The Neuropathic Diathesis, or the Diathesis of the Degenerate

1888 ◽  
Vol 34 (146) ◽  
pp. 167-176
Author(s):  
G. T. Revington
Keyword(s):  
Family History ◽  
Normal Development ◽  
Personal History ◽  
Striking Feature ◽  
General Paralysis ◽  
History Of ◽  
The Creation ◽  
The Individual ◽  
The Mind

I think that the foregoing statistics, and those which follow, together with the large number of cases which I quote, and which connect general paralysis with almost every form of neurotic manifestation, will prove conclusively that neurotic inheritance is a striking feature in the causation of general paralysis. I question whether a distinction between “the cerebral and the insane element” in general paralysis can be maintained. If general paralysis is not a degeneration of the mind-tissue, then the pathology of insanity has no existence, and I would say that the subtle influence for evil, which is transmitted from parents, whose brains are deteriorated by neurotic outbursts, or soaked in alcohol, or wrecked by physiological immorality, tends strongly towards such degeneration. If insanity is, as Dr. Savage says, a perversion of the ego, then a general paralytic is the in-sanest of the insane. We know that the children of a melancholic parent, for example, may develop any form of neurosis—in other words, it is not that melancholia or general paralysis, or any other definite disease, is transmitted, but that a certain tendency to deviate from normal development is transmitted. This tendency to deviate is the neurotic diathesis, and the form of its development is determined by collateral circumstances, and a certain series of collateral circumstances determine the development of general paralysis. Perhaps neurotic inheritance may mean in some cases a limited capital of nervous energy, and if this is wasted recklessly the individual breaks down suddenly and pathologically, as we all do slowly and physiologically. I would also point out that considering the number of histories of insanity which owing to ignorance or reticence we, do not receive, and considering that we never receive information as to the existence of the slighter neuroses, it is marvellous that we get so high a percentage as 51. Of the 145 general paralytics with a reliable history, 38 had a family history of insanity, 28 a family history of drink, 8 of both, 43 had a personal history of drink, 8 of a previous attack too remote to be considered, at least, according to our present ideas, as part of the disease, and the vast majority had a history of some physiological irregularity which must be considered as conducive to the creation of an acquired neurosis. We may now pass to some further statistics.

A Practical Approach to Pediatric Patients Referred With an Abnormal Coagulation Profile

2005 ◽  
Vol 129 (8) ◽  
pp. 1011-1016 ◽  
Author(s):  
Monica Acosta ◽  
Rachel Edwards ◽  
E. Ian Jaffe ◽  
Donald L. Yee ◽  
Donald H. Mahoney ◽  
...  
Keyword(s):  
Family History ◽  
Positive Family History ◽  
Laboratory Data ◽  
Bleeding Risk ◽  
Personal History ◽  
Retrospective Case ◽  
Laboratory Assessment ◽  
Repeat Testing ◽  
Effective Manner ◽  
History Of

Abstract Context.—Workup for prolonged prothrombin time (PT) and activated partial thromboplastin time (PTT) is a frequent referral to a Hematology and Coagulation Laboratory. Although the workup should be performed in a timely and cost-effective manner, the complete laboratory assessment of the coagulation state has not been standardized. Objective.—To determine which clinical and laboratory data are most predictive of a coagulopathy and to formulate the most efficient strategy to reach a diagnosis in patients referred for abnormal coagulation profiles. Design.—Retrospective case review. Medical records of 251 patients referred for prolonged PT and/or PTT to our Hematology Service between June 1995 and December 2002 were reviewed. Results.—The study included 135 males and 116 females with a mean age of 7.0 years. A personal history of bleeding was reported in 137 patients, and a family history of bleeding was reported in 116 patients. Fifty-one patients (20%) had a coagulopathy (ie, a bleeding risk). Factors predictive of a bleeding risk were a positive family history of bleeding (P < .001) and a positive personal history of bleeding (P = .001). Of 170 patients with findings of normal PT and PTT values on repeat testing, 14 were subsequently diagnosed with a coagulopathy. Two of these patients reported no positive personal or family history of bleeding. Conclusions.—Coagulopathy was identified in 20% of the children referred for abnormal PT and/or PTT. In the absence of a personal or family history of bleeding, a normal PT and/or PTT on repeat testing has a negative predictive value of more than 95%.

