scholarly journals Clinical Features and Outcomes of Invasive Breast Cancer: Age-Specific Analysis of a Modern Hospital-Based Registry

2019 ◽  
pp. 1-9
Author(s):  
Ji-Yeon Kim ◽  
Danbee Kang ◽  
Seok Jin Nam ◽  
Seok Won Kim ◽  
Jeong Eon Lee ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Clinical Features ◽  
Invasive Breast Cancer ◽  
Age Groups ◽  
Cox Proportional Hazards ◽  
Curative Surgery ◽  
Old Patients ◽  
Increased Risk ◽  
All Cause Mortality

PURPOSE We evaluated the clinical features and outcomes of invasive breast cancer (BC) among different age groups by analyzing a modern BC registry including subtypes and treatment information. METHODS This was a retrospective cohort study of 6,405 women aged 18 years or older with pathologically confirmed stage I, II, or III BC who underwent curative surgery followed by adjuvant therapy at a university-based hospital in Seoul, South Korea, between January 2003 and December 2011. The study end point was all-cause mortality. We used Cox proportional hazards models and hazard ratios (HRs) with 95% CIs calculated after adjusting for age, body mass index, stage, subtype, and treatment, including type of surgery and use of chemotherapy, radiation therapy, hormone therapy, and targeted therapy. RESULTS During 36,360 person-years of follow-up (median follow-up: 5.45 years; interquartile range, 4.3-7.1), 256 deaths were reported (mortality rate, 7.0/1,000 person-years). The adjusted HR for all-cause mortality was higher in patients older than 40 years (HR, 2.03; 95% CI, 1.44 to 2.87) and older than 60 years (HR, 2.35; 95% CI, 1.63 to 3.39) than in patients aged 40 to 49 years. Across age groups, advanced stage at diagnosis, luminal type as well as triple-negative BC, and not receiving adjuvant treatment were associated with increased risk of mortality. CONCLUSION A strong J-shaped relationship was observed between age and mortality, indicating worse clinical outcomes in young and old patients. This study suggested a possible benefit of personalized BC screening examination and precise and active treatment strategies to reduce BC-related mortality.

scholarly journals Role of Hormones in Cancer Prevention

2014 ◽  
pp. 34-40 ◽  
Author(s):  
Victor G. Vogel
Keyword(s):  
Breast Cancer ◽  
Aromatase Inhibitor ◽  
Postmenopausal Women ◽  
Invasive Breast Cancer ◽  
White Women ◽  
Risk Index ◽  
Breast Cancer Incidence ◽  
The United States ◽  
Increased Risk

Risk for breast cancer can be easily and rapidly assessed using validated, quantitative models. Multiple randomized studies show that the selective estrogen response modifiers (SERMs) tamoxifen and raloxifene can safely reduce the risk of invasive breast cancer in both pre- and postmenopausal women. Treatment resulted in a 38% reduction in breast cancer incidence, and 42 women would need to be treated to prevent one breast cancer event in the first 10 years of follow-up. Reduction was larger in the first 5 years of follow-up than in years 5 to 10, but no studies treated patients for longer than 5 years. Thromboembolic events were significantly increased with all SERMs, whereas vertebral fractures were reduced. Tamoxifen provides net benefit to all premenopausal women who are at increased risk, whereas raloxifene reduces risk nearly as much in postmenopausal women and offers increased safety. Both tamoxifen and raloxifene reduce the incidence of in situ cancers. Lasofoxifene reduced the risk of breast cancer by 79% in postmenopausal women with osteoporosis. The MAP3 trial showed a 65% reduction in the annual incidence of invasive breast cancer in postmenopausal women who were at moderately increased risk for breast cancer who took the aromatase inhibitor exemestane. The IBIS-II trial showed a 53% reduction in the risk of invasive breast cancer in postmenopausal women aged 40 to 70 who took the aromatase inhibitor anastrozole. Of the 50 million white women in the United States aged 35 to 79, 2.4 million would have a positive benefit/risk index for chemoprevention.

