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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 35 | Issue 3
Page Nos. 241-337

Online since Wednesday, August 21, 2019

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ORIGINAL ARTICLES  

Endoscopic endonasal surgery for sinonasal polyposis: a comparative study between general versus local anesthesia regarding compliance of surgery and patients’ acceptance p. 241
Nabil G Zeid, Ehab A Zaid, Ahmed Kamel, Ahmed M El Batawi, Mahmoud A Abu Hassan, Kahled Azooz
DOI:10.4103/ejo.ejo_78_18  
Introduction One of the most common inflammatory mass lesions of the nose are nasal polyps, which affect up to 4% of the population. Endoscopic surgery under local anesthesia may allow for a day-care surgical procedure for the patient; however, extensive procedures, revision surgeries, and uncooperative, and pediatric age group patients will warrant the use of general anesthesia. The aim of this study is to compare the efficacy of local versus general anesthesia for endoscopic surgical treatment of sinonasal polyposis during operation as well as during early and late postoperative periods together with patient’s acceptance for surgery. Patients and methods A total of 60 patients with sinonasal polyposis were divided randomly into two groups. Group 1 underwent endoscopic nasal surgery under local anesthesia and group 2 underwent endoscopic nasal surgery under general anesthesia. Results Most of the patients who were operated under local anesthesia showed good acceptance for surgery, short time of surgery, and less bloody field than those who were operated under general anesthesia (the P value was significant regarding bleeding and time during surgery under local anesthesia). Conclusion Surgery of sinonasal polyposis under local anesthesia is an effective method for the treatment of nasal polyposis as regards patient acceptance for the surgery, time of surgery with very good surgical field, and less cost procedures.
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Nasal polyposis and the role of alphintern p. 246
Agila Al-Barasi
DOI:10.4103/ejo.ejo_7_19  
Introduction Nasal polyposis is a chronic inflammatory disease of the nasal mucosa. The pathogenesis of nasal polyps is still not entirely known. This makes definitive treatment very challenging. The aim of our study is to evaluate the effect of alphintern on the treatment of nasal polyposis. Patients and methods Patients received alphintern tablet for 2 weeks. Before and after drug intake all patients were asked to fill in a questionnaire in which they rated their overall symptoms on visual analog scale; endoscopic physical findings were scored on the Lindholdt staging system. Results Twenty-three patients were included in the study, 14 men and nine women in the age range from 25 to 56 years. Statistical analysis shows no significant difference (P>0.05) before and after treatment with alphintern for severity of symptoms and endoscopic staging of nasal polyposis. Discussion The main goals in the treatment of nasal polyposis, whether medical or surgical, are to relief patient symptoms and to prevent complications. There are few direct comparisons of the medical and surgical treatment in the literature. Those that exist suggest that most patients should be treated medically, with surgery reserved for patients who respond poorly. Intranasal corticosteroids are by far the best documented type of medical treatment for nasal polyposis. Researches for other drugs for the treatment of nasal polyposis were done. In this study, the use of alphintern for the treatment of nasal polyposis shows no significant improvement in the severity of symptoms and size of polyps. Conclusion Topical intranasal steroids are the best documented medical treatment. Alphintern shows no significant effect on the management of nasal polyposis. Further studies with more patients and longer duration of treatment are required for more evaluation of drug effect.
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Effect of steroid-releasing sinus implants after endoscopic sinus surgery (ESS) on postoperative outcomes: A meta-analytical study p. 250
Michael M Stefan, Nabil A Rabie, Tamer S Sobhy, Ahmed M Maarouf
DOI:10.4103/ejo.ejo_92_18  
Aims a meta-analysis to evaluate the steroid-releasing sinus implants in chronic rhinosinusitis (CRS) patients after functional endoscopic sinus surgery (FESS) in order to assess its efficacy. Settings and Design Meta analysis. Methods and Material The 4 trials enrolled a total of 539 patients utilizing an intrapatient control design. Postoperative day 30 videos were obtained for each patient, randomly ordered for grading of efficacy endpoints. The need for postoperative interventions, formation of polyposis, and adhesions were assessed. Results from the 4 studies were then pooled. Statistical analysis used Comprehensive Meta-Analysis© version 2 (Biostat™, NJ, USA). Results Implants were successfully placed. According to the grading done by the panel, drug-releasing implants reduced significant adhesions by 2.5% (P=0.971), middle turbinate lateralization occurrence was 2.5% (P=0.954), polyp formation was 2% (P=0.830), the need for oral steroid intervention was 22% (P=0.173), significantly less need for postoperative therapeutic intervention 33% (P=0.305), or Surgical Lysis of Adhesions (LOA) intervention 14% (P=0.951), compared to controls. Conclusions Steroid-releasing implants improve surgical outcomes by reducing frank polyp formation, sinus adhesions, and middle turbinate lateralization. Steroid-releasing implants reduce the need for surgical intervention, and the need for oral steroid treatment.
