A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis.

Acute pancreatitis (AP) has seen an increase in the incidence in recent years, with several studies reporting a rate of 3.6-13.2/100,000 per year.[] Although it is seen at all ages in the pediatric patient group, the mean age at diagnosis is 9 years, and the male-female ratio is 1:2. (1) Within the etiology of childhood AP, the most frequently seen cause is bile duct diseases, but drugs, trauma, systemic diseases, and sepsis also play a role in the etiology. In approximately 25% of patients, no agent or reason can be found.[,] In the majority of AP cases, tissue damage is self-limiting. Although there is generally a mild clinical course in children, there are studies that have reported complications and even death. Laboratory values, radiological imaging, scoring, and classifications can be used to provide information about the course and prognosis of the disease.[,] We aimed to investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children with AP. The study also included genetic studies of recurrent cases.

The study included pediatric patients aged <18 years who were diagnosed with AP and were followed up with recurrent pancreatitis in the Pediatric Health and Diseases Department of our University Medical Faculty Hospital between January 2010 and April 2021. Patients who were followed up with chronic pancreatitis were not included in the study. Patient information was obtained retrospectively from patient files and computer records and was analyzed. The criteria defined by the International Pediatric Pancreatitis Working Group (INSPPIRE) were used in the diagnosis of AP.[] Patients were classified as mild, moderate, or severe using the Atlanta classification.[] In the current study, the demographic, etiological, and clinical data, complications that developed, pathology evaluations of samples taken, and genetic analysis results were recorded of children followed up in our hospital with a diagnosis of AP. The length of stay in the hospital and complications were reviewed. Differences between these case groups were evaluated. The age, gender, and anthropometric data of the patients at the time of presentation, personal and family history information, genetic factors, complaints on presentation, etiology, physical examination findings, treatments applied in hospital, length of stay in hospital, complications that developed and causes of morbidity and mortality were examined. All the study procedures were in compliance with the principles of the Helsinki Declaration. Approval for the study was granted by the Non-Interventional Research Ethics Committee of our University (decision no: 2021/04-09, dated: 18.03.2021). Statistical analysis Data obtained in the study were analyzed statistically using SPSS version 26.0 software. The conformity of the variables to normal distribution was assessed with the Kolmogorov-Smirnov test. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). In the analysis of independent quantitative data, the Mann-Whitney U-test was used. In the analysis of qualitative data, the Chi-square test was used, or if test assumptions were not met, the Fischer test was applied.