Abstract P146: Serum Magnesium and Mortality in the General US Population: Results From the NHANES I Epidemiologic Follow-up Study

Circulation ◽  
2016 ◽  
Vol 133 (suppl_1) ◽  
Author(s):  
Xi Zhang ◽  
Jin Xia ◽  
Liana C. Del Gobbo ◽  
Adela Hruby ◽  
Ka He ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Reference Group ◽  
Serum Magnesium ◽  
Cox Proportional Hazards ◽  
Follow Up Study ◽  
Normal Reference ◽  
Increased Risk ◽  
All Cause Mortality ◽  
Low Serum

Introduction: Low magnesium (Mg) intake and/or status has been associated with increased risk of chronic disease, including cardiovascular disease (CVD) and cancer. However, whether and to what extent low serum Mg levels are associated with all-cause or cause-specific mortality in the general population is uncertain. Hypothesis: We aimed to quantify the dose-response associations between low concentrations of serum Mg and mortality from all causes, cancer, CVD, and stroke in the general US population. Methods: We analyzed prospective data on 14,353 participants aged 25-74 years with baseline measures of serum Mg concentrations from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study 1971-2006. We estimated the mortality hazard ratios (HRs) for participants within predefined and clinically meaningful categories of serum Mg levels, including <0.7, 0.7-0.74, 0.75-0.79, 0.8-0.9 (normal reference), 0.9-0.94, 0.95-0.99, and ≥1.0 mmol/L, using Cox proportional hazards models. Restricted cubic spline models were applied to examine potentially nonlinear relationships between serum Mg and mortality. Results: During a mean follow-up of 27.6 years, 7,072 deaths occurred, 3,310 (47%) CVD deaths, 1,533 (22%) cancer deaths, and 281 (4%) stroke deaths. Twenty-one percent of all participants had low levels of serum Mg (<0.8 mmol/L) and 1.5% had extremely low serum Mg (<0.7 mmol/L). Age-adjusted all-cause mortality rates were 3845, 3491, 3471, 3400 (normal reference), 3531, 3525, and 3836 per 100,000 person-years for increasing categories of serum Mg; the HRs and 95% confidence intervals for increasing serum Mg were 1.32 (1.02-1.72), 0.93 (0.74-1.16), and 1.06 (0.96-1.18), 1.07 (0.97-1.18), 0.94 (0.77-1.13), and 0.93 (0.72-1.21), compared to the reference group (0.8-0.9 mmol/L). An L-shaped association between serum Mg concentrations and all-cause mortality was observed after adjusting for potential confounders (Figure). No statistically significant associations were observed between serum Mg and cancer, CVD, or stroke mortality. Conclusions: Very low serum Mg levels were significantly associated with all-cause mortality in the general US population. Our findings support the hypothesis that Mg deficiency as defined by very low serum Mg may have an important influence on mortality.

scholarly journals Circulating lipids and breast cancer prognosis in the Malmö diet and cancer study

2021 ◽  
Author(s):  
Sixten Harborg ◽  
Thomas P. Ahern ◽  
Maria Feldt ◽  
Ann H. Rosendahl ◽  
Deirdre Cronin-Fenton ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Invasive Breast Cancer ◽  
Cancer Recurrence ◽  
Apo B ◽  
High Baseline ◽  
Breast Cancer Outcomes ◽  
All Cause Mortality ◽  
Baseline Levels ◽  
Diet And Cancer

