Garuda - Garba Rujukan Digital

Efek Anestesia Aliran Rendah Sevofluran terhadap Respon Inflamasi pada Susunan Saraf Pusat Harimin, Kusuma; Bisri, Tatang
Jurnal Neuroanestesi Indonesia Vol 3, No 2 (2014)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

Show Abstract | Download Original | Original Source | Check in Google Scholar

Anestesi aliran rendah adalah teknik anestesi yang menggunakan aliran gas <1L/menit. Oleh karena adanya rebreathing, maka pada anestesi aliran rendah yang menggunakan sevofluran akan terjadi produk degradasi dengan CO2 absorber sehingga terbentuk senyawa A dan senyawa B. Senyawa A bersifat neprotoksik pada ginjal tikus, karena enzim β liase 30 kali lebih aktif pada tikus dari pada manusia, sedangkan pada manusia tidak terbukti senyawa A berefek neprotoksik. Anestesia sevofluran dapat menimbulkan respons inflamasi yang diawali dengan pelepasan interleukin (IL)–1 dan TNF–α, kemudian menstimulasi IL–6 yang sangat berperan pada respons fase akut. Akan terjadi interaksi antara sistem imun dengan sistem neuroendokrin, yang mana IL–1 dan IL–6 dapat menstimulasi adrenocorticotrophic hormone (ACTH) sehingga terjadi peningkatan pelepasan kortisol. Metabolit sevofluran dan senyawa A tidak dapat menembus sawar darah otak sehingga pengaruh negatif dari metabolit dan produk degradasi sevofluran terhadap otak tidak ada. Bahkan, melalui penelitian lebih lanjut, sevofluran diketahui mempunyai efek neuroproteksi. The Effect of Sevoflurane Low Flow Anesthesia to Inflammatory Response on Central Nervous SystemLow flow anesthetic is an anesthesia technique using gas flow less than 1 L/ min. Due to the rebreathing system, a low flow anaesthesia using sevoflurane will produce degradation products through reaction with the CO2 absorber which will form compound A and compound B. Compound A is nephrotoxic to rat kidney because the β -lyase enzyme in rat is 30-fold more active than in human, and this compound has been proven to be not nephrotoxic in human. Sevoflurane can cause inflammatory response which started with the release of interleukin (IL)-1 and TNF-α followed by stimulation of IL-6, which plays important part in the acute phase. Interaction between the neuroendocrine and immune systems will occur where IL-1 and IL-6 cytokines will stimulate the production of adrenocorticotrophic hormone (ACTH), which in turn will increase the production of cortisol. Sevoflurane metabolites and compound A can not penetrate blood brain barrier, therefore, the negative effects of sevoflurane metabolites and degradation products to the brain does not happen. Further advanced studies even showed that sevoflurane has a neuroprotective effect.

Perbandingan Efektivitas Pemberian Tropisetron 5 mg dan Ondansetron 8 mg untuk Mengurangi Efek Mual dan Muntah Pascaoperasi Ginekologis per Laparatomi Sepriwan, Tori; , Zulkifli; Harimin, Kusuma
Majalah Anestesia dan Critical Care Vol 32 No 3 (2014): Oktober
Publisher : Perdatin Pusat

