Predictors Of Vena Cava Filter Use For Venous Thromboembolism In Cancer Patients

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 935-935
Author(s):  
Gwendolyn Ho ◽  
Ann Brunson ◽  
Richard H. White ◽  
Ted Wun
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Brain Cancer ◽  
Vena Cava ◽  
Severity Of Illness ◽  
Bleeding Risk ◽  
Factors Associated ◽  
Patients With Cancer ◽  
Cancer Types

Abstract Background The use of vena cava filters (VCF) in the treatment of venous thromboembolism (VTE) is controversial. Few studies have evaluated the use of VCFs in cancer patients with acute thrombosis. Aims To determine frequency of VCF placement and factors associated with VCF use in patients with cancer hospitalized for acute VTE, and to compare these findings to patients without cancer hospitalized for acute VTE. Methods Using a retrospective observational study design, we analyzed hospital discharge records in California from 2005-2009 of cases presenting with acute VTE. Patients with cancer were identified by specific ICD-9-CM codes for the index VTE admission or a cancer diagnosis within 6 months prior to the index VTE. Bivariate and multivariable logistic regression analyses were used to determine predictive factors for placement of a VCF in cancer patients. Candidate risk factors included basic demographic parameters, cancer type, severity-of-illness (SOI) on admission, undergoing surgery, bleeding, and hospital characteristics. Results A VCF was placed in 19.6% of 14,000 cancer cases admitted with a principal diagnosis of acute VTE, versus 10.8% of 70,472 non-cancer cases admitted during the same time period. Among cancer cases, there was little variation in percentage that received a VCF based on age, and no significant variation across race or insurance type, except that self pay cancer patients had a lower rate of VCF placement. Variation across hospitals in the percentage of cancer cases that received a VCF was striking, ranging from 0% to 52% among hospitals that admitted a minimum of 15 acute VTE cases. There was a strong correlation (r=0.72, R2=0.52) in the frequency of VCF placement in cancer and non-cancer cases within individual hospitals. Among cancer types, the frequency of VCF placement was highest in cases with brain cancer (43%), with the observed frequency of VCF use among other cancer types ranging from 8%-23%. Patients with brain cancers, which has a high perceived bleeding risk were over 4 fold more likely to have a VCF placed compared to those cancers with low bleeding risk. Having acute leukemia did not predict for VCF placement. Only 8.2% of cancer patients had a strict contraindication to anticoagulation (acute bleeding or recent/imminent surgery), which are the only guideline-based indications for VCF placement. Active bleeding and undergoing surgery were each strongly associated with VCF use: 47% of cases that bled and 58% of cases who underwent surgery had a VCF placed. Results of the multivariable logistic model are shown in the table. In addition to bleeding and undergoing surgery, factors associated with VCF insertion included: larger hospital, urban location, private hospital and greater SOI at the time of admission. Conclusions The frequency of VCF use in cancer patients admitted for acute VTE is much higher than in non-cancer patients. Major risk factors for VCF use include bleeding, undergoing recent surgery, having brain cancer, urban location, and greater severity of illness. The frequency of VCF placement among cancer patients varied widely across hospitals. Given the extraordinary variation in the frequency of use of VCFs between hospitals, more research is needed to better define outcomes of VCF placement in cancer patients. Disclosures: Ho: American Society of Hematology: ASH HONORS trainee research award Other.

scholarly journals 798. Metronidazole Exposure Prior to Clostridiodes difficile Infection (CDI) is a Risk Factor for Severe C. difficile Disease in Cancer Patients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S442-S443
Author(s):  
Denise Marie A Francisco ◽  
Liangliang Zhang ◽  
Ying Jiang ◽  
Adilene Olvera ◽  
Eduardo Yepez Guevara ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Cancer Patients ◽  
Research Study ◽  
Research Support ◽  
Factors Associated ◽  
Patients With Cancer ◽  
Study Investigator ◽  
Severity Levels ◽  
Permutation Analysis