Abstract Purpose Examine the association between circulating lipids and breast cancer outcomes in patients enrolled in the Malmö Diet and Cancer Study (MDCS). Patients and methods Circulating lipid levels were measured in blood sampled upon enrollment in the female MDCS cohort (N = 17,035). We identified all MDCS participants with incident invasive breast cancer diagnosed between 1991 and 2014. Follow-up time began at breast cancer diagnosis and continued until the first event of breast cancer recurrence, death, emigration, or 5 years of follow-up. We estimated the incidence rates of recurrence at 5 years and fit Cox regression models to compute crude and adjusted hazard ratios (HRs) with 95% confidence intervals (95% CI) of breast cancer recurrence as well as all-cause mortality according to cohort-specific tertiles of apolipoprotein A-1 (Apo A-1) and apolipoprotein B (Apo B). Results We enrolled 850 eligible patients. During the 5 years of follow-up, 90 invasive breast cancer recurrences were diagnosed over 3807 person-years. In multivariable analyses, high baseline levels of Apo B were associated with an increased rate of recurrence (tertile 3 vs. 1, HR = 2.30 [95% CI 1.13–4.68]). However, high baseline levels of Apo B were not associated with all-cause mortality (tertile 3 vs. 1, HR = 1.23 [95% CI 0.68–2.25]). We observed no associations between levels of Apo A-1 and recurrence (tertile 3 vs. 1, HR = 1.34 [95% CI 0.70–2.58]) or all-cause mortality (tertile 3 vs. 1, HR = 1.12 [95% CI 0.61–2.05]). Conclusion High pre-diagnostic levels of Apo B were associated with an increased risk of recurrence among breast cancer patients. Circulating Apo A-1 was not associated with breast cancer outcomes.

Abstract P009: Risk of Mortality According to Burden of Atrial Fibrillation: Results From a 60-year Cohort Study

Circulation ◽  
2016 ◽  
Vol 133 (suppl_1) ◽  
Author(s):  
William F McIntyre ◽  
Mahmoud Tourabi ◽  
Philip D St John ◽  
Robert B Tate
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Sinus Rhythm ◽  
Proportional Hazards ◽  
Anticoagulation Therapy ◽  
Cox Proportional Hazards ◽  
Risk Of Death ◽  
Increased Risk ◽  
All Cause Mortality

Introduction: Atrial Fibrillation (AF) is the most common serious cardiac arrhythmia and is associated with an increased risk of stroke and mortality. These risks can be modified with oral anticoagulation therapy. Clinically, the arrhythmia can be permanent or intermittent. Prior studies that have used time-constant, categorical covariates to examine the relationship between the pattern of AF and the occurrence of adverse events have produced conflicting results. We hypothesized that the amount of time that patients spend in AF, hereinafter termed arrhythmia “burden”, may be important in predicting adverse events. Objective: To examine the effects of the burden of AF on all-cause mortality. Methods: The Manitoba Follow-Up Study is a longitudinal, prospective study of 3983 originally healthy young men (mean age at entry 30 years) who have been followed with routine medical and electrocardiographic examinations since 1948. After 60 years of follow-up to July 1, 2008, AF had been documented on the electrocardiograms of 581 men (15% of the cohort) and 3182 (80%) of the original cohort had died. We created a Cox proportional hazards model with time-dependent covariates to estimate relative risks for mortality according to AF burden. AF status during each follow-up visit was classified as persistent when the patient was in AF on consecutive examinations, transient when the patient reverted to sinus rhythm after being in AF and incident when the patient developed AF after a period in sinus rhythm. Results: Results of the Cox proportional hazards regression model are displayed in the Table. Age, persistent AF and incident AF were all significant variables in the model. Holding all the other variables constant, persistent AF increased the risk of death by two times and incident AF increased the risk of death by 87%. Conclusions: Persistent AF and incident AF are associated with increased all-cause mortality. Estimating AF burden may have implications for risk stratification in patients with AF.

scholarly journals SO059ASSOCIATION OF ALL-CAUSE MORTALITY WITH PRE-HEMODIALYSIS PULSE PRESSURE IN CHRONIC HEMODIALYSIS PATIENTS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Hanjie Zhang ◽  
Alhaji Cherif ◽  
Peter Kotanko
Keyword(s):  
Pulse Pressure ◽  
Nonlinear Effects ◽  
Continuous Variable ◽  
Hemodialysis Patients ◽  
Cox Proportional Hazards ◽  
Cardiac Insufficiency ◽  
Cardiovascular Morbidity And Mortality ◽  
Increased Risk ◽  
All Cause Mortality

