Skip to main content
SpringerLink
Log in
Book cover

Textbook of Aging Skin pp 1–14Cite as

Cutaneous Effects and Sensitive Skin with Incontinence in the Aged

  • Living reference work entry
  • First Online:

Abstract

Urinary and fecal incontinence affects a significant portion of the elderly population. While reported prevalence rates vary widely, incontinence tends to increase with age and becomes a relatively common affliction in those over 50. Although urinary and fecal incontinence increases with age, neither are natural sequelae of aging, but disorders which could be treated. Occlusion of the skin, often induced by incontinence pads or other containment devices, has a profound influence on the skin surface. Incontinence in aged skin has the potential to produce chemical irritation, mechanical injury, and increased susceptibility to incontinence dermatitis, dermal infections (both fungal and bacterial), intertrigo, vulvar folliculitis, pruritus ani, and pressure ulcers. Urinary incontinence also represents a psychosocial burden and is associated with a variety of psychiatric disorders. Dermatologists who are knowledgeable about geriatric issues can help to maintain the health and quality of life of their older patients.

This is a preview of subscription content, log in via an institution.

References

  1. Millard RJ, Moore KH. Urinary incontinence: the Cinderella subject. Med J Aust. 1996;165:124–5.

    CAS  PubMed  Google Scholar 

  2. Geriatric medicine. In: Tierney L, McPhee S, Papadakis M, editors. Geriatric medicine. In Current medical diagnosis and treatment 2000. New York: 39th McGraw Hill; 1999;62.

    Google Scholar 

  3. Farage MA, Bramante M. Genital hygiene: culture, practices, and health impact. In: Farage M, Maibach H, editors. The vulva: anatomy, physiology, and pathology. New York: LLC, Routledge/Taylor & Francis Group; 2006.

    Chapter  Google Scholar 

  4. Roberts RO, Jacobsen SJ, Reilly WT, et al. Prevalence of combined fecal and urinary incontinence: a community-based study. J Am Geriatr Soc. 1999;47:837–41.

    Article  CAS  PubMed  Google Scholar 

  5. Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. Vital Health Stat. 2014;3:1–33.

    Google Scholar 

  6. Cooper ZR, Rose S. Fecal incontinence: a clinical approach. Mt Sinai J Med. 2000;67:96–105.

    CAS  PubMed  Google Scholar 

  7. Haugen V. Perineal skin care for patients with frequent diarrhea or fecal incontinence. Gastroenterol Nurs. 1997;20:87–90.

    Article  CAS  PubMed  Google Scholar 

  8. Nelson RL, Furner SE. Risk factors for the development of fecal and urinary incontinence in Wisconsin nursing home residents. Maturitas. 2005;52:26–31.

    Article  PubMed  Google Scholar 

  9. Stevens TK, Soffer EE, Palmer RM. Fecal incontinence in elderly patients: common, treatable, yet often undiagnosed. Cleve Clin J Med. 2003;70:441–8.

    Article  PubMed  Google Scholar 

  10. Gray M. Preventing and managing perineal dermatitis: a shared goal for wound and continence care. J Wound Ostomy Continence Nurs. 2004;31:S2–9. quiz S10–2.

    Article  PubMed  Google Scholar 

  11. Farage MA, Miller KW, Berardesca E, et al. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis. 2007;57:211–7.

    Article  PubMed  Google Scholar 

  12. Burti JS, Santos AMB, Pereira RMR, et al. Prevalence and clinical characteristics of urinary incontinence in elderly individuals of a low income. Arch Gerontol Geriatr. 2012;54:e42–6.

    Article  PubMed  Google Scholar 

  13. Chew AL, Maibach HI, editors. Irritant Dermatitis. Berlin/Heidleberg Springer; 2005.

    Google Scholar 

  14. Rippke F, Schreiner V, Doering T, et al. Stratum corneum pH in atopic dermatitis: impact on skin barrier function and colonization with staphylococcus aureus. Am J Clin Dermatol. 2004;5:217–23.

