scholarly journals Compliance level in children with chronic pathology

2020 ◽  
Keyword(s):  
Diabetes Mellitus ◽  
Current Treatment ◽  
Control Group ◽  
Healthy Children ◽  
Emotional Instability ◽  
Daily Work ◽  
Idiopathic Juvenile Arthritis ◽  
Compliance Level ◽  
Compliance To Treatment ◽  
High Level

Introduction. Current treatment technologies, a significant place is occupied by the issue of interaction between a doctor and a patient. The aim of this study was to determine the level of compliance in children with chronic pathology. Materials and methods. 87 children aged 6 to 17 years were examined, among whom 32 children had idiopathic juvenile arthritis (JIA), 30 children had type 1 diabetes mellitus (DM1) and 25 apparently healthy children made up the control group. All children were interviewed using the Compliance Level Questionnaires for children with chronic pathology or healthy children. All statistical analyzes were performed using the s/n SPSS 17 4a 180844250981. Results. The study of compliance features in patients with IJA showed that the majority (84.4 %) of children had high compliance to treatment, which was much more common than in children with diabetes mellitus (р < 0,01) and control group (р < 0,02). Half of the children with DM1 also had a high level of general compliance. When assessing the structure of compliance in patients with diabetes, moderate levels of all components were found. Children of this group are characterized by an indefinite social position, they act according to the situation. Emotional instability is a typical manifestation. The study of the level of compliance in children of the control group revealed low indicators of general compliancy to the doctor's actions. Each component corresponded to the average level. It was in these children that low indicators of social and behavioral patterns were found, which indicates a negativity towards the treatment process and medical manipulations. Conclusions: 1. Patients with chronic pathology have a higher level of compliance than patients in the control group, which indicates a significant impact on the child's life of the presence of a chronic disease. 2. The level of compliance differs in various chronic diseases, may depend on the characteristics of subjective feelings and medical manipulations. 3. Female patients have a higher level of adherence to treatment, which dictates the need to take into account the gender of the child in the daily work of the doctor, and pay more attention to careful communication with boys.

scholarly journals POS0068 HIGH LEVELS OF PORPHYROMONAS GINGIVALIS AND PREVOTELLA INTERMEDIA ANTIBODIES IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 240.2-241
Author(s):  
F. Zekre ◽  
R. Cimaz ◽  
M. Paul ◽  
J. L. Stephan ◽  
S. Paul ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Juvenile Idiopathic Arthritis ◽  
Periodontal Disease ◽  
Porphyromonas Gingivalis ◽  
Joint Disease ◽  
Control Group ◽  
Prevotella Intermedia ◽  
Igg Antibodies ◽  
Idiopathic Juvenile Arthritis ◽  
High Level