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Role of endoscopy in rhinogenic contact headache not responding to medical treatment p. 256
Sayed M.S Kadah, Sayed M Mokhemar, Tawfik A.E Alkholy, Taghreed M.M Salem
DOI:10.4103/ejo.ejo_6_19  
Objective To assess the role of various anatomical variation of the nose in the pathogenesis of contact point rhinogenic headache of noninfective or organic cause and to evaluate the role of endoscopic surgery with removal or correction of the anatomical variation that caused headache in the management. Patients and methods This study included 30 patients with refractory or resistant headache for more than 1 year and diagnosed to have sinonasal anatomical variations. They were presented to the outpatient clinics of Al-Zahraa University Hospital in the period from May 2015 to May 2018. There ages ranged from 18 to 34 years. A total of 20 (66.7%) patients were males and 10 (33.3%) were females. Data from this group were analyzed retrospectively. Results Multiple anatomical variations were noted by endoscopy and computed tomographic scans in 30 patients. These variations included septum deviation in 30 (100%) patients followed by hypertrophied inferior turbinate in 15 (50%) patients then concha bullosa in 14 (46.7%) patients. In these 30 patients, 25 (83.3%) cases showed complete cure, three (10%) cases showed improvement, whereas two (6.7%) cases were unsatisfied. Conclusion Minor intranasal anatomical variations or hidden infection may be the cause of primary headache misdiagnosed as a headache of unknown etiology. The functional endoscopic sinus surgery had succeeded in eliminating or significantly reducing headache attacks.
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Allergic rhinitis diagnosis: skin-prick test versus laboratory diagnostic methods p. 262
Hany S Mostafa, Mohamed Qotb, Mohammed A Hussein, Ahmed Hussein
DOI:10.4103/ejo.ejo_8_19  
Aim To verify the specificity, sensitivity, and accuracy of the skin-prick tests (SPTs) in allergic rhinitis (AR) compared with blood tests and nasal smears. Study design It is a cohort, prospective, nonrandomized study. Patients and methods A total of 180 patients were enrolled. Group A included 135 patients having AR symptoms for more than 1 year. Group B included 45 patients without AR symptoms candidate for septoplasty surgery who served as controls. All patients were subjected to detailed history, scoring for AR, endoscopic examination, complete blood count, nasal smear eosinophilia, and SPT. Results SPT was positive in 94.1% (n=127) of allergic patients and 20% (n=9) of the controls at least for one allergen. Most of cases were allergic to mixed pollens (66.7%), cotton dust (41.5%), and housefly particles and house dust mite (28.9% equally). The absolute eosinophil count was positive in 70.4% of allergic patients (n=95) and 33.3% of the control (n=15). Nasal smear eosinophilia was positive in 82.9% (n=112) of allergic patients and 20% (n=9) of the controls. SPT possesses high sensitivity and specificity that reached 94.1 and 80%, respectively, and 90.6% accuracy. However, absolute eosinophil count showed the lowest results, where sensitivity and specificity reached 70.4 and 66.7%, respectively, and 69.4% accuracy. Conclusion SPT is accurate for diagnosing AR and possesses high sensitivity and specificity; however, adding a nasal swap test will raise the sensitivity, specificity, and accuracy of diagnosis.