BRCA mutations and their clinical relevance in unselected pancreatic cancer population.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e16240-e16240
Author(s):  
Viola Barucca ◽  
Andrea Petricca Mancuso ◽  
Salvatore De Marco ◽  
Daniela Iacono ◽  
Carmelilia De Bernardo ◽  
...  
Keyword(s):  
Pancreatic Cancer ◽  
Family History ◽  
Disease Progression ◽  
Personal History ◽  
First Line ◽  
Brca Mutations ◽  
Cancer Family ◽  
Cancer Family History ◽  
Brca 2 ◽  
History Of

e16240 Background: Germline pathogenetic mutations in BRCA1/2 genes are described in pancreatic cancer patients (PCP) in about 5–9% of cases. The purpose of this study was to determine their relevance in an unselected consecutive cohort of PCP describing family and clinical history. Methods: Patients (pts) were recruited at a single cancer center from September 2019 to October 2020. Participants provided blood for DNA analysis; cancer family history and treatment records were reviewed; DNA was analyzed by Next Generation Sequencing and multiplex ligation-dependent probe amplification for germline variants in BRCA1/2 Results: 69 pts were included, 61 (88,4%) with locally advanced and metastatic pancreatic cancer received first line chemotherapy and 38 (62%) were full eligible for BRCA analysis; 8 out of 69 pts were BRCA screened even if in adjuvant setting, 10 patients are still under evaluation. Out of the 38 first line screened PCP germline BRCA mutations were found in 9 (19%): 4 pts (8,7%) with pathogenetic BRCA-2 variants (subgroup 1 – S1) and 5 pts (10,8%) with variants of unknown significances (VUSs), i.e. c.5339T>C and c.5096G>A in BRCA1 (subgroup 2 – S2). Samples from 29 pts were established as BRCA wild-type (subgroup 3 – S3). Pathogenetic BRCA-2 variants were observed in 2 male and 2 female (median age, 61.5 years, range 48-69), 3 out 4 without family history of breast, ovarian and pancreatic cancer, one patient (pt) had ovarian cancer family history. All pts had a negative personal history of others cancers. All S1 pts received FOLFIRINOX regimen achieving one complete response, 2 partials responses and 1 disease progression with RECIST criteria. The S2 included 2 male and 3 female (median age, 61 years, range 45-70) 2 with family history of pancreatic cancer, no pt had personal history of others cancers; 2 pts had stable disease and 3 disease progression receiving platinum-based regimen (4 pts) and gemcitabine/nabpaclitaxel (1 pt), respectively. Platinum responders were observed only in the well known pathogenetic BRCA-2 variants group with twice a median progression-free survival (PFS, months -ms-) as compared to the one observed in VUSs group. (>6 C.I. 95% 2- >12 ms; vs 3 ms, 95% C.I. 3-12 ms). S3 included 9 male and 20 female, (median age, 66 years, range 42-78); 5 pts had family history of pancreatic or breast cancer, 5 pts had a personal history of other cancers (breast and thyroid). In this group,16 pts received a platinum based regimen and 12 pts have been treated without platinum based regimen. Conclusions: Our results suggest that: 1) BRCA pathogenetic mutations rate (8,7%) is in line with literature data and seems not to be related with family or personal history, and to be associated with a better outcome; 2) No BRCA mutations were detected in patients over 70 years. 3) VUSs subgroup do not seem to benefit from platinum-regimen.

Is Migraine Associated with Right-to-Left Shunt a Separate Disease? Results of the SAM Study

Cephalalgia ◽  
2008 ◽  
Vol 28 (4) ◽  
pp. 360-366 ◽  
Author(s):  
GP Anzola ◽  
G Meneghetti ◽  
C Zanferrari ◽  
A Adami ◽  
L Dinia ◽  
...  
Keyword(s):  
Family History ◽  
Observational Study ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Genetic Linkage ◽  
Personal History ◽  
Coagulation Disorders ◽  
Foramen Ovale ◽  
History Of ◽  
Pfo Closure