Background:Idiopathic juvenile arthritis (JIA) is a heterogeneous group of pathologies whose origin remains unknown at present (1). They are characterised by a systemic inflammatory and joint disease affecting children under 16 years of age. The current classification groups the different forms of JIA into 7 distinct entities (systemic forms, polyarticular forms with or without rheumatoid factors, oligoarticular forms, inflammatory arthritis associated with enthesopathies (ERA), arthritis associated with psoriasis and unclassifiable arthritis). Exact etiology of JIA is still unknown. To date, the various hypotheses put forward on the occurrence of JIAs integrate the genetic and environmental framework.The link between periodontal disease and rheumatoid arthritis (RA) is largely reported. Recently, Porphyromonas gingivalis (P. gingivalis) infection explained the occurrence of arthritis in rodent and in RA (2). Several studies mention the beneficial effect of P. gingivalis treatment on disease activity.Currently, there are very few studies on the prevalence of P. gingivalis in patients with JIA and the possible involvement of the germ in the development of inflammatory joint diseases in the pediatric population(3)(4).Objectives:The objective of our study is to determine presence of high IgG antibodies against P. gingivalis and Prevotella Intermedia in a cohort of patients with JIA compared to a control population and to determine variation of level according to sub-classes of JIA.Methods:Sera were obtained from 101 patients satisfying the ILAR classification criteria for JIA and in 25 patients with two other dysimmune disorders (type 1 diabetes and juvenile inflammatory bowel disease). Level of IgG antibodies against P. gingivalis and Prevotella Intermedia were obtained by homemade ELISA already used previously (5).Results:In the JIA group, major children were oligarthritis (47.5%), polyarthritis represents 31.7% of JIAs, ERA and systemic forms of JIA are respectively 9 and 11%. For the control group, 10 (40%) children had diabetes and 15 (60%) had IBD.Levels of anti-P. gingivalis anti-Prevotella Intermedia antibodies were higher in AJI group compared at control groups (P<0.01, P<0.05). Theses difference are mainly related to oligoarthritis and ERA subsets for both P. gingivalis and Prevotella Intermedia.Figure 1.Relative titer of antibodies to P. gingivalis and anti Prevotella intermedia. *: P<0.05; **: P<0.01; ***: P<0.001. P. gingivalis (control vs oligoarthritis p= 0.0032. control vs ERA p= 0.0092). Prevotella intermedia (control vs oligoarthritis p= 0.0194. control vs ERA p= 0.0039).Conclusion:We confirmed high level of anti-P. gingivalis and anti-Prevotella intermedia antibodies in JIA compared to other inflammatory disorders. For the first time, we observed that this high level was mainly in oligoarthritis and ERA. Further investigations are required to investigate involvement of oral dysbiosis in AJI pathogenesis. As observed in RA, it could be a new way to integrate in JIA therapy management.References:[1]Thatayatikom A, De Leucio A. Juvenile Idiopathic Arthritis (JIA). StatPearls Publishing; 2020[2]Cheng Z, Meade J, Mankia K, Emery P, Devine DA. Periodontal disease and periodontal bacteria as triggers for rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2017;31(1):19–30.[3]Romero-Sánchez C, Malagón C, Vargas C, Fernanda Torres M, Moreno LC, Rodríguez C, et al. Porphyromonas Gingivalis and IgG1 and IgG2 Subclass Antibodies in Patients with Juvenile Idiopathic Arthritis. J Dent Child Chic Ill. 2017 May 15;84(2):72–9.[4]Lange L, Thiele GM, McCracken C, Wang G, Ponder LA, Angeles-Han ST, et al. Symptoms of periodontitis and antibody responses to Porphyromonas gingivalis in juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2016 Feb 9[5]Rinaudo-Gaujous M, Blasco-Baque V, Miossec P, Gaudin P, Farge P, Roblin X, et al. Infliximab Induced a Dissociated Response of Severe Periodontal Biomarkers in Rheumatoid Arthritis Patients. J Clin Med. 2019 May 26;8(5).Disclosure of Interests:None declared.

scholarly journals Characterization of the Oral Microbiome Among Children With Type 1 Diabetes Compared With Healthy Children

2021 ◽  
Vol 12 ◽  
Author(s):  
Moti Moskovitz ◽  
Mira Nassar ◽  
Nadav Moriel ◽  
Avital Cher ◽  
Sarit Faibis ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 1 Diabetes ◽  
Type 1 Diabetes Mellitus ◽  
Gut Microbiome ◽  
Species Level ◽  
Oral Microbiome ◽  
Control Group ◽  
Healthy Children ◽  
Diabetes Group

Aim: Current microbiome profiling of type 1 diabetes mellitus (T1D) patients is mostly limited to gut microbiome. We characterized the oral microbiome associated with T1D in children after the onset of the disease and explored its relationship with oral physiological factors and dental status.Methods: This cohort study comprised 37 children aged 5–15 years with T1D and 29 healthy children matched in age and gender. Unstimulated whole saliva was collected from diabetic and non-diabetic children, in the morning after brushing their teeth and a fasting period of at least 1 h before sampling. 16S rRNA gene-based analysis was performed by Powersoil Pro kit by Qiagen and Phusion High-Fidelity PCR Master Mix. Oral physiological and dental parameters studied included decayed, missing, and filled teeth index, salivary flow rate, and salivary pH, glucose, calcium, phosphate, and urea levels.Results: Of the identified 105 different genera and 211 different species, the most abundant genera were Streptococcus, Prevotella, Veillonella, Haemophilus, and Neisseria. Streptococcus was more abundant in T1D children. The diabetes group had 22 taxa at the genus level and 33 taxa at the species level that were not present in the control group and the control group exhibited 6 taxa at the genus level and 9 taxa at the species level that did not exist in the diabetes group. In addition, Catonella, Fusobacterium, and Mogibacterium differed between healthy and T1D subjects. Eight species and eight subspecies were significantly more abundant among healthy children than in T1D children. Porphyromonas and Mogibacterium genera were significantly correlated with salivary parameters. We found similarities between taxa revealed in the present study and those found in gut microbiome in type 1 diabetes mellitus according to gutMDisorder database.Conclusions: Salivary microbiome analysis revealed unique microbial taxa that differed between T1D children and healthy subjects. Several genera found in the saliva of T1D children were associated with gut microbiome in T1D individuals.