    Article  PubMed  Google Scholar 

  15. Grubauer G, Elias PM, Feingold KR. Transepidermal water loss: the signal for recovery of barrier structure and function. J Lipid Res. 1989;30:323–33.

    CAS  PubMed  Google Scholar 

  16. Zhai H, Maibach HI. Occlusion vs. skin barrier function. Skin Res Technol. 2002;8:1–6.

    Article  PubMed  Google Scholar 

  17. Aly R, Shirley C, Cunico B, et al. Effect of prolonged occlusion on the microbial flora, pH, carbon dioxide and transepidermal water loss on human skin. J Invest Dermatol. 1978;71:378–81.

    Article  CAS  PubMed  Google Scholar 

  18. Zhai H, Maibach H. Effects of occlusion: percutaneous absorption. In: Bronaugh R, Maibach H, editors. Percutaneous absorption, drug-cosmetics-mechanisms-methodology. Boca Raton: Taylor and Francis; 2005.

    Google Scholar 

  19. Taljebini M, Warren R, Mao-Oiang M, et al. Cutaneous permeability barrier repair following various types of insults: kinetics and effects of occlusion. Skin Pharmacol. 1996;9:111–9.

    Article  CAS  PubMed  Google Scholar 

  20. Fisher LB, Maibach HI, Trancik RJ. Variably occlusive tape systems and the mitotic activity of stripped human epidermis. Effects with and without hydrocortisone. Arch Dermatol. 1978;114:727–9.

    Article  CAS  PubMed  Google Scholar 

  21. Proksch E, Feingold KR, Man MQ, et al. Barrier function regulates epidermal DNA synthesis. J Clin Invest. 1991;87:1668–73.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  22. Emilson A, Lindberg M, Forslind B, et al. Quantitative and 3-dimensional analysis of Langerhans’ cells following occlusion with patch tests using confocal laser scanning microscopy. Acta Derm Venereol. 1993;73:323–9.

    CAS  PubMed  Google Scholar 

  23. Proksch E, Brasch J, Sterry W. Integrity of the permeability barrier regulates epidermal Langerhans cell density. Br J Dermatol. 1996;134:630–8.

    Article  CAS  PubMed  Google Scholar 

  24. Wood LC, Elias PM, Calhoun C, et al. Barrier disruption stimulates interleukin-1 alpha expression and release from a pre-formed pool in murine epidermis. J Invest Dermatol. 1996;106:397–403.

    Article  CAS  PubMed  Google Scholar 

  25. Zhai H, Maibach HI. Skin occlusion and irritant and allergic contact dermatitis: an overview. Contact Dermatitis. 2001;44:201–6.

    Article  CAS  PubMed  Google Scholar 

  26. Kligman A. Hydration injury to human skin. In: Van der Valk P, Maibach H, editors. The irritant contact dermatitis syndrome. Boca Raton: CRC Press; 1996.

    Google Scholar 

  27. Beguin A, Malaquin-Pavan E, Guihaire C, et al. Improving diaper design to address incontinence associated dermatitis. BMC Geriatr. 2010;10:86.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Zulkowski K. Protecting your patient’s aging skin. Nursing. 2003;33:84.

    Article  PubMed  Google Scholar 

  29. Waller JM, Maibach HI. Age and skin structure and function, a quantitative approach (I): blood flow, pH, thickness, and ultrasound echogenicity. Skin Res Technol. 2005;11:221–35.

    Article  PubMed  Google Scholar 

  30. Cerruto MA, D’Elia C, Aloisi A, et al. Prevalence, incidence and obstetric factors’ impact on female urinary incontinence in Europe: a systematic review. Urol Int. 2013;90:1–9.

    Article  PubMed  Google Scholar 

  31. Fiers SA. Breaking the cycle: the etiology of incontinence dermatitis and evaluating and using skin care products. Ostomy Wound Manage. 1996;42:32–4. 36, 38–40, passim.