Abstract Background and Aims Chronic and end-stage kidney disease patients experience significantly increased risk of cardiovascular morbidity and mortality due to multitude of interlinked pathophysiological processes inducing metabolic and inflammatory conditions. Pulse pressure (PP) reports cardiac and vascular conditions, where consistently high PP values are associated with atrial fibrillation, aortic insufficiency, arterial stiffness or arteriovenous malformation, and low PP values may be associated with aortic valve stenosis, cardiac insufficiency or cardiac tamponade. However, the association of pre-hemodialysis (pre-HD) PP with mortality among hemodialysis patients is not well understood. In this study, we aim to explore the extent to which PP is associated with mortality. Method We analyzed pre-HD PP (calculated as pre-HD SBP minus pre-HD DBP) between 1/2001 and 12/2012 in hemodialysis patients treated in U.S. Fresenius Medical Care facilities. A 3-months baseline period was defined as months 4 to 6 after hemodialysis initiation, all-cause mortality was noted during follow-up. Only patients who survived baseline were included. Censoring events were renal transplantation, modality change, or study end. We built Cox proportional hazards models with spline terms, allowing us to model nonlinear effects of pre-HD PP as a continuous variable and its relationship with all-cause mortality. Results We included 152,625 patients. Mean age was 60.8 years, 59% were white and 56% were male. During a median follow-up of 26.0 months 40.4% patients died. We found that for patients with pre-HD PP between 49.2 mmHg and 74.7 mmHg, were associated with better survival. In contrast, a PP below 49.2 mmHg and above 74.7 mmHg were associated with higher mortality. Similar nonlinear effects are seen in SBP for a given pre-HD PP value (see Fig. 1). Conclusion The association of pre-HD PP with mortality is nonlinear, and a better understanding of the nonlinearity will provide further insights into disentangling the associated mediators affecting its dynamics. Our findings may aid risk stratification in HD patients.

Faster Transport Status and Mortality in Anuric Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

2015 ◽  
Vol 40 (2) ◽  
pp. 160-166 ◽  
Author(s):  
Liping Xiong ◽  
Li Fan ◽  
Qingdong Xu ◽  
Qian Zhou ◽  
Huiyan Li ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Continuous Ambulatory Peritoneal Dialysis ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Models ◽  
Increased Risk ◽  
All Cause Mortality ◽  
History Of ◽  
The Relationship

Background: There are limited data regarding the relationship between transport status and mortality in anuric continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: According to the dialysate to plasma creatinine ratio (D/P Cr), 292 anuric CAPD patients were stratified to faster (D/P Cr ≥0.65) and slower transport groups (D/P Cr <0.65). The Cox proportional hazards models were used to evaluate the association of transport status with mortality. Results: During a median follow-up of 22.1 months, 24% patients died, 61.4% of them due to cardiovascular disease (CVD). Anuric patients with faster transport were associated with an increased risk of all-cause mortality (HR (95% CI) = 2.16 (1.09-4.26)), but not cardiovascular mortality, after adjustment for confounders. Faster transporters with pre-existing CVD had a greater risk for death compared to those without any history of CVD. Conclusion: Faster transporters were independently associated with high all-cause mortality in anuric CAPD patients. This association was strengthened in patients with pre-existing CVD.

Abstract 13885: Phenotyping Risk Profiles for Heart Failure With Preserved and Reduced Ejection Fraction Among Breast Cancer Survivors

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Alexi Vasbinder ◽  
Richard Cheng ◽  
Roberta Ray ◽  
Dale Langford ◽  
Ana Barac ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Heart Failure ◽  
Ejection Fraction ◽  
Breast Cancer Survivors ◽  
Proportional Hazards ◽  
Lifestyle Factors ◽  
Left Ventricular ◽  
Cox Proportional Hazards ◽  
Increased Risk