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Anti-immunoglobulin E therapy: is it a valid option for the management of chronic rhinosinusitis with nasal polyposis? p. 269
Ashraf A Wahba, Ahmed M Abdelfattah
DOI:10.4103/ejo.ejo_19_19  
Objectives To evaluate the efficacy of omalizumab (OMA) therapy for patients with chronic rhinosinusitis with nasal polyposis as a sole therapeutic line versus traditional therapy. Patients and methods Eighty-six patients were randomly divided into two equal groups: study patients received OMA [0.016 mg/kg/immunoglobulin E (IgE) (IU/ml)] therapy only and control patients received conventional therapy. All patients completed a questionnaire to determine the total subjective score (TSS), who underwent rigid nasal endoscopy for endoscopic scoring according to the Lund-Kennedy scoring system, had paranasal sinuses computed tomographic (CT) imaging for scoring according to the Lund-Mackay scale, and estimation of pretreatment serum IgE levels. Study outcomes included the therapeutic effect determined as more than 50% decrease of TSS with improvement on endoscopic findings, recurrence rate, and frequency of decision; shift to surgery or repeat the trial of OMA therapy. Results Serum IgE level positively correlated with TSS and endoscopic and CT scores. Seventeen patients had successful response without recurrence with significantly lower TSS in the study versus control patients. Twenty-seven patients had recurrence after primary successful outcome with significantly lower TSS in study than control patients and significantly longer duration till recurrence with OMA than conventional therapy. Forty-two patients showed no response to the first session of therapy. Nineteen study patients with recurrent manifestations received a second session of OMA therapy; 11 had successful response, five patients had rerecurrence, and three patients failed to respond. Surgery-sparing effect is significantly higher with OMA than conventional therapy (46.5 vs. 18.6%). Endoscopic and CT scores of total patients, at the end of follow-up, were nonsignificantly lower in control while they were significantly lower in the study group. Conclusion OMA significantly superiorly improved the outcome of conservative treatment of chronic rhinosinusitis with nasal polyposis than conventional with higher surgery-sparing rate. The second session of OMA minimized the recurrence rate of manifestations.
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Assessment of the preoperative computed tomographic predictability for round window membrane visibility and accessibility during cochlear implant surgery p. 278
Ahmed Galal, Omneya G Eldin, Fatthi Baki, Mario Sanna
DOI:10.4103/ejo.ejo_4_19  
Objectives The aim of the present study was to assess the preoperative predictability of multi-slice computed tomography for round window membrane (RWM) visibility and accessibility through round window niche (RWN) intraoperatively. Patients and methods Computed tomographic scans of 61 adult cochlear implant patients with otherwise normal temporal bone anatomy were studied for RWN extent using two methods. The first was a modification of a method by Park and colleagues and another simple method proposed by our group. The visibility of the RWN through RWN was assessed intraoperatively after performing the posterior tympanotomy and good exposure of the RWN. Statistical analysis was then performed. Results Modified Park and colleagues method was statistically significant in predicting RWM visibility (P=0.018) and a cutoff point was detected at more than or equal to 0.7 with a specificity of 69.23% for low or no visibility of RWM. Our proposed method was also statistically significant (P=0.001) with a cutoff point of more than or equal to 1.43 mm with a specificity of 96.15%. Discussion RWN depth has been studied repeatedly in the literature with only rarely correlation to intraoperative findings. These methods were also frequently either cadaveric or radiological with complex reconstruction, thus were with doubtful clinical value. In the present study, two methods were used and were found to be significant to predict the degree of visibility of RWN visibility through RWM. Conclusion The modified Park’s and our proposed methods can statistically significantly predict RWM visibility through RWN. However, our proposed method had higher specificity and smaller P value.
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Intranasal versus systemic corticosteroids in treatment of otitis media with effusion in the presence or absence of adenoid hypertrophy in children p. 288
Sayed M.S Kadah, Tawfik A.E Elkholy, Hebatullah K.E Tammam
DOI:10.4103/ejo.ejo_10_19  
Background Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without signs or symptoms of acute infection. The condition is common and affects ∼90% of children before school age, who develop an average of four episodes of OME per year, most often between the ages of 6 months and 4 years. Aim The aim of this study was to investigate the role of systemic versus local corticosteroids in treatment of OME in the presence or the absence adenoid hypertrophy in children. Patients and methods In our study, 60 children who fulfilled the inclusion criteria were divided into two equal groups: group A included children with OME with adenoidal hypertrophy and group B included children with OME without adenoidal hypertrophy. Then, each group was subdivided into two groups, where one received topical intranasal steroids (A1 and B1), and the other one received oral steroids (A2 and B2). Tympanograms were done for all patients every 2 weeks. Results The final result is that both topical intranasal and systemic steroids are effective in the treatment of OME in children, without significant difference between the two methods, so oral steroid complications could be avoided by using local steroid spray, and the effectiveness of steroids (oral or topical) in treatment of OME is better in absence of adenoidal hypertrophy than in the presence of adenoidal hypertrophy. Conclusion Both topical intranasal and oral steroids are effective adjunctive treatment for OME in children in the short term.
