ABSTRACT
OBJECTIVES: The objective of this study was to assess the association between serological markers and changes of the intestinal mucosa in children with celiac disease (CD). METHODS: Clinical data from CD patients under 15 years old were collected from the participating centers in an on-line multicenter nationwide observational Spanish registry called REPAC-2 (2011-2017). Correlation between anti-tissue transglutaminase antibodies (t-TGA) levels and other variables, including mucosal damage and clinical findings (symptoms, age, and gender), was assessed. RESULTS: A total of 2955 of 4838 patients had t-TGA and a small bowel biopsy (SBB) performed for CD diagnosis. A total of 1931 (66.2%) patients with normal IgA values had a Marsh 3b-c lesion and 1892 (64.9%) had t-TGA Immunoglobulin A (IgA) ≥ 10 times upper limit of normal (ULN). There is a statistically significant association between t-TGA IgA levels and the degree of mucosal damage ( P < 0.001), the higher the t-TGA IgA levels the more severe the mucosal damage. Those patients who reported symptoms had more severe mucosal damage ( P = 0.001). On the contrary, there was a negative association between age and changes of the intestinal mucosa ( P < 0.001). No association was found with gender. Regarding the IgA-deficient patients, 47.4% (18 cases) had t-TGA Immunoglobulin A (IgA) ≥ 10 times ULN and a Marsh 3b-c lesion was observed in 68.4% (26 patients). No statistical relation was found between t-TGA IgG levels and the changes of the intestinal mucosa, neither a relation with age, gender, or symptoms. CONCLUSIONS: There is a positive correlation between t-TGA IgA levels and the severity of changes of the intestinal mucosa. Such correlation was not found in IgA-deficient patients who had positive t-TGA IgG serology. The results in this group of patients support the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition recommendations about the need of performing a SBB in IgA-deficient individuals despite high t-TGA IgG levels.
Subject(s)
Celiac Disease , Adolescent , Child , Humans , Autoantibodies , Biopsy , Celiac Disease/diagnosis , Immunoglobulin A , Immunoglobulin G , TransglutaminasesABSTRACT
OBJECTIVES: Over the last several decades, there has been a tendency towards a predominance of less symptomatic forms of coeliac disease (CD) and an increase in the patient age at diagnosis. This study aimed to assess the clinical presentation and diagnostic process of paediatric CD in Spain. METHODS: A nationwide prospective, observational, multicentre registry of new paediatric CD cases was conducted from January 2011 to June 2017. The data regarding demographic variables, type of birth, breast-feeding history, family history of CD, symptoms, height and weight, associated conditions, serological markers, human leukocyte antigen (HLA) phenotype, and histopathological findings were collected. RESULTS: In total, 4838 cases (61% girls) from 73 centres were registered. The median age at diagnosis was 4âyears. Gastrointestinal symptoms were detected in 71.4% of the patients, and diarrhoea was the most frequent symptom (45.9%). The most common clinical presentation was the classical form (65.1%) whereas 9.8% ofthe patients were asymptomatic. There was a trend towards an increase in the age at diagnosis, proportion of asymptomatic CD cases, and usage of anti-deamidated gliadin peptide antibodies and HLA typing for CD diagnosis. There was, however, a decreasing trend in the proportion of patients undergoing biopsies. Some of these significant trend changes may reflect the effects of the 2012 ESPGHAN diagnosis guidelines. CONCLUSIONS: Paediatric CD in Spain is evolving in the same direction as in the rest of Europe, although classical CD remains the most common presentation form, and the age at diagnosis remains relatively low.
Subject(s)
Celiac Disease , Registries , Antibodies , Celiac Disease/complications , Celiac Disease/diagnosis , Celiac Disease/epidemiology , Child , Female , Gliadin , Humans , Male , Prospective Studies , Spain/epidemiologyABSTRACT
La enfermedad celíaca es un proceso sistémico de carácter inmunológico, desencadenado por el consumo de gluten, que se da en sujetos genéticamente predispuestos. Se expresa con una gran variedad de síntomas clínicos, marcadores serológicos específicos, haplotipo HLA-DQ2/DQ8 y enteropatía. El tratamiento consiste en eliminar de por vida el gluten de la dieta, por lo que es fundamental un diagnóstico adecuado. Los criterios seguidos para ello han sido habitualmente los establecidos por la European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) desde 1969. Estos criterios han ido evolucionando desde la necesidad de varias biopsias intestinales para el diagnóstico a, gracias al desarrollo de pruebas serológicas de alta sensibilidad y especificidad, considerar la enteropatía como un elemento más en este diagnóstico y posibilitar en determinadas circunstancias realizarlo sin necesidad de biopsia intestinal. La revisión actualizada en 2019 de los criterios 2012 aporta nueva evidencia sobre algunos aspectos, como el papel del HLA, el diagnóstico de los pacientes asintomáticos y la eficacia de los marcadores serológicos. Estos aspectos se revisan en detalle, con el objetivo de facilitar la aplicación de los nuevos criterios 2020 de una forma racional en todos los niveles asistenciales. En este sentido el pediatra de Atención Primaria es fundamental para la búsqueda activa de casos y realizar un primer estudio serológico, recomendándose que el diagnóstico sea siempre establecido por un pediatra gastroenterólogo
Coeliac disease is a systemic immune-mediated disorder triggered by the ingestion of gluten, which is given in genetically predisposed subjects. It manifests with a wide variety of clinical symptoms, specific serological markers, HLA-DQ2/DQ8 haplotype and enteropathy. The criteria followed for this have usually been those established by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) since 1969. These criteria have advanced from the need of several intestinal biopsies to, thanks to the development of serological tests of high sensitivity and specificity, considering the enteropathy as one more element in this diagnosis and makes it possible to perform a diagnosis without the need of an intestinal biopsy in certain circumstances. The updated review of the 2012 criteria in 2019 provides new evidence on some aspects, such as the role of HLA, the diagnosis of asymptomatic patients, and the effectiveness of the serological markers. These aspects are reviewed in detail, with the aim of facilitating the rational application of the new 2020 criteria at all care levels. In this sense, Paediatric Primary Care is fundamental in the search for active cases and to perform a first serological study, being recommended that the diagnosis is always established by a Paediatric Gastroenterologist
Subject(s)
Humans , Child , Celiac Disease/diagnosis , HLA-DQ Antigens/genetics , Celiac Disease/genetics , Gastroenterology , Glutens/adverse effects , Sensitivity and SpecificityABSTRACT
Coeliac disease is a systemic immune-mediated disorder triggered by the ingestion of gluten, which is given in genetically predisposed subjects. It manifests with a wide variety of clinical symptoms, specific serological markers, HLA-DQ2/DQ8 haplotype and enteropathy. The criteria followed for this have usually been those established by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) since 1969. These criteria have advanced from the need of several intestinal biopsies to, thanks to the development of serological tests of high sensitivity and specificity, considering the enteropathy as one more element in this diagnosis and makes it possible to perform a diagnosis without the need of an intestinal biopsy in certain circumstances. The updated review of the 2012 criteria in 2019 provides new evidence on some aspects, such as the role of HLA, the diagnosis of asymptomatic patients, and the effectiveness of the serological markers. These aspects are reviewed in detail, with the aim of facilitating the rational application of the new 2020 criteria at all care levels. In this sense, Paediatric Primary Care is fundamental in the search for active cases and to perform a first serological study, being recommended that the diagnosis is always established by a Paediatric Gastroenterologist.
Subject(s)
Celiac Disease/diagnosis , HLA-DQ Antigens/genetics , Celiac Disease/genetics , Child , Gastroenterology , Glutens/adverse effects , Humans , Sensitivity and SpecificityABSTRACT
No disponible
Subject(s)
Humans , Early Diagnosis , Celiac Disease/diagnosis , Clinical Protocols , Primary Health Care , Immunoglobulin A/analysis , SerologyABSTRACT
No disponible
Subject(s)
Consensus Development Conferences as Topic , 52503 , Diet/methods , Diet/trends , Motor Activity/physiology , Life Style , Hospital Care , Anthropometry/methodsABSTRACT
The assessment of dietary intake in children and adolescents is of great interest for different purposes. The characteristics of each developmental stage and associated cognitive abilities are two factors that influence the ability of children to provide valid and reliable information on food consumption. The ability to remember, limitations of vocabulary or the ability to identify different foods are some of the relevant aspects. In addition, often parents or caregivers provide surrogate information and their degree of knowledge depends on the time they spend with the child and on whether they share meals. As children grow they become more independent and increasingly spend more time away from their parents. Children also have limitations to recognize food models and photographs and associate them with different amounts of food consumed. On the other hand, often children and adolescents perceive long interviews or self-administered questionnaires they as long and boring. The use of new technologies is contributing to the development of new tools adapting dietary assessment the methods to the cognitive abilities of children, introducing gaming environments and narrative structures that attract their interest and improve the quality of information they report (AU)
El análisis de la ingesta alimentaria en niños y adolescentes es de gran interés con diferentes fines. Las características propias de cada etapa del desarrollo evolutivo y las capacidades cognitivas en cada edad son dos factores que influyen sobre la capacidad de los niños para proporcionar información válida y fiable sobre el consumo de alimentos. La capacidad de recordar, limitaciones de vocabulario o la capacidad para identificar distintos alimentos son algunos de los aspectos relevantes. Además a menudo son los padres o cuidadores quienes facilitan la información y su grado de conocimiento depende del tiempo que pasen con el niño y si comparten las comidas. A medida que crecen los niños son más independientes y cada vez pasan más tiempo sin sus padres. Los niños también tienen limitaciones a la hora de reconocer modelos de alimentos y asociarlos con diferentes cantidades. Por otro lado, las entrevistas largas o los cuestionarios auto-administrados les resultan largos y aburridos. El uso de las nuevas tecnologías están favoreciendo el desarrollo de nuevas herramientas que permiten adaptar los métodos de análisis de la ingesta a la capacidad cognitiva de los niños, introduciendo componentes lúdicos y narrativos que atraigan su interés y mejoren la calidad de la información (AU)
Subject(s)
Humans , Male , Female , Child , Adolescent , Eating/physiology , Feeding Behavior/physiology , Feeding Behavior/physiology , Child Nutrition , Adolescent Nutrition , Health Knowledge, Attitudes, Practice , Adolescent Behavior/physiology , Adolescent Behavior/psychology , Child Behavior/physiology , Child Behavior/psychologySubject(s)
Diet Surveys/methods , Exercise , Health Surveys/methods , Life Style , Nutritional Sciences/methods , Consensus , HumansABSTRACT
The assessment of dietary intake in children and adolescents is of great interest for different purposes. The characteristics of each developmental stage and associated cognitive abilities are two factors that influence the ability of children to provide valid and reliable information on food consumption. The ability to remember, limitations of vocabulary or the ability to identify different foods are some of the relevant aspects. In addition, often parents or caregivers provide surrogate information and their degree of knowledge depends on the time they spend with the child and on whether they share meals. As children grow they become more independent and increasingly spend more time away from their parents. Children also have limitations to recognize food models and photographs and associate them with different amounts of food consumed. On the other hand, often children and adolescents perceive long interviews or self-administered questionnaires they as long and boring. The use of new technologies is contributing to the development of new tools adapting dietary assessment the methods to the cognitive abilities of children, introducing gaming environments and narrative structures that attract their interest and improve the quality of information they report..
El análisis de la ingesta alimentaria en niños y adolescentes es de gran interés con diferentes fines. Las características propias de cada etapa del desarrollo evolutivo y las capacidades cognitivas en cada edad son dos factores que influyen sobre la capacidad de los niños para proporcionar información válida y fiable sobre el consumo de alimentos. La capacidad de recordar, limitaciones de vocabulario o la capacidad para identificar distintos alimentos son algunos de los aspectos relevantes. Además a menudo son los padres o cuidadores quienes facilitan la información y su grado de conocimiento depende del tiempo que pasen con el niño y si comparten las comidas. A medida que crecen los niños son más independientes y cada vez pasan más tiempo sin sus padres. Los niños también tienen limitaciones a la hora de reconocer modelos de alimentos y asociarlos con diferentes cantidades. Por otro lado, las entrevistas largas o los cuestionarios auto-administrados les resultan largos y aburridos. El uso de las nuevas tecnologías están favoreciendo el desarrollo de nuevas herramientas que permiten adaptar los métodos de análisis de la ingesta a la capacidad cognitiva de los niños, introduciendo componentes lúdicos y narrativos que atraigan su interés y mejoren la calidad de la información..
