Neoadjuvant therapy (NAT) for breast cancer at the Odette Cancer Centre: What have we been doing and how do we compare?

2012 ◽  
Vol 30 (27_suppl) ◽  
pp. 131-131
Author(s):  
Claudia Arce ◽  
Sonal Gandhi
Keyword(s):  
Breast Cancer ◽  
Care Pathway ◽  
Clinical Care ◽  
Locally Advanced ◽  
Cancer Centre ◽  
Significant Difference ◽  
Before And After ◽  
Her 2 ◽  
Cancer Phenotype ◽  
Clinical Care Pathway

131 Background: NAT is standard of care for locally advanced breast cancer (LABC). Early breast cancer (EBC) may also benefit, particularly certain subtypes, such as HER2-enriched or basal- like. We developed a clinical care pathway to standardize the assessment and treatment of LABC and higher-risk EBC at the Odette Cancer Centre (OCC). Purpose: Evaluate treatment patterns within the LABC/NAT program at the OCC, and to determine if these patterns changed after the introduction of a clinical care pathway. This study also aimed to evaluate treatment efficacy (pCR rates) by NAT regimen and breast cancer phenotype, as compared to the literature. Methods: Retrospective chart review of patients treated with NAT at the OCC from January 2008 to March 2012. Results: 158 patients were reviewed. Median age at diagnosis was 50 years (28-85), and median tumor size was 7 cm (0-21). 74% were stage IIB-IIIB, and 11.2% were considered non-LABC (or EBC). 65.8% of breast cancers were estrogen receptor positive (ER+), and 29.7% were HER-2 positive (HER2+). 96% of NAT chemotherapy regimens were anthracycline and taxane-based, and trastuzumab was given to 29.7% of HER-2 positive cases. pCR was achieved in 20.9% of all cases and this did not vary by type of chemotherapy regimen; pCR rates did vary by breast cancer phenotype, with 6.25%, 57.5% and 25% pCR achieved for ER+, HER2+ and triple negative (TN) cancers, respectively. Median follow-up was 13 months (0-46), and overall DFS was 90%; survival did not vary by NAT regimen or pCR, but did vary by phenotype, whereby DFS was 100% for HER-2 positive, 90% for ER+, and 78% for TN cancers. There was no significant difference found in types of patients, NAT regimen, or pCR rates before and after the pathway was introduced. Conclusions: Practice patterns at the OCC in NAT for breast cancer remained unchanged before and after development of a clinical care pathway, which was meant to standardize the approach to and to possibly increase the use of NAT from beyond LABC to higher-risk EBC. This is likely due to limited pathway dissemination, but other factors contributing to this should be evaluated. pCR rates by cancer phenotype were similar to those found in the literature.

scholarly journals The Effect of Chemotherapy on Estradiol Levels in Patients with HER 2-Overexpression Breast Cancer in Dr Moewardi General Hospital, Surakarta, Indonesia

2021 ◽  
Vol 9 (B) ◽  
pp. 1570-1574
Author(s):  
Imam Hafidh Zaini ◽  
Widyanti Soewoto ◽  
Ida Bagus Budhi
Keyword(s):  
Breast Cancer ◽  
Adjuvant Chemotherapy ◽  
Estradiol Level ◽  
Rank Test ◽  
Her2 Overexpression ◽  
Significant Difference ◽  
Before And After ◽  
Her 2 ◽  
The Mean ◽  
Estradiol Levels

