scholarly journals OR-052 Effects of Exercise Intervention on Cancer-Related Fatigue in Breast Cancer Survivors

2018 ◽  
Vol 1 (2) ◽  
Author(s):  
Zhiling Xie ◽  
Weibing Ye
Keyword(s):  
Breast Cancer ◽  
Cancer Survivors ◽  
Aerobic Exercise ◽  
Breast Cancer Survivors ◽  
Exercise Intervention ◽  
Moderate Intensity ◽  
Control Group ◽  
Short Term ◽  
Cancer Related Fatigue ◽  
Significant Difference

Objective cancer-related fatigue(CRF) is the most commonly reported and most distressing symptom in cancer patient.The purpose of this study was to review the effect of exercise intervention on cancer-related fatigue in breast cancer survivors. Methods From 1998 to 2018 in Chinese and English literature of Wanfang Database, Pubmed, SportDiscus and Springer databases, picked out the randomized controlled trials which up to standard. Keywords cancer, exercise, fatigue, etc. were used for systematic search and tracking. 12 experiments were reviewed to analyze the effect differences between exercise intervention and exercise-related fatigue. Results Most interventions use aerobic exercise as the primary form of exercise. Generally, exercise interventions are effective for cancer-related fatigue, but some findings are not. Many studies have shown that moderate intensity aerobic exercise has a significant effect on cancer-related fatigue, with 50-70% heart rate reserve and 3-5 times of exercise per week for at least 30 minutes each time. Exercise methods mainly include walking, yoga, cycling and tai chi. Firstly, Supervised aerobic exercise was statistically more effective than conventional care in improving CRF among breast cancer survivors. It has been shown that group-based, supervised exercise produces positive psychosocial‘side-effects’ due to social interactions, improved self-efficacy, and attention from a trainer. Secondly, Cancer fatigue is divided into acute and chronic fatigue, 18 weeks of exercise intervention can reduce the short-term fatigue, at 36 weeks, baseline levels of fatigue index responses and contrast on the issue of the multivariate statistics. Thirdly, usual-care group were reported that they had been actively engaged in regular exercise before study enrollment. During the exercise intervention, most studies on the control ways are according to the daily life or to take care of, but studies have reported, before intervention, to a high level of 40% in the control group often exercise, exercise also as usual during the intervention, which causes the control to the baseline level is higher, but the intervention group and control group will be difference, no significant difference, lead to the result is invalid. Conclusions First, the exercise intervention of cancer-related fatigue needs to be supervised; second, the exercise intervention is effective for short-term cancer-related fatigue; third, the daily exercise level of the control group will affect the intervention effect.

The effect of aerobic exercise on the metabolic risk profile of breast cancer survivors 2-6 months post chemotherapy.

2011 ◽  
Vol 29 (27_suppl) ◽  
pp. 244-244
Author(s):  
E. M. Guinan ◽  
J. M. Hussey ◽  
J. M. Walsh ◽  
M. J. Kennedy ◽  
E. M. Connolly
Keyword(s):  
Breast Cancer ◽  
Cancer Survivors ◽  
Aerobic Exercise ◽  
Breast Cancer Survivors ◽  
Exercise Intervention ◽  
Risk Profile ◽  
Control Group ◽  
Metabolic Risk ◽  
Model Assessment ◽  
Supervised Exercise

