean (standard deviation [SD]) prescribed MME was 289.7 (101.3), and the mean (SD) consumed MME was 100.6 (109). Similarly, the mean (SD) number of opioid tablets prescribed was 42.4 (9.7), and the mean number of tablets consumed was 14.7 (16.3). Gender, procedure performed (septoplasty or rhinoplasty), use of Doyle splints, and surgeon were not associated with the amount of opioids prescribed or used. Subjective pain control was the only factor associated with an increase in opioid use ( P = .0288). There was an overabundance of opioid pain medications prescribed compared to the amount consumed for pain control after septoplasty or rhinoplasty. Abuse of prescription opioids represents an important component of the nation’s opioid crisis. Surgeons must be cognizant of the problem and adjust prescribing practices accordingly.

Prescription and Usage Pattern of Opioids after Thyroid and Parathyroid Surgery

2018 ◽  
Vol 160 (3) ◽  
pp. 388-393 ◽  
Author(s):  
Sallie M. Long ◽  
Catherine J. Lumley ◽  
Alexander Zeymo ◽  
Bruce J. Davidson
Keyword(s):  
Postoperative Pain ◽  
Length Of Stay ◽  
Pain Score ◽  
Opioid Consumption ◽  
Prescribing Patterns ◽  
Parathyroid Surgery ◽  
Opioid Use ◽  
Pain Scores ◽  
Maximum Pain ◽  
The Mean

Objective We seek to characterize the prescribing patterns of opioids, opioid consumption, and pain severity after thyroid and parathyroid surgery. We also aim to determine if a relationship exists between preoperative medication use and postoperative pain or opioid consumption. Study Design Case series with chart review. Setting Academic university hospital. Subjects and Methods Medical records of 237 adult patients undergoing thyroid and parathyroid surgery were included. Clinicopathologic data were collected, including pain scores, preoperative medications, and inpatient pain medications. Results The mean maximum pain score was 5.74 and varied by surgery type (range, 0-10). Mean pain score decreased to 2.61 upon discharge (0-8) and to 0.51 at the first postoperative visit. Patients with a length of stay exceeding 1 day had significantly higher maximum pain scores than those with a length of stay of 0 or 1 day (8 vs 5.58, P < .001). Morphine milligram equivalents while in the hospital averaged 25.4 per day and were significantly influenced by preoperative opioid use (0-202). Acetaminophen/oxycodone was the most commonly prescribed opioid. The mean number of pills prescribed postoperatively was 43.1 (0-120). Conclusion In our population, patients are discharged with opioid prescriptions that may be in excess of their requirements following thyroid and parathyroid surgery. Preoperative opioid use was associated with higher postoperative pain score and, on multivariate analysis, greater inpatient opioid consumption. Further investigation is warranted to ensure that we are prescribing opioids appropriately following thyroid and parathyroid surgery.

Assessment of post-operative opioid prescribing practices in a community hospital ambulatory surgical center

2021 ◽  
Vol 17 (3) ◽  
pp. 241-249
Author(s):  
Warren D. Bromberg, MD, FACS ◽  
Tracey Emanuel, MSN, RN, FNP-BC ◽  
Valerie Zeller, MA, RN ◽  
Elizabeth Galloway, BSN, RN, CAPA ◽  
Susan Mogan, DNP, ANP-BC, ACHPN, AP-PMN ◽  
...  
Keyword(s):  
Pain Management ◽  
Pain Control ◽  
Community Hospital ◽  
Outpatient Surgery ◽  
Opioid Consumption ◽  
Ambulatory Setting ◽  
Prescribing Practices ◽  
Patient Centered ◽  
Opioid Prescribing ◽  
The Mean