Show Abstract | Download Original | Original Source | Check in Google Scholar

Salah satu efek samping pascaoperasi dengan anestesi umum adalah mual muntah. Obat 5-HT3 reseptor antagonis telah terbukti efektif mencegah terjadinya mual dan muntah pascaoperasi. Ondansetron merupakan 5-HT3 reseptor antagonis yang sering dipakai, namun memiliki efek samping nyeri kepala. Tropisetron merupakani obat alternatif untuk mencegah mual muntah pascaoperasi. Tujuan penelitian adalah membandingkan efektifitas pemberian tropisetron 5 mg dengan ondansetron 8 mg untuk mengurangi efek mual dan muntah pascaoperasi ginekologis per laparatomi. Uji klinik acak tersamar ganda dilakukan pada 66 pasien di bagi menjadi dua kelompok perlakuan, kelompok tropisetron dan kelompok ondansetron. Data hasil penelitian diuji secara statistik dengan uji t dan uji chi-kuadrat. dari data penelitian diperoleh hasil bahwa skor mual pada kelompok tropisetron berbeda bermakna dibanding kelompok ondansetron sebesar dengan p<0,05. Keluhan mual pada kelompok ondansetron yaitu sebanyak 21 subjek (63,6%) sedangkan pada kelompok tropisentron sebanyak 10 subjek (30,3%) berbeda bermakna dengan p<0,05. Tidak ada perbedaan bermakna pada kedua kelompok pada keluhan muntah dengan 2 subjek (6,1%) yang mengalami muntah. Simpulan penelitian ini adalah pemberian tropisetron 5 mg lebih efektif dibandingkan dengan ondansetron 8 mg untuk mengurangi efek mual dan muntah pascaoperasi ginekologis perlaparatomi.Kata kunci: Mual muntah, ondansetron, skor mual, tropisetron. Post operative nausea and vomitus (PONV) is one of side effect caused by general anesthesia. 5- HT3 antagonist receptor is effectively proven in preventing PONV. Ondansetron is a common antagonist 5- HT3 receptor widely used with side effect especially complaints of headache. Tropistron can be used as an alternative to prevent PONV. The aim of this study is to compare the effectiveness of 5 mg tropisetron to 8 mg ondansetron in reducing PONV. Double blind randomized control trial was delivered to 66 patients divided into 2 treatment groups, tropisetron and ondansetron. The result of the study was statistically tested with t test and chi square test. The study shows the score of nausea in tropisetron group was less than ondansetron group with p<0,05. Nausea was complained in 21 subject of ondansetron group (63,6%), while in tropisetron group was complained in 10 subject (30,3%) with p<0,05. No significance difference was found in both group with 2 subject ( 6,1%) complaining vomiting. The conclusion of this study is tropisetron 5 mg is more effective than ondansetron 8 mg in reducing PONV Key words: nausea score, nausea and vomiting, ondansetron, tropisetron Reference Tsui SL, Ng KFJ, Wong LC, Tang GW, Pun TC, Yang JC. Prevention of postoperative nausea and vomiting in gynaecological laparotomies: a comparison of tropisetron and ondansetron. Anaesthesia and Intensive Care. 1999;27:471–6. Watcha MF, White PR. Postoperative nausea and vomiting, its etiology, treatment and prevention Lerman J. Surgical and patient factors involved in postoperative nausea and vomiting. Br J Anaesth. 1992;69:24S–32S. Junger A, Klasen J, Benson M, et al. Factors determining length of stay of surgical daycase patients. Eur J Anaesthesiol. 2001;18: 14–21. Wu CL, Berenholtz SM, Pronovost PJ, et al. Systematic review and analysis of postdischarge symptoms after outpatient surgery. Anesthesiology. 2002;96:994–1003. Gan T, Sloan F, Dear Gde L, El-Moalem HE, Lubarsky DA. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg. 2001;92:393–400. Bosek V, Hu P and Robinson LA. Acute myocardial ischemia after administration of ondansetron hydrochloride. Anesthesiology. 2000;92: 885–7. Gan TJ, Meyer TC, Christian C, Cheng F, Davis PJ, Eubank S, dkk. Consenseus guideline for managing postoperative nausea and vomiting. Anest Analg. 2003;97:62–71. Morgan GE, Mikhail MS, Murria MJ, Larson CP. Clinical Anethesiology. Edisi ke-3. California: McGraw-Hill Medical Publishing Division;2002.Hlm. 242–50. Jokela R. Prevention of postoperative nausea and vomiting-studies on different antimetic, their combination and doping regiments. Academic dissertation: Dep ofAnaesthesiology University of Oulu, Findaln; 2003. Raman Sikka, Kaul TK, Anju G, Aprajita S. Postoperative nausea and vomiting. Anesth Clin Pharmacol. 2007;23(4):341–356. Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg. 2000;91:1408-14. Gautam PL. Kaul TK. PONV-an unsolved problem. J Anaesth Clin Pharmacol. 2002; 18(1):3–6. White H, Black RJ, Jones M, Mar Fan GC. Randomized comparison of two antiemetic strategies in high risk patients undergoing day cas gynecological surgery. Br J Anaesth. 2007;98:470–6. Sebastian P, Gaelle C, Christian C. A risk store Dependent antiemetic approach effectively reduce postoperative nausea and vomiting a continous quality improvement initiative Can J Anaesth. 2004;51:320–5. Rama MP, Ferreira TA, Molin N, Sanduence Y, Bautista AP. Less postoperative nausea and vomitting after propofol remifentanil versus propofol fentanyl anaesthesia during plastic surgery. Acta Anaesthesiologica Scandinavia. 2005;49:305–11. Hill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PS, dkk. Costeffectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. Anesthesiology. 2000;92: 958–67. Figueredo ED and Canosa LG. Ondansetron in the prophylaxis of postoperative vomiting:a metaanalysis. J Clin Anesth. 1998; 10: 211–21. Arcioni R, della Rocca M, Romano S, et al. Ondansetron inhibits the analgesic effects of tramadol: a possible 5-HT(3) spinal receptor involvement in acute pain in humans. Anesth Analg. 2002; 94: 1553–7 Deane Y, Valentine RGN. An audit of nausea and vomiting in a post anaesthetic care unit. British Journal of Anaesthetic & Recovery Nursing. 2005;6:4–6.

Efektivitas Penambahan Sufentanil 10 mg pada Anestesi Epidural 15 mL Levobupivakain 0,5% untuk Tindakan Operasi Ekstremitas Bawah Werda Laksana, Ngurah Putu; , Zulkifli; Harimin, Kusuma; , Theodorus
Majalah Anestesia dan Critical Care Vol 32 No 2 (2014): Juni
Publisher : Perdatin Pusat

Show Abstract | Download Original | Original Source | Check in Google Scholar

Walaupun memiliki profil keamanan yang lebih baik daripada racemic, levobupivakain tetap memiliki mula kerja lambat dan lama kerja terbatas. Kombinasi opioid lipofilik sufentanil-levobupivakain akan memberikan efek sinergistik sehingga memperbaiki kekurangan tersebut, tetapi masih sedikit penelitian yang menilai kombinasi ini. Tujuan penelitian ini adalah untuk menilai efektivitas penambahan sufentanil 10 μg pada anestesi epidural levobupivakain 0,5% 15 mL dalam hal mula dan lama kerja blokade sensorik-motorik. Uji klinik randomized control trial (RCT) telah dilakukan terhadap 44 pasien (dibagi 2 kelompok; kelompok I (sufentanil 10 μg), kelompok II (2 mL NaCl 0,9%)) yang menjalani operasi ekstremitas bawah dengan anestesi epidural levobupivakain 0,5% di RSUP Dr. Mohammad Hoesin Palembang dari bulan Mei–Agustus 2013 yang memenuhi kriteria inklusi. Dilakukan penelitian terhadap mula, lama kerja blokade sensorik-motorik. Analisis data menggunakan SPSS® versi 20.0. Mula dan lama kerja blokade sensorik kelompok sufentanil secara statistik lebih bermakna daripada kelompok NaCl (p<0,001), sedangkan mula dan lama kerja blokade motorik tidak memiliki perbedaan bermakna secara statistik. Penambahan sufentanil 10 μg pada anestesi epidural levobupivakain 0,5% 15 mL mempercepat mula dan memperpanjang durasi kerja blokade sensorik. Kata kunci: Anestesi epidural, levobupivakain, sufentanil Although levobupivacaine has better safety profile than racemic bupivacaine, it has a slow onset of action and limited blockade duration. Combination of lipophilic opioid sufentanil-levobupivakain will provide synergetic effects that improve the shortcomings, but lack of research to support this. The aim of this study is to evaluate the efficacy of additional 10 μg sufentanyl to 15 mL 0.5% levobupivacaine epidural anesthesia toward sensory-motoric blockade onset and duration. Randomized controlled trials double blind study (RCT) has been conducted to 44 patients (divided into 2 groups : group I (sufentanil 10 μg), group II (2 mL NaCl0.9%)) underwent lower extremity surgery with epidural anesthesia 15 mL 0,5% levobupivakain in Dr. Mohammad Hoesin central hospital from May–August 2013 that met inclussion criteria. Onset and duration of action sensory-motoric blockade were studied. Data analysis using SPSS® version 2.0. The onset and the duration of sensory blockade in sufentanil group is statistically significant than NaCl group (p<0.001). However the onset and duration of motoric blockade are not statistically significant. The addition of 10 μg sufentanil to 15 mL of 0.5% levobupivacaine epidural anesthesia hasten the onset and prolong the duration of sensory blockade. Key words: Epidural anesthesia, levobupivacaine, sufentanyl Reference Bajwa SJS, Kaur J. Clinical profile of levobupivacaine in regional anesthesia: a systematic review. J Anaesth Clin Pharmaco. 2013;29:530–9. Burlacu CL, Buggy DJ. Update on local anesthetics: focus on levobupivacaine. Therapeutics and Clinical Risk Management. 2008;4(2):381–92. Casimiro C, Rodrigo J, Mendiola MA, Rey F, Barrios A, Gilsanz F. dkk. Levobupivacaine plus fentanyl versus racemic bupivacaine plus fentanyl in epidural anaesthesia for lower limb surgery. Minerva Anestesiol. 2008;74:381–91. Liu SS, Lin Y. Local Anesthetics. Dalam: Barash PG, Cullen, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, penyunting. Clinical anesthesia. Edisi ke-6. Philadelphia: Lippincott Williams & Wilkins; 2009. hlm. 531–48. Leone S, Cianni SD, Casati A, Fanelli G. Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed. 2008;79:92–105. Khangure N. Adjuvant agents in neuroaxial blockade [document on the internet]. Western Australia: World Federation of Societies of Anaesthesiologist; 2011 [diperbarui tanggal 2011 July 4; diunduh 1 Februari 2013]. Tersedia dari: http://www.totw. anaesthesiologists.org. Kaur M. Adjuvants to local anesthetics: a combination wisdom. Anesth Essays Res. 2010:4;122–3. Christiansson L. Update on adjuvants in regional anaesthesia. Periodicum Biologorum. 2009;111:161–70. Yeerdaoolaiti Y, Long W, Jian-Hua DU. Clinical effect of sufentanil combined with ropivacaine used in epidural anesthesia for abdominal hysterectomy. Modern Preventive Medicine. 2011;19:4096–103. Bachman-Mennenga B, Veit G, Stenicke B, Biscoping J, Heesen M. Efficacy of sufentanil addition to ropivacaine epidural anaesthesia for caesarean section. Acta Anaesthesiol Scand. 2005;49:532–7. Bachman-Mennenga B, Veit G, Biscoping J, Stenicke B, Heesen M. Epidural ropivacaine 1% with and without sufentanil addition for caesarean section. Acta Anaesthesiol Scand. 2005;49:525–31. Prabowo RSE. Pengaruh penambahan fentanil 1,5 μg.kg1 pada ropivakain 0,75% terhadap mula dan lama kerja blokade anestesi epidural untuk operasi ekstermitas bawah. Dokter Spesialis Anestesi [Tesis]. Bandung: Universitas Padjajaran; 2004. Macres SM, Moore PG, Fishman SM. Acute pain management. Dalam: Barash PG, Cullen, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, penyunting. Clinical anesthesia Edisi ke-6. Philadelphia: Lippincott Williams & Wilkins; 2009. hlm. 1473–1504. NYSORA. Epidural Blockade [document on the internet]. New York: New York School of Regional Anesthesia; 2009 [diperbarui tanggal 2009 January 3; diunduh 1 Februari 2013]. Tersedia dari http://www.nysora.com. Pain Community Centre. Epidural: the mode of action of local anaesthetics and opioids in the epidural. Wales: Cardiff University; 2012[diunduh 1 Februari 2013]. Tersedia dari: http://www.paincommunitycentre.org. Vora KS, Shah VR, Patel B, Parikh GP, Butala BP. Postoperative analgesia with epidural opioids after cesarean section: Comparison of sufentanil, morphine and sufentanil-morphine combination. J Anaesth Clin Pharmaco. 2012;28:491–5. Visser WA, Lee RA, Gielen MJM. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Intern Anesth Research Soc. 2008;107(2):708–21. Staahl C, Olesen AE, Andreses T, Arendt- Nielsen L, Drewes AM. Assesing analgesic actions of opioids by experimental pain models in healthy volunteers-an updated review. Bri J Clin Pharmaco.2009;68(2):49–68. George MJ. The site of action of epidurally administered opioids and its relevance to postoperative paint management. Anaesthesia. 2006;61:659–64. Veering BT, Cousins MJ. Epidural neural blockade. Dalam: Cousins MJ, Bridenbaugh PO, penyunting. Neural blockade in clinical anesthesia and management of pain Edisi ke-4. Philadelphia: Lippincott–Raven Publishers; 2008. hlm. 241–95.

Perbandingan Efektivitas Salin Normal dengan Udara dalam Pengembangan Balon Pipa Endotracheal untuk Mengurangi Risiko Sakit Tenggorokan Pascaintubasi Adhriyani, Dessy; Harimin, Kusuma; Saleh, Irsan
Majalah Anestesia dan Critical Care Vol 32 No 1 (2014): Februari
Publisher : Perdatin Pusat

Show Abstract | Download Original | Original Source | Check in Google Scholar

Membandingkan efektivitas penggunaan saline normal dan udara dalam pengembangan balon pipa endotrakeal untuk mengurangi risiko sakit tenggorokan pascaintubasi pada pasien yang mendapatkan anestesi umum inhalasi dan N2O. Penelitian ini merupakan uji klinik secara tersamar buta ganda terhadap 70 pasien dengan status fisik American society of anesthesiologist (ASA) I-II yang akan menjalani anestesi umum. Pasien dibagi dalam dua kelompok dengan jumlah masing-masing 35 pasien. Kelompok pertama menggunakan udara sebagai media pengembangan balon pipa endotrakeal, sedangkan kelompok kedua menggunakan saline normal. Rasa nyeri dinilai dengan mengunakan skala VAS. Hasil dari penelitian menunjukkan bahwa rata-rata tekanan balon pipa endotrakeal pada kelompok salin normal lebih rendah dibandingkan dengan kelompok media udara dimana rata-rata tekanan balon selama operasi pada kelompok salin normal 26,71±0,92 mmHg dengan rata-rata VAS adalah 0,91±1,29 cm sedangkan pada kelompok media udara 34,63±4,81 mmHg dengan rata-rata VAS adalah 2,37±1,190 cm (p<0,0001). Penggunaan salin normal lebih efektif dibandingkan dengan media udara dalam pengembangan cuff ETT untuk mengurangi risiko sakit tenggorokan pascaintubasi pada pasien yang mendapatkan anestesi umum inhalasi dan N2O. Kata kunci: Sakit Tenggorokan, salin normal, udara Comparison between The Effectiveness of Normal Saline and Air With The Expansion of Endotracheal Tube Cuff to Reduce The Risk of Sore Throat Postintubation To compare the effectiveness of using normal saline and air medium with the expansion of endotracheal tube cuff to reduce the risk of sore throat postintubation in patients under general anesthesia using N2O.Method. This study is a randomized controlled trial with double blind method. Total patients are 70, ASA I-II status with general anestesi. Patients divided into 2 groups, where each group composed of 35 patients. The first group will be using air as a media inflation of cuff ETT, and the second group uses normal saline. The pain is examined using VAS.The result shows that mean pressure of intracuff in normal saline group is lower than media air group where there is intracuff mean pressure undergoing surgery in normal saline group is 26,71±0,92 mmHg with VAS 0,91±1,29 cm but for media air group 34,63±4,81 mmHg with VAS 2,37±1,190 cm where p<0,0001.The using of normal saline is more effective compared to air medium in the expansion of ETT cuff to reduce the risk of sore throat postintubation in patients under general anesthesia using N2O. Key words: Air, normal saline, sore throat Dullenkopf A, Gerber AC, Weiss M. Nitrous oxide diffusion into tracheal tube cuffs: comparison of five different tracheal tube cuffs. Acta Anaesthesiol Scand. 2004;48:1180–40. Morgan GE, Mikhail MS, Murray MJ. Airway management. Dalam: Clinical Anesthesiology. Edisi Ke-4. McGraw-Hill Companie. 2006. Hlm. 91–116. Fine GF, Borland LM. The future of the cuffed endotracheal tube. Pediatric Anesthesia. 2004;14: 38–42. Prerana P, Shroff, Vijay P. Efficacy of cuff inflation media to prevent postintubation related emergence phenomenon: air, saline and alkalinized lignocaine. Eur J Anaesthesiol. 2008;18:458–60. Nguyen H, Saidi N, Lieutaud T, Duvaldestin P. Nitrous oxide increases endotracheal cuff pressure and the incidence of tracheal lesions in anesthetized patients. Anesth Analg. 1999;89:187–90. Cerqueiera JR, Camacho LH, Takata IH. Endotracheal tube cuff pressure: need for precise measurement. Sao Paulo Med J/Rev Paul Med. 1999;117(6):243–7. Felten ML, Schmautz E, Orliaguet GA, Carli PA. Endotracheal tube cuff pressure 2003;97:1612–16. Karasawa F, Ozhima T, Takamatsu I, Uchihashi Y dkk. The effect on intracuff pressure of various nitrous oxide concentration used for inflating an endotracheal tube cuff. Anesth Analg. 2000;91:708–13. Karasawa F, Takita A, Mori T, Takamatsu I at all. The brandtm tube system attenuates the cuff deflationary phenomenon after anesthesia with nitrous oxide. Anesth Analg. 2003;96:606–10. Fitriyadi D, King LS. A simple endotracheal tube cuff pressure measuring device: an inexpensive alternative [Thesis]. Manilla: Santo Tomas University Hospital; 2004. Devys JM, Schauvliege F, Taylor G, Plaud B. Cuff compliance of pediatric and adult cuited tracheal tubes: an experimental study. Pediatric Anesthesia. 2004;14:676–80. Karasawa S, Okuda T, Mori T, Oshima T. Maintenance of stable cuff pressure in the Brandttm tracheal tube during anaesthesia with nitrous oxide. Br J Anaesth. 2002; 89(2):271–6. Fagan C, Frizelle HP, Laffey J, dkk. The effects of intracuff lidocaine on endotracheal-tubeinduced emergence phenomena after generalanesthesia. Anesth Analg. 2001;92:1075. Bennett MH, Isert PR, Cumming RG. Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff–a randomized controlled trial. Anaesth Intensive Care. 2000;28:408–13. Raeder JC, Borchgrevink PC, Sellevold OM. Tracheal tube cuff pressures. The effects of different gas mixtures. Anaesthesia. 1985;40:444–7. Karasawa F, Tokunaga M, Aramaki Y, saizukuisai M, Satoh T. An assassment of a method of inflating cuffs with nitrous oxide mixture to prevent on increase in intracuff pressure in five different tracheal tube designs. Anesthesia. 2001;56:155–9. Morgan GE, Mikhail MS, Murray MJ. The Practice of anesthesiology. Dalam: Clinical Anesthesiology.4th ed. McGraw-Hill Companies, Dalam;2006. Hlm. 1–9. Darsch JA, Darsch SE. Tracheal tubes. In: Understanding anesthesia equipment penyunting. edisi ke 4. Williams and Wilkins Pennsylvania; 1999. Hlm. 557–635. Combes X, Schauvliege F, Peyrouset O, etal. Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia. Anesthesiology. 2001;95:1120–4. Mitchell V, Adams T, Calder I. Choice of cuff inflation medium during nitrous oxide anaesthesia. Anaesthesia. 1999; 54: 32–6. Hata TM, Moyers JR. Preoperative evaluation and management. Dalam: Barash PG, Cullen BF, Stoelting RK, penyunting. Clinical Anesthesia. Edisi ke-5. Lippincott Williams and Wilkins; 2006. Hlm. 475–9.

Title

Found 4 Documents
Search

Abstract

Abstract

Abstract

Abstract

Title Search

Found 4 Documents Search

Abstract

Abstract

Abstract

Abstract

Title

Found 4 Documents
Search