• Users Online: 670
  • Home
  • Print this page
  • Email this page
Home Current issue Archives Ahead of print Search Subscribe Instructions Submit article About us Editorial board Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 40  |  Issue : 1  |  Page : 24-30

Cognitive and psychological evaluation of a sample of egyptian patients with behcet’s disease without neurological manifestations: a case–control study


1 Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assuit University, Assuit, Egypt
2 Department of Neuropsychiatry, Faculty of Medicine, Assuit University, Assuit, Egypt
3 Department of Neuropsychiatry, Faculty of Medicine, South Valley University, Qena, Egypt

Date of Submission08-Nov-2018
Date of Acceptance02-Dec-2018
Date of Web Publication9-May-2019

Correspondence Address:
Tarek Desoky
Lecturer of psychiatry, Department of Neuropsychiatry, Faculty of Medicine, South Valley University, Qena, 83511
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_32_18

Rights and Permissions
  Abstract 


Objective Behcet’s disease (BD) is a chronic autoimmune multisystemic vasculitis of unknown cause that affects one case per 170 000 persons in the USA. There are few studies in the literature that targeted BD patient group for cognitive and psychological evaluation and scarce studies that evaluated the patients with BD without neurological manifestations. In this study, we aimed to assess those who have BD without neurological manifestations for cognitive and psychological impairments.
Patients and methods A case–control study was conducted. A total of 45 consecutive adult patients, aged 18–60 years, diagnosed with BD without neurological manifestations were evaluated for cognitive and psychological impairments and compared with 30 age-matched and sex-matched healthy control participants. Detailed clinical evaluation was done including disease activity measurement using Behçet’s Disease Current Activity Form. Participants completed a group of neuropsychological assessment including Memory Assessment Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Short Form 36 Quality-Of-Life questionnaire, and Global Assessment of Functioning scale.
Results Compared with the control group, patients with BD scored lower in Memory Assessment Scale (total and subscores), Short Form 36 Quality-Of-Life questionnaire, and Global Assessment of Functioning scores. BD group showed significantly higher prevalence of depression and anxiety.
Conclusion BD without neurological manifestations was associated with cognitive and psychological impairment, and this was not restricted to cases with neuro-BD.

Keywords: anxiety, Behcet, ’s disease, cognitive impairment, depression, psychological evaluation


How to cite this article:
Rashad SM, Abda EA, Gabra RH, Razek MR, Desoky T, Talaat EA. Cognitive and psychological evaluation of a sample of egyptian patients with behcet’s disease without neurological manifestations: a case–control study. Egypt J Psychiatr 2019;40:24-30

How to cite this URL:
Rashad SM, Abda EA, Gabra RH, Razek MR, Desoky T, Talaat EA. Cognitive and psychological evaluation of a sample of egyptian patients with behcet’s disease without neurological manifestations: a case–control study. Egypt J Psychiatr [serial online] 2019 [cited 2019 Dec 7];40:24-30. Available from: http://new.ejpsy.eg.net/text.asp?2019/40/1/24/257848




  Introduction Top


Behcet’s disease (BD) is a systemic inflammatory disease of still unclear etiopathogenesis characterized by recurrent oral and genital ulcers, ocular involvement, and neuropsychiatric manifestations (Sakane et al., 1999).

Neuro-Behcet’s disease (NBD) is a term that refers to the neurological manifestations of BD and lies on a wide spectrum of conditions and may be life threatening and severe (Serdaroglu, 1998; Monastero et al., 2003), reported in 5% of patients with BD (Serdaroglu, 1998; Akman-Demir et al., 1999) and represents a poor prognostic factor (Siva et al., 2001). Epilepsy, stroke-like episodes, dural venous sinous thrombosis, meningoencephalitis, and cranial nerve palsies are common manifestations of NBD (Oktem-Tanor et al., 1999; Joseph and Scolding, 2007).

Neuropsycho-Behcet is a new term that refers to the psychiatric manifestations of BD. Depression and anxiety are the most common psychiatric manifestations of BD (Siva et al., 2001).

Few of the previous studies have investigated the cognitive impairment among patients with BD without neurological manifestations. So, we aimed at this study to evaluate such category of patients with BD for cognitive dysfunction.

