scholarly journals The Complex Association Between Bariatric Surgery and Depression: a National Nested-Control Study

2021 ◽  
Author(s):  
Chanpreet Singh Arhi ◽  
Roise Dudley ◽  
Osama Moussa ◽  
Maddalena Ardissino ◽  
Samantha Scholtz ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
Cox Regression ◽  
De Novo ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Cox Regression Analysis ◽  
Cox Proportional Hazard ◽  
Kaplan Meier ◽  
Reduce Weight Loss ◽  
History Of

Abstract Background Although bariatric surgery has been shown to reduce weight loss and obesity-related conditions, an improvement in depression remains unclear. The aim of this study was to determine whether bariatric surgery is associated with a resolution of depression, and the prevention of its onset. Method Patients with a BMI ≥ 30 kg/m2 who had undergone bariatric surgery were identified from the Clinical Practice Research Datalink (CPRD), matched 5:1 to controls. Cox regression analysis was used to determine the risk of developing de novo depression. Kaplan-Meier analysis compared the proportion of patients with no further consultations related to depression between the two groups. Results In total, 3534 patients who underwent surgery, of which 2018 (57%) had pre-existing depression, were matched to 15,480 controls. Cox proportional hazard modelling demonstrated surgery was associated with a HR of 1.50 (95% CI 1.32–1.71, p < 0.005) for developing de novo depression. For those with pre-existing depression, by 5 years, just over 20% of post-surgical patients had no further depression episodes compared with 17% of controls. Conclusion In individuals with a history of depression, bariatric surgery is associated with an improvement in mental health. On the contrary, the finding of increased de novo diagnoses of depression following surgery indicates the need for further study of the mechanisms by which bariatric surgery is associated with depression in this subset of patients.

Natural history definition and a suggested clinical approach to Buerger's disease: a case-control study with survival analysis

Vascular ◽  
2012 ◽  
Vol 20 (4) ◽  
pp. 198-202 ◽  
Author(s):  
Bahare Fazeli ◽  
Hassan Ravari ◽  
Reza Assadi
Keyword(s):  
Multivariate Analysis ◽  
Natural History ◽  
Cox Regression ◽  
Major Amputation ◽  
Clinical Approach ◽  
Buerger’S Disease ◽  
Buerger's Disease ◽  
Cox Regression Analysis ◽  
Kaplan Meier ◽  
History Of

The aim of this study was first to describe the natural history of Buerger's disease (BD) and then to discuss a clinical approach to this disease based on multivariate analysis. One hundred eight patients who corresponded with Shionoya's criteria were selected from 2000 to 2007 for this study. Major amputation was considered the ultimate adverse event. Survival analyses were performed by Kaplan–Meier curves. Independent variables including gender, duration of smoking, number of cigarettes smoked per day, minor amputation events and type of treatments, were determined by multivariate Cox regression analysis. The recorded data demonstrated that BD may present in four forms, including relapsing-remitting (75%), secondary progressive (4.6%), primary progressive (14.2%) and benign BD (6.2%). Most of the amputations occurred due to relapses within the six years after diagnosis of BD. In multivariate analysis, duration of smoking of more than 20 years had a significant relationship with further major amputation among patients with BD. Smoking cessation programs with experienced psychotherapists are strongly recommended for those areas in which Buerger's disease is common. Patients who have smoked for more than 20 years should be encouraged to quit smoking, but should also be recommended for more advanced treatment for limb salvage.

Two-Year Outcomes of Orbital Atherectomy Combined With Drug-Coated Balloon Angioplasty for Treatment of Heavily Calcified Femoropopliteal Lesions

2020 ◽  
Vol 27 (3) ◽  
pp. 492-501 ◽  
Author(s):  
Damianos G. Kokkinidis ◽  
Omar Jawaid ◽  
David Cantu ◽  
Brad J. Martinsen ◽  
Zsuzsanna Igyarto ◽  
...  
Keyword(s):  
Cox Regression ◽  
De Novo ◽  
Combined Therapy ◽  
Statistical Significance ◽  
Retrospective Chart Review ◽  
Cox Regression Analysis ◽  
Kaplan Meier ◽  
Effective Combination ◽  
Orbital Atherectomy ◽  
Procedural Complications

