scholarly journals Role of the Appendicular Skeletal Muscle Index for Predicting the Recurrence-Free Survival of Head and Neck Cancer

Diagnostics ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. 309
Author(s):  
Kun-Yun Yeh ◽  
Hang Huong Ling ◽  
Shu-Hang Ng ◽  
Cheng-Hsu Wang ◽  
Pei-Hung Chang ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Body Composition ◽  
Head And Neck Cancer ◽  
Mass Loss ◽  
Lean Mass ◽  
Recurrence Free Survival ◽  
Skeletal Muscle Index ◽  
Free Survival ◽  
Prognostic Predictor ◽  
Appendicular Skeletal Muscle

Background: This study investigates whether the appendicular skeletal muscle index (ASMI) was an independent prognostic predictor for patients with locally advanced head and neck cancer (LAHNC) receiving concurrent chemoradiotherapy (CCRT) and whether there were any differences in lean mass loss in different body regions during CCRT. Methods: In this prospective study, we analyzed the clinicopathological variables and the total body composition data before and after treatment. The factors associated with the 2-year recurrence-free survival rate (RFSR) were analyzed via logistic regression analysis. Results: A total of 98 patients were eligible for analysis. The body weight, body mass index, and all parameters of body composition significantly decreased after CCRT. The pretreatment ASMI was the only independent prognostic factor for predicting the 2-year RFSR (hazard ratio, 0.235; 95% confidence interval, 0.062–0.885; p = 0.030). There was at least 5% reduction in total lean and fat mass (p < 0.001); however, the highest lean mass loss was observed in the arms (9.5%), followed by the legs (7.2%), hips (7.1%), waist (4.7%), and trunk (3.6%). Conclusions: The pretreatment ASMI was the only independent prognostic predictor for the 2-year RFSR of LAHNC patients undergoing CCRT. Asynchronous loss of lean mass may be observed in different body parts after CCRT.

scholarly journals Responsiveness to Resistance-Based Multimodal Exercise Among Men With Prostate Cancer Receiving Androgen Deprivation Therapy

2019 ◽  
Vol 17 (10) ◽  
pp. 1211-1220 ◽  
Author(s):  
Dennis R. Taaffe ◽  
Robert U. Newton ◽  
Nigel Spry ◽  
David J. Joseph ◽  
Daniel A. Galvão
Keyword(s):  
Prostate Cancer ◽  
Skeletal Muscle ◽  
Body Composition ◽  
Muscle Strength ◽  
Physical Function ◽  
Androgen Deprivation Therapy ◽  
Lean Mass ◽  
Androgen Deprivation ◽  
Whole Body ◽  
Appendicular Skeletal Muscle

Background: Androgen deprivation therapy (ADT) in the management of prostate cancer (PCa) results in an array of adverse effects, and exercise is one strategy to counter treatment-related musculoskeletal toxicities. This study assessed the prevalence of exercise responsiveness in men with PCa undergoing ADT in terms of body composition, muscle strength, and physical function. Methods: Prospective analyses were performed in 152 men (aged 43–90 years) with PCa receiving ADT who were engaged in resistance exercise combined with aerobic or impact training for 3 to 6 months. Whole-body lean mass and fat mass (FM), trunk FM, and appendicular skeletal muscle were assessed with dual x-ray absorptiometry; upper and lower body muscle strength were assessed with the one-repetition maximum; and physical function was assessed with a battery of tests (6-m usual, fast, and backward walk; 400-m walk; repeated chair rise; stair climb). Results: Significant improvements were seen (P<.01) in lean mass (0.4±1.4 kg [range, −2.8 to +4.1 kg]), appendicular skeletal muscle (0.2±0.8 kg [range, −1.9 to +1.9 kg]), and all measures of muscle strength (chest press, 2.9±5.8 kg [range, −12.5 to +37.5 kg]; leg press, 29.2±27.6 kg [range, −50.0 to +140.0 kg]) and physical function (from −0.1±0.5 s [range, +1.3 to −2.1 s] for the 6-m walk; to −8.6±15.2 s [range, +25.2 to −69.7 s] for the 400-m walk). An increase in FM was also noted (0.6±1.8 kg [range, −3.6 to +7.3 kg]; P<.01). A total of 21 men did not exhibit a favorable response in at least one body composition component, 10 did not experience improved muscle strength, and 2 did not have improved physical function. However, all patients responded in at least one of the areas, and 120 (79%) favorably responded in all 3 areas. Conclusions: Despite considerable heterogeneity, most men with PCa receiving ADT responded to resistance-based multimodal exercise, and therefore our findings indicate that this form of exercise can be confidently prescribed to produce beneficial effects during active treatment.

scholarly journals Impact of Body Composition on the Risk of Hepatocellular Carcinoma Recurrence After Liver Transplantation

2019 ◽  
Vol 8 (10) ◽  
pp. 1672
Author(s):  
Karolina Grąt ◽  
Ryszard Pacho ◽  
Michał Grąt ◽  
Marek Krawczyk ◽  
Krzysztof Zieniewicz ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Skeletal Muscle ◽  
Liver Transplantation ◽  
Body Composition ◽  
Adipose Tissue ◽  
Visceral Fat ◽  
Recurrence Free Survival ◽  
Muscle Area ◽  
Free Survival ◽  
Hcc Recurrence

Background: Body composition parameters are reported to influence the risk of hepatocellular carcinoma (HCC) recurrence after liver resection, yet data on patients undergoing liver transplantation are scarce. The aim of this study was to evaluate the impact of the amount of abdominal adipose tissue and skeletal muscles on the risk of HCC recurrence after liver transplantation. Methods: This was a retrospective observational study performed on 77 HCC patients after liver transplantation. Subcutaneous fat area (SFA), visceral fat area, psoas muscle area and total skeletal muscle area were assessed on computed tomography on the level of L3 vertebra and divided by square meters of patient height. The primary outcome measure was five-year recurrence-free survival. Results: Recurrence-free survival in the entire cohort was 95.7%, 90.8%, and 86.5% after one, three, and five years post-transplantation, respectively. SFA was significantly associated with the risk of HCC recurrence (p = 0.013), whereas no significant effects were found for visceral fat and skeletal muscle indices. The optimal cut-off for SFA for prediction of recurrence was 71.5 cm2/m2. Patients with SFA < 71.5 cm2/m2 and ≥71.5 cm2/m2 exhibited five-year recurrence-free survival of 96.0% and 55.4%, respectively (p = 0.001). Conclusions: Excessive amount of subcutaneous adipose tissue is a risk factor for HCC recurrence after liver transplantation and may be considered in patient selection process.

Arm lean mass determined by Dual-energy X-ray absorptiometry is superior to characterize skeletal muscle and predict sarcopenia-related mortality in cirrhosis

2021 ◽  
Author(s):  
Christian Skou Eriksen ◽  
Nina Kimer ◽  
Charlotte Suetta ◽  
Søren Møller
Keyword(s):  
Skeletal Muscle ◽  
Liver Disease ◽  
Lean Mass ◽  
Dual Energy ◽  
Mortality Data ◽  
Skeletal Muscle Index ◽  
X Ray ◽  
Appendicular Skeletal Muscle ◽  
Child Class ◽  
Leg Edema

Introduction: Sarcopenia worsens survival in patients with advanced liver disease including cirrhosis. In this study we aimed to characterize skeletal muscle status by Dual-energy X-ray Absorptiometry (DXA) in patients with cirrhosis and examine the association between different skeletal muscle compartments and mortality. Methods: We included 231 men and 84 women (Child A, B, and C) with cirrhosis and 315 healthy matched controls (231 men and 84 women). Body composition was assessed with DXA. Appendicular skeletal muscle index (ASMI), arms index (AI), and legs index (LI) was calculated by normalizing lean mass to height squared. Low ASMI was defined as ASMI < 7.0 kg/m2 in men and < 5.5 kg/m2 in women. Biochemical and hemodynamic data were recorded for cirrhotic patients and mortality data retrieved from registers. Results: Low ASMI was more prevalent in both men (49%) and women (43%) with cirrhosis compared to healthy men (8%) and women (5%) (p<0.001). ASMI and LI were lowest in Child B, whereas AI decreased gradually with advancing Child Class. ASMI was inversely associated to mortality in men (HR = 0.74 [0.59-0.93], p <0.01), and this was mainly driven by AI (HR = 0.37 [0.18-0.71], p <0.01). Conclusion: AI showed closer association than ASMI or LI to both the severity of liver disease and to mortality, which may be due to increasing prevalence of leg edema with disease progression in this population. Determination of arm lean mass may add information on survival in patients with cirrhosis.

Body composition in head and neck cancer patients undergoing concurrent chemoradiation.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20531-e20531
Author(s):  
Lauren Azure Zatarain ◽  
Barbara A. Murphy ◽  
Mary S. Dietrich ◽  
Heidi J. Silver ◽  
Jill Gilbert ◽  
...  
Keyword(s):  
Body Composition ◽  
Head And Neck Cancer ◽  
Mass Loss ◽  
Head And Neck ◽  
Neck Cancer ◽  
Lean Mass ◽  
Concurrent Chemoradiation ◽  
Low Weight ◽  
Long Term Follow Up ◽  
The Impact

e20531 Background: We report results of a randomized pilot study assessing the impact of amifostine and a low weight tailored resistance exercise (LWTRE) on body composition in head and neck cancer (HNC) patients undergoing concurrent chemoradiation (CCR). Methods: Forty patients with stage III-IVB HNC scheduled for primary or adjuvant CCR were enrolled. Patients underwent primary randomization to CCR +/- amifostine and secondary randomization to nutrition counseling +/- LWTRE. IV amifostine was administered prior to radiation. Nutritional counseling and LWTRE began day 1 of CCR and continued through month 6 post-CCR. Weight was obtained at baseline, 1, 3 and 6-months post-CCR. Patients underwent lean mass measures by dual-energy X-ray absorptiometry (DEXA) at baseline, 1 and 3 months post-CCR. Results: Mean weight loss (WL) was 11.6 ± 6.3 kg (p < 0.001) from baseline to 6 months post-CCR. Mean lean mass loss (LML) was 3.5 ± 3.0 kg (p< 0.001) from baseline to 3 months post-CCR. The greatest change occurred from baseline to 1-month post-CCR: 10% and 7% decrease in weight and lean mass respectively. The LWTRE was feasible and safe (no adverse events). Neither amifostine nor LWTRE impacted weight or lean mass loss. Conclusions: Results failed to demonstrate decline in WL/LML with either intervention. Data confirmed WL/LML as profound acute treatment toxicity. It underscored the protracted course of WL/LML. LML has been shown to predict clinical outcomes such as reduced functionality leading to decreased quality of life. Long term follow-up of patients is needed to clearly understand the trajectory and sequellae of body composition changes in HNC patients post-CCR. Novel interventions must be designed and tested to prevent LML. Clinical trial information: NCT00503776. [Table: see text]

scholarly journals P191 Lower values of skeletal muscle index measured by bioelectrical impedance in active IBD patients

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S234-S234
Author(s):  
D Vranesic Bender ◽  
V Domislović ◽  
A Barišić ◽  
I Karas ◽  
D Ljubas Kelečić ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Body Composition ◽  
Muscle Strength ◽  
Lean Mass ◽  
Bioelectrical Impedance ◽  
Inactive Disease ◽  
Skeletal Muscle Index ◽  
Inflammatory Bowel ◽  
Underweight Patients ◽  
Active Disease

Abstract Background Inflammatory bowel disease (IBD) is commonly associated with alteration in fat and lean mass. Body mass index (BMI) is not a prime index for assessing nutritional status, while a better way to evaluate it would be to bioimpedance analysis. In addition, correlation of body composition with disease severity has not been well studied. The aim of this study was to evaluate the association of body composition and muscle strength with disease activity in adult patients with Crohn’s disease (CD) and ulcerative colitis (UC). Methods All patients underwent the analysis of body composition measured by bioelectrical impedance analysis (TANITA body composition analyser, BC-420MA). Lean mass (LM), fat-free mass index (FFMI) and skeletal muscle index (SMI) were calculated using standard formulae. Muscle strength was obtained from handgrip strength values (HS) measured with Jamar Hydraulic Hand Dynamometer. Medical history data were obtained from clinical and electronic medical records. Active disease was defined as Crohn’s disease Activity Index (CDAI) &gt;150 for CD and Partial Mayo Score ≥3 for UC patients. Underweight patients were defined as BMI&lt;18.5 kg/m2. Results In this study we have enrolled 120 patients (CD = 86, UC = 34; 65% male). Average age was 37.5 (35.3–39.6). Clinically active disease was present in 23 patients (19.1%), CD (n = 15), UC (n = 8). There were no statistically significant differences among patients with active and inactive disease in FFMI (kg/m2) 17(15–19.8) vs. 18.5 (15.7–20.3), p = 0.18, LM (kg) 56.5 (44.3–65.1) vs. 48.3 (43–67.2), p = 0.21, fat mass (%) 16 (11.5–23) vs. 11.8 (7.9–21), p = 0.14, and MS 33.3( ± 11.5) vs. 28.3 ( ± 9.9), p &gt; 0.05. The SMI (kg/m2) was significantly lower in patients with active disease comparing to group with inactive disease 8.1(7.7–9.9) vs. 10(8.6–10.6), p = 0.032. Underweight patients were significantly more prevalent in active group comparing to inactive (30.4% vs. 6.4%, p = 0.0011). Conclusion IBD patients with active disease have lower skeletal muscle index, while there was no difference in other components of body composition. In addition, underweight patients have a significantly higher proportion of active disease. Body composition analysis by BIA could be a useful tool in the evaluation of patients with inflammatory bowel diseases; however, there is a need to define age-, gender- and disease-specific, percentile-based thresholds specifically for patients with IBD, which can simplify the screening procedures in clinical practice, and suggest nutritional intervention.

scholarly journals Association between −308 G/A TNF-αPolymorphism and Appendicular Skeletal Muscle Mass Index as a Marker of Sarcopenia in Normal Weight Obese Syndrome

2013 ◽  
Vol 35 ◽  
pp. 615-623 ◽  
Author(s):  
L. Di Renzo ◽  
F. Sarlo ◽  
L. Petramala ◽  
L. Iacopino ◽  
G. Monteleone ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Body Composition ◽  
Muscle Mass ◽  
Lean Mass ◽  
Skeletal Muscle Mass ◽  
Normal Weight ◽  
Sarcopenic Obesity ◽  
Appendicular Skeletal Muscle ◽  
Skeletal Muscle Mass Index ◽  
Appendicular Skeletal Muscle Mass

Background and Aim. Normal weight obese (NWO) syndrome is characterized by normal body mass index (BMI), but high amount of fat mass and reduced lean mass. We evaluated allelic frequency of the G/A −308 TNF-αpolymorphism and prevalence of sarcopenia in NWO.Methods. We enrolled 120 Italian healthy women, distinguished into 3 groups: normal weight (NW); NWO, and preobese-obese (PreOB/OB) and evaluated anthropometric parameters, body composition by dual X-ray absorptiometry, blood tests, and genotyping of G/A −308 TNF-αpolymorphism.Results. We found a positive association between sarcopenic obesity and −308 TNF-αpolymorphism. All obese women were sarcopenic and were no carrier of mutation (G/G). Among all G/G, NWO showed significant differences in lean mass and total body lean mass (TBLean) with respect to NW and PreOB/OB (P<0.001). Regarding appendicular skeletal muscle mass index values, 4.21% of NW were sarcopenic (50% G/G and 50% G/A); the same percentage was observed in NWO subjects (100% G/G). Moreover, 2.10% of PreOB/OB were sarcopenic and all were G/G.Conclusion. Our study suggests that TNF-αpolymorphism contributes to sarcopenic obesity susceptibility, in association with body composition. This is the first study that shows the importance of TNF-αpolymorphism to determine TBLean variation in NWO syndrome.

scholarly journals The Influence of Body Composition on the Systemic Exposure of Paclitaxel in Esophageal Cancer Patients

2021 ◽  
Vol 14 (1) ◽  
pp. 47
Author(s):  
Leni van Doorn ◽  
Marie-Rose B. S. Crombag ◽  
Hánah N. Rier ◽  
Jeroen L. A. van Vugt ◽  
Charlotte van Kesteren ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Esophageal Cancer ◽  
Body Composition ◽  
Dose Range ◽  
Systemic Exposure ◽  
Lumbar Vertebra ◽  
Skeletal Muscle Index ◽  
Mixed Effects Modeling ◽  
Significance Threshold ◽  
A Prospective Study

Changes in body composition are associated with chemotherapy-related toxicities and effectiveness of treatment. It is hypothesized that the pharmacokinetics (PK) of chemotherapeutics may depend on body composition. The effects of body composition on the variability of paclitaxel PK were studied in patients with esophageal cancer. Skeletal muscle index (SMI), visceral adipose tissue (VAT), and skeletal muscle density (SMD) were measured at the third lumbar vertebra on computed tomography (CT) scans performed before treatment. Paclitaxel PK data were collected from a prospective study performed between May 2004 and January 2014. Non-linear mixed-effects modeling was used to fit paclitaxel PK profiles and evaluate the covariates body surface area (BSA), SMI, VAT, and SMD using a significance threshold of p < 0.001. Paclitaxel was administered to 184 patients in a dose range of 50 to 175 mg/m2. Median BSA was 1.98 m2 (range of 1.4 to 2.8 m2). SMI, VAT, and SMD were not superior to BSA in predicting paclitaxel PK. The additive value of SMI, VAT, and SMD to BSA was also negligible. We did not find evidence that paclitaxel dosing could be further optimized by correcting for SMI, VAT, or SMD.

Appendicular skeletal muscle mass to truncal fat mass ratio as a new index for osteosarcopenic obesity syndrome in older adults: emphasizing the role of central obesity

2020 ◽  
Author(s):  
Lazuardhi Dwipa ◽  
Rini Widiastuti ◽  
Alif Bagus Rakhimullah ◽  
Marcellinus Maharsidi ◽  
Yuni Susanti Pratiwi ◽  
...  
Keyword(s):  
Older Adults ◽  
Skeletal Muscle ◽  
Body Composition ◽  
Muscle Mass ◽  
Fat Mass ◽  
Central Obesity ◽  
Skeletal Muscle Mass ◽  
Positive Correlation ◽  
Appendicular Skeletal Muscle ◽  
Appendicular Skeletal Muscle Mass

Abstract Background The relationship between obesity and low bone mineral density (BMD) in older adults is still unclear. Most of the previous study did not account the factor of sarcopenia which is the progressive loss of skeletal muscle mass due to aging, and distribution of fat in obesity. Thus, this study was aimed to explore the correlation between appendicular skeletal muscle mass (ASMM), total fat mass (FM), and truncal fat mass (TrFM) as well as indexes (ASMM/FM and ASMM/TrFM ratio) with BMD in older adults.Methods This was an analytic cross-sectional study. Dual x-ray absorptiometry (DXA) and bioelectric impedance analysis (BIA) were used to assess BMD and body composition, respectively. Appendicular Skeletal Muscle Mass (ASMM) were used in the analysis to reflect sarcopenia, Fat Mass (FM) and Trunkal Fat Mass (TrFM) were used to reflect general and central obesity, respectively. All data were obtained from medical records of Geriatric Clinic of Hasan Sadikin General Hospital Bandung Indonesia from January 2014 to December 2018. The correlation between body compositions variable with BMD were analyzed using Spearman’s test. We also conducted a comparison analysis of body composition variables between low and normal BMD using Mann-Whitney test. Results A total of 112 subjects were enrolled in the study. ASMM and TrFM were positive (rs=0.517, p<0.001) and negative (rS=-0.22, p=0.02) correlated with BMD, respectively. FM were not correlated with BMD, rS=-0.113 (p=0.234). As indexes, ASMM/FM and ASMM/TrFM had positive correlation with BMD, rS=0.277 (p<0.001), and rS=0.391 (p<0.001), respectively. The ASMM, TrFM, and ASMM/TrFM ratio between normal and low BMD also significantly different (p<0.001), meanwhile FM were not (p=0.204).Conclusion ASMM and TrFM have a positive and negative correlation with BMD, respectively. ASMM/TrFM ratio as new sarcopenia-central obesity index has a positive correlation with BMD.

scholarly journals Muscle Characteristics Obtained Using Computed Tomography as Prognosticators in Patients with Castration-Resistant Prostate Cancer

Cancers ◽  
2020 ◽  
Vol 12 (7) ◽  
pp. 1864
Author(s):  
Jongsoo Lee ◽  
Jee Soo Park ◽  
Ji Eun Heo ◽  
Hyun Kyu Ahn ◽  
Won Sik Jang ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Computed Tomography ◽  
Skeletal Muscle ◽  
Body Composition ◽  
Survival Rates ◽  
Castration Resistant Prostate Cancer ◽  
Vertebral Level ◽  
Skeletal Muscle Index ◽  
Castration Resistant ◽  
Muscle Attenuation

Limited studies have investigated the correlation between body composition and prostate cancer outcomes. We analyzed the effect of muscle mass and quality on castration-resistant prostate cancer (CRPC) outcomes. Skeletal muscle index (SMI) and skeletal muscle attenuation (SMA) were measured for 411 patients at the L3 vertebral level using computed tomography at CRPC diagnosis and were dived to low and high groups at the value of median. Analysis of the skeletal phenotypes and age (<70 and >70 years) was performed to evaluate the effect of SMI and SMA. The median survival rates for patients with low and high SMI were 19 and 24 months (p = 0.015), and those with low and high SMAs were 15 and 26 months (p < 0.001), respectively. In the subgroup analysis by age, SMA was a significant prognosticator in both groups, while SMI was a significant prognosticator only in patients aged >70 years. Patients with low SMA + low SMI had the worst prognosis. Muscle characteristics seems to be a prognosticator in survival of CRPC patients and may be considered in treatment planning.

scholarly journals Erythrocyte Long Chain Omega 3 Fatty Acids Are Associated with Higher Lean Mass in Postmenopausal Women Newly Diagnosed with Breast Cancer (P05-024-19)

2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Martha Belury ◽  
Rachel Cole ◽  
Rebecca Andridge ◽  
Qing Xie ◽  
Ashleigh Keiter ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Skeletal Muscle ◽  
Fatty Acids ◽  
Body Composition ◽  
Lean Mass ◽  
Cardiometabolic Health ◽  
Omega 3 ◽  
Appendicular Lean Mass ◽  
Muscle Health ◽  
Long Chain

Abstract Objectives Cancer contributes to adverse changes in body composition that may increase risk of cardiometabolic diseases. Skeletal muscle is a main driver of cardiometabolic health. We hypothesize that higher intake of long chain omega-3 polyunsaturated fatty acids (LCn3PUFAs) is associated with muscle health. This study evaluates whether LCn3PUFA exposure assessed in diet and in blood is associated with markers of muscle health in women with breast cancer. Methods This is a cross-sectional analysis evaluating LCn3PUFA exposure and markers of muscle health in women (N = 150) prior to treatment for breast cancer. Exposure to LCn3PUFAs was assessed by a diet history questionnaire (DHQ), a question specifically about supplement usage and biomarker of LCn3PUFAs in red blood cells (RBC). Body composition were measured at the same visit using dual x-ray absorptiometry. Linear regression models were used to test for associations. Results 13% (N = 19) of women reported using fish oil supplements (e.g., Supplement Users) and had significantly higher levels of RBC LCn3PUFAs than Supplement Non-users. In Supplement Non-users, there was a positive association between reported dietary exposure by DHQ and RBC LCn3PUFA levels. The n3 index (e.g., sum of RBC EPA + DHA) and DHA (22:6n3) were positively associated with appendicular lean mass/BMI. There were no significant correlations between RBC LCn3PUFAs with grip strength and or other measurements of body composition. Conclusions As a biomarker of intake, RBC LCn3PUFAs are positively associated with appendicular lean mass, a measure of skeletal muscle mass. A future study should prospectively evaluate whether higher LCn3PUFA exposure (as measured in blood) is associated with maintaining better muscle health during and following cancer treatment. Funding Sources Funding was provided by the National Cattleman's Beef Association, NIH (JKG) CA186720, Ohio Agriculture Research and Development Center and the Carol S. Kennedy Professorship.

Sign in / Sign up

Export Citation Format

Share Document