Migraine with aura (MA) is associated with the persistence of patent foramen ovale (PFO) in about 50% of cases, and migraineurs tend to have larger shunts than controls, suggesting that right-to-left shunt (RILES) determined by PFO could play a role in triggering migraine attacks. Moreover, some preliminary reports have suggested that PFO closure may give relief to both migraine and aura attacks. The aim of this study was to clarify if shunt-associated migraine (SAM) has clinical features that allow a distinction from shunt-unrelated migraine (SUM), in a prospective, multicentre, observational study (SAM study). We enrolled consecutive MA patients, who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. All were systematically screened for RILES with transcranial Doppler, and for coagulation disorders. Overall, 460 patients were included; the SUM and SAM classes comprised 58% and 42% of patients, respectively. SAM patients were significantly younger (34.1 ± 10 vs. 37.1 ± 11 years), had a more frequent family history of migraine (76% vs. 66%) and a higher frequency of sensory symptoms of aura (51% vs. 41%); by contrast, there was a lesser association of SAM with other cardiac abnormalities and with coagulation disorders. The SAM study suggests that the effect of RILES on migraine features is not relevant. The higher family history of migraine in SAM suggests a possible genetic linkage between migraine and RILES.

scholarly journals Individual vulnerabilities to psychosis after antiepileptic drug administration

2020 ◽  
Vol 2 (2) ◽  
pp. e000036
Author(s):  
Nozomi Akanuma ◽  
Naoto Adachi ◽  
Peter Fenwick ◽  
Masumi Ito ◽  
Mitsutoshi Okazaki ◽  
...  
Keyword(s):  
Family History ◽  
Focal Epilepsy ◽  
Individual Characteristics ◽  
New Drugs ◽  
Individual Vulnerability ◽  
Intellectual Function ◽  
State Dependent ◽  
History Of ◽  
History Of Epilepsy ◽  
The Individual

BackgroundPsychosis often develops after the administration of antiepileptic drugs (AEDs) in patients with epilepsy. However, the individual vulnerability and clinical condition of such patients have been rarely scrutinised. We investigated the effect of individually consistent (trait-dependent) and inconsistent (state-dependent) characteristics.MethodsThe individual characteristics, clinical states and psychotic outcome of patients from eight adult epilepsy clinics were retrospectively reviewed over 6-month periods after a new drug (AED or non-AED) administration between 1981 and 2015.ResultsA total of 5018 new drugs (4402 AEDs and 616 non-AEDs) were used in 2015 patients with focal epilepsy. Subsequently, 105 psychotic episodes (81 interictal and 24 postictal) occurred in 89 patients. Twelve patients exhibited multiple episodes after different AED administrations. Trait-dependent characteristics (early onset of epilepsy, known presumed causes of epilepsy, lower intellectual function and a family history of psychosis) were significantly associated with the patients who exhibited psychosis. Absence of family history of epilepsy was also associated with psychosis but not significantly. Subsequent logistic regression analysis with a model incorporating family history of psychosis and epilepsy, and intellectual function was the most appropriate (p=0.000). State-dependent characteristics, including previous psychotic history and epilepsy-related variables (longer duration of epilepsy, AED administration, higher seizure frequency and concomitant use of AEDs) were significantly associated with psychotic episodes. Subsequent analysis found that a model including AED administration and previous psychotic history was the most appropriate (p=0.000).ConclusionPsychosis occurring after new AED administration was related to the individual vulnerability to psychosis and intractability of epilepsy.

scholarly journals Family history of cancer, personal history of medical conditions and risk of oral cavity cancer in France: the ICARE study

BMC Cancer ◽  
2013 ◽  
Vol 13 (1) ◽  
Author(s):  
Loredana Radoï ◽  
Sophie Paget-Bailly ◽  
Florence Guida ◽  
Diane Cyr ◽  
Gwenn Menvielle ◽  
...  
Keyword(s):  
Family History ◽  
Oral Cavity ◽  
Oral Cavity Cancer ◽  
Personal History ◽  
Medical Conditions ◽  
Family History Of Cancer ◽  
History Of ◽  
History Of Cancer

Prospective Comparison of the Pediatric Bleeding Questionnaire (PBQ) and the International Society On Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) in Children Referred to a Tertiary-Care Pediatric Centre.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2229-2229
Author(s):  
Veerle Labarque ◽  
Victor S. Blanchette ◽  
Dewi S. Clark ◽  
Paula D. James ◽  
Margaret L. Rand
Keyword(s):  
Family History ◽  
Prospective Study ◽  
Assessment Tool ◽  
Tertiary Care ◽  
Bleeding Disorders ◽  
History Of ◽  
The Individual ◽  
Individual Scores ◽  
Score Range ◽  
Mucocutaneous Bleeding

Abstract Abstract 2229 Mucocutaneous bleeding symptoms, such as epistaxis and bruising, are frequent complaints in childhood; a detailed bleeding history is a crucial initial step in determining whether a child presenting with such symptoms has an underlying bleeding disorder. A Pediatric Bleeding Questionnaire (PBQ), based on the MCMDM-1 VWD Bleeding Questionnaire, incorporates 6 pediatric-specific bleeding symptoms (see below) to quantify bleeding severity in children. Bleeding symptoms are scored in a −1 to +4 range, with a −1 score assigned for tooth extraction or surgery if bleeding did not occur in at least 2 procedures, and are summed for all symptoms. An overall PBQ score of ≥2 predicts a diagnosis of von Willebrand disease (VWD). The PBQ has also been used to quantify the severity of bleeding symptoms in children with VWD or platelet function disorders (Bowman et al, J Thromb Haemost 2009;7:1418; Biss et al, J Thromb Haemost 2010;8:950; Biss et al, J Thromb Haemost 2010;8:1416). The ISTH has developed a Bleeding Assessment Tool (ISTH-BAT) to standardize the reporting of bleeding symptoms in adult and pediatric populations; bleeding symptoms are scored in a 0 to +4 range, and are summed (Rodeghiero et al, J Thromb Haemost 2010;8:2063). Criteria for scoring of each symptom are similar between the two questionnaires, but not identical. Here, we have performed a detailed comparison between PBQ and ISTH-BAT scores in a prospective study of children with mucocutaneous bleeding and/or a family history of VWD or a platelet function disorder referred to our tertiary-care pediatric bleeding disorders clinic. To date, we have enrolled 75 subjects, with a mean age of 9.9 yrs (range: 0.5–17.8 yrs), of whom 36 are males. The median overall PBQ score of these children was 3 (range: 0–12), as was the median overall ISTH-BAT score (range: 0–13). In 37/75 children (49%), the overall PBQ score was identical to the overall ISTH-BAT score. In the majority of these children (34/37; 92%), the individual scores for each symptom were identical. However, in 3 children, there were differences in the individual scores that balanced out, resulting in identical overall scores. For 38/75 children (51%), the overall PBQ and ISTH-BAT scores were different. In the majority of these children (33/38; 87%), the difference between the scores was only 1, with the ISTH-BAT being lower in 19/38 children, and higher in 14/38 children. In 2/38 children, the overall ISTH-BAT was lower by 2, in 2/38, higher by 2 and in 1/38, higher by 3. A lower overall ISTH-BAT score was mainly due to a lower score for cutaneous bleeding symptoms (14/21 children). A higher overall ISTH-BAT score was mainly due to a −1 PBQ score for a child who did not bleed on at least 2 tooth extractions or surgeries (observed in 11/17 children) and/or a higher ISTH-BAT score for menorrhagia (observed in 6/17 children, specifically, 6/9 postmenarchal adolescent females). 10/75 (13%) children had a normal overall PBQ score of 0 or 1 (median: 1). The median overall ISTH-BAT score in these children was also 1 (range: 0–3), but 5 children had a score of 2 or 3. In the remaining 65/75 children (87%) with a positive, abnormal PBQ score, the median score was 3 (range: 2–12), as was the median overall ISTH-BAT score (range: 2–13). In contrast with previous prospective studies using the PBQ/ISTH-BAT in which pediatric-specific symptoms were not observed (Bowman et al, J Thromb Haemost 2009;7:1418; Bidlingmaier et al, J Thromb Haemost 2012;10:1335), 12/75 children (16%) received scores for macroscopic hematuria, post-circumcision bleeding, cephalohematoma, umbilical stump bleeding, post-venipuncture bleeding, or conjunctival hemorrhage. In summary, in this prospective study, we have observed similar, but not identical, overall PBQ and ISTH-BAT scores and the occurrence of pediatric-specific bleeding symptoms in children referred to a tertiary-care bleeding disorders clinic with mucocutaneous bleeding and/or a family history of VWD or platelet dysfunction. Thus, the inclusion of pediatric-specific bleeding symptoms in the standardized questionnaires is useful, and if the ISTH-BAT is to be adopted for general use to aid in the evaluation of whether a child has an underlying bleeding disorder, it will be essential to determine the cut-off for an abnormal ISTH-BAT bleeding score in children <18 yrs of age. Disclosures: James: CSL-Behring, Baxter, Bayer: Honoraria, Research Funding.

Clinical and Economic Impact of Pre-Operative Coagulation Screening in Children

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3379-3379
Author(s):  
Trishala Agrawal ◽  
Louisa Mazza-Hilway ◽  
Alice J. Cohen ◽  
Sari H Jacoby
Keyword(s):  
Family History ◽  
Major Bleeding ◽  
Conflicts Of Interest ◽  
Personal History ◽  
Screening Tests ◽  
Factor Vii ◽  
Factor Xii ◽  
Coagulation Tests ◽  
History Of ◽  
The Mean

Abstract Abstract 3379 Background: The literature in the past has recommended pre-operative (PRE-O) coagulation screening only when indicated by history or physical exam. Despite these recommendations, surgeons continue to order PT and PTT prior to surgery, especially in children, because they have often not been hemostatically challenged. We evaluated the usefulness of screening tests in identifying significant bleeding risk and associated cost. Methods: We performed a retrospective audit on children referred to the hemophilia center sent for further evaluation of abnormal PT and PTT on PRE-O screening. We reviewed 62 patients who had 80 procedures, out of which 70 procedures were evaluable with complete data. Age, personal and family history of bleeding, coagulation tests, PRE-O and post-operative (PO) treatment, and immediate PO bleeding were assessed. Results: The most common procedure that led to PRE-O screening was tonsillectomy/adenoidectomy at 61% (49/80). Other procedures included orthopedic, GI, oral, dental extractions, and myringotomies. Only 2.5% (2/80) were cardiac procedures. The mean patient age was 6 years (range 1–16). 55% (34/62) had no personal or family history of bleeding. 22.5% (14/62) had a family history of mild bleeding such as epistaxis or menorrhagia. 8% (5/62) had a family history of major bleeding disorders such as Von Willebrand disease (VWD) or hemophilia. 14.5% (9/62) had a personal history of bleeding, mild or major. The most common abnormal screening test was the PT at 40% (25/62). 27% (17/62) had an abnormal PTT (3.2% \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(262\) \end{document} with a significantly abnormal PTT above 50). 22.5% (14/62) were referred for abnormal PT/PTT. 8% (5/62) with an abnormal PT and/or PTT corrected on repeat studies. The remaining 9.6% (6/62) were referred for other reasons such as positive family or personal history and a high risk procedure. Additional coagulation tests ordered because of prolonged PT or PTT varied and included additional factor assays (Table 1). The mean cost of additional testing was >$1000. Factor VII was the most common factor deficiency identified with a mean activity of 47% (27–54%) (normal 55–163%) followed by factor XII deficiency with a mean activity of 39% ( 19–49%) (normal 46–168%). PRE-O, 5 patients received support with either Humate P, Stimate, Amicar, or DDAVP, 4 with a diagnosis of VWD and 1 with Jacobsen Syndrome; 3 of these patients received PO Amicar. PO, 69/70 procedures were completed with minimal (2–45 mL) bleeding. Only 1/70 procedures had significant PO bleeding, despite normal tests. This patient did not have any significant immediate PO bleeding, but had delayed bleeding reported at day 7 requiring cauterization. No other cases of delayed PO bleeding were reported to our clinic. Conclusion: In patients who undergo routine screening by laboratory testing only, the most common abnormality found was a prolonged PT. Subsequent workup of patients with abnormal screening tests identified factor VII or factor XII deficiencies most frequently. Only one patient with abnormal PT/PTT was diagnosed with a significant bleeding disorder, VWD. Major bleeding occurred rarely. This study demonstrates that the cost of extensive PRE-O coagulation testing is high with minimal clinical impact. Disclosures: No relevant conflicts of interest to declare.

Making Space

2020 ◽  
Vol 35 (3) ◽  
pp. 132-141
Author(s):  
Jasmine Nichole Cobb
Keyword(s):  
Nineteenth Century ◽  
Family History ◽  
Black Culture ◽  
Personal History ◽  
Cultural Institutions ◽  
Cultural Contexts ◽  
Black Artists ◽  
Look Back ◽  
Iconic Images ◽  
History Of

In this interview, artist and scholar Deborah Willis describes the work of excavating and organizing the history of Black photography. Willis’s groundbreaking scholarship helped to formally establish an archive of Black visual practice before libraries and cultural institutions began to purposely catalogue such materials. Across projects, she has engaged questions of beauty, citizenship, Black culture, and family history from the nineteenth century to the present by closely examining the camera practices of legendary photographers and the cultural contexts surrounding iconic images. In this interview, Willis describes her research as a student relying on periodical records as well as on the support of Black artists such as Roy DeCarava, Carrie Mae Weems, Gordon Parks, and James VanDerZee. This conversation with the author intertwines Willis’s personal history and the history of creating a visual archive to offer a look back and a look forward at the practice of Black photography.

The Royal Marines on Franklin's last expedition

Polar Record ◽  
2004 ◽  
Vol 40 (4) ◽  
pp. 319-326 ◽  
Author(s):  
Ralph Lloyd-Jones
Keyword(s):  
Family History ◽  
Social History ◽  
Northwest Passage ◽  
The Social ◽  
History Of ◽  
The Individual

Using methods developed by family history researchers, it is possible to discover a remarkable amount about the individual lives of many men involved in Sir John Franklin's last fatal attempt to discover a Northwest Passage. This work constitutes what might be called ‘the social history’ of Franklin studies, relevant to that voyage in particular, and the early Victorian navy in general. Light is shed upon the lives of the Royal Marines aboard both HMS Erebus and HMS Terror, men who sailed and died with Franklin.

scholarly journals Elucidating the phenotypic variability associated with the polyT tract and TG repeats in CFTR

2020 ◽  
Author(s):  
Keith Nykamp ◽  
Rebecca Truty ◽  
Darlene Riethmaier ◽  
Julia Wilkinson ◽  
Sara L. Bristow ◽  
...  
Keyword(s):  
Genetic Counseling ◽  
Family History ◽  
Hereditary Cancer ◽  
Phenotypic Variability ◽  
Clinical Information ◽  
History Of ◽  
Disease Risks ◽  
Reduced Penetrance ◽  
The Individual ◽  
Single Organ

ABSTRACTPurposeTo evaluate the risk and spectrum of phenotypes associated in individuals with one or two of the CFTR T5 haplotype variants (TG11T5, TG12T5 and TG13T5) in the absence of the R117H variant.MethodsIndividuals who received testing with CFTR NGS results between 2014 and 2019 through Invitae at ordering provider discretion were included. TG-T repeats were detected using a custom-developed haplotype caller. Frequencies of the TG-T5 variants (biallelic or in combination with another CF-causing variant [CFvar]) were calculated. Clinical information reported by the ordering provider (via requisition form) or the individual (during genetic counseling appointments) was examined.ResultsAmong 548,300 individuals, the minor allele frequency of the T5 allele was 4.2% (TG repeat distribution: TG11=68.1%, TG12=29.5%, TG13=2.4%). When present with a CFvar, each of the TG[11-13]T5 variants were significantly enriched in individuals with a “high suspicion” of CF/CFTR-RD (personal/family history of CF/CFTR-RD) compared to those with very “low suspicion” for CF or CFTR-RD (hereditary cancer testing, CFTR not requisitioned). Compared to CFvar/CFvar individuals, TG[11-13]T5/CFvar individuals generally had single organ involvement, milder symptoms, variable expressivity, and reduced penetrance.DiscussionData from this study provides a better understanding of disease risks associated with inheriting TG[11-13]T5 variants and has important implications for reproductive genetic counseling.

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