Subject(s)
Diet Surveys/methods , Feeding Behavior , Adolescent , Child , Humans , Nutrition Assessment , Surveys and QuestionnairesABSTRACT
El análisis de la ingesta alimentaria en niños y adolescentes de gran interés con diferentes fines. Las características propias de cada etapa del desarrollo evolutivo y las capacidades cognitivas en cada edad son dos factores que influyen sobre la capacidad de los niños para proporcionar información válida y fiable sobre el consumo de alimentos. La capacidad de recordar, limitaciones de vocabulario o la capacidad para identificar distintos alimentos son algunos de los aspectos relevantes. Además a menudo son los padres o cuidadores quienes facilitan la información y su grado de conocimiento depende del tiempo que pasen con el niño y si comparten las comidas. A medida que crecen los niños son más independientes y cada vez pasan más tiempo sin sus padres. Los niños también tienen limitaciones a la hora de reconocer modelos de alimentos y asociarlos con diferentes cantidades. Por otro lado, las entrevistas largas o los cuestionarios auto-administrados les resultan largos y aburridos. El uso de las nuevas tecnologías están favoreciendo el desarrollo de nuevas herramientas que permiten adaptar los métodos de análisis de la ingesta a la capacidad cognitiva de los niños, introduciendo componentes lúdicos y narrativos que atraigan su interés y mejoren la calidad de la información
The assessment of dietary intake in children and adolescents is of great interest for different purposes. The characteristics of each developmental stage and associated cognitive abilities are two factors that influence the ability of children to provide valid and reliable information on food consumption. The ability to remember, limitations of vocabulary or the ability to identify different foods are some of the relevant aspects. In addition, often parents or caregivers provide surrogate information and their degree of knowledge depends on the time they spend with the child and on whether they share meals. As children grow they become more independent and increasingly spend more time away from their parents. Children also have limitations to recognize food models and photographs and associate them with different amounts of food consumed. On the other hand, often children and adolescents perceive long interviews or self-administered questionnaires they as long and boring. The use of new technologies is contributing to the development of new tools adapting dietary assessment the methods to the cognitive abilities of children, introducing gaming environments and narrative structures that attract their interest and improve the quality of information they report
Subject(s)
Humans , Male , Female , Child , Adolescent , Eating , Recommended Dietary Allowances/trends , Feeding Behavior/classification , Nutrition Assessment , Child Nutrition/education , Adolescent Nutrition/education , Nutritional RequirementsABSTRACT
La enfermedad celíaca es una alteración sistémica de carácter autoinmune desencadenada por el consumo de gluten y prolaminas relacionadas en individuos con predisposición genética (principalmente HLA), caracterizada por una combinación variable de: manifestaciones clínicas gluten-dependientes, anticuerpos específicos de enfermedad celíaca, haplotipo HLA-DQ2 y/o DQ8 y enteropatía. Los anticuerpos específicos comprenden autoanticuerpos anti-TG2, incluyendo antiendomisio y antipéptidos deamidados de gliadina. En la infancia y adolescencia, la biopsia intestinal podría omitirse en sujetos sintomáticos con títulos de anticuerpos anti-TG2-IgA > 10 veces el punto de corte, verificados por anticuerpos antiendomisio y HLA-DQ2 y/o DQ8 positivos, y solo en este supuesto se podría realizar el diagnóstico e iniciar la dieta sin gluten. En todos los demás casos, la primera biopsia intestinal, antes de retirar el gluten de la dieta, es obligatoria para evitar diagnósticos incorrectos (AU)
Coeliac disease is a systemic autoimmune disorder that is triggered by the ingestion of gluten and associated prolamins in individuals with genetic susceptibility (mainly HLA), characterised by a variable combination of specific antibodies: gluten-dependent clinical manifestations, specific coeliac disease antibodies, HLA-DQ2 and/or DQ8 haplotype and enteropathy. The specific antibodies consist of anti-TG2 antibodies, including endomysial and deamidated gliadin peptide antibodies. In childhood and adolescence, the intestinal biopsy could be omitted in symptomatic subjects with anti-TG2-IgA antibody titres > 10 times the cut-off point, verified by a positive antibodies endomysial and HLA-DQ2 and/or DQ8, and only in this case, the diagnosis could be made and treatment started with gluten-free diets. In all the rest of the cases, a first intestinal biopsy, before withdrawal of the gluten diet, is mandatory to prevent incorrect diagnoses (AU)