    CAS  PubMed  Google Scholar 

  32. Zimmerer RE, Lawson KD, Calvert CJ. The effects of wearing diapers on skin. Pediatr Dermatol. 1986;3:95–101.

    Article  CAS  PubMed  Google Scholar 

  33. Andersen PH, Maibach HI. Skin irritation in man: a comparative bioengineering study using improved reflectance spectroscopy. Contact Dermatitis. 1995;33:315–22.

    Article  CAS  PubMed  Google Scholar 

  34. Nangia A, Andersen PH, Berner B, et al. High dissociation constants (pKa) of basic permeants are associated with in vivo skin irritation in man. Contact Dermatitis. 1996;34:237–42.

    CAS  PubMed  Google Scholar 

  35. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol. 1986;3:102–6.

    Article  CAS  PubMed  Google Scholar 

  36. Berg RW. Etiologic factors in diaper dermatitis: a model for development of improved diapers. Pediatrician. 1987;14 Suppl 1:27–33.

    PubMed  Google Scholar 

  37. Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol. 1994;11:18–20.

    Article  CAS  PubMed  Google Scholar 

  38. Andersen PH, Bucher AP, Saeed I, et al. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis. 1994;30:152–8.

    Article  CAS  PubMed  Google Scholar 

  39. Sivamani R, Wu G, Maibach H, et al. Tribological studies on skin: measurement of the coefficient of friction. In: Serup J, Jemec B, Grove G, editors. Handbook of non-invasive methods and the skin. Boca Raton: Taylor and Francis; 2006.

    Google Scholar 

  40. Panel for the prediction and prevention of pressure ulcers in adults. Pressure ulcers in adults: prediction and prevention. US Department of Health and Human Services, Agency for Health Care Policy and Research; 1992.

    Google Scholar 

  41. Roskos KV, Guy RH. Assessment of skin barrier function using transepidermal water loss: effect of age. Pharm Res. 1989;6:949–53.

    Article  CAS  PubMed  Google Scholar 

  42. Brown DS. Perineal dermatitis: can we measure it? Ostomy Wound Manage. 1993;39:28–30. 31.

    CAS  PubMed  Google Scholar 

  43. Fiers S, Thayer D. Management of intractable incontinence. In: Doughty D, editor. Urinary and fecal incontinence: nursing management. St. Louis: Mosby; 2000.

    Google Scholar 

  44. Scardillo J, Aronovitch SA. Successfully managing incontinence-related irritant dermatitis across the lifespan. Ostomy Wound Manage. 1999;45:36–40. 42–4.

    CAS  PubMed  Google Scholar 

  45. Long MA, Reed LA, Dunning K, et al. Incontinence-associated dermatitis in a long-term acute care facility. J Wound Ostomy Continence Nurs. 2012;39:318–27.

    Article  PubMed  Google Scholar 

  46. Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;39:61–74.

    Article  PubMed  Google Scholar 

  47. Gray M. Context for WOC practice: peristomal recurrence of Crohn’s disease, hospital-acquired pressure ulcers, negative pressure wound therapy, and incontinence-associated dermatitis. J Wound Ostomy Continence Nurs. 2012;39:227–9.

    Article  PubMed  Google Scholar 

  48. Kirss F, Lang K, Toompere K, et al. Prevalence and risk factors of urinary incontinence among Estonian postmenopausal women. Springerplus. 2013;2:524.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Bliss DZ, Harms S, Garrard JM, et al. Prevalence of incontinence by race and ethnicity of older people admitted to nursing homes. J Am Med Dir Assoc. 2013;14:451.e1–7.

    Article  Google Scholar 

  50. Whitman D. Intra-abdominal infections: pathophysiology and treatment. Frankfurt: Hoechst; 1991.

    Google Scholar 

  51. Lutz J. Etiology of adult incontinence dermatitis. Pre-conference workshop: device use and skin care management of incontinence. Multispecialty Nursing Conference on Urinary Continence in Adults. Phoenix. 20 Jan 1984.