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Intratympanic dexamethasone as an adjuvant to oral imipramine hydrochloride (Tofranil, a TCA) 25 mg twice daily in management of idiopathic unilateral subjective tinnitus p. 300
Tamer A Abo El Ezz, Fathy N Fattoh, Tahany Rabie
DOI:10.4103/ejo.ejo_82_17  
Background In this report, we summarize our clinical experience with intratympanic (IT) dexamethasone treatment for control of idiopathic unilateral tinnitus when used as an adjunct treatment with Tricyclic antidepressant (TCA) imipramine hydrochloride 25 mg twice daily for 1 month. Objectives To assess the clinical benefit of adding dexamethasone by IT route to the tricyclic antidepressant imipramine hydrochloride in the management of idiopathic unilateral subjective tinnitus. Study design A prospective randomized clinical trial was conducted. Results Results from this study showed significant subjective improvement of patients with unilateral subjective tinnitus when comparing the two arms of the study, both to pretreatment assessment and between the two arms, giving significant advantage to the group treated with combination of intratympanic dexamethasone with imipramine hydrochloride 25 mg twice daily for 2 weeks using tinnitus handicap inventory questionnaire, subjective tinnitus loudness as measured by a visual analog scale, and tinnitus awareness score. Conclusion Intratympanic dexamethasone injection in combination with TCA imipramine maleate could be subjectively beneficial when compared with imipramine hydrochloride alone.
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Hearing loss among hypertensive patients p. 307
Stephen S Yikawe, Samuel U Uguru, Joseph H Solomon, Andrew M Adamu, Frederick Damtong, Kingsley Osisi, Foluso M Adeyeye
DOI:10.4103/ejo.ejo_16_19  
Background Hypertension is a leading cause of mortality and morbidity worldwide. Hypertensives have been observed to have elevated hearing thresholds in various studies. Aims and objectives The aims of this study were to assess the hearing thresholds of hypertensives in a tertiary hospital in Nigeria and compare it with nonhypertensive controls. Patients and methods This was a cross-sectional study conducted among hypertensives and age-matched and sex-matched controls from August 2015 to April 2016. A pretested questionnaire was used to obtain information on demographic and medical history. General physical examination and blood pressure measurements were done. Hearing thresholds were then measured with a diagnostic pure tone audiometer. Data analysis The pure tone average was calculated. Data analysis was done using the Statistical Package for Social Sciences, version 23. Results A total number of 104 participants were enrolled into the study. Fifty-two were hypertensives while the other 52 were nonhypertensive controls. The mean age of the participants was 49.1±10.3 years, with ages ranging from 34 to 85 years. There were 38 (36.5%) women and 66 (63.5%) men. Among the hypertensive participants, 20 (38.5%) had various degrees of hearing loss, whereas seven (13.5%) of the non-hypertensives had hearing loss (P=0.004, χ2=8.45). The mean pure tone average (air conduction) among the hypertensive participants was 27.8±13.3 dB HL and 16.7±7.9 dB HL among the nonhypertensive control group. Among the hypertensives, 17 (32.7%) had mild hearing loss, while all seven (13.5%) patients in the nonhypertensive group had mild hearing loss. Conclusion This study has observed a 38.5% prevalence of hearing loss among hypertensives. It has shown an association between hypertension and hearing thresholds. All frequencies tested were observed to have elevated hearing thresholds among hypertensives as compared with the nonhypertensive control group.
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Auditory and vestibular dysfunction in patients with Parkinson’s disease p. 313
Mona Hussein, Rabab Koura
DOI:10.4103/ejo.ejo_18_18  
Background Motor dysfunction in patients with Parkinson disease (PD) is just the tip of the iceberg. Auditory and vestibular dysfunction in patients with PD gained much attention owing to them being one of the nonmotor symptoms. Aim To explore abnormalities of pure tone audiometry (PTA), brainstem auditory evoked potentials (BAEPs), vestibular evoked myogenic potential (VEMP), and videonystagmography (VNG) in patients with PD and their correlation with motor and cognitive dysfunction. Patients and methods The study was conducted on 20 patients with PD and 15 controls. Selected patients were subjected to evaluation of motor symptoms using Unified Parkinson’s Disease Rating Scale (UPDRS) and cognitive function using Parkinson disease-Cognitive Rating Scale (PD-CRS). PTA, BAEPs, cervical VEMPs, and VNG were carried out for all patients and controls. Results Patients with PD show higher mean hearing thresholds at all PTA frequencies in both ears than controls. Analysis of BAEP demonstrated that patients with PD have significantly prolonged absolute latencies of wave III and wave V and interpeak latencies of I–III and I–V in both ears than controls. VEMP findings revealed that patients have significantly delayed P13 and N23 latencies and smaller P13–N23 amplitude in both ears than controls. VNG findings showed canal paresis in 60% of patients with PD and nystagmus in 60% of patients with PD. Correlative results revealed statistically significant correlations between VEMP parameters and UPDRS as well as PD-CRS, but there were no statistically significant correlations between PTA frequencies or BAEP latencies and UPDRS or PD-CRS. Conclusion Auditory and vestibular dysfunction is common in PD but cannot be totally correlated with the motor and cognitive symptoms.