Subject(s)
Humans , Male , Female , Celiac Disease/diagnosis , Celiac Disease/therapy , Gliadin , Celiac Disease/diet therapy , Genetic Markers , Genetic Markers/physiology , Serology/methods , Serology/trends , Glutaminase , Celiac Disease/epidemiology , Celiac Disease/physiopathologySubject(s)
Gastroenteritis/diagnosis , Gastroenteritis/therapy , Acute Disease , Child, Preschool , Humans , InfantSubject(s)
Fluid Therapy , Gastroenteritis/therapy , Nutritional Support , Acute Disease , Child, Preschool , Humans , InfantABSTRACT
Multidisciplinary experts in the areas of nutrition and health met in Chinchón, Madrid, on November 25-26, 2013 under the auspices of the Fundación para la Investigación Nutricional (Nutrition Research Foundation) and with the collaboration of the Madrid Regional Government's Health Ministry, the International Sweeteners Association and the Carlos III Health Institute CIBER of Physiopathology of Obesity and Nutrition. They analyzed the current status of scientific knowledge on low- and no-calorie sweeteners (LNCS) and developed a consensus Decalogue on their use; this constitutes the Chinchón Declaration. Sweeteners, including sugar, represent a subject of undeniable interest and are currently a popular topic, although areas relating to their safety and benefits remain unknown to segments of academia and the general public. The nature of LNCS makes them vulnerable to biased and even contradictory information. They are food additives that are broadly used as sugar substitutes to sweeten foods, medicines and food supplements when non-nutritional or non-caloric alternatives are needed. The Chinchón Decalogue is the outcome of a meeting for reflection and consensus by a group of experts with backgrounds in different scientific disciplines (toxicology, clinical nutrition, community nutrition, physiology, food science, public health, pediatrics, endocrinology and nutrition, nursing, pharmaceutical care and food legislation). The Decalogue includes different aspects of LNCS related to regulation, use, benefits and safety. In general, benefits of LNCS have been traditionally neglected in comparison with the tendency for emphasising unexisting or unproven possible risks. The need to strengthen research on LNCS in Spain was emphasized, as well as the need to educate both professionals and the public.
Expertos de carácter multidisciplinar de las áreas de conocimiento de la nutrición y la salud reunidos en Chinchón, Madrid, los días 25 y 26 de noviembre de 2013 , bajo los auspicios de la Fundación para la Investigación Nutricional y con la colaboración de la Consejería de Sanidad del Gobierno de la Comunidad de Madrid, la International Sweeteners Association y el CIBER de Fisiopatología de la Obesidad y la Nutrición del Instituto de Salud Carlos III, analizaron el estado actual del conocimiento científico en torno a los Edulcorantes sin y bajos en calorías (ESBC) y desarrollaron un Decálogo sobre su uso que constituye la Declaración de Chinchón. Los edulcorantes, incluido el azúcar, constituyen un elemento de indudable interés y actualidad, aunque no exento de desconocimiento por algunos sectores tanto académicos como de la población en general. La propia naturaleza de los ESBC los hace susceptibles de informaciones tergiversadas e incluso contradictorias. Son aditivos alimentarios ampliamente utilizados como sustitutivos del azúcar para endulzar alimentos, medicamentos y complementos alimenticios cuando se persiguen fines no nutritivos. El Decálogo de Chinchón es fruto de una reunión de reflexión y consenso por parte de un grupo de expertos procedentes de distintas disciplinas científicas (toxicología, nutrición clínica, nutrición comunitaria, fisiología, bromatología, salud pública, atención primaria, pediatría, endocrinología y nutrición, enfermería, atención farmacéutica y legislación alimentaria). El decálogo incluye diferentes aspectos de los EBSC relacionados con la legislación, uso, beneficios y seguridad. En general, los beneficios de los EBSC han sido tradicionalmente desatendidos en comparación con la tendencia de destacar posibles riesgos inexistentes o que no han sido probados. Hace especial hincapié en la necesidad de fortalecer la investigación de los EBSC en España, así como la necesidad de formar en este ámbito a los profesionales y a los consumidores en general.
Subject(s)
Sweetening Agents , Body Weight , Dental Health Surveys , History, 20th Century , Humans , Legislation, Food , Sweetening Agents/adverse effects , Sweetening Agents/history , Taste/physiologyABSTRACT
Multidisciplinary experts in the areas of nutrition and health met in Chinchón, Madrid, on November 25-26, 2013 under the auspices of the Fundación para la Investigación Nutricional (Nutrition Research Foundation) and with the collaboration of the Madrid Regional Governments Health Ministry, the International Sweeteners Association and the Carlos III Health Institute CIBER of Physiopathology of Obesity and Nutrition. They analyzed the current status of scientific knowledge on low- and no-calorie sweeteners (LNCS) and developed a consensus Decalogue on their use; this constitutes the Chinchón Declaration. Sweeteners, including sugar, represent a subject of undeniable interest and are currently a popular topic, although areas relating to their safety and benefits remain unknown to segments of academia and the general public. The nature of LNCS makes them vulnerable to biased and even contradictory information. They are food additives that are broadly used as sugar substitutes to sweeten foods, medicines and food supplements when non-nutritional or non-caloric alternatives are needed. The Chinchón Decalogue is the outcome of a meeting for reflection and consensus by a group of experts with backgrounds in different scientific disciplines (toxicology, clinical nutrition, community nutrition, physiology, food science, public health, pediatrics, endocrinology and nutrition, nursing, pharmaceutical care and food legislation). The Decalogue includes different aspects of LNCS related to regulation, use, benefits and safety. In general, benefits of LNCS have been traditionally neglected in comparison with the tendency for emphasising unexisting or unproven possible risks. The need to strengthen research on LNCS in Spain was emphasized, as well as the need to educate both professionals and the public (AU)
Expertos de carácter multidisciplinar de las áreas de conocimiento de la nutrición y la salud reunidos en Chinchón, Madrid, los días 25 y 26 de noviembre de 2013 , bajo los auspicios de la Fundación para la Investigación Nutricional y con la colaboración de la Consejería de Sanidad del Gobierno de la Comunidad de Madrid, la International Sweeteners Association y el CIBER de Fisiopatología de la Obesidad y la Nutrición del Instituto de Salud Carlos III, analizaron el estado actual del conocimiento científico en torno a los Edulcorantes sin y bajos en calorías (ESBC) y desarrollaron un Decálogo sobre su uso que constituye la Declaración de Chinchón. Los edulcorantes, incluido el azúcar, constituyen un elemento de indudable interés y actualidad, aunque no exento de desconocimiento por algunos sectores tanto académicos como de la población en general. La propia naturaleza de los ESBC los hace susceptibles de informaciones tergiversadas e incluso contradictorias. Son aditivos alimentarios ampliamente utilizados como sustitutivos del azúcar para endulzar alimentos, medicamentos y complementos alimenticios cuando se persiguen fines no nutritivos. El Decálogo de Chinchón es fruto de una reunión de reflexión y consenso por parte de un grupo de expertos procedentes de distintas disciplinas científicas (toxicología, nutrición clínica, nutrición comunitaria, fisiología, bromatología, salud pública, atención primaria, pediatría, endocrinología y nutrición, enfermería, atención farmacéutica y legislación alimentaria). El decálogo incluye diferentes aspectos de los EBSC relacionados con la legislación, uso, beneficios y seguridad. En general, los beneficios de los EBSC han sido tradicionalmente desatendidos en comparación con la tendencia de destacar posibles riesgos inexistentes o que no han sido probados. Hace especial hincapié en la necesidad de fortalecer la investigación de los EBSC en España, así como la necesidad de formar en este ámbito a los profesionales y a los consumidores en general (AU)
Subject(s)
Humans , Sweetening Agents/analysis , Nutritive Value , Drug-Related Side Effects and Adverse Reactions/epidemiology , Sweetening Agents , Non-Nutritive Sweeteners/analysis , Nutritive Sweeteners/analysis , Patient SafetyABSTRACT
No disponible
Subject(s)
Humans , Male , Female , Infant , Child, Preschool , Gastroenteritis , Practice Patterns, Physicians'/organization & administration , Guidelines as Topic/standardsABSTRACT
No disponible