    Google Scholar 

  52. Rohwer K, Bliss DZ, Savik K. Incontinence-associated dermatitis in community-dwelling individuals with fecal incontinence. J Wound Ostomy Continence Nurs. 2013;40:181–4.

    Article  PubMed Central  PubMed  Google Scholar 

  53. Shannon ML, Lehman CA. Protecting the skin of the elderly patient in the intensive care unit. Crit Care Nurs Clin North Am. 1996;8:17–28.

    CAS  PubMed  Google Scholar 

  54. Lyder CH, Clemes-Lowrance C, Davis A, et al. Structured skin care regimen to prevent perineal dermatitis in the elderly. J ET Nurs. 1992;19:12–6.

    CAS  PubMed  Google Scholar 

  55. Skin bacteria and their role in infection. New York: McGraw-Hill; 1965.

    Google Scholar 

  56. Miller J, Hoffman E. The causes and consequences of overactive bladder. J Womens Health (Larchmt). 2006;15:251–60.

    Article  Google Scholar 

  57. Sibbald RG, Campbell K, Coutts P, et al. Intact skin – an integrity not to be lost. Ostomy Wound Manage. 2003;49:27–8. 30, 33 passim, contd.

    PubMed  Google Scholar 

  58. Bardsley A. Prevention and management of incontinence-associated dermatitis. Nurs Stand. 2013;27:41–6.

    Article  PubMed  Google Scholar 

  59. Shenefelt PD, Fenske NA. Aging and the skin: recognizing and managing common disorders. Geriatrics. 1990;45:57–9. 63-6.

    CAS  PubMed  Google Scholar 

  60. Maibach HI, Kligman AM. The biology of experimental human cutaneous moniliasis (Candida albicans). Arch Dermatol. 1962;85:233–57.

    Article  CAS  PubMed  Google Scholar 

  61. LeLievre S. Skin care for older people with incontinence. Elder Care. 2000;11:36–8.

    CAS  PubMed  Google Scholar 

  62. Krasner D. Alterations in skin integrity related to continence management/incontinence: some problems and solutions. Ostomy Wound Manage. 1990;28:62–3.

    CAS  PubMed  Google Scholar 

  63. Omura Y, O’Young B, Jones M, et al. Caprylic acid in the effective treatment of intractable medical problems of frequent urination, incontinence, chronic upper respiratory infection, root canalled tooth infection, ALS, etc., caused by asbestos & mixed infections of Candida albicans, Helicobacter pylor i & Cytomegalovirus with or without other microorganisms & mercury. Acupunct Electrother Res. 2011;36:19–64.

    Article  PubMed  Google Scholar 

  64. Scheinfeld N. Infections in the elderly. Dermatol Online J. 2005;11:8.

    PubMed  Google Scholar 

  65. Caquant F, Collinet P, Deruelle P, et al. Perineal cellulitis following trans-obturator sub-urethral tape Uratape. Eur Urol. 2005;47:108–10.

    Article  CAS  PubMed  Google Scholar 

  66. Connolly TP. Necrotizing surgical site infection after tension-free vaginal tape. Obstet Gynecol. 2004;104:1275–6.

    Article  PubMed  Google Scholar 

  67. Nathan L. Vulvovaginal disorders in the elderly woman. Clin Obstet Gynecol. 1996;39:933–45.

    Article  CAS  PubMed  Google Scholar 

  68. Edlich RF, Winters KL, Woodard CR, et al. Pressure ulcer prevention. J Long Term Eff Med Implants. 2004;14:285–304.

    Article  PubMed  Google Scholar 

  69. Temkin-Greener H, Cai S, Zheng NT, et al. Nursing home work environment and the risk of pressure ulcers and incontinence. Health Serv Res. 2012;47:1179–200.

    Article  PubMed Central  PubMed  Google Scholar 

  70. Fader M, Clarke-O’Neill S, Cook D, et al. Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health. J Clin Nurs. 2003;12:374–86.

    Article  PubMed  Google Scholar 

  71. Clever K, Smith G, Bowser C, et al. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy Wound Manage. 2002;48:60–7.