scholarly journals Psyсhologiсal defense mechanisms of children with cerebral palsy in the context of mothers attitude to a child’s disease

2017 ◽  
Vol 5 (3) ◽  
pp. 58-65
Author(s):  
Galina V. Pyatakova ◽  
Irina I. Mamajchuk ◽  
Valery V. Umnov
Keyword(s):  
Cerebral Palsy ◽  
Defense Mechanisms ◽  
Defense Mechanism ◽  
Parental Behavior ◽  
The Body ◽  
Control Group ◽  
Healthy Children ◽  
Psychological Defense ◽  
Prolonged Immobilization ◽  
High Level

Introduction. Cerebral palsy (CP) has a significant prevalence in industrialized countries and is characterized by a high level of disability. Children and adolescents with CP face challenging situations. Physical defects repeatedly manifest in the daily life of a child in the form of other extraordinary events such as hospitalization, surgery, prolonged immobilization, and separation from family. Such events can be accompanied by feelings of fear, anxiety, helplessness, and pronounced symptoms of maladjustment. Under these conditions, certain biological and social compensatory manifestations help to identify such complicated conditions and restore the normal functioning of the body. Compensatory manifestations are a type of compensatory defense mechanisms. The major role in establishing a system of protection is played by the relationship between a child and his or her parents. Defense mechanisms can be formed during the process of assimilation of protective parental behavior, or because of the inappropriate attitude of mothers to the child’s illness. The purpose of the research was to study the defense mechanisms in children with CP in the context of mothers’ relationship to her child’s illness. Materials and methods. The research involved 120 people. The experimental group included 30 children with CP aged 5 to 11 years and their mothers. The control group consisted of relatively healthy children (30) and their mothers. The following was used to achieve the goal: the elements of clinical and biographical method, projective technique, the technique of diagnostics of attitude to the child’s illness. Results and discussion. The repertoire of psychological defense mechanisms in children with CP is limited in comparison with those in healthy children. Children with CP are dominated by the defense mechanism of “denial” that can play a negative role in the process of adaptation of these children in a situation involving complex treatments. The mothers of children with CP share an emotionally intense relationship with their child’s disease. Excessively disturbing attitudes of the mother to the disease of her child can contribute to the formation of negative psychological defense mechanisms of negation type in the child, which reduces the child’s psychological compensatory capacity and capability of adaptation in conditions of complex treatment.

scholarly journals Influence of Type 1 Diabetes Mellitus on the Ocular Biometry of Chinese Children

2019 ◽  
Vol 2019 ◽  
pp. 1-6 ◽  
Author(s):  
Ying Xiao ◽  
Tao Li ◽  
Yan Jia ◽  
Shanshan Wang ◽  
Chenhao Yang ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 1 Diabetes ◽  
Type 1 Diabetes Mellitus ◽  
Glycosylated Hemoglobin ◽  
Diabetes Duration ◽  
Control Group ◽  
Healthy Children ◽  
Ocular Biometry ◽  
The Mean

Purpose. To compare ocular biometry between children with type 1 diabetes mellitus (T1DM) and healthy children in China and to determine the correlation of ocular biometry with the glycosylated hemoglobin (HbA1c) level and diabetes duration. Methods. A case-control study was conducted at Children’s Hospital of Fudan University between T1DM children and healthy children. The participants were evaluated for central corneal thickness (CCT), anterior chamber depth (ACD), lens thickness (LT), K1 and K2 keratometry, and axial length (AL); also cycloplegic refraction was performed, and spherical equivalent (SE) was acquired. HbA1c levels of the T1DM cases were obtained. Results. Fifty-four eyes of 54 children with T1DM and 53 eyes of 53 healthy children were included. The mean age of T1DM group and control group was 10.59 ± 3.40 years and 9.55 ± 1.89 years, respectively, and the differences between age and gender were not significant (p=0.052, p=0.700). The mean LT in T1DM group (3.49 ± 0.18 mm) was thicker than that in the control group (3.40 ± 0.16 mm) (p=0.018), the mean ACD in T1DM group (3.52 ± 0.26 mm) was shallower than that in the control group (3.72 ± 0.26 mm) (p<0.001), and there were no significant differences of CCT, K1, K2, AL, and SE (p=0.088, p=0.672, p=0.821, p=0.094, and p=0.306, respectively). There was no significant correlation between HbA1c or diabetes duration and ocular biometry. Conclusions. Thicker LT and shallower ACD occurred in T1DM children rather than age-matched and sex-matched healthy children, but the overall refraction was not affected. HbA1c or diabetes duration was not correlated with ocular biometry in T1DM children.

Salivary interleukin-8 levels in children suffering from Type 1 diabetes mellitus

2013 ◽  
Vol 37 (4) ◽  
pp. 377-380 ◽  
Author(s):  
D Dakovic ◽  
M Colic ◽  
S Cakic ◽  
I Mileusnic ◽  
Z Hajdukovic ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 1 Diabetes ◽  
Type 1 Diabetes Mellitus ◽  
Children And Adolescents ◽  
Statistical Significance ◽  
Control Group ◽  
Healthy Children ◽  
Study Results ◽  
Type 1 Dm

Objective: The aim of this study was to investigate the differences between the salivary levels of IL-8 in patients with Type 1 diabetes mellitus (DM) with (DM+P) or without (DM-P) concomitant periodontitis and healthy subjects. The correlations between the levels of these cytokines and clinical periodontal parameters were also established. Methods: Twenty children and adolescents with Type 1 DM (10 diagnosed with periodontitis, 10 presenting no signs of periodontitis) and a control group consisting of 20 healthy children and adolescents aged 7-18 years were recruited for this study. Results: The Salivary IL-8 level was statistically significantly (p&lt;0.005) elevated in subjects with Type 1 DM (474.47 ± 716.76) compared to non-diabetic control group (101.99 ± 68.32). There was no difference (p≯0.05) in the salivary IL-8 level when subjects with Type 1 DM with concomitant periodontitis were compared to diabetics without periodontitis. When the salivary IL-8 level in subjects with Type 1 DM was correlated with the clinical parameters, no statistical significance was found. Conclusion: An elevated salivary IL-8 level in subjects with Type 1 DM without concomitant periodontitis plays a major role in the development of diabetic micro and macroangiopathy and pathogenesis of atherosclerosis. Consequently, this may offer a basis for the assessment of risk, prophylaxis and treatment of diabetic complications.

scholarly journals Asymmetric dimethylarginine and the effect of folate substitution in children with familial hypercholesterolemia and diabetes mellitus type 1

2009 ◽  
pp. 179-184
Author(s):  
P Jehlička ◽  
F Stožický ◽  
O Mayer ◽  
J Varvařovská ◽  
J Racek ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Folic Acid ◽  
Endothelial Dysfunction ◽  
Familial Hypercholesterolemia ◽  
Asymmetric Dimethylarginine ◽  
Diabetes Mellitus Type 1 ◽  
Diabetes Mellitus Type ◽  
Control Group ◽  
Healthy Children