Purpose: To examine whether the combination of orbital atherectomy (OA) and drug-coated balloons (DCB) can lead to superior procedural and 2-year outcomes compared with DCB only in heavily calcified femoropopliteal (FP) lesions. Materials and Methods: A retrospective chart review was conducted to identify patients treated with DCB only or OA+DCB for de novo FP lesions at a single center over a 4-year period (2014–2017). In the observation period, 113 patients met the inclusion criteria: 63 treated with DCB only (mean age 69.0±8.6 years; 62 men) vs 50 treated with OA+DCB (mean age 70.3±7.1 years; 48 men). The OA+DCB group had higher calcification rates (78% with severe calcification vs 37% in the DCB only group). Propensity score matching (PSM) was used to adjust for baseline differences between the 2 groups. Cox regression analysis was used to compare the follow-up outcomes between lesions treated with OA+DCB vs DCB only. Results: No difference in procedural complications or success was found. After PSM adjustment, the OA+DCB group was associated with lower bailout stenting rates (39.4% vs 66.7% in the DCB only group; p=0.026). The 2 groups had similar long-term outcomes, although the OA+DCB arm had a trend toward reduced TLR rates that did not reach statistical significance. The Kaplan-Meier estimates for 2-year freedom from TLR were 76.1% for the OA+DCB group vs 55.5% for the DCB only group (p=0.109). Conclusion: OA+DCB is a safe and effective combination for the treatment of calcified FP lesions. The combined therapy decreased the bailout stenting rates in the adjusted analysis. Larger cohorts and randomized trials are needed to examine OA efficacy in FP lesions.

scholarly journals Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer

2020 ◽  
Vol 9 (9) ◽  
pp. 3009
Author(s):  
José Antonio Rubio ◽  
Sara Jiménez ◽  
José Luis Lázaro-Martínez
Keyword(s):  
Diabetic Foot ◽  
Cox Regression ◽  
Foot Ulcers ◽  
Diabetic Foot Ulcers ◽  
Cox Regression Analysis ◽  
Kaplan Meier ◽  
Hazard Ratios ◽  
History Of

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

scholarly journals Prevalence of comorbid mental and physical illnesses and risks for self-harm and premature death among primary care patients diagnosed with fatigue syndromes

2019 ◽  
Vol 50 (7) ◽  
pp. 1156-1163
Author(s):  
Matthew J. Carr ◽  
Darren M. Ashcroft ◽  
Peter D. White ◽  
Nav Kapur ◽  
Roger T. Webb
Keyword(s):  
Cox Regression ◽  
Premature Mortality ◽  
Premature Death ◽  
Epidemiological Studies ◽  
Adverse Outcomes ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Hazard Ratios ◽  
History Of ◽  
Self Harm

AbstractBackgroundFatigue syndromes (FSs) affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited.MethodsCohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10 477 patients aged 15 years and above, diagnosed with a FS during 2000–2014, were individually matched with up to 20 comparator patients without a history of having a FS. Prevalence ratios (PRs) were estimated to compare the FS and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models.ResultsAmong patients diagnosed with FSs, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72–1.82), anxiety disorders (PR 1.92; 1.85–1.99), depression (PR 1.89; 1.83–1.96), psychotropic prescriptions (PR 1.68; 1.64–1.72) and comorbid physical illness (PR 1.28; 1.23–1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91–1.09), natural death (HR 0.99; 0.90–1.09), unnatural death (HR 1.00; 0.59–1.72) or suicide (HR 1.68; 0.78–3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56–2.15.ConclusionsThe absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes.

Complete Response (CR) with Total Therapy 2 (TT2) for Multiple Myeloma (MM): Low Frequency in Case of Prior MGUS without Adverse Consequences for Survival - Yet Critical for Disease Control in Presumed “De Novo” MM.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1172-1172
Author(s):  
Athanasios Fassas ◽  
Erik Rasmussen ◽  
John Shaughnessy ◽  
Guido Tricot ◽  
Maurizio Zangari ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Cox Regression ◽  
De Novo ◽  
Low Frequency ◽  
Clinical History ◽  
Complete Response ◽  
Prior History ◽  
Solitary Plasmacytoma ◽  
Kaplan Meier ◽  
History Of

Abstract Background: It is now widely accepted that stringently defined CR is a prerequisite for durable EFS and OS also in MM. Patients and Methods: The results of TT2 (4 cycles of intensive induction prior to and consolidation chemotherapy after tandem autotransplant) have recently been reported (ASCO 2005), demonstrating a significantly higher CR rate and longer EFS but not OS among those randomized to thalidomide. Baseline laboratory variables and the clinical history off 668 patients enrolled in TT2 were examined for their potential impact on CR and, in turn CR’s impact on EFS and OS. The Kaplan-Meier method was used to estimate EFS and OS. Cox regression was used to evaluate multivariate factors of CR, EFS, and OS; the prognostic value of CR and 1st and 2nd transplants were modeled as time-dependent covariates in order to adjust for the guarantee time associated with reaching these treatment markers. Results: Of 668 patients enrolled, 45 had a documented history of prior MGUS (n=22) or smoldering MM (SMM) (n=23); 20 had a prior solitary plasmacytoma (SPC) of bone. 2-yr estimates of CR (negative immunofixation, normal bone marrow) were 47% for the 588 without history of preceding SPC/MGUS/SMM, 55% for SPC and 22% for the MGUS/SMM groups. EFS and OS at 4 yrs were 57% and 71%, independent of a preceding disorder. Multivariate analysis revealed faster onset and higher frequency of CR with only light chain MM (HR, 2.6; p&lt;.001), in the absence of MGUS/SMM (HR, 1.8; p=.049), and with thalidomide (HR, 1.7: p&lt;0.001). Cytogenetic abnormalities (CA), del13q14 and amp1q21, while adversely affecting EFS/OS, did not influence CR. On multivariate analysis for EFS and OS accounting, in addition to baseline variables, also for T, CR, 1st and 2nd transplant, and pre-MM history of MGUS/SMM, we observed that patients attaining a CR had significantly improved EFS and OS independent of key baseline variables (amp1q21, del13q14, CA, LDH, albumin) and treatment markers (T, 1st and 2nd transplants). Conclusion: We confirm that documented MGUS/SMM pre-MM is associated with lower CR rate without impacting survival negatively, probably implying the re-establishment of the precursor condition. For the remainder, CR was critical for prolonged survival. Gene expression analysis is applied to recognize, in the absence of prior history, those patients likely having evolved from MGUS and thus contribute fundamentally to a distinction of “de novo” MM from “MGUS-evolved MM”. Those results will be presented at the meeting.

Emerging clinical phenotype of bone metastatic urothelial cancer (mUC): Association of early osseous metastases (EOM) and outcomes.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e17007-e17007
Author(s):  
Ariel Ann Nelson ◽  
Robert Cronk ◽  
Aniko Szabo ◽  
Emily Lemke ◽  
Thomas A. Giever ◽  
...  
Keyword(s):  
Cox Regression ◽  
De Novo ◽  
Opioid Analgesic ◽  
Unmet Need ◽  
Chi Square ◽  
Cox Regression Analysis ◽  
Osseous Metastases ◽  
Kaplan Meier ◽  
Metastatic Urothelial Cancer ◽  
Platinum Based Chemotherapy

e17007 Background: Outcomes of patients (pts) with mUC with EOM have not thoroughly been described in the age of immuno-oncology. We hypothesized that EOM is associated with worse outcomes when compared to pts with non-osseous metastases (NOM). Methods: We used a multi-institutional database of pts with mUC who received systemic treatment (trt) between March 2005 and August 2019, to assess survival and palliative outcomes of pts with EOM vs NOM at the time of metastatic diagnosis (met dx). Wilcoxon rank-sum and chi-square tests were performed. Survival was estimated by Kaplan-Meier method, Cox regression analysis was performed. Results: We identified 270 pts, 72% men, mean age 67 ± 11 years, 28% never smokers. At met dx, 27% (n = 72) had ≥ 1 EOM; these pts were more likely to have de novo metastases vs. those with recurrent metastases (42% vs 19%, p < 0.001). Pts with EOM were more likely to have a change or stop in 1st line trt due to clinical progression (30.6% vs 15.7%, p = 0.006), and received fewer total lines of systemic trt, median of 1.0 (1.0-5.0) vs. 2.0 (1.0-8.0), p = 0.05. Pts with EOM had shorter median overall survival (OS) vs. those with NOM, (6.1 vs 13.7 months, p < .0001), HR = 2.79 (95% CI:1.95-3.97, p < .0001). Median OS was shorter for pts with EOM who received 1st line immune checkpoint inhibitor (n = 14) vs platinum-based chemotherapy (n = 43), (1.6 vs 9.1 months, p = 0.003). Pts with EOM received higher opioid analgesic doses at the first and last oncology outpatient visits compared to pts with NOM with mean morphine milligram equivalent (MME) dose of 60 ± 91 vs 28 ± 65 at first visit, p = 0.004, and 171 ± 214 vs. 94 ± 229 at last visit, p < 0.001. Conclusions: The presence of EOM in mUC is associated with worse outcomes vs. pts with NOM. Pts with EOM may benefit from 1st line platinum-based chemotherapy vs. checkpoint immunotherapy. Furthermore, pts with EOM experience more pain than pts with NOM and may benefit from early engagement with palliative care. Pts with EOM represent a population with a highly unmet need for systemic, targeted and/or radiation interventions. Molecular subtypes may further define these pts and analysis is planned. We encourage ongoing clinical trials to report outcomes in pts with EOM. A consensus on reporting of non-measurable disease is also needed. [Table: see text]

scholarly journals Risk factors for rerupture after conservative management of acute Achilles tendon rupture

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0030
Author(s):  
Kang Lee ◽  
Jong-Hwa Won
Keyword(s):  
Achilles Tendon ◽  
Conservative Management ◽  
Tendon Rupture ◽  
Cox Regression ◽  
Achilles Tendon Rupture ◽  
Achilles Tendinopathy ◽  
Complete Healing ◽  
Cox Regression Analysis ◽  
Kaplan Meier ◽  
History Of

Category: Sports Introduction/Purpose: Recently, results after conservative management for acute Achilles tendon rupture have been improving after the introduction of real time assessment of tendon healing using ultrasonography and introduction of early weight-bearing and functional brace. Yet, many surgeons prefer surgical management of all acute ruptures due to the risk of tendon rerupture. The purposes of this study are to evaluate incidence and pattern of rerupture of Achilles tendon after complete healing, and to investigate factors related to it. Methods: A total of 202 patients with acute Achilles tendon rupture, who underwent conservative management with cast(3 to 7 weeks) and functional brace, were the subjects of this study. In patients having both tendons injured, only one side was randomly selected for analysis. Hence, for 202 patients, migration free survivorship was analyzed using Kaplan-Meier method, and association with possible risk factors was analyzed by Cox regression analysis using proportional hazards model. Factors include age, sex, history of Achilles tendinopathy, cast duration, calf atrophy(mean calf circumference difference at least 2 cm), possibility of SHR(single heel raise), Achilles thickness after complete healing, and insufficient opposition of tendon ends(10mm>gap>5 mm) after cast, initial gap with ankle neutral. Results: Rerupture occurred in 7 of 202 patients. Factors significantly associated with rerupture in Kaplan-Meier survivorship analysis and univariate Cox regression analysis were sex, history of Achilles tendinopathy, calf atrophy, possibility of SHR. When these factors were analyzed by multivariate analysis, possibility of SHR was the only significant factor with a hazard ratio of 3.14. Conclusion: Our data suggest that possibility of SHR requires special attention during the follow-up. The risk of rerupture after conservative management of acute Achilles tendon rupture can be reduced by sufficient recovery of calf muscle strength with early weightbearing and accelerated rehabilitation with aid of ultrasonography.

scholarly journals Role of RET genetic variants in MEN2-associated pheochromocytoma

2014 ◽  
Vol 170 (6) ◽  
pp. 821-828 ◽  
Author(s):  
Débora Rodrigues Siqueira ◽  
Lucieli Ceolin ◽  
Carla Vaz Ferreira ◽  
Mírian Romitti ◽  
Silvana Cavalcante Maia ◽  
...  
Keyword(s):  
Cox Regression ◽  
Cox Regression Analysis ◽  
Cox Proportional Hazard ◽  
Kaplan Meier ◽  
Age Related ◽  
Increased Risk ◽  
Tertiary Teaching ◽  
Cox Proportional Hazard Models ◽  
Tertiary Teaching Hospital ◽  
Estimated Risk

Background: RET polymorphisms have been involved in the clinical presentation and prognosis of multiple endocrine neoplasia type 2 (MEN2)-associated medullary thyroid carcinoma.ObjectiveTo investigate the effect of RET variants on the penetrance of pheochromocytoma (PHEO) in MEN2 patients. Methods: The RET variants L769L, S836S, and G691S/S904S were evaluated in a cohort of 153 MEN2 patients attending a tertiary teaching hospital. A comparison of RET variant frequencies between patients with and without PHEO was performed. Kaplan–Meier curves and Cox regression analysis were used to estimate the effect of RET variants on the age-dependent penetrance.ResultsA total of 48 (31.4%) patients presented with MEN2-associated PHEOs. The mean age at diagnosis was 35.5±13.4 years, 60.4% of patients were women, and 92.8% had RET mutations at codon 634. The frequencies of RET polymorphisms were as follows: 20.1% L769L, 4.75% S836S, and 17.3% S904S/G691S. We did not observe any association between the frequencies of L769L, S836S, or S904S/G691S variants and PHEO development (all P>0.05). However, individuals carrying two RET polymorphic alleles had an increased estimated risk of PHEO (2.63; 95% CI, 1.4–5.0; P=0.004) and were younger at diagnosis when compared with those with one or no polymorphism (29.6±6.3 and 39.3±14.4 years respectively; P=0.006). Accordingly, additional analysis using Cox proportional hazard models demonstrated that the presence of two RET variants was associated with an increased risk for early PHEO development (hazard ratio, 5.99 (95% CI, 2.24–16.03); P<0.001).ConclusionsRET polymorphic alleles have an additive effect on the estimated risk of age-related PHEO penetrance in MEN2 patients.