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Auditory brainstem response to chirp stimulus in children with moderate and severe sensorineural hearing loss p. 322
Abu-Mossa Hoda, Enass Sayed, Sanaa Mahran
DOI:10.4103/ejo.ejo_25_18  
Background Click auditory brainstem response (ABR), is abrupt and rapid onset, have broad spectrum nonfrequency-specific response. ABR needs good neural synchrony, the greater number of neurons that fire results in a larger response amplitude. The application of chirp stimuli aims to produce a synchronized response from a large portion of hair cells in the basilar membrane. The chirp was designed to produce simultaneous displacement maxima along the cochlear partition by compensating for frequency-dependent traveling-time differences. Objectives The aim of this study was to correlate between pure-tone audiometry (PTA) threshold and click and chirp-ABR thresholds in children with moderate and severe sensory neural hearing loss. Patients and methods This study included two groups: control group (G1), which consisted of 30 children with normal peripheral hearing and study group (G2), which consisted of 60 children with moderately severe sensorineural hearing loss (SNHL). Results Results showed that significant correlation between chirp and behavioral PTA and between click and behavioral PTA in normal hearing and hearing-impaired children, except in severe steeping SNHL. In steeping SNHL, there was a reduced correlation between behavioral PTA and click ABR stimuli. In addition, there was a significant correlation between narrow band-chirp at 500, 1000, and 4000 Hz and behavioral PTA in normal hearing and sensory neural hearing loss in children, otherwise in severe steeping SNHL. In this category, there was a reduced the correlation between behavioral PTA and narrow band-chirp-ABR stimuli.
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Effect of Television Exposure on Attention and Language in Preschool Children p. 327
Eman Mostafa
DOI:10.4103/ejo.ejo_47_18  
Aim To evaluate the effects of television (TV) on language and attention in preschool children. Introduction There are contradictory reports of the effects of TV watching on children language, cognition, and attention. No research has been conducted to study these effects on Arabic-speaking children. Patients and methods A cross-sectional study was conducted on parents of preschool children with delayed language development aged 1.5–6 years recruited from the Phoniatric Unit in Sohag University Hospital. A total of 112 parents are asked if their children are watching TV, average duration of daily TV watching, type of programs, and if there is interaction during the day. All data are correlated with children language and attention. Results There is a strong negative correlation between receptive and expressive language age and inattention (r=−0.8) and the duration of TV watching (r=−0.6). This indicates that the poorer the inattention and the longer TV watching, the more unfavorable the results of receptive and expressive language age. There is a significant difference between certain types of song channels and inattention (P=0.03). Conclusion The quality of televised programs that promote language learning for preschool children should be encouraged in the Arabic-speaking society. Moreover, the duration of watching TV should be decreased to allow proper interaction of children with their parents and caregivers. Educating parents and increasing their awareness of the adverse effects of TV on their child’s development, cognition, language, and attention should be pursued and addressed.
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CASE REPORTS Top

Bilateral mixed laryngopyocele as a rare cause of acute airway obstruction: a case report p. 332
Mohamed Zahran, Ahmed Youssef, Ahmed Abdo, Khaled Almulla
DOI:10.4103/ejo.ejo_17_19  
Laryngocele is defined as abnormal dilatation of the saccule of the laryngeal ventricle in connection with the lumen of the larynx. The exact etiology of this herniation is unknown and unclear. We present acase of bilateral combined laryngopyocele presenting as acute airway obstruction and discuss the workup and management. The study was approved by the Alexandria University Hospital ethics committee and informed consent was obtained from the patient. Conclusion Laryngopyocele is a serious complication of laryngocele as it can present with acute airway obstruction. Adequate and close collaboration between the surgeon and the anesthesiologist is mandatory for securing the airway. Definitive surgical excision can be performed either endoscopically or via the external approach.
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Hurdles in managing tracheoesophageal fistula: case report p. 334
Azliana Aziz, Norhafiza M Lazim, Hazama Mohamad, Irfan Mohamad, Mohd R Abdul Samad
DOI:10.4103/ejo.ejo_24_18  
Congenital tracheoesophageal fistula (TOF) is a rare anomaly. With the development of endoscopic techniques, the diagnosis of TOF has made marked progress. It requires surgical repair in infancy by either open or thoracoscopic approach. Diagnosing and locating the location of fistula may be difficult particularly in smaller fistula. We report three cases of TOF, to highlight the role of bronchoscopy and endoscopy and also the challenges in managing the aforementioned cases, which may present with airway embarrassment.
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