Abstract Background Antibiotic use is a risk factor for CDI. Few studies have correlated use of prior antibiotics with CDI severity in cancer patients. This study identified clinical and microbiology risk factors associated with severe CDI in patients with cancer. We hypothesized that previous antibiotic exposure and microbiome composition at time of CDI presentation, are risk factors for severe disease in cancer patients. Methods This non-interventional, prospective, single-center cohort study examined patients with cancer who had their first episode or first recurrence of CDI between Oct 27, 2016 and Jul 1, 2019. C. difficile was identified using nucleic acid amplification testing. Multivariate analysis was used to determine significant clinical risk factors for severe CDI as defined in the 2018 IDSA/SHEA guidelines. Alpha, and beta diversities were calculated to measure the average species diversity and the overall microbial composition. Differential abundance analysis and progressive permutation analysis were used to single out the significant microbial features that differed across CDI severity levels. Results Patient (n=200) demographics show mean age of 60 yrs., 53% female, majority White (76%) and non-Hispanic (85%). Prior 90 day metronidazole use (Odds Ratio OR 4.68 [1.47-14.91] p0.009) was a significant risk factor for severe CDI. Other factors included Horn’s Index > 2 (OR 7.75 [1.05-57.35] p0.045), Leukocytosis (OR 1.29 [1.16-1.43] p< 0.001), Neutropenia (OR 6.01 [1.34-26.89] p0.019) and Serum Creatinine >0.95 mg/dL (OR 25.30 [8.08-79.17] p< 0.001). Overall, there were no significant differences in alpha and beta diversity between severity levels. However, when identifying individual microbial features, the high presence of Bacteroides uniformis, Ruminococceae, Citrobacter koseri and Salmonella were associated with protection from severe CDI (p< 0.05). Table 1 - Results of multivariate logistic regression analysis of factors associated with severe CDI Figure 1. Microbiome features identified by progressive permutation analysis as seen in a volcano plot. Conclusion A number of risk factors for severe CDI were identified among this population, including prior 90 day metronidazole use. Also, increased relative abundance of Bacteroides uniformis, Ruminococceae, Citrobacter koseri and Salmonella were linked to protection from severe CDI. Reducing metronidazole use in patients with cancer may help prevent subsequent severe CDI. Disclosures Adilene Olvera, MPH MLS (ASCP), MERK (Grant/Research Support, Scientific Research Study Investigator) Kevin W. Garey, PharmD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator) Ryan J. Dillon, MSc, Merck & Co., Inc., (Employee) Engels N. Obi, PhD, Merck & Co. (Employee)

Outcomes After Vena Cava Filter Placement In Cancer Patients Hospitalized For Acute Venous Thromboembolism

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 936-936
Author(s):  
Richard H. White ◽  
Ann Brunson ◽  
Gwendolyn Ho ◽  
Ted Wun
Keyword(s):  
Venous Thromboembolism ◽  
Propensity Score ◽  
Cancer Patients ◽  
Statistical Significance ◽  
Multivariable Analysis ◽  
Vena Cava ◽  
Severity Of Illness ◽  
Vena Cava Filter ◽  
Risk Of Death ◽  
Adjusted Model