    PubMed  Google Scholar 

  72. Thompson P, Langemo D, Anderson J, et al. Skin care protocols for pressure ulcers and incontinence in long-term care: a quasi-experimental study. Adv Skin Wound Care. 2005;18:422–9.

    Article  PubMed  Google Scholar 

  73. Beeckman D, Woodward S, Rajpaul K, et al. Clinical challenges of preventing incontinence-associated dermatitis. Br J Nurs. 2011;20:784–6. 788,790.

    Article  PubMed  Google Scholar 

  74. Bryant R. Acute and chronic wounds: nursing management. St. Louis: Mosby; 1992.

    Google Scholar 

  75. Corcoran E, Woodward S. Incontinence-associated dermatitis in the elderly: treatment options. Br J Nurs. 2013;22:450–2. 454–7.

    Article  PubMed  Google Scholar 

  76. Beldon P. Incontinence-associated dermatitis: protecting the older person. Br J Nurs. 2012;21:402. 404–7.

    Article  PubMed  Google Scholar 

  77. Nix D, Haugen V. Prevention and management of incontinence-associated dermatitis. Drugs Aging. 2010;27:491–6.

    Article  PubMed  Google Scholar 

  78. Talasz H, Jansen SC, Kofler M, et al. High prevalence of pelvic floor muscle dysfunction in hospitalized elderly women with urinary incontinence. Int Urogynecol J. 2012;23:1231–7.

    Article  PubMed  Google Scholar 

  79. Beeckman D, Woodward S, Gray M. Incontinence-associated dermatitis: step-by-step prevention and treatment. Br J Community Nurs. 2011;16:382–9.

    Article  PubMed  Google Scholar 

  80. Gray M. Optimal management of incontinence-associated dermatitis in the elderly. Am J Clin Dermatol. 2010;11:201–10.

    Article  PubMed  Google Scholar 

  81. Farage MA, Maibach HI. Sensitive skin: new findings yield new insights. In: Baran R, Maibach HI, editors. Textbook of cosmetic dermatology. New York: Informa Healthcare; 2010.

    Google Scholar 

  82. Farage MA, Miller KW, Maibach HI. Degenerative changes in aging skin. In: Farage MA, Miller KW, Maibach HI, editors. Textbook of aging skin. Berlin/Heidleberg: Springer; 2010.

    Chapter  Google Scholar 

  83. Farage MA. Perceptions of sensitive skin with age. In: Farage MA, Miller KM, Maibach HI, editors. Textbook of aging skin. Berlin/Heidleberg: Springer; 2010.

    Chapter  Google Scholar 

  84. Sparavigna A, Di Pietro A, Setaro M. ‘Healthy skin’: significance and results of an Italian study on healthy population with particular regard to ‘sensitive’ skin. Int J Cosmet Sci. 2005;27:327–31.

    Article  CAS  PubMed  Google Scholar 

  85. Stach-Lempinen B, Hakala A, Laippala P, et al. Severe depression determines quality of life in urinary incontinent women. Neurourol Urodyn. 2003;22:563–8.

    Article  PubMed  Google Scholar 

  86. Perry S, McGrother CW, Turner K. An investigation of the relationship between anxiety and depression and urge incontinence in women: development of a psychological model. Br J Health Psychol. 2006;11:463–82.

    Article  PubMed  Google Scholar 

  87. Jackson S. The patient with an overactive bladder – symptoms and quality-of-life issues. Urology. 1997;50:18–22. discussion 23–4.

    Article  CAS  PubMed  Google Scholar 

  88. Specht JKP. 9 myths of incontinence in older adults: both clinicians and the over-65 set need to know more. Am J Nurs. 2005;105:58–68. quiz 69.

    Article  PubMed  Google Scholar 

  89. Farage MA, Miller KW, Berardesca E, et al. Psychosocial and societal burden of incontinence in the aged population: a review. Arch Gynecol Obstet. 2008;277:285–90.