BD is a chronic multisystemic disease that affects globally the functioning and quality of life of patients. A disease of such characteristic should be associated with psychological sequelae such as depression and anxiety. The aim of this study is to detect the relationship between the disease and the prevalence of depression and anxiety and to verify the factors that regulate such relationship.

Aim

We aimed, in this study, to investigate the prevalence and pattern of the cognitive profile and the prevalence of depression and anxiety and to assess the quality of life of patients with BD and to address the factors that may affect such relationships.


  Patients and methods Top


Study population

A total of 45 patients diagnosed with BD and 30 healthy control participants of the same sex and age were examined and evaluated for cognitive impairment, depression, anxiety, and quality of life. Patients were recruited from the rheumatology and rehabilitation outpatient clinics of Assiut and South Valley University Hospitals, of an age range 18–60 years. Cases with overt neurological manifestations, uncontrolled hypertension, diabetes, substance abuse, and mixed rheumatological disorders were ruled out of the study.

An informed written consent was given by the all participants. The study was approved by the Ethics Committee of Assiut and South Valley Universities, and all data of the study were confidential.

Methods

  1. Clinical and neurological examination: for justifying inclusion and exclusion criteria and detecting the prevalence of the clinical manifestations of the disease.
  2. Behçet’s Disease Current Activity Form (BDCAF) (Bhaktaet al., 1999): it is an assessment tool that evaluates BD for activity during the last four weeks before assessment, through symptoms of the disease such as oral/genital ulcers, arthritis, fatigue, skin manifestations, vasculitis, gastrointestinal, and central nervous system manifestations on scale from 0 to 12. Scores above four were considered to be active disease.
  3. Neuropsychological tests:


BD and control participants passed the following neuropsychological tests:
  1. Memory Assessment Scale (MAS) (Williams, 1991): it is a psychometric tool that assesses three types of memory functioning; short memory, verbal memory and visual memory. It consists of 12 subtests based on seven memory tasks: List Learning, Verbal Span, Visual Span, Visual Reproduction Prose memory, Visual Recognition, and Names-Faces.
  2. Hamilton Depression Rating Scale (Hamilton, 1960): it consists of 17 points, each scored between 0 (no depression) and 4 (severe depression). Total score equal or less than 7 is considered normal, 8–16 mild depression, 17–23 moderate, and scores above 24 are considered as severe depression. The maximum score is 52.
  3. Hamilton Anxiety Rating Scale (Hamilton, 1959): it consists of 14 points, each scored between 0 (no anxiety) and 4 (severe anxiety). Maximum total score is 56, where <17 (mild), 18–24 (mild to moderate), and >25 (moderate to severe).
  4. Short Form 36 Quality-Of-Life (SF-36 QOL) questionnaire (Ware and Sherbourne, 1992): it is an eight-item questionnaire that assesses different areas of the quality of life. These items include social function, emotional well-being, pain, general health, limitation owing to emotional problems, and limitation owing to physical health and physical function. Items are scored on a 0–100 scale, where 0 is the lowest and 100 the highest score. The high score equals higher quality of life and vice versa.
  5. Global Assessment of Functioning (GAF) scale (DSM-IV-TR, 2000): a 0 through 100 scale that assesses the occupational, psychological, and social functioning in adults.


Statistical analysis

Statistical analysis was carried out using IBM SPSS software, version 24 (International Business Machines Corporation (IBM), Armonk, New York, United States). Data were presented as mean±SD. For comparing means of two independent variables, we used independent t-test. For comparing means of dependent variables, we used paired t-test. We used Spearman’s and Pearson’s correlation coefficients to test correlation between variables as appropriate for data type. P value was considered significant if less than 0.05 with 95% confidence interval.


  Results Top


Sociodemographic data

This study was carried out in Assiut and South Valley University Hospitals, where cases had been recruited from the rheumatology outpatient clinics of both hospitals. The study included 45 patients diagnosed with BD, comprising 35 (77.8%) males, and 10 (22.2%) females. Their ages ranged between 18 and 60 years, with a mean age of 34.27±10.70 years. More than half (57.6%) of patients were married. Thirty age-matched and sex-matched control participants were also included in the study. Approximately two-third of patients with BD (68.9%) and 50.0% of the control participants lie in the middle of the socioeconomic scale ([Table 1]).
Table 1 Sociodemographic characteristics of the studied sample

Click here to view


Clinical characteristics

Clinical manifestations of the disease group had been shown in [Table 2]. Duration of illness ranged between 0.5 and 21.0 years, with a mean of 6.16±5.62 ([Table 3]). Approximately 24 (53.3%) patients were in active disease ([Table 4]).
Table 2 Clinical characteristics of patients with Behcet’s disease

Click here to view
Table 3 Duration of illness among studied participants with Behcet’s disease patients

Click here to view
Table 4 Activity score in patients with Behcet’s disease

Click here to view


Neuropsychological evaluation

Memory Assessment Scale

MAS in all its variables showed highly significant lower scores in patients with BD than in control participants (P=0.000). The mean short-term memory of BD patients was 55.09±4.89, mean verbal memory was 76.93±8.92, mean visual memory was 56.04±3.50, and the mean total memory score was 62.47±5.90 ([Table 5]).
Table 5 Comparison between Behcet’s disease and control individuals regarding Memory Assessment Scale

Click here to view


Hamilton Depression Rating Scale

The mean Hamilton Depression Rating Scale score for patients with BD was 29.18±7.57 and for control participants was 8.30±1.21, with a highly significant difference between both groups (P=0.000) ([Table 6]).
Table 6 Comparison between Behcet’s disease and control individuals regarding Hamilton Depression Rating Scale

Click here to view


Hamilton Anxiety Rating Scale

The mean score of Hamilton Anxiety Rating Scale for BD was 16.58±4.44 and for control participants was 8.40±1.13, with a highly significant difference between both groups (P=0.000) ([Table 7]).
Table 7 Comparison between Behcet’s disease and control individuals regarding Hamilton Anxiety Rating Scale

Click here to view


Short Form 36 Quality-Of-Life questionnaire

The mean scores of all items of SF-36 QOL questionnaire, namely, physical function, limitation owing to physical health, limitation owing to emotional problems, energy–fatigue, emotional well-being, social function, pain and general health, were highly significantly lower in patients with BD than in control participants (P=0.000) ([Table 8]).
Table 8 Short Form 36 Quality-Of-Life questionnaire

Click here to view


Global Assessment of Functioning scale

The mean GAF score of patients with BD (64.00±8.94) was highly significantly lower than that of the control participants (81.00±6.82) (P=0.000) ([Table 9]).
Table 9 Global Assessment of Functioning scale

Click here to view


Factors affecting memory deficit, depression, and anxiety among patients with Behcet’s disease

Clinical manifestations

There was no significant relationship between various clinical manifestations on one side and memory deficit, depression, and anxiety on the other side ([Table 10]).
Table 10 Relationship between various clinical manifestations on one side and memory deficit, depression, and anxiety on the other side

Click here to view


Disease activity

There was no significant difference between active and inactive groups of BD regarding MAS, Hamilton Depression Scale, and Hamilton Anxiety Scale ([Table 11]).
Table 11 Comparison between active and inactive groups of Behcet’s disease regarding Hamilton Depression Scale, Memory Assessment Scale, and Hamilton Anxiety Scale

Click here to view


Disease duration

Duration of the disease was not significantly correlated with the prevalence of memory deficit, depression, and anxiety among patients with BD, correlated neither with their quality of life nor with the serum levels of interleukin-17 and interleukin-23 ([Table 12]).
Table 12 Correlation between disease duration of Behcet’s disease and Memory Assessment Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Short Form 36 Quality-Of-Life questionnaire

Click here to view



  Discussion Top


Cognitive studies in BD are restricted, and cognitive dysfunction in BD was mostly associated with neurological involvement. Attention impairment, memory deficit, and executive malfunctioning were reported to be characteristic of BD cognitive profile in previous reports (Akman-Demir et al., 1999; Oktem-Tanor et al., 1999).

Frontal and temporal cortical dysfunction owing to subcortical damage, mainly of the brainstem, was reported to be one of the theories behind pathogenesis of cognitive manifestations of BD (Monastero et al., 2004).

In this study, memory scores in patients with BD (measured by MAS) were significantly lower than in control participants. This was in consistence with many previous studies (Akman-Demir et al., 1999; Monastero et al., 2004).

Cognitive impairment is rationalized for patients with NBD; however, just few studies examined the prevalence and pattern of cognitive dysfunction in non-NBD patients. In a cross-sectional study including 72 participants, in three groups, each comprising 24 patients, a comparison between patients with NBD, patients BD without neurological manifestations, and a healthy control group was done in terms of prevalence of cognitive dysfunction among patients with BD. The resulting findings showed higher prevalence of cognitive dysfunction among BD cases in comparison with control participants. However, visual memory impairment prevalence was higher only in NBD group, whereas executive dysfunction was higher in both patients with NBD and patients with BD without neurological manifestations relative to healthy control group (Dutra et al., 2013).Similarly, in a case–control study of a similar aim, 30 patients with BD without explicit neurological manifestations were evaluated for executive dysfunction using Wisconsin Card Sorting Test and other neuropsychological tools, scores of which were found to be significantly lower than those of control participants, which means that BD without neurological manifestations also might show cognitive dysfunction as well (Erberk-Ozen et al., 2006).

In another study that included 26 patients with BD without neurological manifestations and same number of control participants, a higher prevalence of cognitive dysfunction was reported, with memory being the most affected domain. Unlike this findings, the high disease activity (assessed by the BDCAF) was associated with increased prevalence of cognitive impairment. However, the duration of illness, in consistence with this study, was not associated with cognitive impairment in patients with BD (Monastero et al., 2004).

This indicates that cognitive impairment occurs in BD independently of presence or absence of NBD.

In many previous studies, depression and anxiety were significantly higher in patients with BD than in patients without BD (Calikoglu et al., 2001; Bagheri et al., 2013).

Depression was estimated in some studies by an incidence of 86% early in the disease (De Oliveira Ribeiro et al., 2014).

The poor quality of sleep was considered as one of the commonly encountered clinical findings in BD, present according to some reports in 67% of patients (Kim et al., 2016). Many reports found a positive correlation between poor sleep quality and resulting overall poor quality of life and depression and cognitive dysfunction in patients with BD (Uygunoglu et al., 2014; Kim et al., 2016; Lee et al., 2017).

In this study, all items of the SF-36 QOL scored lower in patients with BD in contrast to control participants; this might be a contributor in the higher prevalence of depression and anxiety among patients with BD, and this was supported by many previous reports that related the poor quality of life to the disease, especially the active form (Bodur et al., 2006; Uğuz et al., 2007; Canpolat and Yurtsever, 2011).

Other studies reported that fibromyalgia is commonly seen in patients with BD, and the primer is commonly associated with depression and anxiety (Jobanputra et al., 2017).

The presence of arthritis, as a painful condition that is being expected to affect the quality of life in patients with BD and may therefore predispose to depression and anxiety, was investigated, and the findings showed that patients with BD without arthritis had a significantly higher incidence of depression measured by Beck Depression Inventory and anxiety measured by State-Trait Anxiety Inventory than healthy control participants (Gur et al., 2006).

In comparison with other chronic pathologies, BD and rheumatoid arthritis (RA) were investigated for depressive and cognitive disorders, and the results revealed that both disorders had a mental disorder background specifically depression and cognitive impairment; the rates of depression in BD and RA reached (94 vs. 79%, respectively). The recurrent depression and chronic depression were diagnosed in both disorders, but were more prevalent in RA (58.4 vs. 39.2%). Most patients with BD and RA showed some sort of cognitive dysfunction with variable severity but with higher incidence in BD (73 vs. 66.4%); impaired memory and attention were the most found cognitive dysfunctions diagnosed in BD (Veltishchev et al., 2017).

Psoriasis, as a chronic dermatological disorder that is intimately related to disturbed psychological background including anxiety and depression, was investigated versus BD in various comparative studies, and the prevalence of these psychological disorders was significantly higher in patients with BD relative to its prevalence in psoriasis (Calikoglu et al., 2001; Taner et al., 2007).

In this study, there was no positive relationship between disease activity and cognitive dysfunction, depression, or anxiety. Disease activity was investigated in several previous reports. Koca et al. (2015) investigated the effect of disease activity (assessed using BDCAF) on BD-associated depression and sleep quality, and the results revealed a significant positive correlation between disease activity and depression and sleep quality. Similarly, Kim et al. (2016) found a positive correlation between disease activity (measures by BDCAF) and depression and poor quality of sleep in Korean populations.


  Conclusion Top


BD, as well as other rheumatological disorders, is commonly associated with mental disorders including depression, anxiety, and cognitive dysfunction. A multidisciplinary approach of management had become a necessity, and psychiatric assessment of patients with BD should be a main part of their evaluation for ideal treatment outcome.[30]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Uncited references Top


De Oliveira Ribeiro et al. (2014) and Neves et al. (2008).



 
  References Top

1.
Akman-Demir G, Serdaroglu P, Tasci B (1999). Clinical patterns of neurological involvement in Behcet’sdesease: evaluation of 200 patients. The Neuro-Behcet Study Group. Brain 122:2171–2181.  Back to cited text no. 1
    
2.
Bagheri F, Mani A, Tadayyoni A, Firozi F, Nazarinia MA (2013). The prevalence of Psychiatric symptoms in the patients with Behcet’s disease in Shiraz, Southwest of Iran. J Mood Disord 3:28–32.  Back to cited text no. 2
    
3.
Bhakta BB, Brennan P, James TE, Chamberlain MA, Noble BA, Silman AJ (1999). Behçet’s disease: evaluation of a new instrument to measure clinical activity. Rheumatology (Oxford) 38:728–733.  Back to cited text no. 3
    
4.
Bodur H, Borman P, Özdemir Y, Atan C, Kural G (2006). Quality of life and life satisfaction in patients with Behçet’s disease: relationship with disease activity. Clin Rheumatol 25:329–333.  Back to cited text no. 4
    
5.
Calikoglu E, Onder M, Cosar B, Candansayar S (2001). Depression, anxiety levels and general psychological profile in Behcet’s disease. Dermatology 203:238–240.  Back to cited text no. 5
    
6.
Canpolat Ö, Yurtsever S (2011). The quality of life in patients with Behçet’s disease. Asian Nurs Res 4:229–235.  Back to cited text no. 6
    
7.
De Oliveira Ribeiro NP, de Mello Schier AR, Pessoa TM, Pereira VM, Machado S, Arias-Carrión O et al. (2014). Depression as a comorbidity in Behcet’s syndrome. CNS Neurol Disord Drug Targets 13:1041–1048.  Back to cited text no. 7
    
8.
DSM-IV-TR (APA 2000). The GAF scale. p. 34.  Back to cited text no. 8
    
9.
Dutra LA, de Souza AW, Alessi H, Guedes Bde V, Braga-Neto P, Pedroso JL et al. (2013). Cognitive impairment in Brazilian patients with Behçet’s disease occurs independently of neurologic manifestation. J Neurol Sci 327:1–5.  Back to cited text no. 9
    
10.
Erberk-Ozen N, Birol A, Boratav C, Kocak M (2006). Executive dysfunctions and depression in Behçet’s disease without explicit neurological involvement. Psychiatry Clin Neurosci 60:465–472.  Back to cited text no. 10
    
11.
Gur A, Sarac AJ, Burkan YK, Nas K, Cevik R (2006). Arthropathy, quality of life, depression, and anxiety in Behcet’s disease: relationship between arthritis and these factors. Clin Rheumatol 25:524–531.  Back to cited text no. 11
    
12.
Hamilton M (1959). The assessment of anxiety status by rating. Br J Med Psychol 32:50–55.  Back to cited text no. 12
    
13.
Hamilton M (1960). A rating scale for depression. J Neurol Neurosurg Psychiatry 12:56–62.  Back to cited text no. 13
    
14.
Jobanputra C, Richey RH, Nair J, Moots RJ, Goebel A (2017). Fibromyalgia in Behçet’s disease: a narrative review. Br J Pain 11:97–101.  Back to cited text no. 14
    
15.
Joseph FG, Scolding NJ (2007). Neuro-Behçet’s disease in Caucasians: a study of 22 patients. Eur J Neurol 14:174–180.  Back to cited text no. 15
    
16.
Kim SS, Lee J, Kim YS, Kim HS, Hong SJ, Jeong HJ et al. (2016). Sleep quality in Behcet’s disease is associated with disease activity, depression, and quality of life in Korean population. Ann Rheum Dis 75:1102.  Back to cited text no. 16
    
17.
Koca I, Savas E, Ozturk ZA, Tutoglu A, Boyaci A, Alkan S et al. (2015). The relationship between disease activity and depression and sleep quality in Behçet’s disease patients. Clin Rheumatol 34:1259–1263.  Back to cited text no. 17
    
18.
Lee J, Kim SS, Jeong HJ, Son CN, Kim JM, Cho YW, Kim SH (2017). Association of sleep quality in Behcet disease with disease activity, depression, and quality of life in Korean population. Korean J Intern Med 32:352–359.  Back to cited text no. 18
    
19.
Monastero R, Mannino M, Camarda C, Cannizaro C, Camarda LKC, Ciccia F. (2003). Prevalance of headache in patients with BD without overt neurological involvement. Cephalalgia 23:105–108.  Back to cited text no. 19
    
20.
Monastero R, Camarda C, Pipia C, Lopez G, Camarda LK, Baiamonte V et al. (2004). Cognitive impairment in Behcet’s disease patients without overt neurological involvement. J Neurol Sci 220:99–104.  Back to cited text no. 20
    
21.
Oktem-Tanor O, Baykan-Kurt B, Gurvit IH, Akman-Demir G, Serdaroglu P (1999). Neuropsychological follow-up of 12 patients with neuro-Behçet’s disease. J Neurol 246:113–119.  Back to cited text no. 21
    
22.
Sakane T, Takeno M, Suzuki N, Inaba G (1999). Behçet’s disease. N Engl J Med 341:1284–1291.  Back to cited text no. 22
    
23.
Serdaroglu P (1998). Behcet’s disease and the nervous system. J Neurol 245:197–205.  Back to cited text no. 23
    
24.
Siva A, Kantarci OH, Saip S, Altintas A, Hamuryudan V, Islak C. (2001). Behçet’s disease: diagnostic and prognostic aspects of neurological involvement. J Neurol 248:95–103.  Back to cited text no. 24
    
25.
Taner E, Coşar B, Burhanoğlu S, Calikoğlu E, Onder M, Arikan Z (2007). Depression and anxiety in patients with Behçet’s disease compared with that in patients with psoriasis. Int J Dermatol 46:1118–1124.  Back to cited text no. 25
    
26.
Uygunoglu U, Benbir G, Saip S, Kaynak H, Siva A (2014). A polysomnographic and clinical study of sleep disorders in patients with Behcet and neuro-Behcet syndrome. Eur Neurol 71:115–119.  Back to cited text no. 26
    
27.
Uğuz F, Dursun R, Kaya N, Cilli AS (2007). Quality of life in patients with Behçet’s disease: the impact of major depression. Gen Hosp Psychiatry 29:21–24.  Back to cited text no. 27
    
28.
Veltishchev D, Lisitsyna T, Kovalevskaya O, Seravina O, Ishchenko D (2017). Depression and cognitive disorders in Behçet’s disease and rheumatoid arthritis patients. Eur Psychiatry 41(Suppl):S510.  Back to cited text no. 28
    
29.
Ware JE Jr, Sherbourne CD (1992). The MOS 36-Item Short-Form Health Survey (SF-36): I. Conceptual Framework and Item Selection. Medical Care 30:473–483.  Back to cited text no. 29
    
30.
Williams JM (1991). Memory Assessment Scales Manual. Odessa, FL: Psychological Assessment Resources.  Back to cited text no. 30
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
Uncited references
References
Article Tables

 Article Access Statistics
    Viewed355    
    Printed52    
    Emailed0    
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]