scholarly journals Risk of venous thromboembolism in people with lung cancer: a cohort study using linked UK healthcare data

2016 ◽  
Vol 115 (1) ◽  
pp. 115-121 ◽  
Author(s):  
Alex J Walker ◽  
David R Baldwin ◽  
Tim R Card ◽  
Helen A Powell ◽  
Richard B Hubbard ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Cohort Study ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Cox Regression ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Related Factors ◽  
Cox Regression Analysis ◽  
Healthcare Data

Abstract Background: Venous thromboembolism (VTE) is a potentially preventable cause of death in people with lung cancer. Identification of those most at risk and high-risk periods may provide the opportunity for better targeted intervention. Methods: We conducted a cohort study using the Clinical Practice Research Datalink linked to Hospital Episode Statistics and Cancer Registry data. Our cohort comprises 10 598 people with lung cancer diagnosed between 1997 and 2006 with follow-up continuing to the end of 2010. Cox regression analysis was performed to determine which demographic, tumour and treatment-related factors (time-varying effects of chemotherapy and surgery) independently affected VTE risk. We also determined the effect of a VTE diagnosis on the survival of people with lung cancer. Results: People with lung cancer had an overall VTE incidence of 39.2 per 1000 person-years (95% confidence interval (CI), 35.4–43.5), though rates varied depending on the patient group and treatment course. Independent factors associated with increased VTE risk were metastatic disease (hazard ratio (HR)=1.9, CI 1.2–3.0 vs local disease); adenocarcinoma subtype (HR=2.0, CI 1.5–2.7, vs squamous cell; chemotherapy administration (HR=2.1, CI 1.4–3.0 vs outside chemotherapy courses); and diagnosis via emergency hospital admission (HR=1.7, CI 1.2–2.3 vs other routes to diagnosis). Patients with VTE had an approximately 50% higher risk of mortality than those without VTE. Conclusions: People with lung cancer have especially high risk of VTE if they have advanced disease, adenocarcinoma or are undergoing chemotherapy. The presence of VTE is an independent risk factor for death.

scholarly journals Repetition of acute poisoning in Oslo: 1-year prospective study

2009 ◽  
Vol 194 (1) ◽  
pp. 73-79 ◽  
Author(s):  
Fridtjof Heyerdahl ◽  
Mari Asphjell Bjornaas ◽  
Rune Dahl ◽  
Knut Erik Hovda ◽  
Anne Kathrine Nore ◽  
...  
Keyword(s):  
Cox Regression ◽  
Middle Age ◽  
Psychiatric Treatment ◽  
Hospital Setting ◽  
Acute Poisoning ◽  
Cox Regression Analysis ◽  
Prospective Multicentre Study ◽  
Kaplan Meier ◽  
History Of ◽  
Previous Suicide Attempt

BackgroundThe repetition of acute poisoning occurs frequently. The intention may change between episodes and many poisonings are treated outside the hospital setting. Few studies have taken this into account.AimsTo quantify the repetition frequency regardless of the level of health care or the intention behind the poisoning, and to identify possible risk factors for repetition.MethodA prospective multicentre study of all acute poisonings in Oslo treated in hospital, at an out-patient clinic or by the ambulance service. Repetition was estimated using Kaplan– Meier calculations, and predictive factors were identified using Cox regression analysis.ResultsThe estimated 1-year repetition rate was 30% (95% CI 24–35). Independent predictors of repetition were middle age (30–49 years), poisoning with opiates or sedatives, unemployment or living on social welfare, a previous suicide attempt, and a history of psychiatric treatment. Intention was not a significant predictor.ConclusionsRepetition of acute poisoning is high, irrespective of the level of healthcare and the intention behind the poisoning.

Sign in / Sign up

Export Citation Format

Share Document