A recently discussed cardiovascular risk factor, asymmetric dimethylarginine (ADMA), is known to act as an endogenous inhibitor of endothelial nitric oxide synthase. The aim of this study was to establish 1) the relationship between ADMA and ultrasonographically or biochemically determined endothelial dysfunction in children, and 2) the effect of folate supplementation on these parameters. The study cohort included 32 children with familial hypercholesterolemia (FH), 30 with diabetes mellitus type 1 (DM1) and 30 age-matched healthy children as the control group. Furthermore, twenty-eight randomly selected FH and DM1 children were re-examined after 3-months supplementation with folic acid. Baseline levels of ADMA and oxidized low density lipoproteins (oxLDL) were significantly higher in FH group than in DM1 and healthy children. Children in DM1 group had significantly lower concentration of homocysteine, but ADMA levels were normal. Folic acid supplementation significantly lowered homocysteine and hsCRP levels in both FH and DM1 group; however, ADMA and oxLDL concentrations remained unaltered. In conclusion, ADMA and oxLDL appear to be associated with endothelial dysfunction in children with FH. Administration of folic acid did not influence these markers in both FH and DM1 children.

scholarly journals Acrochordons and diabetes mellitus: A Case control study

2016 ◽  
Vol 13 (1) ◽  
pp. 32-37
Author(s):  
Pratistha Shrestha ◽  
Y Poudyal ◽  
S L Rajbhandari
Keyword(s):  
Diabetes Mellitus ◽  
Control Group ◽  
Medical Sciences ◽  
Increased Risk ◽  
Skin Tags ◽  
High Level ◽  
Dermatologic Disease ◽  
And Control ◽  
Early Diagnosis Of Diabetes ◽  
Control Study

Background: Acrochordons (Skin tags) are common benign skin tumors usually occurring on the neck and major flexors of older people. These range in size from 1 mm to 1cm in diameter and are skin colored or brownish. A possible association with diabetes mellitus has been suggested in previous studies, but the result is not conclusive. Objectives: The aim of this study was to find out the association of diabetes mellitus with acrochordons. Material and Methods: One hundred and two patients were selected for the study. Among them 51 (males-23 and females-28) with acrochordons were taken as cases and 51 with other dermatologic disease after matching age and sex were taken as controls. The patients were selected from OPD of Department of Dermatology and Venereology in Universal College of Medical Sciences - Teaching Hospital (UCMS-TH). Blood glucose level including both fasting plasma glucose and 2-hour  post-glucose  load  were  determined  for  both  case  and  control  and  compared. Results: Patients with acrochordons had significantly higher frequency of diabetes than the control group (p<0.001). Total of 48.5% and 40% of patients with acrochordons having diabetes were obese and overweight respectively. Conclusion: There is an increased risk of diabetes mellitus in patients with acrochordons. With regard to the importance of early diagnosis of diabetes, it is recommended a high level of suspicion for diabetes mellitus in patients with acrochordons.NJDVL Vol. 13, No. 1, 2015 Page: 32-37

Constitutional features of connective tissue as a risk factor of chronic pain in adolescents

2016 ◽  
Vol 7 (3) ◽  
pp. 63-69
Author(s):  
Vadim G Arsentev ◽  
Ekaterina A Voloshina ◽  
Elena V Vyutrih ◽  
Yuriy S Sergeev ◽  
Nikolai P Shabalov
Keyword(s):  
Chronic Pain ◽  
Abdominal Pain ◽  
Connective Tissue ◽  
Clinical Laboratory ◽  
Control Group ◽  
Primary Headaches ◽  
Healthy Children ◽  
Emotional Instability ◽  
Functional Abdominal Pain ◽  
Head Pain

A total of 504 male adolescents aged 14-18, cadet schools students were examined to identify primary head pain and functional abdominal pain. A 4-stage-blind clinical laboratory and case-control psychological examination, in which are formed two groups: basic - 90 boys with primary head pain and functional abdominal pain, and 93 healthy children (control group). Total number of teens with headaches was 76 (48 isolated headaches and 28 - headaches in conjunction with abdominal pain). The number of cadets with abdominal pain was 42, 14 was manifested monosemeiotic and 28 - in conjunction with headaches. Complex research revealed pathogenetic common primary headaches and functional abdominal pain, to identify risk factors for their development. The analysis of the results of complex examination adolescents univariate statistics significant association features of the connective tissue with the presence of primary headache, especially in combination with functional abdominal pain. Obtained significant differences in many biological, psychological and social characteristics. This fact indicates eligibility review genesis of functional disorders with painful symptoms in adolescents from the perspective of the biopsychosocial model. The present results indicate the importance of the state of the connective tissue as an essential component of the formation of predisposition to chronic pain. Other predictors of pain were advancing sexual development, emotional instability, additional sports classes.