Abstract Background Evidence supporting use of an inferior vena cava filter (VCF) to prevent death or recurrent venous thromboembolism (rVTE) in cancer patients who are hospitalized for acute VTE is limited. Aims To determine the effectiveness of VCF placement on the 15-day and 30-day incidence of death and the 180-day incidence of rVTE manifested as pulmonary embolism (PE) or recurrent deep-vein thrombosis (DVT) alone among cancer patients hospitalized for acute-VTE. Methods Using a large retrospective observational study of discharge records in California, we analyzed outcomes after VCF placement in cancer patients hospitalized 2005-2009 for acute VTE using propensity-score methodology. We excluded all patients who had a history of a prior VCF placement (1991-2009). Outcomes were death <15-days and <30-days and rVTE (as PE or DVT alone) at 6 months. We used 3 analytic methods: 1) standard risk-adjusted multivariable analysis, 2) adjustment using propensity-score and inverse probability weighing (IPW) and 3) comparison based on matching (2:1) based on propensity score (caliper method). The multivariate model used to generate the propensity score included age, race/ethnicity, insurance coverage, expected bleeding risk, metastatic disease, bleeding present-on-admission, location of bleeding, recent or impending major surgery, use of thrombolytic agents, number of chronic co-morbidities, severity-of-illness (ascertained by 3M, APR-DRG grouper), index PE vs. DVT, and hospital characteristics. IPW of propensity score was applied to a risk-adjusted logistic model to predict death; IPW was applied to risk-adjusted Cox models predicting rVTE (as PE or DVT alone). In the model predicting death, risk-of-mortality on admission was used instead of severity-of-illness. Results Among 14,000 cancer-associated acute-VTE cases, the overall crude 15-day mortality rate was 1396 (10%) and the 30-day mortality was 2247 (16.1%). For 11,253 no-VCF patients, the crude 15-day mortality was 1089 (9.7%) and at 30 days it was 1727 (15.3%). A VCF was placed in 2747 patients (19.6%). The crude mortality in VCF patients was 307 (11.2%) at 15-days, and 520 (18.9%) at 30-days. After accounting for propensity to insert a VCF (using IPW) in a risk-adjusted model, there was no significant reduction in the risk of death associated with VCF use at 15-days (OR=0.90, CI:0.8-1.1, p=0.26) or 30 days (OR=1.04, 95%CI:0.9-1.2, p=0.57); findings were the same using standard multivariable analysis and matching based on propensity score. The crude 180-day incidence of recurrent PE was 3.3%: 2.6% in VCF patients and 3.4% in the no-VCF patients. In the adjusted model using IPW the risk of rVTE manifested as PE, the risk was lower in VCF patients (HR=0.81 95%CI:0.6-1.1, p=0.14) but this did not reach statistical significance. The crude 180-day incidence of rVTE manifested as DVT alone was 4.2% overall: 5.4% in VCF patients and 3.9% in no-VCF patients. In the IPW propensity score model, the risk of rVTE manifested as DVT at 180 days was significantly higher in VCF patients (HR=1.55, 95%CI:1.3-1.9, p<0.001). Models for recurrent VTE manifested by PE or DVT gave similar results whether based on propensity-score matching or multivariable analysis. Conclusions Use of a VCF in cancer patients hospitalized specifically for acute VTE was not associated with a significant reduction in the risk of death at 15 or 30 days, and the overall 30-day mortality was high. There was a 20% reduction in the risk of rVTE manifested as PE at 180-days but this did not reach the level of statistical significance (p>0.05). VCF use was associated with a 55% higher risk of rVTE manifested as DVT at 180 days. Further refinements in modeling incorporating competing outcomes (e.g., death) are underway. Disclosures: Ho: American Society of Hematology: ASH HONORS trainee research award Other.

scholarly journals Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism

2021 ◽  
Vol 7 (2) ◽  
pp. 27-38
Author(s):  
Katalin Makó
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Term Treatment ◽  
Long Term Treatment ◽  
High Bleeding Risk ◽  
Cancer Associated Thrombosis

Abstract Cancer-associated thrombosis (CAT) is a major cause of death in oncological patients. The mechanisms of thrombogenesis in cancer patients are not fully established, and it seems to be multifactorial in origin. Also, several risk factors for venous thromboembolism (VTE) are present in these patients such as tumor site, stage, histology of cancer, chemotherapy, surgery, and immobilization. Anticoagulant treatment in CAT is challenging because of high bleeding risk during treatment and recurrence of VTE. Current major guidelines recommend low molecular weight heparins (LMWHs) for early and long-term treatment of VTE in cancer patients. In the past years, direct oral anticoagulants (DOACs) are recommended as potential treatment option for VTE and have recently been proposed as a new option for treating CAT. This manuscript will give a short overview of risk factors involved in the development of CAT and a summary on the recent recommendations and guidelines for treatment of VTE in patients with malignancies, discussing also some special clinical situations (e.g. renal impairment, catheter-related thrombosis, and thrombocytopenia).

Abstract 13145: Differences of Cancer Types in Hospital Mortality in Patients With Venous Thromboembolism

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Okushi Yuichiro ◽  
Kenya Kusunose ◽  
Takayuki Ise ◽  
Takeshi Tobiume ◽  
Koji Yamaguchi ◽  
...  
Keyword(s):  
Big Data ◽  
Venous Thromboembolism ◽  
Hospital Mortality ◽  
Cancer Patients ◽  
Biliary Tract ◽  
Gynecological Cancer ◽  
Cancer Type ◽  
Patients With Cancer ◽  
Liver Cancers ◽  
Cancer Types

Introduction: We sought to evaluate the clinical characteristics and outcomes of patients with cancer-associated VTE, compared with the matched cohort without cancer using real-world big data of VTE. Background: Cancer is associated with a high incidence of Venous Thromboembolism (VTE) and there are many guidelines/recommendations about VTE. However, the prognosis of cancer-VTE patients is not well known because of a lack of big data. Moreover, there is also no knowledge on how cancer type is related to prognosis. Methods: This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). We identified 28,247 patients who were first hospitalized with VTE from April 2012 to March 2017. 26.0% were cancer patients. Compared with national statistics of cancer incidence in 2015 from National Cancer Center of Japan, the proportion of gynecological cancer patients was higher, but other cancer types had similar prevalence rates. Propensity score (PS) was estimated with logistic regression model, with cancer as the dependent variable and 18 clinically relevant covariates. Results: We included 24,576 patients after exclusion. The median age was 71years (range: 59-80 years), and 42.0% were male. On PS-matched analysis with 12,418 patients, patients with cancer had higher total in-hospital mortality (9.5% vs. 3.8%, P<0.001; OR, 2.72, 95% CI: 2.33-3.19) and in-hospital mortality within 30days (6.8% vs. 3.2%, P<0.001; OR, 2.20, 95% CI: 1.85-2.62). On analysis for each type of cancer, in-hospital mortality in 10 types of cancer was significantly high, especially pancreas (OR: 9.65, 95%CI: 4.31-21.64), biliary tract (OR: 8.36, 95%CI: 2.42-28.89) and liver (OR: 7.33, 95%CI: 1.92-28.02). Conclusions: Patients with cancer had a higher in-hospital mortality for VTE than those without cancer, especially in pancreatic, biliary tract and liver cancers.

Epidemiology, risk and outcomes of venous thromboembolism in cancer

2012 ◽  
Vol 32 (02) ◽  
pp. 115-125 ◽  
Author(s):  
L. Russo ◽  
A. Falanga
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Brain Cancer ◽  
Prediction Models ◽  
Disease Stage ◽  
Individual Factors ◽  
Scientific Societies ◽  
Risk Prediction Models ◽  
Patients With Cancer ◽  
Increased Risk

SummaryCancer is associated with a fourfold increased risk of venous thromboembolism (VTE). The risk of VTE varies according to the type of malignancy (i. e. pancreatic cancer, brain cancer, lymphoma) and its disease stage and individual factors (i. e. sex, race, age, previous VTE history, immobilization, obesity). Preventing cancer-associated VTE is important because it represents a significant cause of morbidity and mortality. In order to identify cancer patient at particularly high risk, who need thromboprophylaxis, risk prediction models have become available and are under validation. These models include clinical risk factors, but also begin to incorporate biological markers. The major American and European scientific societies have issued their recommendations to guide the management of VTE in patients with cancer.In this review the principal aspects of epidemiology, risk factors and outcome of cancer-associated VTE are summarized.

Risk factors for in-hospital mortality and prolonged length of stay in older patients with solid tumors

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 9550-9550
Author(s):  
M. Shayne ◽  
E. Culakova ◽  
M. S. Poniewierski ◽  
D. A. Wolff ◽  
G. H. Lyman
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Cancer Patients ◽  
Solid Tumors ◽  
Older Patients ◽  
Cancer Type ◽  
Additional Risk ◽  
Factors Associated

9550 Background: Little is known about risk factors that contribute to prolonged hospitalization and mortality in older patients with cancer. Methods: Cancer patients ≥65 years of age hospitalized between 1995 and 2003 at 133 academic medical centers were evaluated using the University Health System Consortium discharge database. This study identified 386,377 older hospitalized patients with various solid tumors. Multivariate analyses were performed to determine variables independently associated with the primary endpoints: length of stay (LOS) ≥10 days and in-hospital mortality (IHM). Results: Average LOS was 7.5 days with 23% hospitalized ≥10 days. A significant improvement in LOS was observed over the study timeframe (p<.0001). Patients with gastric cancer had the greatest risk of prolonged LOS while those with breast cancer had the lowest risk. Additional risk factors for prolonged LOS included infection, venous thromboembolism and red blood cell transfusion (RBCT). The overall rate of IHM was 7.3% with a significant improvement in risk over the study timeframe (p<.0001). IHM was strongly associated with prolonged LOS (p<.0001). Older patients with primary central nervous system malignancies had the highest rates of IHM (OR=1.81; 95% CI: 1.59–2.07), followed by esophageal and lung cancer. Male gender was a risk factor for both IHM and prolonged LOS (p<.0001). Older African American cancer patients were more likely to experience prolonged LOS and IHM compared with Caucasian patients (p<.0001) after adjustment for cancer type and comorbidities. Additional risk factors associated with IHM included metastatic disease, active infection, neutropenia, renal disease, lung disease, arterial and venous thromboembolism, congestive heart failure, hepatic disease, and RBCT. Conclusions: Improving trends in LOS and IHM for older patients with solid tumors were observed over time in this study. Risk factors associated with IHM such as infection, neutropenia and RBCT, when modified, could potentially further reduce rates of prolonged LOS and IHM in older cancer patients. [Table: see text]

Treatment and secondary prevention of venous thromboembolism in cancer patients

2012 ◽  
Vol 03 (03) ◽  
pp. 121-125
Author(s):  
I. Pabinger ◽  
C. Ay
Keyword(s):  
Clinical Trials ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Factor Xa ◽  
New Oral Anticoagulants ◽  
Phase Iii ◽  
Patients With Cancer ◽  
Potential Use

SummaryCancer is a major and independent risk factor of venous thromboembolism (VTE). In clinical practice, a high number of VTE events occurs in patients with cancer, and treatment of cancerassociated VTE differs in several aspects from treatment of VTE in the general population. However, treatment in cancer patients remains a major challenge, as the risk of recurrence of VTE as well as the risk of major bleeding during anticoagulation is substantially higher in patients with cancer than in those without cancer. In several clinical trials, different anticoagulants and regimens have been investigated for treatment of acute VTE and secondary prophylaxis in cancer patients to prevent recurrence. Based on the results of these trials, anticoagulant therapy with low-molecular-weight heparins (LMWH) has become the treatment of choice in cancer patients with acute VTE in the initial period and for extended and long-term anticoagulation for 3-6 months. New oral anticoagulants directly inhibiting thrombin or factor Xa, have been developed in the past decade and studied in large phase III clinical trials. Results from currently completed trials are promising and indicate their potential use for treatment of VTE. However, the role of the new oral thrombin and factor Xa inhibitors for VTE treatment in cancer patients still has to be clarified in further studies specifically focusing on cancer-associated VTE. This brief review will summarize the current strategies of initial and long-term VTE treatment in patients with cancer and discuss the potential use of the new oral anticoagulants.

Risk Factors for Bleeding during Treatment of Acute Venous Thromboembolism

1996 ◽  
Vol 76 (05) ◽  
pp. 682-688 ◽  
Author(s):  
Jos P J Wester ◽  
Harold W de Valk ◽  
Karel H Nieuwenhuis ◽  
Catherine B Brouwer ◽  
Yolanda van der Graaf ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Surface Area ◽  
Body Surface Area ◽  
Body Surface ◽  
Small Body ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Risk Of Bleeding ◽  
Acute Venous Thromboembolism

Summary Objective: Identification of risk factors for bleeding and prospective evaluation of two bleeding risk scores in the treatment of acute venous thromboembolism. Design: Secondary analysis of a prospective, randomized, assessor-blind, multicenter clinical trial. Setting: One university and 2 regional teaching hospitals. Patients: 188 patients treated with heparin or danaparoid for acute venous thromboembolism. Measurements: The presenting clinical features, the doses of the drugs, and the anticoagulant responses were analyzed using univariate and multivariate logistic regression analysis in order to evaluate prognostic factors for bleeding. In addition, the recently developed Utrecht bleeding risk score and Landefeld bleeding risk index were evaluated prospectively. Results: Major bleeding occurred in 4 patients (2.1%) and minor bleeding in 101 patients (53.7%). For all (major and minor combined) bleeding, body surface area ≤2 m2 (odds ratio 2.3, 95% Cl 1.2-4.4; p = 0.01), and malignancy (odds ratio 2.4, 95% Cl 1.1-4.9; p = 0.02) were confirmed to be independent risk factors. An increased treatment-related risk of bleeding was observed in patients treated with high doses of heparin, independent of the concomitant activated partial thromboplastin time ratios. Both bleeding risk scores had low diagnostic value for bleeding in this sample of mainly minor bleeders. Conclusions: A small body surface area and malignancy were associated with a higher frequency of bleeding. The bleeding risk scores merely offer the clinician a general estimation of the risk of bleeding. In patients with a small body surface area or in patients with malignancy, it may be of interest to study whether limited dose reduction of the anticoagulant drug may cause less bleeding without affecting efficacy.

scholarly journals An Exploration of Heart Failure Risk in Breast Cancer Patients Receiving Anthracyclines with or without Trastuzumab in Thailand: A Retrospective Study

2021 ◽  
Vol 11 (3) ◽  
pp. 484-493
Author(s):  
Jukapun Yoodee ◽  
Aumkhae Sookprasert ◽  
Phitjira Sanguanboonyaphong ◽  
Suthan Chanthawong ◽  
Manit Seateaw ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Risk Factors ◽  
Cancer Patients ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Breast Cancer Patients ◽  
Ventricular Ejection Fraction ◽  
Factors Associated ◽  
Palliative Intent ◽  
Increased Risk

Anthracycline-based regimens with or without anti-human epidermal growth factor receptor (HER) 2 agents such as trastuzumab are effective in breast cancer treatment. Nevertheless, heart failure (HF) has become a significant side effect of these regimens. This study aimed to investigate the incidence and factors associated with HF in breast cancer patients treated with anthracyclines with or without trastuzumab. A retrospective cohort study was performed in patients with breast cancer who were treated with anthracyclines with or without trastuzumab between 1 January 2014 and 31 December 2018. The primary outcome was the incidence of HF. The secondary outcome was the risk factors associated with HF by using the univariable and multivariable cox-proportional hazard model. A total of 475 breast cancer patients were enrolled with a median follow-up time of 2.88 years (interquartile range (IQR), 1.59–3.93). The incidence of HF was 3.2%, corresponding to an incidence rate of 11.1 per 1000 person-years. The increased risk of HF was seen in patients receiving a combination of anthracycline and trastuzumab therapy, patients treated with radiotherapy or palliative-intent chemotherapy, and baseline left ventricular ejection fraction <65%, respectively. There were no statistically significant differences in other risk factors for HF, such as age, cardiovascular comorbidities, and cumulative doxorubicin dose. In conclusion, the incidence of HF was consistently high in patients receiving combination anthracyclines trastuzumab regimens. A reduced baseline left ventricular ejection fraction, radiotherapy, and palliative-intent chemotherapy were associated with an increased risk of HF. Intensive cardiac monitoring in breast cancer patients with an increased risk of HF should be advised to prevent undesired cardiac outcomes.

Sign in / Sign up

Export Citation Format

Share Document