Introduction: Breast cancer (BC) survivors (BCS) are at increased risk for incident heart failure (HF). In this population, the risk for HF with preserved ejection fraction (HFpEF) has been understudied compared to HF with reduced EF (HFrEF). The purpose of this study was to estimate 1) the incidence of HFpEF and HFrEF, and 2) the phenotypic profiles conferring risk for incident HFpEF and HFrEF in BCS. Methods: This Women’s Health Initiative analysis was conducted in women with invasive BC stages I-IV in the Medical Records Cohort (MRC). Those with pre-existing HF were excluded. Exposures of interest were lifestyle factors [e.g. body mass index (BMI)], comorbidities [e.g. hypertension, diabetes, and myocardial infarction (MI)], and BC treatment. Lifestyle factors and comorbidities most proximal and prior to BC diagnosis were assessed. In the MRC, BC and HF as well as left ventricular EF (LVEF) were ascertained through chart review and physician-adjudication. LVEF ≥50% was classified as HFpEF; and <50% for HFrEF per AHA/ACC guidelines. Cox proportional hazards models estimated risks of HFpEF and HFrEF. Follow up time began at BC diagnosis and HF events were recorded through March 1, 2019. All models adjusted for age at BC diagnosis. Results: In 2,250 BCS, 153 developed HF after BC during a median follow-up of 7.3 years. Of those, 49 had HFrEF and 75 had HFpEF. The cumulative incidences of HFrEF and HFpEF over follow-up were 7.3% and 4.6%, respectively. Diabetes and MI were associated with both HFpEF and HFrEF (Table). Smoking, BMI ≥30, and hypertension were associated with HFpEF. Anthracycline use was associated with HFrEF but not HFpEF (p=0.03). Conclusions: In BCS, lifestyle factors were associated with incident HFpEF, whereas anthracycline use was associated with a higher risk for HFrEF. Understanding risk factors associated with incident HFpEF and HFrEF in BCS is important to guide the implementation of risk profile-specific preventative measures and interventions.

Abstract 14262: Atrial Fibrillation Burden and Clinical Outcomes in Patients With Cardiac Implanted Electronic Devices

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Derek S Chew ◽  
Zhen Li ◽  
Benjamin A Steinberg ◽  
Emily C Obrien ◽  
Jessica Pritchard ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Cumulative Incidence ◽  
De Novo ◽  
Electronic Device ◽  
Cox Proportional Hazards ◽  
Adverse Outcomes ◽  
Increased Risk ◽  
All Cause Mortality

Introduction: The relationship between atrial fibrillation (AF) burden and the risk of adverse outcomes is incompletely understood. Methods: In a longitudinal cohort study of patients with a clinical history of non-permanent AF who underwent a new implantation of an Abbott cardiac implantable electronic device (CIED) between 2010 and 2016, we linked Merlin.net TM remote-monitoring data with Medicare claims to assess the association between device-detected AF burden (daily percentage in AF) and outcomes of all-cause mortality, all-cause hospitalization, cardiovascular (CV) hospitalization, or ischemic stroke over 1-year of follow up via Kaplan-Meier estimates, cumulative incidence function and Cox proportional hazards modeling. Results: Among 39,710 AF patients with de novo CIEDs, the median age was 77.1±8.7 years, 60.7% were male, and the mean CHA 2 DS 2 -VASc score was 4.9±1.3. Over the 1-year follow up period, there were 3,523 (cumulative incidence of 9%) deaths, 446 (1.1%) ischemic strokes, 15,736 (40%) hospitalizations, and 11,869 (30%) CV-related hospitalizations. Increasing AF burden (per 10 percentage points) was significantly associated with an increased risk of all-cause mortality (hazard ratio (HR) 1.06, 95% confidence interval 1.05-1.08), all-cause hospitalization (HR 1.04, 95% CI 1.03, 1.05), CV hospitalization (HR 1.04, 95% CI 1.03-1.05) and ischemic stroke (HR 1.05, 95% CI 1.01-1.10). There was a similar direction in these outcome associations when AF burden was analyzed as a categorical variable (Figure) or using an alternate definition of AF burden (maximum single-episode AF duration). Conclusions: Among older patients with non-permanent AF, there is an exposure-response relationship between AF burden and adverse outcomes. These data suggest that early intervention and CV risk factor modification aimed at slowing the progression of AF may reduce long term AF-related adverse CV outcomes.

Decreased Risk of Stroke Among 10-Year Survivors of Breast Cancer

2006 ◽  
Vol 24 (34) ◽  
pp. 5388-5394 ◽  
Author(s):  
Maartje J. Hooning ◽  
Lucille D.A. Dorresteijn ◽  
Berthe M.P. Aleman ◽  
Arnoud C. Kappelle ◽  
Jan G.M. Klijn ◽  
...  
Keyword(s):  
Breast Cancer ◽  
General Population ◽  
Proportional Hazards ◽  
Hormonal Treatment ◽  
Cox Proportional Hazards ◽  
Radiation Fields ◽  
Cerebrovascular Events ◽  
Increased Risk ◽  
Internal Mammary

Purpose To assess treatment-specific risk of cerebrovascular events in early breast cancer (BC) patients, accounting for cerebrovascular risk factors. Patients and Methods We studied the incidence of cerebrovascular accidents (CVA; stroke and transient ischemic attack [TIA]) in 10-year survivors of early BC (n = 4,414) treated from 1970 to 1986. Follow-up was 96% complete until January 2000. Treatment-specific incidence of CVA was evaluated by standardized incidence ratios (SIRs) based on comparison with general population rates and by Cox proportional hazards regression. Results After a median follow-up of 18 years, 164 strokes and 109 TIAs were observed, resulting in decreased SIRs of 0.8 (95% CI, 0.6 to 0.9) for stroke and 0.8 (95% CI, 0.7 to 1.0) for TIA. Significantly increased risk of stroke was found in women who had received hormonal treatment (HT; tamoxifen) and in women who had hypertension or hypercholesterolemia, with hazard ratios (HRs) of 1.9, 2.1, and 1.6, respectively. Patients irradiated on the supraclavicular area and/or internal mammary chain (IMC) did not experience a higher risk of stroke (HR = 1.0; 95% CI, 0.7 to 1.6) or TIA (HR = 1.4; 95% CI, 0.9 to 2.5) compared with patients who did not receive radiotherapy or who were irradiated on fields other than the supraclavicular area or IMC. Conclusion Long-term survivors of BC experience no increased risk of cerebrovascular events compared with the general population. HT is associated with an increased risk of stroke. Radiation fields including the carotid artery do not seem to increase the risk of stroke compared with other fields.

scholarly journals Antipsychotics, Prolactin and Breast Cancer

2021 ◽  
Author(s):  
Tahir Rahman ◽  
John Sahrmann ◽  
Margaret A. Olsen ◽  
Katelin B. Nickel ◽  
j Philip Miller ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Antipsychotic Drug ◽  
Invasive Breast Cancer ◽  
Antipsychotic Drugs ◽  
Drug Exposure ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Serum Prolactin ◽  
Cox Proportional Hazards Models ◽  
Increased Risk

Objective: Antipsychotic drugs are well established to alter circulating prolactin levels by blocking dopamine D-2 receptors in the pituitary. Prolactin activates many genes important in the development of breast cancer. The aim of this study was to evaluate the risk of breast cancer in women exposed to antipsychotic drugs, stratified by prolactin elevating potential (high, mid, and low), compared to women taking anticonvulsants and/or lithium. Methods: The IBM MarketScan Commercial and Medicaid Databases were used to establish a large, observational cohort of women taking antipsychotics drugs compared to control drugs. Invasive breast cancer was identified using diagnostic codes. Bivariable and multivariable Cox proportional hazards models were used to evaluate the risk of breast cancer by antipsychotic drug exposure, both as pooled antipsychotics and by prolactin specific categories. Results: A total of 2,708 (0.2%) cases of invasive breast cancer were identified among 1,562,839 women. Exposure to antipsychotics with high prolactin elevating potential was associated with a 23% increased risk of breast cancer (aHR 1.23; 95% CI, 1.11-1.35), whereas mid and low prolactin categories of antipsychotics were not significant. Conclusion: In the largest study of antipsychotics taken by women, a modest risk between antipsychotic drug use and the risk for breast cancer was observed, with a differential higher association with high prolactin elevating drugs. Residual confounding factors included incomplete information on parity, race and socioeconomic status, and differential outpatient visits. Clinicians should consider monitoring serum prolactin levels and adopting vigilant mammography screening practices, especially in older women taking category one antipsychotics.

Sign in / Sign up

Export Citation Format

Share Document