    Article  PubMed  Google Scholar 

  90. Farage MA, Maibach HI. The vulvar epithelium differs from the skin: implications for cutaneous testing to address topical vulvar exposures. Contact Dermatitis. 2004;51:201–9.

    Article  PubMed  Google Scholar 

  91. Britz MB, Maibach HI, Anjo DM. Human percutaneous penetration of hydrocortisone: the vulva. Arch Dermatol Res. 1980;267:313–6.

    Article  CAS  PubMed  Google Scholar 

  92. Farage MA, Warren R, Wang-Weigand S. The vulva is relatively insensitive to menses-induced irritation. Cutan Ocul Toxicol. 2005;24:243–6.

    Article  PubMed  Google Scholar 

  93. Squier CA, Hall BK. The permeability of skin and oral mucosa to water and horseradish peroxidase as related to the thickness of the permeability barrier. J Invest Dermatol. 1985;84:176–9.

    Article  CAS  PubMed  Google Scholar 

  94. Farage MA, Stadler A, Elsner P, et al. Safety evaluation of modern feminine hygiene pads: two decades of use. Female Patient. 2004;29:23–30.

    Google Scholar 

  95. Farage MA, Bowtell P, Katsarou A. The relationship among objectively assessed vulvar erythema, skin sensitivity, genital sensitivity, and self-reported facial skin redness. J Appl Res. 2006;6:272.

    Google Scholar 

  96. Lee CH, Maibach HI. The sodium lauryl sulfate model: an overview. Contact Dermatitis. 1995;33:1–7.

    Article  PubMed  Google Scholar 

  97. Basketter DA, Wilhelm KP. Studies on non-immune immediate contact reactions in an unselected population. Contact Dermatitis. 1996;35:237–40.

    Article  CAS  PubMed  Google Scholar 

  98. Farage MA. Vulvar susceptibility to contact irritants and allergens: a review. Arch Gynecol Obstet. 2005;272:167–72.

    Article  PubMed  Google Scholar 

  99. Marren P, Wojnarowska F, Powell S. Allergic contact dermatitis and vulvar dermatoses. Br J Dermatol. 1992;126:52–6.

    Article  CAS  PubMed  Google Scholar 

  100. Farage MA. Perceptions of sensitive skin: women with urinary incontinence. Arch Gynecol Obstet. 2009;280:49–57.

    Article  PubMed  Google Scholar 

  101. Agency for Health Care Policy and Research (AHCPR). Overview: urinary incontinence in adults, clinical practice guideline update. http://www.ahrq.gov/clinic/uiovervw.htm. Accessed 18 Jan 2015.

Download references

Author information

Authors and Affiliations

  1. The Procter & Gamble Company, Winton Hill Business Center, 6110 Center Hill Avenue, Cincinnati, OH, 45224, USA

    Miranda A. Farage & Kenneth W. Miller

  2. San Gallicano Dermatological Institute, Rome, Italy

    Enzo Berardesca

  3. Department of Dermatology, University of San Francisco, 90 Medical Center Way, Surge 110, 0989, San Francisco, CA, 94143-0989, USA

    Howard I. Maibach

Authors
  1. Miranda A. Farage
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kenneth W. Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enzo Berardesca
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Howard I. Maibach
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Miranda A. Farage .

Editor information

Editors and Affiliations

  1. Procter & Gamble Co., Cincinnati, Ohio, USA

    Miranda A. Farage

  2. Procter & Gamble Co., Cincinnati, Ohio, USA

    Kenneth W. Miller

  3. Department Dermatology, University of California, San Francisco School of Medicine, San Francisco, California, USA

    Howard I. Maibach

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer-Verlag Berlin Heidelberg

About this entry

Cite this entry

Farage, M.A., Miller, K.W., Berardesca, E., Maibach, H.I. (2015). Cutaneous Effects and Sensitive Skin with Incontinence in the Aged. In: Farage, M., Miller, K., Maibach, H. (eds) Textbook of Aging Skin. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-27814-3_64-2

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-27814-3_64-2

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Online ISBN: 978-3-642-27814-3

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation