Medicine and Health Sciences Commons^™

The Prevalence Of Stress And Stressors Among Pediatric Oncology Nurses Working In Pediatric Oncology Units In Pakistan - An Analytical Cross-Sectional Study, Shenila Anwarali

Theses & Dissertations

Introduction: Pediatric oncology nurses in Pakistan are at the forefront of caring for young cancer patients. In Pakistan, thousands of children are diagnosed with cancer every year, however the country's healthcare system lacks a comprehensive National cancer registry. Pediatric oncology nurses face high stress levels due to the demanding nature of their work, lack of specialized training, and communication challenges with patients and families. This study aims to explore the prevalence of stress and its predictors among these nurses in Pakistan, addressing a significant research gap.
Purpose: The purpose for the study was to measure stress and identify its predictors …

Quality Indicators In Surgical Oncology: Systematic Review Of Measures Used To Compare Quality Across Hospitals, Megan Mcleod, Kari Leung, C S. Pramesh, Peter Kingham, Miriam Mutebi, Julie Torode, Andre Ilbawi, Jade Chakowa, Richard Sullivan, Ajay Aggarwal

General Surgery, East Africa

Background: Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups.

Methods: A literature search …

A Rare Case Of Breast Carcinoma Metastasis Into A Meningioma In A 64-Year-Old Female Patient, Edwin Mogere, Miriam Mutebi, Allan Njau, Manel Haj Mansour

General Surgery, East Africa

This report discusses the occurrence of tumor-to-tumor metastasis—an atypical phenomenon in oncology where a secondary malignancy develops within an existing primary tumor. The case of a 64-year-old woman is presented, who, with a history of stage II invasive ductal carcinoma of the breast treated with mastectomy and chemoradiotherapy, developed neurological symptoms indicative of a secondary brain tumor. MRI and subsequent histopathological analysis post-craniotomy confirmed a meningioma with a metastatic breast carcinoma, demonstrating the clinical importance of considering tumor-to-tumor metastasis in similar patient histories.

Regulatory Approval Of Clinical Trials: Is It Time To Reinvent The Wheel?, Mansoor Saleh, Karishma Sharma, Aisleen Shamshudin, Innocent Abayo, Stacey Gondi, Noureen Karimi

Haematology and Oncology, East Africa

Less than 1% of all clinical trials are conducted in Africa. In 2019, only six of 26 oncology clinical trials conducted in Africa were conducted in countries with subjects of African ancestry. There are multiple barriers that hinder the conduct of cancer clinical trials in Africa. Time to trial activation (TTA) is the administrative and regulatory process required before a study can be activated—an important metric and often a major barrier for site selection. In Kenya, TTA involves review by Institutional Review Board (IRB), Pharmacy and Poisons Board, National Commission for Science, Technology and Innovation and Ministry of Health, all …

Evaluating The Symptoms And Treatment-Related Knowledge Of Cancer Patients Receiving Chemotherapy In A Tertiary Care Hospital, Kiran Nawaz Ali

Theses & Dissertations

Background: Cancer has become the leading source of mortality and morbidity worldwide. Its prevalence is rising and high-risk behaviours are being adopted by the people in society. Knowledge about cancer and its management helps in adjusting the resource allocations and in terms of public health policy. Moreover, patient education about symptoms, treatment, and side effects is crucial and must be addressed.
Knowledge about cancer, its side effects, and the possible treatment outcomes is essential, as it helps in deciding about adherence to the treatment. It is observed that many oncology patients have information gaps related to cancer and chemotherapy. However, …

Women, Power, And Cancer: A Lancet Commission, Ophira Ginsburg, Verna Vanderpuye, Ann Marie Beddoe, Nirmala Bhoo-Pathy, Freddie Bray, Carlo Caduf, Narjust Florez, Ibtihal Fadhil, Nazik Hammad, Miriam Mutebi

General Surgery, East Africa

Women interact with cancer in complex ways, as healthy individuals participating in cancer prevention and screening activities, as individuals living with and beyond a cancer diagnosis, as caregivers for family members and friends, as patient advocates, as health workers and healthcare professionals, and as cancer researchers and policy makers. The topic of women and cancer spans broad terrain, beyond women’s cancers and the biomedical aspects of any type of cancer that women in all their diversities might experience. It is inclusive of the ways in which sex and gender influence exposures to cancer risk factors, interactions with the cancer health …

Morphological And Metabolic Criteria Of Covid-19 Vaccine Associated Axillary Nodes On 18-Fluorodeouxyglucose Pet/Ct Imaging In Breast Cancer Patients, Nosheen Fatima, Unaiza Zaman, Areeba Zaman, Sidra Zaman, Rabia Tehseen, Maseeh Uz Zaman

Department of Radiology

Background: In the current era vaccine-associated lymphadenopathy (VAL) is not an uncommon presentation on 18F-FDG PET/CT examinations in patients inoculated with Coronavirus disease 2019 (COVID-19) vaccination. In this study, we are presenting data of VAL on 18F-FDG PET/CT regarding its prevalence, temporal response to vaccination and imaging characteristics of VAL.
Methods: Seventy-eight (78) consecutive vaccinated breast cancer (BC) patients who had 18FDG PET/CT were retrospectively analyzed. All patients had COVID-19 vaccine shots in contralateral arms and none in breast cancer site axilla (BSA). In 35 patients 18FDG avid nodes were found in vaccine site axilla (VSA). In 25 patients 18FDG …

Editorial: Resilience, Quality Of Life And Psychosocial Outcomes Of Cancer Patients And Their Caregivers, Nida Zahid, Nargis Asad, Ashraf El-Metwally

Department of Surgery

No abstract provided.

Population-Specific Mutation Patterns In Breast Tumors From African American, European American, And Kenyan Patients, Wei Tang, Jung S. Byun, Tiffany H. Dorsey, Harris G. Yfantis, Anuoluwapo Ajao, Huaitian Liu, Margaret S. Pichardo, Catherine M. Pichardo, Alexandra R. Harris, Shahin Sayed

Pathology, East Africa

Women of African descent have the highest breast cancer mortality in the United States and are more likely than women from other population groups to develop an aggressive disease. It remains uncertain to what extent breast cancer in Africa is reminiscent of breast cancer in African American or European American patients. Here, we performed whole-exome sequencing of genomic DNA from 191 breast tumor and non-cancerous adjacent tissue pairs obtained from 97 African American, 69 European American, 2 Asian American, and 23 Kenyan patients. Our analysis of the sequencing data revealed an elevated tumor mutational burden in both Kenyan and African …

Clinical Characteristics And Treatment Outcome Of Paediatric Non-Hodgkin's Lymphoma At A Tertiary Care Hospital In Pakistan, Juverya Naqvi, Mir Ibrahim Sajid, Saiqa Khan, Zaib Un Nisa Kamran, Zehra Fadoo

Medical College Documents

Objectives: To highlight the clinical characteristics of paediatric patients presenting with non-Hodgkin's lymphoma, treatment toxicities, and outcome.
Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of all paediatric patients aged 0-18 years diagnosed with non-Hodgkin's lymphoma from 2010 to 2020. Demographic characteristics, presentation, treatment provided, complications, if any, and treatment outcome were recorded. Data was analysed using SPSS 21.
Results: Of the 92 patients, 69(75.0%) were males. The overall mean age was 14.35±5.80 years. The most common presenting complaint was pyrexia 42(45.7%), the most common diagnosis was Burkitt lymphoma 40(43.5%), the most …

Unveiling The Potential Application Of Intraoperative Brain Smear For Brain Tumor Diagnosis In Low-Middle-Income Countries: A Comprehensive Systematic Review, Muhammad Shakir, Ahmed Altaf, Hawra Hussain, Syed Muhammad Aqeel Abidi, Zoey Petitt, Mahnoor Tariq, Ahmed Gilani, Syed Ather Enam

Section of Neurosurgery

Background: Immediate intraoperative histopathological examination of tumor tissue is indispensable for a neurosurgeon to track surgical resection. A brain smear is a simple, rapid, and cost-effective technique, particularly important in the diagnosis of brain tumors. The study aims to determine the effectiveness of intraoperative brain smear in the diagnosis of brain tumors in low- and middle-income countries (LMICs), while also evaluating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy.
Methods: A comprehensive search of the literature was conducted using PubMed, Scopus, and Google Scholar. The retrieved articles were independently screened by two reviewers. The …

Pitfalls In Machine Learning-Based Assessment Of Tumor-Infiltrating Lymphocytes In Breast Cancer: A Report Of The International Immuno-Oncology Biomarker Working Group On Breast Cancer, Jeppe Thagaard, Glenn Broeckx, Chowdhury Arif Jahangir, Sara Verbandt, Rajarsi Gupta, Reena Khiroya, Khalid Abduljabbar, Gabriela Acosta Haab, Balazs Acs, Shahin Sayed

Pathology, East Africa

Abstract: The clinical significance of the tumor-immune interaction in breast cancer is now established, and tumor-infiltrating lymphocytes (TILs) have emerged as predictive and prognostic biomarkers for patients with triple-negative (estrogen receptor, progesterone receptor, and HER2-negative) breast cancer and HER2-positive breast cancer. How computational assessments of TILs might complement manual TIL assessment in trial and daily practices is currently debated. Recent efforts to use machine learning (ML) to automatically evaluate TILs have shown promising results. We review state-of-the-art approaches and identify pitfalls and challenges of automated TIL evaluation by studying the root cause of ML discordances in comparison to manual TIL …

Early-Onset/Young-Onset Colorectal Carcinoma: A Comparative Analysis Of Morphological Features And Biomarker Profile, Atif A. Hashmi, Mahnoor Aslam, Khushbakht Rashid, Abrahim H. Ali, Tanim Ud Dowlah, Umair Arshad Malik, Shamail Zia, Sunder Sham, Fazail Zia, Muhammad Irfan

Medical College Documents

Introduction: Colorectal carcinoma (CRC) is one of the most common cancers that involve the human body. Young-onset CRC (YO-CRC) or early-onset CRC (EO-CRC) is defined as CRC that develops before the age of 50 years, as opposed to CRC that is diagnosed after the age of 50, referred to as late-onset CRC (LO-CRC). EO-CRC is sparsely studied in our population. Therefore, in this study, we evaluated the clinicopathological parameters and biomarker profile of EO-CRC and compared them with those of LO-CRC.
Methods: This was a retrospective study conducted at the Department of Histopathology, Liaquat National Hospital, Karachi, Pakistan. A total …

A Review Of The Current State Of Global Surgical Oncology And The Role Of Surgeons Who Treat Cancer: Our Profession’S Imperative To Act Upon A Worldwide Crisis In Evolution, Aaron C. Saunders, Miriam Mutebi, T. Subramanyeshwar Rao

General Surgery, East Africa

Worldwide, the capacity of healthcare systems and physician workforce is woefully inadequate for the surgical treatment of cancer. With major projected increases in the global burden of neoplastic disease, this inadequacy is expected to worsen, and interventions to increase the workforce of surgeons who treat cancer and strengthen the necessary supporting infrastructure, equipment, staffing, financial and information systems are urgently called for to prevent this inadequacy from deepening. These efforts must also occur in the context of broader healthcare systems strengthening and cancer control plans, including prevention, screening, early detection, safe and effective treatment, surveillance, and palliation. The cost of …

Microbiome Diversity In African American, European American, And Egyptian Colorectal Cancer Patients, Amr Elkholy, Nagavardhini Avuthu, Mohammed Abdalla, Michael Behring, Prachi Bajpai, Hyung-Gyoon Kim, Doaa Header, Reham Ah. Elwafa, Hesham Saed, Mansoor Saleh

Internal Medicine, East Africa

Purpose: Although there is an established role for microbiome dysbiosis in the pathobiology of colorectal cancer (CRC), CRC patients of various race/ethnicities demonstrate distinct clinical behaviors. Thus, we investigated microbiome dysbiosis in Egyptian, African American (AA), and European American (EA) CRC patients.

Patients and methods: CRCs and their corresponding normal tissues from Egyptian (n = 17) patients of the Alexandria University Hospital, Egypt, and tissues from AA (n = 18) and EA (n = 19) patients at the University of Alabama at Birmingham were collected. DNA was isolated from frozen tissues, and the microbiome composition was analyzed by 16S rRNA …

Integrating Human Papillomavirus Testing As A Point-Of Care Service Using Genexpert Platforms: Findings And Lessons From A Kenyan Pilot Study (2019–2020), Valerian Mwenda, Joan-Paula Bor, Mary Nyangasi, James Njeru, Sharon Olwande, Patricia Njiri, Marc Arbyn, Philippe Tummers, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

Background: Globally, cervical cancer is a major public health problem, with about 604,000 new cases and over 340,000 deaths in 2020. In Kenya, it is the leading cause of cancer deaths, with over 3,000 women dying in 2020 alone. Both the Kenyan cancer screening guidelines and the World Health Organization’s Global Cervical Cancer Elimination Strategy recommend human papillomavirus (HPV) testing as the primary screening test. However, HPV testing is not widely available in the public healthcare system in Kenya. We conducted a pilot study using a point of care (POC) HPV test to inform national roll-out.

Methods: The …

Hiv Prevalence And Characteristics Among Patients With Aids-Defining And Non–Aids-Defining Cancers In A Tertiary Hospital In Kenya, Diana Muturi, Sitna Mwanzi, Felix Riunga, Jasmit Shah, Reena Shah

Internal Medicine, East Africa

Purpose: Antiretroviral therapy (ART) has resulted in a higher life expectancy of persons living with HIV. This has led to an aging population at risk for both non–AIDS-defining cancers (NADCs) and AIDS-defining cancers (ADCs). HIV testing among patients with cancer in Kenya is not routinely performed, making its prevalence undefined. The aim of our study was to determine the prevalence of HIV and the spectrum of malignancies among HIV-positive and HIV-negative patients with cancer attending a tertiary hospital in Nairobi, Kenya.

Materials and Methods: We conducted a cross-sectional study between February 2021 and September 2021. Patients with a …

Spontaneous Large Volume Hemothorax Managed With A Small-Bore Chest Tube, Moiz Salahuddin, Samia Ayub

Department of Medicine

A 67-year-old male with metastatic lung cancer presented with acute shortness of breath and increasing oxygen requirements. He had a decreasing hemoglobin for which he required red blood cell transfusions. His chest x-ray showed near complete white-out of the left lung. Bedside ultrasound (Handheld Sonostar C4PL) showed a large pleural effusion with swirling echogenic material suggestive of plankton sign. The pleural effusion was aspirated and showed frank blood, after which a small-bore chest tube (SBCT) was inserted. A total of 3200ml of blood was drained with the SBCT. There was complete clearance of the pleural space, and no further blood …

Preparedness, Resilience And Unmet Needs Of Informal Caregivers Of Advanced Cancer Patients In A Regional Mission Hospital In Kenya: Qualitative Study, Too Wesley, Faith Lelei, Mary Adam, Pete Halestrap

School of Nursing & Midwifery, East Africa

Background: Cancer is the third highest cause of death in Kenya. Eighty percent of cancer cases arrive at advanced stages, when there is nothing that can be done to cure them, and palliative care is the best alternative. Although the majority of end-of-life care in Kenya is provided at home, little is known about the caregivers’ preparedness, resilience and continued unmet needs. The goal of this qualitative study was to explore caregivers’ perceived preparedness, resilience and continued unmet needs in their caregiving role to patients with advanced stages of cancer.

Methods: A purposive sampling method was used to identify and …

Does Mainstream Brca Testing Affect Surgical Decision-Making In Newly-Diagnosed Breast Cancer Patients?, Quratul Ain, Caroline Richardson, Miriam Mutebi, Angela George, Zoe Kemp, Jennifer E. Rusby

General Surgery, East Africa

Background: Germline pathogenic variants mutations) in the BRCA1 and BRCA2 genes cause an increased risk of breast cancer and ovarian cancer. Mainstream cancer genetic testing (MCG) was introduced for breast cancer patients in our unit in 2013. Non-geneticist clinicians have been trained to offer genetic testing during initial treatment planning. We assessed the impact of timely test results on surgical decision-making.

Methods: Women who had undergone mainstream genetic testing for breast cancer between September 2013 and September 2018 were identified from a prospective database. Surgical data were collected retrospectively.

Results: 580 eligible women had mainstream genetic testing. …

A Single Centre Experience Of Local Perforator Flaps In Oncoplastic Breast Surgery: A Cross-Sectional Study, Sana Zeeshan, Lubna Vohra, Uzma Shamsi, Nida Zahid, Danish Ali, Nargis Asad, Cristina Garusi

Section of General Surgery

Background & objectives: Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women.
Materials & methods: This cross-sectional study was conducted from March 2019 to February 2021 enrolling …

Does Mainstream Brca Testing Affect Surgical Decision-Making In Newly-Diagnosed Breast Cancer Patients?, Quratul Ain, Caroline Richardson, Miriam Mutebi, Angela George, Zoe Kemp, Jennifer E. Rusby

General Surgery, East Africa

Background: Germline pathogenic variants mutations) in the BRCA1 and BRCA2 genes cause an increased risk of breast cancer and ovarian cancer. Mainstream cancer genetic testing (MCG) was introduced for breast cancer patients in our unit in 2013. Non-geneticist clinicians have been trained to offer genetic testing during initial treatment planning. We assessed the impact of timely test results on surgical decision-making.

Methods: Women who had undergone mainstream genetic testing for breast cancer between September 2013 and September 2018 were identified from a prospective database. Surgical data were collected retrospectively.

Results: 580 eligible women had mainstream genetic testing. …

Anticancer Effect Of Illicium Verum (Star Anise Fruit) Against Human Breast Cancer Mcf-7 Cell Line, Asra Khan Pahore, Shagufta Khan, Nasim Karim

Department of Biological & Biomedical Sciences

Objective: To investigate the anticancer effect of Illicium verum against human breast cancer MCF-7 cell line.
Methods: An experimental study was conducted in Multidisciplinary and Tissue Culture Laboratory, Aga Khan University in collaboration with Pharmacology Department of Bahria University Medical and Dental College, Karachi, Pakistan from January 2021 to June 2021. MCF-7 cells of Luminal-A breast cancer were seeded in 96-well plate and treated with I.verum methanol extract. After incubation, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) dye was used for cell viability and cell proliferation assays to determine the number of dead and viable cells, and the absorbance was measured using an enzyme-linked …

Amplification Of The Plag-Family Genes-Plagl1 And Plagl2-Is A Key Feature Of The Novel Tumor Type Cns Embryonal Tumor With Plagl Amplification, Michaela-Kristina Keck, Martin Sill, Andrea Wittmann, Piyush Joshi, Damian Stichel, Pengbo Beck, Konstantin Okonechnikow, Philipp Sievers, Annika K. Wefers, Nasir Uddin

Department of Pathology and Laboratory Medicine

Pediatric central nervous system (CNS) tumors represent the most common cause of cancer-related death in children aged 0-14 years. They differ from their adult counterparts, showing extensive clinical and molecular heterogeneity as well as a challenging histopathological spectrum that often impairs accurate diagnosis. Here, we use DNA methylation-based CNS tumor classification in combination with copy number, RNA-seq, and ChIP-seq analysis to characterize a newly identified CNS tumor type. In addition, we report histology, patient characteristics, and survival data in this tumor type. We describe a biologically distinct pediatric CNS tumor type (n = 31 cases) that is characterized by focal …

Simultaneous Onset Of Haematological Malignancy And Covid: An Epicovideha Survey, Chiara Cattaneo, Jon Salmanton-García, Francesco Marchesi, Shaimaa El-Ashwah, Federico Itri, Barbora Weinbergerová, Maria Gomes Da Silva, Michelina Dargenio, Julio Dávila-Valls, Natasha Ali

Department of Pathology and Laboratory Medicine

Background: The outcome of patients with simultaneous diagnosis of haematological malignancies (HM) and COVID-19 is unknown and there are no specific treatment guidelines.
Methods: We describe the clinical features and outcome of a cohort of 450 patients with simultaneous diagnosis of HM and COVID-19 registered in the EPICOVIDEHA registry between March 2020 to February 2022.
Results: Acute leukaemia and lymphoma were the most frequent HM (35.8% and 35.1%, respectively). Overall, 343 (76.2%) patients received treatment for HM, which was delayed for longer than one month since diagnosis in 57 (16.6%). An overall response rate was observed in 140 (40.8%) patients …

Chronic Diarrhea: A Rare Presentation Of Hodgkin's Lymphoma, Saira Furqan, Sajjad Ali Khan, Dania Ali, Kaleemullah Badini

Section of Diabetes, Endocrinology and Metabolism

Hodgkin's Lymphoma is a cancer affecting the lymphatic system. There are two subtypes of Hodgkin's Lymphoma: Nodular lymphocyte predominant (NLPHL) and classical Hodgkin's Lymphoma which has further four types. It has a bimodal distribution and is more common among males. The most common presentation is painless swelling in the neck, armpit or groin region. Associated Symptoms include night sweats, unintentional weight loss, fever, persistent cough or dyspnea. Involvement of the gastrointestinal tract is a rare occurrence. Diagnosis is based on hematological, radiological and histochemical studies. Here we report a rare presentation of a 47-year-old male who presented with symptoms of …

Cancer Research Across Africa: A Comparative Bibliometric Analysis, Miriam Mutebi, Grant Lewison, Ajay Aggarwal, Olusegun Isaac Alatise, Christopher Booth, Miska Cira, Surbhi Grover, Ophira Ginsburg, Julie Gralow, Serine Gueye

General Surgery, East Africa

Introduction Research is a critical pillar in national cancer control planning. However, there is a dearth of evidence for countries to implement affordable strategies. The WHO and various Commissions have recommended developing stakeholder-based needs assessments based on objective data to generate evidence to inform national and regional prioritisation of cancer research needs and goals.

Methodology Bibliometric algorithms (macros) were developed and validated to assess cancer research outputs of all 54 African countries over a 12-year period (2009–2020). Subanalysis included collaboration patterns, site and domain-specific focus of research and understanding authorship dynamics by both position and sex. Detailed subanalysis was performed …

Breast Surgery Super-Specialization: Impact On Advanced Surgical Training And Research, Danish Ali, Sana Zeeshan, Nifasat Farooqi, Lubna Vohra

Medical College Documents

The earliest records of breast cancer (BC) date back to 3,000 - 2,500 B.C., ever since multiple curative options have been explored. First known wide margin excision was performed around 1st Century AD and a prototype of the modern-day BC surgery, Halsted radical mastectomy, was performed in the 20th Century. BC is the most common cancer in Pakistan accounting for up to 14.5% of the total cancer incidences. Accredited breast surgery fellowships were established in the UK and USA in 2002 and 2003, respectively. In Pakistan, the movement was delayed and the two-year College of Physicians and Surgeons Pakistan (CPSP) …

Surgical And Oncological Outcomes Of Hepatic Resection For Hepatocellular Carcinoma: Report From A Low Volume Centre In A Developing Country, Muhammad Rizwan Khan, Saleema Begum, Muhammad Tayyab Ul Hasan Siddiqui

Section of General Surgery

Objective: To review the surgical and oncological outcomes of patients who underwent hepatic resection for hepatocellular carcinoma (HCC).
Study design: Cohort study.
Place and duration of study: Department of Surgery of the Aga Khan University Hospital Karachi, from 2008 to 2019.
Methodology: Consecutive patients who underwent hepatic resection for HCC at the Hospital were included. The data were collected and analysed on aspects including demographics, liver function status, tumour characteristics, perioperative management, and surgical and oncological outcomes. Survival analyses were performed using the Kaplan-Meier method, and log-rank test was applied to determine the influence of variables on overall and disease-free …

Time For Reintroducing Hpv Vaccine In Pakistan For Primary Prevention Of Cervical Cancer, Uzma Shamsi, Afshan Anwar, Zainab Samad

Community Health Sciences

No abstract provided.