scholarly journals STATISTICAL ANALYSIS OF THE IMPACT OF CLUSTERS ON CARIES PREVALENCE AND INTENSITY IN CHILDREN AGED 6-7 WITH DIFFERENT SOMATIC HEALTH STATUSES

2020 ◽  
Vol 73 (3) ◽  
pp. 434-440
Author(s):  
Oksana V. Klitynska ◽  
Andriy V. Stishkovskyy ◽  
Natalia V. Hasiuk ◽  
David S. Avetikov ◽  
Viktoria Z. Ivaskevych
Keyword(s):  
Statistical Analysis ◽  
Calcium Content ◽  
Second Grade ◽  
Control Group ◽  
Healthy Children ◽  
Caries Prevalence ◽  
The Third ◽  
High Level ◽  
The Impact ◽  
Serum And Urine

The aim: Determining the influence of cluster factors on the emergence and progression of caries in first- and second-grade children is appropriate in terms of determining the most significant ones. Materials and methods: The dental status of 73 children, residents of Uzhhorod, who study in the first grades of secondary schools, has been assessed, three groups have been singled (the control group 26 healthy children). The indices of essential micro- and macronutrients in the hair, saliva, serum and urine, as well as anxiety level have been determined and the statistical analysis has been performed. Results: Decreased magnesium and calcium content in hair, serum, urine and mouth fluid, iodine is absent. Children of the third group have high levels of anxiety (80%), high rates of caries (14,8) and significantly reduced levels of magnesium relative to normal. Conclusions: In the patients of the main groups, a direct correlation was found between the presence of somatic pathology and the level of anxiety. In 80% of children of the third group (CSPS≥3) the level of anxiety is high In the main group patients, a direct correlation was found between the presence of somatic pathology, the level of anxiety, and the decrease in magnesium; The intensity of caries only interacts with a high level of anxiety (1.00), that is, in children who are in constant stress, the intensity of caries increases.

scholarly journals High Level of Complement Factor Ba Within 11 to 17 Weeks of Gestation Increases the Risk of Subsequent Gestational Diabetes: A Propensity Score-Matched Study

2021 ◽  
Author(s):  
Ying Shen ◽  
Junxian Li ◽  
Hairong Tian ◽  
Ye Ji ◽  
Ziyun Li ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Propensity Score ◽  
Gestational Diabetes ◽  
Pregnant Women ◽  
Influencing Factor ◽  
Control Group ◽  
Oral Glucose ◽  
Complement Factor ◽  
High Level ◽  
The Impact

Abstract Background: Several studies have shown that the over activation of complement factor B(CFB) was related to obesity, insulin resistance(IR) and type 2 diabetes mellitus. This study was to assess whether circulating complement factor Ba (CFBa) within 11 to 17 weeks of gestation is associated with subsequent gestational diabetes mellitus (GDM) or not.Methods: Biochemical parameters and blood samples were collected from 399 pregnant women within 11 to 17 weeks of gestation. At 24 to 28 weeks of pregnancy, all participants underwent 75-g oral glucose tolerance test (fasting for more than 8 hours before blood sampling) and were assigned to GDM group(n=80) and normal control group(n=319). Perinatal data were collected after delivery. A propensity score-matched (PSM) analysis was performed to reduce the impact of confounding factors on glucose metabolism during pregnancy between the two groups.Results: Two groups of 74 well-matched patients who maintained balance in terms of baseline characteristics. The levels of CFBa in pregnant women who later developed GDM were significantly higher than those in healthy pregnant women [0.4(0.1-0.8) vs. 0.2(0.2-0.3), P=0.031]. Logistic regression results confirmed that the level of CFBa was an independent influencing factor for the occurrence of GDM (OR=1.52, 95% CI: 1.25-1.85, P=0.000). Further grouping according to the quartile of CFBa level, it was found that the incidence of GDM in category 3 was markedly higher than that in the first and the second categories. Conclusions: High level of the CFBa within 11 to 17 weeks of gestation increased the risk of subsequent GDM, and maybe a biomarker for predicting GDM.

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