Objective: To evaluate the prescribing practices and opioid consumption in an ambulatory setting to inform the development of evidence-based guidelines.Design: A prospective study of adults undergoing outpatient open and laparoscopic surgeries over 3 months. One week after discharge, a telephonic interview quantified the number of opioids prescribed and consumed, degree of pain control and satisfaction, and whether additional pain medication was requested. Setting: Community hospital ambulatory surgery center in Westchester County, New York.Participants: This study included 304 adults undergoing a variety of procedures by surgeons from multiple specialties.Main outcome measures: Quantify surgeons’ postoperative opioid prescribing compared with patient opioid consumption.Results: Eighty-one percent (N = 245) responded to the survey, of which 64 percent were prescribed opioids. Males and females were equally represented with the mean age of 59.4 years. Of those prescribed opioids, 92 percent filled the prescription. The most commonly prescribed opioids reported by the patients that filled their prescription (N = 145) were oxycodone (36.5 percent), oxycodone/acetaminophen (28.9 percent), and tramadol (22.7 percent). The mean number of opioid pills prescribed was 20 and the mean consumption was 6.7 pills, resulting in an average of 13 retained pills. Only 3.8 percent of the patients prescribed opioids at discharge called their provider for additional analgesia. Despite the low opioid consumption patients reported high satisfaction (4.5 on scale of 0-5) with pain control. Only 10.4 percent reported that the surgeon recommended an over the counter (OTC) analgesic option. There was variability in the amount of opioids prescribed within each surgical category.Conclusions: One week after outpatient surgery, patients consumed one-third of physician-prescribed opioids, yet they reported high pain management satisfaction. Our study will inform the development of a patient-centered interdisciplinary perioperative education program to more effectively tailor multimodal pain management in ambulatory surgical patients and collaterally reduce the number of retained opioids.

scholarly journals Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries

2019 ◽  
Vol 14 (12) ◽  
pp. 737-745 ◽  
Author(s):  
Marisha Burden ◽  
Angela Kingston ◽  
Mary Anderson Wallace ◽  
Jason W Busse ◽  
Jordi Casademont ◽  
...  
Keyword(s):  
Pain Control ◽  
Opioid Analgesics ◽  
The United States ◽  
Cross Sectional Study ◽  
Hospitalized Patients ◽  
Prescribing Patterns ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Cross Sectional ◽  
The Us

BACKGROUND: Hospitalized patients are frequently treated with opioids for pain control, and receipt of opioids at hospital discharge may increase the risk of future chronic opioid use. OBJECTIVE: To compare inpatient analgesic prescribing patterns and patients’ perception of pain control in the United States and non-US hospitals. DESIGN: Cross-sectional observational study. SETTING: Four hospitals in the US and seven in seven other countries. PARTICIPANTS: Medical inpatients reporting pain. MEASUREMENTS: Opioid analgesics dispensed during the first 24-36 hours of hospitalization and at discharge; assessments and beliefs about pain. RESULTS: We acquired completed surveys for 981 patients, 503 of 719 patients in the US and 478 of 590 patients in other countries. After adjusting for confounding factors, we found that more US patients were given opioids during their hospitalization compared with patients in other countries, regardless of whether they did or did not report taking opioids prior to admission (92% vs 70% and 71% vs 41%, respectively; P < .05), and similar trends were seen for opioids prescribed at discharge. Patient satisfaction, beliefs, and expectations about pain control differed between patients in the US and other sites. LIMITATIONS: Limited number of sites and patients/ country. CONCLUSIONS: In the hospitals we sampled, our data suggest that physicians in the US may prescribe opioids more frequently during patients’ hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control. Efforts to curb the opioid epidemic likely need to include addressing inpatient analgesic prescribing practices and patients’ expectations regarding pain control.

Cardiovascular Risk After Sepsis: Understanding the Role of Statin Indications and the Impact of Clinical Inertia on Prescribing Patterns

2020 ◽  
Vol 25 (6) ◽  
pp. 541-547
Author(s):  
Vedant A. Gupta ◽  
Talal S. Alnabelsi ◽  
Sandipan Shringi ◽  
Steve W. Leung ◽  
Vincent L. Sorrell
Keyword(s):  
Cohort Analysis ◽  
Prescribing Patterns ◽  
Clinical Inertia ◽  
Major Adverse Cardiovascular Events ◽  
Prescribing Practices ◽  
Retrospective Cohort Analysis ◽  
The Mean ◽  
The Impact ◽  
Statin Use

Introduction: Patients with sepsis have high rates of major adverse cardiovascular events (MACE) in the literature, but the stratification of those at risk has been limited. Statin indicated groups provides clear criteria for therapy, but the risk of MACE after sepsis based on these groups has never been assessed. Materials and Methods: This was a retrospective cohort analysis conducted on adult patients admitted from January 1, 2013, to December 31, 2013, with suspected or confirmed sepsis and data available on statin use. Patients’ past medical history; statin use prior, during, or at time of discharge; and occurrence of MACE were recorded from electronic health records. Result: A total of 321 patients were screened and 265 were found to have data available on statin use. The mean age of the patients was 59 ± 15 years and 47% were female. Overall, 9% were observed to have a MACE at 1 year, with significantly higher rates in those in a statin indicated group (12.2%). On admission, 174 patients were not taking a statin out of whom 52% were in a statin indicated group. Among those in a statin indicated group who survived to hospital discharge, only 10% not on a statin on admission received a statin on discharge, whereas 89% on a statin on admission received a statin on discharge. Conclusion: There is a high risk of MACE after sepsis especially among those in statin indicated groups with significant clinical inertia in prescribing practices.

Postoperative Opioid Use in Rhinoplasty Procedures: A Standardized Regimen

2020 ◽  
Author(s):  
Ryan V. Marshall ◽  
Nicholas J. Rivers ◽  
Sudhir Manickavel ◽  
Jessica W. Grayson ◽  
Artemus J. Cox
Keyword(s):  
Linear Regression Analysis ◽  
Tertiary Hospital ◽  
Clinic Visit ◽  
Prescribing Patterns ◽  
Opioid Use ◽  
Patient Demographics ◽  
Pain Scores ◽  
Pill Counts ◽  
The Mean ◽  
A Prospective Study

AbstractThe objective of this study was to create a standardized regimen for preoperative and postoperative analgesic prescribing patterns in rhinoplasty. A prospective study including patients (n = 35) undergoing rhinoplasty by a single surgeon at a tertiary hospital was conducted. Patients were enrolled in this study from August 2018 to November 2019. Patients then completed a diary documenting pain scores and analgesic use for 14 days postoperatively. Patient demographics, complications, rhinoplasty technique performed, and medical history were noted. At the second postoperative clinic visit, the diaries were submitted and pill counts were conducted to ensure accuracy. A total of 23 patients completed this study. The average age of the cohort was 39.07 ± 15.01 years, and 48% were females. The mean number of opioids consumed was 6.15 ± 4.85 pills (range: 0–18). Females consumed an average of 7.2 ± 5.2 pills and males consumed 4.5 ± 3.96 pills. The mean number of acetaminophen and ibuprofen tablets consumed were 7.48 ± 8.52 pills (range: 0–36) and 10.83 ± 10.99 pills (range 0–39), respectively. No postoperative nosebleeds were reported. Males had significantly higher pain scores than females on postoperative days 1 to 8. The mean pain score for postoperative days 8 to 14 was less than 1. Linear regression analysis showed that there was no association between the rhinoplasty technique used and the number of opioids consumed. Rhinoplasty is typically associated with mild pain even when osteotomies are included with the procedure. Our results suggest that surgeons can limit rhinoplasty opioid prescriptions to around seven pills and achieve sufficient pain control in most patients. Preoperative counseling suggesting a low postoperative pain level and the encouragement of nonsteroidal anti-inflammatory drug use will help reduce the risk and misuse of opioid prescriptions.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

2019 ◽  
Vol 129 (2) ◽  
pp. 142-148 ◽  
Author(s):  
Molly N. Huston ◽  
Rouya Kamizi ◽  
Tanya K. Meyer ◽  
Albert L. Merati ◽  
John Paul Giliberto
Keyword(s):  
The United States ◽  
Opioid Abuse ◽  
Prescribing Patterns ◽  
Opioid Analgesia ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Opioid Prescription ◽  
Opioid Prescribing

Background: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. Objective: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. Methods: A cross-sectional survey of otolaryngologists at a national laryngology meeting. Results: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. Conclusions: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

How do we compare with best practice? A completed audit of benzodiazepine and z-hypnotic prescribing

2016 ◽  
Vol 35 (4) ◽  
pp. 321-324 ◽  
Author(s):  
R. Rowntree ◽  
J. Sweeney ◽  
N. Crumlish ◽  
G. Flynn
Keyword(s):  
Best Practice ◽  
Maximum Dose ◽  
Prescribing Patterns ◽  
Data Sets ◽  
Prescribing Practices ◽  
Psychiatric Unit ◽  
Medical Practitioners ◽  
The Mean ◽  
Number Of Individuals ◽  
Inpatient Psychiatric Unit

ObjectivesTo compare benzodiazepine and z-hypnotic prescribing practices in an inpatient psychiatric unit to best practice standards.MethodsMedication charts of all inpatients in the psychiatric unit, over a 1-week period, were reviewed. Details of current benzodiazepine and z-hypnotic prescriptions were collected. Information collected included the substance prescribed, duration and administration instructions. Feedback was communicated to medical practitioners through a presentation and email. A re-audit was completed 4 months later.ResultsThere were increases in total benzodiazepine and z-hypnotic prescribing despite intervention. A reduction of 2 mg occurred in the mean regular dose of benzodiazepine prescribed. Lorazepam was the most prescribed benzodiazepine throughout. In both data sets, at least 50% of regular z-hypnotics and benzodiazepines were initiated before admission. There was an increase of 14% in regular benzodiazepines initiated in hospital exceeding 4 weeks in duration. In neither data collection did regular z-hypnotics initiated in hospital exceed this cut off. A greater number of individuals were in the process of being withdrawn from regular benzodiazepine or z-hypnotic prescriptions in the re-audit. There were minimal improvements in ‘as required’ prescribing as regards documentation of an indication, time limit and maximum dose.ConclusionThe increase in overall prescribing, despite intervention, maybe because these medications continued to be indicated in the acute presentations needing inpatient treatment. The small improvements in ‘as required’ prescribing patterns suggest that the intervention was limited in effecting change in this area.

scholarly journals Opioid Use After Common Sports Medicine Procedures: A Systematic Review

2020 ◽  
Vol 12 (3) ◽  
pp. 225-233 ◽  
Author(s):  
Ujash Sheth ◽  
Mitesh Mehta ◽  
Fernando Huyke ◽  
Michael A. Terry ◽  
Vehniah K. Tjong
Keyword(s):  
Systematic Review ◽  
Sports Medicine ◽  
Management Strategies ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Eligibility Criteria ◽  
Level Of Evidence ◽  
Opioid Prescribing ◽  
Arthroscopic Procedures

Context: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. Objective: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. Data Sources: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. Study Selection: Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. Results: A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. Conclusion: Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

scholarly journals Characterizing the Effect of Opioid Tablet Strength on Post-Operative Opioid Consumption Following ACL Reconstruction

2020 ◽  
Vol 8 (7_suppl6) ◽  
pp. 2325967120S0050
Author(s):  
Ehab Nazzal
Keyword(s):  
Acl Reconstruction ◽  
Pain Control ◽  
The United States ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Lower Strength ◽  
Pain Scores ◽  
Post Operative Pain ◽  
Tablet Strength ◽  
Management Protocol

Objectives: Prescription opioid abuse continues to be a national crisis in the United States. Orthopaedic surgeons contribute significantly to this crisis, prescribing nearly a tenth of annual opioid prescriptions. With Anterior Cruciate Ligament (ACL) reconstruction being a common orthopaedic procedure performed at high volumes, understanding how physician opioid prescribing practices affects patient post-operative opioid utilization is of critical importance to curbing the orthopaedic contribution to the opioid epidemic. We aimed to assess how opioid tablet strength affects post-operative opioid consumption following ACL reconstruction. We hypothesized that prescribing a lower strength opioid tablet would not adversely influence post-operative pain or increase opioid consumption Methods: All data was collected prospectively from patients undergoing ACL reconstruction at a single academic ambulatory surgery center.All patients received the same peri-operative pain management protocol, which consisted of an adductor canal block at the time of surgery, Naprosyn 500 mg to be taken as needed, and pre-operative opioid education that outlined safe opioid use practice. Percocet was prescribed at two dosages in a consecutive fashion. Between March 2018 to October 2018, patients received Percocet at a strength of 7.5 mg (7.5 mg Oxycodone/325 Acetaminophen). From November 2018 to May 2019, patients received prescriptions at a dose of 5 mg. At the first post-operative clinic visit, patients completed a survey describing the quantity of opioid tablets consumed, days of postoperative opioid use, and opioid-related adverse effects. In addition, patients used a smart-phone application to assess post-operative pain on a numeric rating scale from post-operative day (POD) 1 to POD 6. Results: 148 patients were prospectively enrolled. 78 (51.3%) received Percocet at a strength of 7.5 mg per tablet and 69 (46.9%)received Percocet at a strength of 5 mg. The median age was 23 years (interquartile range: 18-36) and 49.7% were female. The 7.5 mg cohort took an average of 12.4 tablets (±7.0), while the 5 mg cohort took an average of 8.6 (±7.4) tablets, a 3.7 tablet decrease (p=0.002). Both cohorts consumed opioids for the same amount of post-operative days (5mg cohort: 3.1 days, 7.5mg cohort: 3.5 days; p=0.289). The incidence of opioid related side effect were equivalent between the 5 mg and 7.5 mg cohorts, which included constipation (34.8% and 34.6%, p=0.983), euphoria (5.8% v. 10.3%, p=0.324), nausea/vomiting (13.0% v. 16.7%, p=0.539), fatigue (2.9% v. 6.4%, p0.319), and pruritus (2.9% v. 5.1%, p=0.495). There was no difference in post-operative numeric pain scores in the 5 mg vs. the 7.5 mg cohort (POD 1: 5.7 ±1.9 vs. 5.4 ± 2.0, p=0.633; POD 6: 3.3 ± 2.1 vs. 2.9 ± 1.8, p=0.726). Conclusion: Prescribing a lower strength of oxycodone after ACL reconstruction did not increase pain scores or opioid consumption.This suggests that it is possible to achieve similar pain control while lowering the total opioid prescribed. These finding support future research focusing on optimizing pain control at minimal opioid doses.

scholarly journals Opioid overprescription in adolescents and young adults undergoing hip arthroscopy

2021 ◽  
Author(s):  
Mahad M Hassan ◽  
Omar F Rahman ◽  
Zaamin B Hussain ◽  
Stephanie L Burgess ◽  
Yi-Meng Yen ◽  
...  
Keyword(s):  
Young Adults ◽  
Hip Arthroscopy ◽  
Pain Control ◽  
Median Number ◽  
Opioid Consumption ◽  
Adolescents And Young Adults ◽  
Opioid Use ◽  
Prescription Patterns ◽  
Factors Associated ◽  
Age At Surgery

Abstract Few studies have examined factors related to the increased consumption of opioids after hip arthroscopy in adolescents and young adults. This study sought to determine prescription patterns following hip arthroscopy in this population, and to determine clinical or surgical factors associated with increased post-operative opioid use. Daily post-operative opioid intake was obtained from pain-control logbooks of adolescents and young adults who underwent hip arthroscopy between January 2017 and 2020. Study outcomes were defined as the median total number of opioid tablets consumed, total days opioids were consumed, mean daily opioid consumption and the ratio of opioids prescribed post-operatively to consumed. Clinical and surgical factors were analyzed to determine any association with opioid consumption. Fifty-eight (20%) patients returned completed logbooks. Most patients (73%) were prescribed 30 oxycodone tablets. The median number of tablets consumed was 7 (range 0–41) over a median duration of 7 days (range 1–22). The median ratio of tablets consumed to prescribed was 20%. Increasing patient age at surgery was associated with increased total number of tablets consumed (r = 0.28, P = 0.04) and to the ratio of tablets consumed to prescribed (r = 0.30, P = 0.03). Patients who were prescribed more than 30 tablets consumed on average 7.8 more tablets than patients prescribed fewer (P = 0.003). Patients who underwent regional anesthesia consumed tablets for longer compared with those who did not (median, 10 versus 4 days; P = 0.03). After undergoing hip arthroscopy, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed.

Sign in / Sign up

Export Citation Format

Share Document