244 Background: Current literature suggests that weight gain during treatment for breast cancer is associated with a poorer prognosis and an increased risk of developing secondary health problems such as the metabolic syndrome (MetSyn). Physical activity (PA) can alter features of the MetSyn and improve body composition by reducing abdominal adiposity. We report metabolic results of a prospective randomized controlled trial (PEACH trial; Walsh JM, et al. [2010] BMC Cancer. 10[42]) which examines the effect of an exercise intervention on the metabolic risk profile of breast cancer survivors 2-6 months post chemotherapy. Methods: All subjects gave written informed consent and were randomized to an 8-week, twice weekly aerobic exercise intervention programme or a usual care control group consisting of routine medical advice about PA. The five clinical features of the MetSyn were measured: waist circumference (WC), resting blood pressure (BP), triglycerides, high-density lipoprotein cholesterol (HDL-C) and fasting glucose. Insulin resistance was estimated by the homeostatic model assessment (HOMA). Statistical analysis was carried out using independent sample t-tests with significance set at p < 0.05. Results: Twenty-six breast cancer survivors participated (mean (± SD) age 48.13 (8.75) years). At baseline, 50% (n = 13) of subjects were overweight and 23.1% (n = 6) were obese, with 73.1% (n = 19) centrally obese. 34.6% (n = 9) of subjects were classified with the MetSyn. There were no significant differences between groups at baseline. Intention-to-treat analysis showed no significant changes, however, analysis of those who adhered to > 70% of the supervised exercise intervention showed a significant improvement in WC when compared to the control group (p < 0.05). Conclusions: Results show that an 8-week aerobic exercise intervention significantly reduced WC but did not modify other features of the MetSyn. The decrease in WC demonstrated by this short intervention may have important implications in terms of improving survival and the metabolic risk profile of breast cancer survivors. Final follow-up assessments are ongoing and will enable change in WC over time to be evaluated further.

scholarly journals Practice and Outcome of Exercise Intervention on Breast Cancer-Specific Quality of Life of Breast Cancer Survivors in Nigeria

2021 ◽  
pp. 174-182
Author(s):  
Linda C Odikpo ◽  
Edith N Chiejina
Keyword(s):  
Breast Cancer ◽  
Quality Of Life ◽  
Cancer Survivors ◽  
Breast Cancer Survivors ◽  
Exercise Intervention ◽  
Intervention Group ◽  
Moderate Intensity ◽  
Control Group ◽  
Post Intervention

Background: Lifestyle modification like exercise is an essential rehabilitation measure that improves the quality of life (QoL) of women with breast cancer and helps in preventing cancer related complications. This study assessed the practice and outcome of exercise interventions on breast cancer-specific quality of life of survivors in Delta State, Nigeria. Methods: Experimental design was applied with intervention (47) and control (47) groups. This design involved a pre-test, an intervention, and a post-test. Exercise intervention (aerobic, resistance and flexibility exercises, including warm-up with Swiss ball and dance, climbing of stairs, treadmill, stationary exercise bicycle, shoulder, and arm exercises) was administered to the intervention group for twelve weeks. The assessment of breast cancer survivors' specific quality of life in the two groups was done with the English version of The European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life Questionnaire (QLQ- EORTC-BR23) before and after the exercise intervention. Results: The overall pre and post-intervention breast cancer-specific functional quality of life was 65.4±22.7 (intervention group); 71.3±23.4 (control group) and 75.05 ±10.4 (intervention group); 58.65±12.9 (control group) while the pre and post breast cancer-specific symptoms QoL was 22.2±6.2 (intervention group); 24.1±9.6 (control group) and 11.8±13.0 (intervention group); 30.9±21.2 (control group), respectively. All the women in the intervention group practiced exercise only at mild/moderate intensity and no notable side effects were observed during the practice by many of them (n=39). Significant differences existed in the overall post-intervention breast cancer-specific functional and symptoms QoL between the two groups (p<0.001) and no significant differences were observed among most of the specific QoL scales in relation to age, duration of diagnosis, and stage of the cancer diagnosis. Conclusion: Exercise remains beneficial to women with breast cancer and has proven to be one of the necessary means to improve their overall well-being. Therefore, healthcare providers that manage these patients in different hospitals should always counsel and support them to initiate the recommended exercises for cancer survivors to enhance their survival.

scholarly journals Effects of exercise in breast cancer patients: implications of the trials within cohorts (TwiCs) design in the UMBRELLA Fit trial

2021 ◽  
Author(s):  
Roxanne Gal ◽  
Evelyn M. Monninkhof ◽  
Carla H. van Gils ◽  
Rolf H. H. Groenwold ◽  
Sjoerd G. Elias ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Physical Activity ◽  
Beneficial Effect ◽  
Cancer Survivors ◽  
Breast Cancer Survivors ◽  
Exercise Intervention ◽  
Intervention Group ◽  
Control Group ◽  
Physical Fatigue ◽  
Trials Within Cohorts

Abstract Purpose The Trials within Cohorts (TwiCs) design aims to overcome problems faced in conventional RCTs. We evaluated the TwiCs design when estimating the effect of exercise on quality of life (QoL) and fatigue in inactive breast cancer survivors. Methods UMBRELLA Fit was conducted within the prospective UMBRELLA breast cancer cohort. Patients provided consent for future randomization at cohort entry. We randomized inactive patients 12–18 months after cohort enrollment. The intervention group (n = 130) was offered a 12-week supervised exercise intervention. The control group (n = 130) was not informed and received usual care. Six-month exercise effects on QoL and fatigue as measured in the cohort were analyzed with intention-to-treat (ITT), instrumental variable (IV), and propensity scores (PS) analyses. Results Fifty-two percent (n = 68) of inactive patients accepted the intervention. Physical activity increased in patients in the intervention group, but not in the control group. We found no benefit of exercise for dimensions of QoL (ITT difference global QoL: 0.8, 95% CI = − 2.2; 3.8) and fatigue, except for a small beneficial effect on physical fatigue (ITT difference: − 1.1, 95% CI = − 1.8; − 0.3; IV: − 1.9, 95% CI = − 3.3; − 0.5, PS: − 1.2, 95% CI = − 2.3; − 0.2). Conclusion TwiCs gave insight into exercise intervention acceptance: about half of inactive breast cancer survivors accepted the offer and increased physical activity levels. The offer resulted in no improvement on QoL, and a small beneficial effect on physical fatigue. Trial registration Netherlands Trial Register (NTR5482/NL.52062.041.15), date of registration: December 07, 2015.

scholarly journals Polyunsaturated Fatty Acids, Exercise, and Cancer-Related Fatigue in Breast Cancer Survivors

2021 ◽  
Vol 12 ◽  
Author(s):  
Yutaka Matsuoka ◽  
Katsunori Tsuji ◽  
Eisuke Ochi
Keyword(s):  
Breast Cancer ◽  
Cancer Survivors ◽  
Breast Cancer Survivors ◽  
Exercise Group ◽  
Control Group ◽  
Omega 3 ◽  
Pufa Supplementation ◽  
Exercise Interventions ◽  
Cancer Related Fatigue ◽  
Omega 6

Cancer-related fatigue (CRF) is one of the most frequently reported and disabling symptoms in cancer survivors. With its negative impact on the activities of daily living, work, social activities, and mood, CRF causes severe impairment of quality of life. A previous study showed that omega-6 polyunsaturated fatty acid (PUFA) supplementation unexpectedly reduced CRF compared with omega-3 PUFA supplementation and that omega-6 PUFA supplementation reduced pro-inflammatory serum markers in fatigued American breast cancer survivors. Meanwhile, a recent meta-analysis of individual patient data revealed significant benefits of exercise interventions on CRF. Recently, we completed our randomized controlled trial among early-stage Japanese breast cancer survivors, in which we examined the effect of baseline blood PUFA characteristics on change in CRF during the 12-week trial by exercise group and confirmed that increased Cancer Fatigue Scale (CFS) was associated with both docosahexaenoic acid (DHA) (p = 0.06) and omega-3 index (p = 0.08) at baseline in all participants (n = 46, omega-6/omega-3 ratio = 6.79, SD = 1.90). On the contrary, DHA at baseline was positively correlated with change in CRF (r = 0.40, p = 0.06) in the control group (n = 24, omega-6/omega-3 ratio = 7.0). Moreover, eicosapentaenoic acid (EPA) at baseline was positively correlated with leg strength (r = 0.39, p = 0.10) in the exercise group. In conclusion, blood PUFA balance might be associated with the effect of exercise on CRF. In addition, higher EPA in individuals who conducted exercise likely has a beneficial effect on muscle strength. Further investigation is needed to clarify the interaction between PUFAs and exercise for alleviating CRF.

scholarly journals PO-285 A review of effects of exercise on the quality of life in breast cancer survivors

2018 ◽  
Vol 1 (5) ◽  
Author(s):  
Feng Hong
Keyword(s):  
Breast Cancer ◽  
Quality Of Life ◽  
Physical Exercise ◽  
Cancer Survivors ◽  
Aerobic Exercise ◽  
Breast Cancer Survivors ◽  
Exercise Group ◽  
Control Group ◽  
Supervised Exercise

Objective Breast cancer is one of the most common malignant tumors in women.The number of women diagnosed with breast cancer each year is also increasing.It is also the leading cause of cancer deaths in women, accounting for 14-23% of cancer deaths.However, with the development of medical technology, the survival rate of breast cancer patients is improving.In general, the treatment of breast cancer mainly includes surgical treatment, adjuvant chemotherapy and radiotherapy，But these treatments can do a lot of damage to breast cancer patients.These injuries can limit some of the physical activity of breast cancer patients, and can be accompanied by significant psychological damage，Therefore, the quality of life of breast survivors is largely destroyed.Physical exercise is one of the important ways to improve the overall health of the human body.It also plays an important role in increasing people's mood and quality of life.So whether physical exercise has a positive impact on improving the quality of life of breast cancer survivors or there is some doubt.Therefore, the main purpose of this study is to explore the impact of physical exercise on the quality of life of breast cancer survivors, and then to prove the impact of supervised exercise and individual exercise on the quality of life of breast cancer survivors. Methods Data bases searched were MEDLINE, EMBASE, CINAHL, PubMed.Keywords were“breast cancer and quality of life” in combination with “exercise”or “physical activity”.At the same time, the references of the included articles were reviewed to obtain more relevant studies.In terms of the criteria for inclusion and exclusion of literature, the paper was initially screened to determine whether the title and abstract of the paper were consistent with the research topic.The criteria for inclusion are ①the subjects were breast cancer survivors,②the type of intervention was physical exercise,③the measured result is quality of life,④the type of experiment is randomized controlled trial.The exclusion criteria of the article are ①the subject's occupation was athlete，②quality of life is not measured on a formal scale，③article type is review or abstract. Results A total of 14 articles are included in our review.Quality of life was measured using scale tools in all included studies, of which two scales were used in all included articles.The two scales used can reflect the real life quality of the subjects, of which FACT-G is a mass life quality scale and FACT-B is a life quality scale designed specifically for breast cancer patients. Both scales are globally recognized by the public.In our review, we found that exercise significantly improved the quality of life of breast cancer survivors, particularly aerobic exercise.In the studies included in our study, except Nanette et al. used aerobic exercise combined with resistance strength training as the intervention method in their study, all the other studies used aerobic exercise as the intervention method for the subjects.Among the 14 included studies, 10 indicated that physical exercise significantly increased the quality of life of breast cancer survivors, and 4 found that compared with the control group, the quality of life of breast cancer survivors did not have significant changes, but there was a trend of improving the quality of life.At the same time, our review found that monitoring breast cancer survivors improved quality of life.In two of the studies we included, subjects were divided into individual exercise groups and supervised exercise groups.In their study, Anne et al. divided the recruited research samples into the supervision intervention group and the routine control group. Among them, the supervision intervention group received physical exercise 5 times a week for 12 weeks, and the quality of life of breast cancer survivors was significantly improved.In the study of Cadmus et al., the subjects recruited were divided into individual exercise group, supervised exercise group and routine control group, and the exercise group performed physical exercise with the same load and frequency. The result was that there was no physical activity in the home individual exercise group or the routine control group that improved the quality of life for breast cancer survivors.However, in the supervised exercise group, breast cancer survivors' scores for FACT-B and SF-36 (a measure reflecting quality of life) were significantly improved. Conclusions Exercise can improve the quality of life for breast cancer survivors, especially aerobic exercise. Supervised exercise intervention for breast cancer survivors can better improve their quality of life and alleviate social and psychological problems than individual exercise.The supervised aerobic exercise can be integrated into the life of breast cancer survivors so as to better promote the recovery of breast cancer survivors.

scholarly journals Effects of Short-Term Unsupervised Exercise, Based on Smart Bracelet Monitoring, on Body Composition in Patients Recovering from Breast Cancer

2021 ◽  
Vol 20 ◽  
pp. 153473542110407
Author(s):  
Liuqing Xu ◽  
Changming Zhou ◽  
Yiqun Ling ◽  
Huiping Ding ◽  
Qiong Wang ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Quality Of Life ◽  
Body Composition ◽  
Cancer Survivors ◽  
Body Fat ◽  
Fat Mass ◽  
Breast Cancer Survivors ◽  
Moderate Intensity ◽  
Short Term

Objective: We aimed to investigate the effects of exercise, monitored and managed using smart bracelets, on body composition, and quality of life in breast cancer survivors. Methods: A before-and-after study was conducted in 109 patients who were in the recovery phase of breast cancer and attended the Breast Surgery Department of the Cancer Hospital of Fudan University up to December 2017. Patients were advised to adhere to at least 150 minutes of moderate-intensity exercise per week, and a smart bracelet was issued to each participant to record their daily exercise data for 3 months. Bioelectrical impedance analysis was used to observe the effects of short-term unsupervised exercise intervention on body composition in patients recovering from breast cancer. Patients completed the Functional Assessment of Cancer Therapy-Breast to assess health-related quality of life. Results: Weight, body mass index (BMI), body fat mass (BFM), fat mass index (FMI), percent body fat (PBF), arm circumference (AC), arm muscle circumference (AMC), and visceral fat area (VFA) were lower than baseline after exercising for 3 months based on data from the wearable devices ( P < .05). The only significant improvement was found in the “additional concerns about breast cancer” category among the quality-of-life assessments ( P < .05). The average walking time was negatively associated with BFM, PBF, and FMI, while the average calorie consumption due to running was positively associated with fat free mass (FFM). Conclusion: In this study, we demonstrated that short-term exercise may be beneficial for postoperative breast cancer survivors. A wearable device could help patients track physical data easily and promote a healthier and more positive life.

Concurrent Exercise Interventions in Breast Cancer Survivors with Cancer-related Fatigue

2020 ◽  
Author(s):  
Itiziar Pagola ◽  
Javier S. Morales ◽  
Lidia B. Alejo ◽  
Olga Barcelo ◽  
Marta Montil ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Cancer Survivors ◽  
Training Program ◽  
High Intensity ◽  
Breast Cancer Survivors ◽  
Moderate Intensity ◽  
Concurrent Training ◽  
Exercise Interventions ◽  
Cancer Related Fatigue ◽  
Intensity Training

AbstractThis study compared the effects of two supervised concurrent training interventions in breast cancer survivors with cancer-related fatigue at baseline. Twenty-three female breast cancer survivors (50±8 years) were randomized to a high- (n=13) or a moderate-intensity (n=10) training program. Both interventions lasted 16 weeks and included the same resistance exercises, but the aerobic component was supervised and more intense in the former (i.e., rating of perceived exertion of 7–8 vs. 6 on a 1–10 scale for the high and moderate-intensity intervention, respectively). The primary endpoint was fatigue perception. Endpoints were assessed at baseline and after 16 weeks. The p-value for statistical significance was set at 0.004 after Bonferroni correction for multiple comparisons. The high-intensity training program increased lower-limb muscle strength significantly (p=0.002) and tended to improve fatigue perception (p=0.006), waist circumference (p=0.013), neutrophil-to-lymphocyte ratio (p=0.028) and some quality of life items (p=0.011). Although the moderate-intensity training program did not provide such benefits in general (i.e., higher p-values for pre vs post-intervention comparisons), no significant differences were found between interventions (all p>0.004). Further research is needed to elucidate if the benefits provided by high-intensity concurrent training are superior to those elicited by moderate-intensity training in breast cancer survivors.

Perceived physical fatigability improves after an exercise intervention among breast cancer survivors: A pilot randomized clinical trial.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 12050-12050
Author(s):  
Yujia (Susanna) Qiao ◽  
G J. Van Londen ◽  
Jill Brufsky ◽  
Janette T. Poppenberg ◽  
Rebecca W. Cohen ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Clinical Trial ◽  
Cancer Survivors ◽  
Randomized Clinical Trial ◽  
Breast Cancer Survivors ◽  
Exercise Intervention ◽  
Exercise Group ◽  
Whole Body ◽  
Control Group ◽  
Patient Reported

12050 Background: Among breast cancer populations, exercise interventions resulted in positive but relatively small improvements on fatigue, which may have been masked by using single-item, non-specific measures of global fatigue. Perceived fatigability – whole-body tiredness anchored to standardized tasks/activities of specific intensity and duration – accounts for self-pacing bias as an individual likely titrates their usual activities and exertion level to avoid exhaustion. We examined whether this novel fatigability measure could replace global fatigue in an exercise intervention trial in breast cancer survivors. Methods: This pilot single-center randomized clinical trial of 49 breast cancer survivors was conducted from 2015-17, among which 41 participants (exercise = 22, control = 19) completed the trial and reported their perceived physical fatigability and global fatigue at the first (V1) and the last visit (V3). Perceived physical fatigability was measured using the 10-item, self-administered Pittsburgh Fatigability Scale (PFS) scored 0-50, higher PFS Physical scores = greater fatigability. Global fatigue was assessed with a single question “I have a lack of energy” scored 0 “not at all” to 4 “very much” from the Functional Assessment of Cancer Therapy-Endocrine Subscale (FACT-ES). The exercise intervention consisted of three one-on-one training sessions over 6-14 weeks, plus two optional email/phone consultations. The trainer developed a personalized, home-based exercise program with a goal of achieving the recommended ≥150 minutes/week of moderate to vigorous exercise based on ACSM guidelines. Those randomized to the control group met the trainer for V1 and again 6-14 weeks later at V3, but no exercise prescription was provided. We computed mean differences in perceived physical fatigability and global fatigue between V3 and V1 and compared by intervention groups. Results: Among the 41 women in the study (mean age = 54.9±9.8 years; 80% white), sociodemographic and clinical characteristics were similar by intervention groups, except for antiestrogen use. Post-intervention changes (mean ± SE) in PFS Physical scores were -4.4±1.4 (-22.5%) in the exercise group and 0.2±1.4 (+1.0%) in the control group (p =.022), whereas change in global fatigue scores were -0.64±0.23 in the exercise group and 0.00±0.22 in the control group (p =.054). Conclusions: These findings add to mounting evidence that an exercise intervention reduces fatigue among breast cancer survivors. Importantly, the PFS showed a clinically meaningful reduction after the exercise intervention that was masked when using global fatigue as the measurement. Therefore, the PFS serves as a more sensitive instrument to measure perceived physical fatigability and can better evaluate patient-reported outcomes in future cancer trials, especially those focused on cancer survivorship. Clinical trial information: NCT 02770781.

scholarly journals A Randomized Controlled Pilot Trial About the Influence of Kyusho Jitsu Exercise on Self-efficacy, Fear, Depression, and Distress of Breast Cancer Patients within Follow-up Care

2021 ◽  
Vol 20 ◽  
pp. 153473542110379
Author(s):  
Jannike L Salchow ◽  
Maximilian A Strunk ◽  
Timo Niels ◽  
Jule Steck ◽  
Carrie-Ann Minto ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Cancer Survivors ◽  
Self Efficacy ◽  
Breast Cancer Survivors ◽  
Intervention Group ◽  
Control Group ◽  
Psychological Issues ◽  
Significant Difference ◽  
Follow Up Care

Introduction Breast cancer survivors are faced with several psychological issues. We report the influence on self-efficacy by a holistic orientated training schedule based on the “Kyusho Jitsu” martial art and explore the effects on self-efficacy, distress, fear, and depression. Methods Breast cancer survivors (N = 51) were randomly assigned to an intervention (n = 30) or control group (n = 21). The intervention group participated in a Kyusho Jitsu intervention twice a week over a period of 6 months, the control group received no intervention. Patients from both groups were measured at baseline, 3 and 6 months on level of self-efficacy (German General-Self-Efficacy Scale, SWE), stress (Perceived Stress Questionnaire, PSQ20), and fear and depression (Hospital Anxiety and Depression Scale, HADS). Results Analysis of the original data showed a significant difference between both groups regarding the subscale “joy” ( P = .018). Several significant results within the intervention group were seen in self-efficacy ( P = .014), fear ( P = .009) and the overall score for fear and depression ( P = .043). Both groups improved significantly within “worries” (intervention P = .006, control P = .019) and the PSQ20 overall score (both P = .005). The control group also significantly improved in the subscale for “demands” ( P = .019). Conclusion To summarize, our pilot study showed that Kyusho Jitsu training is safe and feasible. Though, the intervention alone cannot be considered as being effective enough to help breast cancer survivors regarding relevant psychological issues, but might be an important supplement offer within follow-up care.

Sign in / Sign up

Export Citation Format

Share Document