AIM: This study aims to evaluate the effect of adjuvant chemotherapy on estradiol levels in patients with HER 2-overexpression breast cancer in a developing country. METHODS: This comparative study with pre- and post-design model observation approach, involving patients with HER 2-overexpression breast cancer who had undergone surgery and had never received chemotherapy or hormonal therapy before, who were then given adjuvant chemotherapy. Estradiol levels were measured before and after chemotherapy. The study was carried out in the surgical oncology division of RSUD Dr. Moewardi (RSDM) Surakarta from January 2020-December 2020. Descriptive data are presented in a frequency table based on age, menstrual status, parity status, breastfeeding status, contraception, contraception duration, family history, stage, and histological grade. Before and after chemotherapy in patients with breast cancer, the estradiol levels employed the paired sample t-test of the Wilcoxon rank test because the data did not meet the normality assumption. RESULTS: From the total data of 21 patients, 15 patients experienced a decrease in estradiol levels after chemotherapy, while six patients underwent an increase. The mean estradiol level before chemotherapy was 89.41 pg/ml, whereas the mean estradiol level after chemotherapy was 55.90 pg/ml. It indicates a difference in the decrease in estradiol levels of 33.51 pg/ml. The statistical test results also obtained a p-value of = 0.033 (p < 0.05), which signifies a significant difference between estradiol levels before and after chemotherapy. Thus, chemotherapy is effective in lowering estradiol levels in patients with breast cancer. CONCLUSION: Chemotherapy affects decreasing estradiol levels in patients with HER2 overexpression breast cancer.

scholarly journals Effects of Neoadjuvant Fluorouracyl-Adriamycin- Cytoxan (FAC) Chemotherapy Response to CD4 + Serum Levels In Breast Cancer

2018 ◽  
Vol 1 (1) ◽  
pp. 1-9
Author(s):  
Ade Permana ◽  
Benny Kusuma ◽  
Nur Qodir ◽  
Legiran
Keyword(s):  
Breast Cancer ◽  
Neoadjuvant Chemotherapy ◽  
Advanced Breast Cancer ◽  
Locally Advanced Breast Cancer ◽  
Locally Advanced ◽  
Advanced Breast ◽  
Chemotherapy Response ◽  
Breast Cancer Chemotherapy ◽  
Significant Difference ◽  
Before And After

Introduction. CD4+ T-helper has an important role in immune system modulation especially to maintain long-term anti tumor effect. CD4+ also serves to activate CD8+ for destroyed the tumor cells. It was expected there were role of immunity on tumor growth and response of breast cancer chemotherapy to CD4+ levels serum. Furthermore, this study was aimed to investigate the effects of neoadjuvant chemotherapy on CD4+ levels in patients with locally advanced breast cancer at General Hospital Dr. Mohammad Hoesin Palembang. Method. This study was a non-comparable clinical trial by looking at serum CD4+ levels in patients with locally advanced breast cancer before and after neoadjuvant chemotherapy.   Results. Of the 30 subjects the subject age ranged from 33-66 years with an average of 45 years. There were 17 patients with contraception history (56.7%), 13 patients with family history of breast cancer (43.3%). From this study, it was obtained 23 patients with good chemotherapy response (76.7%) and there were 7 patients who had poor chemotherapy response after neoadjuvan chemotherapy (23.3%). Paired t-test analysis showed that there was a significant difference in mean CD4+ count before and after neoadjuvan chemotherapy. At the CD4+ level before chemotherapy 775.55 had a sensitivity of 60% and a specificity of 57% (cut of point). While CD4+ levels after chemotherapy 470.85 with sensitivity of 60% and specificity of 57%.   Conclusion. CD4+ pre-chemotherapy examination had a sensitivity score of 60% and a specificity of 57% in predicting neoadjuvant chemotherapy response.    

Changing demographics of locally advanced breast cancer: Data from a regional cancer centre

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 10780-10780
Author(s):  
R. Segal ◽  
S. F. Dent ◽  
S. Verma ◽  
C. M. Canil ◽  
J. Azzi ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Advanced Breast Cancer ◽  
Ductal Carcinoma ◽  
Locally Advanced Breast Cancer ◽  
Clinical Care ◽  
Locally Advanced ◽  
Advanced Breast ◽  
Degree Relative ◽  
Cancer Data ◽  
Her 2

10780 Background: Locally advanced breast cancer (LABC) (including inflammatory breast cancer (IBC)) accounts for less than 5% of women diagnosed with breast cancer in North America each year. This population of women continues to represent a challenge in terms of timely diagnosis and treatment. Methods: A retrospective database was developed using the American Joint Committee on Cancer (AJCC)2002 staging classification for all women who presented to TOHRCC with LABC between Jan 1/02 - April 1/05. Information was abstracted from clinic charts and the patient self-reported health questionnaires. Results: These results reflect the demographics of the first 50 women entered into our database. Median age at presentation was 57 years (range 28–88); 62% were post-menopausal and 28% had a 1st/2nd degree relative with breast cancer. Clinical diagnosis was made by: self-detection (79%); mammography (5%), routine physical exam (9%) and CT scan (2%). Clinical tumour stage at presentation was: IIIA (25.6%); IIIB (53.5%) and IIIC (9.3%). The majority of women were diagnosed with infiltrating ductal carcinoma (72%). Women with T4d tumours (IBC) (38%) tended to be younger (54.5 vs 59.2 years); presented earlier (2.7 vs. 6.3 months); had larger tumours at the time of diagnosis (9.7 vs 5.5 cm); were more likely grade III (30 vs 20%) and were more often ER negative (42.1% vs 33.3%) and PR negative (63.2% vs. 50%). Only 13% of women in this database were tested for HER-2 of whom 70% were positive. Conclusions: This data utilizing the new AJCC (2002) staging system reflects important shifts in LABC that will influence clinical care in the future. Compared to historical databases, patients tended to be younger and have more aggressive disease including ER negative and HER-2 positive disease. Supplemental microarray studies to further explore this entity are planned. We will present clinical management outcomes in an additional submission. No significant financial relationships to disclose.

COMPARISON OF THE QUALITY OF LIFE OF PATIENTS IN THE LOCALY ADVANCED BREAST CANCER FORMS AFTER SYSTEM AND INTRALYMPHATIC POLYCHEMOTHERAPY

2018 ◽  
Vol 4 ◽  
pp. 3-13
Author(s):  
Yuriy Dumanskiy ◽  
Oleksandr Bondar ◽  
Oleksandr Tkachenko ◽  
Evhenii Stoliachuk ◽  
Vasilii Ermakov
Keyword(s):  
Breast Cancer ◽  
Quality Of Life ◽  
Locally Advanced ◽  
Developed Countries ◽  
Control Group ◽  
Preoperative Treatment ◽  
Discrete Elements ◽  
Important Indicator ◽  
Significant Difference

In recent years, breast cancer (BC) is the most common cancer pathology and the most common cause of disability among women in developed countries. Finding the most effective ways of interaction between the patient and the doctor creates the preconditions for the necessary analysis of the treatment process from an objective and subjective point of view. Therefore, an important indicator to be taken into account is the quality of life of a patient. To compare the indicators of a comprehensive assessment of the quality of life of patients to the adverse locally advanced forms (LA) of breast cancer before and after systemic intravenous polychemotherapy (SPCTx) and selective endolymphatic polychemotherapy (ELPCTx) in neoadjuvant mode. The study was conducted on the basis of a random analysis of outpatient cards from 112 patients with LA BC T4A-DN0-3M0 who received a comprehensive antitumor treatment on the basis of the Donetsk regional antitumor center and the University Clinic of the Odessa National Medical University from 2000 to 2017, which was proposed a questionnaire at various stages of preoperative treatment. The first (control) group consisted of 65 patients (58 %) with inoperable forms of LA BC, which was performed in neoadjuvant mode by SPCTx. The second (study group) included 47 patients (42 %) with inoperable forms of LA BC, which was performed as a neoadjuvant course ELPCTx. According to the integral indicators of quality of life and quality of health between patients in the control and study groups, there was no statistically significant difference. In a detailed analysis of the indicators of symptomatic scales, the difference between the groups did not exceed the critical. Based on the results of a study conducted among patients receiving endolymphatic chemotherapy in a neoadjuvant mode, the subjective evaluations of treatment in absolute numbers have better reference values without statistical superiority. The study of the integrative indicator of quality of life and its discrete elements is an ergonomic and economical means of heuristic assessment of the health of patients in order to further develop more rational and convenient ways of solving urgent issues of modern oncology by increasing compliance and finding a compromise between the physician and the patient.

Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

2020 ◽  
Vol 3 (2) ◽  
pp. 116-123
Author(s):  
Mathew Cherian ◽  
Pankaj Mehta ◽  
Shriram Varadharajan ◽  
Santosh Poyyamozhi ◽  
Elango Swamiappan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Retrospective Review ◽  
Stroke Unit ◽  
Care Pathway ◽  
Clinical Care ◽  
Stroke Care ◽  
First Year ◽  
Proof Of Concept ◽  
Mobile Stroke Unit ◽  
Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

scholarly journals Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Nutrients ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 2635
Author(s):  
Koen Huysentruyt ◽  
Kim Brunet-Wood ◽  
Robert Bandsma ◽  
Leah Gramlich ◽  
Bonnie Fleming-Carroll ◽  
...  
Keyword(s):  
Health Care Professionals ◽  
Care Pathway ◽  
Clinical Care ◽  
Tertiary Care ◽  
Nationwide Survey ◽  
Nutritional Screening ◽  
Pediatric Hospitals ◽  
Adoption And Implementation ◽  
Clinical Care Pathway

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway

2021 ◽  
pp. 105566562110174
Author(s):  
Thomas R. Cawthorn ◽  
Anna R. Todd ◽  
Nina Hardcastle ◽  
Adam O. Spencer ◽  
A. Robertson Harrop ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Cleft Palate ◽  
Care Pathway ◽  
Clinical Care ◽  
Oral Intake ◽  
Opioid Consumption ◽  
Complication Rates ◽  
Cleft Palate Repair ◽  
Palate Repair ◽  
Clinical Care Pathway

Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

scholarly journals Increase in recruitment upon integration of trial into a clinical care pathway: an observational study

2021 ◽  
Vol 8 (1) ◽  
pp. e000967
Author(s):  
Kay Por Yip ◽  
Simon Gompertz ◽  
Catherine Snelson ◽  
Jeremy Willson ◽  
Shyam Madathil ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Hospital Admissions ◽  
Care Pathway ◽  
Clinical Care ◽  
Intensive Therapy ◽  
Respiratory Support ◽  
Trial Recruitment ◽  
Recruitment Process ◽  
Support Unit ◽  
Clinical Care Pathway

IntroductionMany respiratory clinical trials fail to reach their recruitment target and this problem exacerbates existing funding issues. Integration of the clinical trial recruitment process into a clinical care pathway (CCP) may represent an effective way to significantly increase recruitment numbers.MethodsA respiratory support unit and a CCP for escalation of patients with severe COVID-19 were established on 11 January 2021. The recruitment process for the Randomised Evaluation of COVID-19 Therapy-Respiratory Support trial was integrated into the CCP on the same date. Recruitment data for the trial were collected before and after integration into the CCP.ResultsOn integration of the recruitment process into a CCP, there was a significant increase in recruitment numbers. Fifty patients were recruited over 266 days before this process occurred whereas 108 patients were recruited over 49 days after this process. There was a statistically significant increase in both the proportion of recruited patients relative to the number of COVID-19 hospital admissions (change from 2.8% to 9.1%, p<0.0001) and intensive therapy unit admissions (change from 17.8% to 50.2%, p<0.001) over the same period, showing that this increase in recruitment was independent of COVID-19 prevalence.DiscussionIntegrating the trial recruitment process into a CCP can significantly boost recruitment numbers. This represents an innovative model that can be used to maximise recruitment without impacting on the financial and labour costs associated with the running of a respiratory clinical trial.

Abstract 6101: Cost Effectiveness of Cardiac Computed Tomography Compared to Myocardial Perfusion Imaging (MPI) as an Effective Gatekeeper to Cardiac Catheterization in the Evaluation of Asymptomatic Firefighters with an Abnormal Treadmill Test

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Matthew Budoff ◽  
Robert Karwasky ◽  
Naser Ahmadi MD Ahmadi ◽  
Cyrus A Nasserian ◽  
William W Chang ◽  
...  
Keyword(s):  
Los Angeles ◽  
Care Pathway ◽  
Cardiac Computed Tomography ◽  
Clinical Care ◽  
Invasive Coronary Angiography ◽  
Calcium Score ◽  
Computed Tomographic Angiography ◽  
Sensitivity Analyses ◽  
Computed Tomographic ◽  
Clinical Care Pathway

To identify CAD among patients who fail treadmill tests, the traditional clinical care pathway is MPI, then invasive coronary angiography (ICA). In a retrospective cohort study, we compared the direct costs for detecting CAD using the traditional clinical care pathway and an alternative that incorporates MDCT, with coronary calcium score (CCS) followed by computed tomographic angiography (CTA) and ICA. Over a 2-year period, 3,950 Los Angeles, CA Firefighters underwent wellness/fitness exams at 6 contracted medical facilities. A total of 495 cases had abnormal treadmill tests and were referred for follow-up cardiology evaluation. All cases received CCS, followed by CTA for calcium scores >10, and ICA for abnormal CTA (>50% obstruction in at least one vessel). MPI results were estimated based on the prior year’s experience, with abnormal MPI receiving ICA. Costs to detect CAD were calculated for both the MPI and MDCT pathways based on results for the cohort and current Medicare reimbursement costs. Sensitivity analyses were performed by varying each of the clinical and cost components of the model to “low” and “high” levels and computing net costs. Most model inputs were varied by ±50% of baseline values to gauge the robustness of the results. Among 495 cases with abnormal treadmill tests, 146 (29.5%) would have required ICA due to abnormal MPI tests; 131 (26.9%) had abnormal CCS (>10) and went to CTA; 40 (8.1%) had abnormal CTA (>50% stenosis) and went to ICA. ICA showed 38 (7.7%) cases of CAD. The computed cost to detect CAD was $1,376 per case for the traditional route with MPI as gatekeeper and $503 per case for CCS as gatekeeper. All sensitivity analyses showed lower costs for the MDCT compared to MPI pathways. The net cost to ICA-confirmed diagnosis of CAD is substantially lower with MDCT compared to MPI as gatekeeper to ICA.

scholarly journals Clinical Profile of Patients Presenting with Breast Cancer in Nepal

2013 ◽  
Vol 10 (3) ◽  
pp. 3-7 ◽  
Author(s):  
Sandhya Chapagain Acharya ◽  
AK Jha ◽  
T Manandhar
Keyword(s):  
Breast Cancer ◽  
Locally Advanced ◽  
Tnm Staging ◽  
Clinical Profile ◽  
Stage Iii ◽  
Disease Stage ◽  
Case Report Form ◽  
South Asian Population ◽  
Receptor Status ◽  
Her 2

Background Breast cancer is the second most common cancer in women in Nepal. Even though the evaluation and treatment of patients is done as per western guidelines, there are considerable variations in risk factors, presenting stage and prognostic factors such as receptor status. Objective To evaluate the clinical profile of patients presenting with breast cancer in Nepal. Method The study was conducted at Department of Radiotherapy and Oncology, Bir Hospital and Department of Radiation Oncology, BP Koirala Memorial Cancer Hospital, Bharatpur from 16th July 2007 to 15th June 2008 for a period of one year and 114 patients were enrolled. Detailed history, clinical examination and necessary investigations performed. Histological features including receptor status were recorded. Tumor Node Metastasis (TNM) staging system was as per American Joint Committee on Cancer (AJCC), fifth edition. Data was collected in preformed case report form and was managed using SPSS version 13. Results The incidence was high (34.2%) among perimenopausal women age ranging from 41 to 50. The majority of women presented with lump (98.2%) and others with pain (21.9%), nipple retraction (16.7%), ulceration (7.9%), discharge (7%), or symptoms of metastasis (6.1%). Regarding receptor status, the majority (64.0%) were Estrogen receptor (ER) and Progesterone receptor (PR) negative with 21.9 percent. ER+PR+, Younger women were more likely to be both ER and PR negative. Where available, Her-2 immunohistochemistry showed that 45.0 % of post menopausal women were Her-2 neative, compared to 64.0 % of premenopausal women. Incidence of Triple negative disease was 41.3 %. The most common stage at presentation was stage III (26.3%). Conclusion Majority of patients were perimenopausal, presenting with locally advanced disease (Stage III and Stage II) and with average tumor size two to five cm and were hormonal receptor negative. These findings are similar to other South Asian population but is inverse than profile reported in Western populations.Kathmandu University Medical Journal | VOL.10 | NO. 3 | ISSUE 39 | JUL- SEP 2012  | Page 3-7 DOI: http://dx.doi.org/10.3126/kumj.v10i3.8009

Sign in / Sign up

Export Citation Format

Share Document