Evaluation was made of 54 (50%) female and 54 (50%) male patients, with a mean age of 9.96 ± 4.8 years (range, 2-17 years). A diagnosis of acute recurrent pancreatitis was made in 23 (21%) patients, and chronic pancreatitis in 8 (7%). Parental consanguinity was present in 24 (22.2%) patients, and family history was determined in 6 (5.6%) patients. The mean body weight of patients was 38.44 ± 23.32 kg, the mean height was 137.19 ± 27.89 cm, and the mean body mass index (BMI) was calculated as 18.31 ± 5.29 kg/m2. Obesity was determined in 6 (5%) patients. Acute protein energy malnutrition was determined to have developed in 16 (14%) patients, and chronic protein energy malnutrition was present in 24 (22%). The most common complaint recorded was abdominal pain (94.4%), vomiting in 65 (60.2%) patients, followed by malnutrition in 39 (36.1%), nausea in 19 (17.6%), diarrhea in 14 (13%), and fever in 14 (13%). The etiology of AP was idiopathic in 21 (19.4%) patients. In the patients where etiology could be determined, hyperlipidemia was present in 21 (19.4%) patients, cholelithiasis in 17 (15.7%), and malnutrition in 13 (12%). The distribution of the most frequently seen etiologies of the cases is shown in Table 1. There were determined to be 4 (3%) patients with systemic disease, with a diagnosis of type 1 diabetes mellitus, Alport syndrome, nephrotic syndrome, Wilson disease, autoimmune chronic hepatitis, and liver storage disease. One patient had a history of operated parathyroid adenoma. One patient was followed up with a diagnosis of the annular pancreas and one with a diagnosis of an operated choledochal cyst. In one patient, calculi developed in the gall bladder as a result of sudden weight loss and consequently, there was a history of acute pancreatitis. Hypocalcaemia was observed in 2 patients and hypercalcemia in one patient. Uremia was determined in 3 (2%) patients and anemia in one. Sepsis and disseminated intravascular coagulopathy were observed to have developed in one patient. The complications that developed in patients during follow-up are shown in Table 2. Genetic tests in respect of recurrent pancreatitis and chronic pancreatitis were requested for 19 (17.6%) patients. In these patients, PRSS1, PRSS2, CFTR, and SPINK1 gene mutations were investigated. PRSS1 positivity was determined in 2 (1.9%) of the patients, and PRSS1 gene negativity was observed in 17 (16.3%). No PRSS2 gene mutation was determined in any patient. The PRSS2 genetic analysis was determined to be negative in one patient. SPINK1 mutation was positive in 1 (0.9%) patient and negative in 18 (19.4%). No CTRC gene mutation was determined in any patient. PRSS2 pseudogene mutation was determined to be positive in 7 (6.5%) patients. The laboratory values of the patients at the time of presentation are shown in Table 3. A significant increase in amylase and/or lipase was determined in 92 (85.2%) patients at the time of presentation. Of these patients, the increase in both amylase and lipase was accepted as significant in 44 (40%). The imaging findings of the patients at the time of presentation are shown in Table 4. The results of ERCP and endoscopic USG applied with interventional methods are presented in Tables 5 and 6. The pathology results obtained for the patients are shown in Table 7. Percutaneous cystostomy and drainage procedures were applied to one patient, cholecystectomy to two patients, hepaticojejunostomy to one, liver cyst drainage to one, and cystogastrostomy to one. Blood culture was taken from 18 (16%) patients and urine culture from 15 (13%). Reproduction was determined in the blood cultures of 5 (4%) patients and in the urine cultures of 5 (4%). S. epidermidis, Coagulase negative staphylococci, streptococcus strains, Enterobacter cloacea, and Streptococcus parasanguinis were determined as agents in the blood cultures, and S. intermedius, streptococcus strains, E. coli, and E. faeceum in the urine cultures. On the radiological images of the cases according to the Atlanta classification, the clinical condition defined was seen to be accompanied by findings of pancreatic-peripancreatic fluid collection and pancreatic necrosis in moderate-severe AP cases, and in severe pancreatitis, organ failure lasting longer than 48 hours.[] A total of 108 patients were evaluated radiologically. Mild pancreatitis was determined to have developed in 71 (65.7%). In 37 (34.3%), peripancreatic fluid and pancreatic necrosis were observed radiologically and these patients were thought to have developed moderate-severe pancreatitis. Patients were also evaluated in respect of admission to the Intensive Care Unit (ICU). The mean length of stay in ICU was 6.85 ± 5.92 days, and total parenteral nutrition (TPN) was applied to 34 (31.5%) patients. The laboratory results were compared between the patients with mild AP and those with moderate-severe AP to determine results at a level of statistical significance (P < 0.05). The results of the comparisons are shown in Table 8. The comparisons of the results of the mild AP patients and the moderate-severe AP patients with those of the patients admitted to the ICU are shown in Tables 9 and 10. From the data in Tables 8-10, when the significance of the P values was examined for the leukocyte, amylase, lipase, GGT, total bilirubin, direct bilirubin, calcium, and CRP parameters, length of stay in the hospital, and time for amylase and lipase to return to normal after treatment, there was determined to be a highly statistically significant difference between the mild AP and moderate-severe AP groups in respect of amylase and lipase levels (P < 0.05). A statistically significant difference was determined between the mild AP patients and the patients admitted to ICU in respect of CRP values (P < 0.05). A statistically significant difference was determined between the moderate-severe AP patients and the patients admitted to the ICU in respect of amylase values (P < 0.05). These results showing a significant level of difference can be of guidance for which parameters to use in the follow-up of patients.

Acute pancreatitis (AP), which has a currently increasing frequency in childhood, is an acute inflammatory disease, in which systemic and local effects can be seen in the body.[] Acute pancreatitis can be seen at any age in childhood. Vitale et al.[] examined 118 children diagnosed with AP between 2013 and 2017 and reported the mean age to be 13.56 ± 13.47 years. In the same study, the male/female numbers were reported to be 62/56, which was a ratio of 1.1:1. In another study by Nauka et al.,[] there were 79 males and 33 females with the male: female ratio determined as 1.39:1, and mean age of 14 ± 1.63 years. The current study included 54 males and 54 females, and chronic pancreatitis was observed to have developed in 8 at a later stage. The remaining 100 patients comprised 50 males and 50 females at a ratio of 1:1, with a mean age of 9.96 ± 4.8 years (range, 2-17 years). The most common complaints on presentation in the current study were abdominal pain (94.4%), vomiting (60.2%), malnutrition (36.1%), nausea (17.6%), diarrhea (13%) and fever (13%). In a study by Lal et al.[] of 101 children, complaints were reported as abdominal pain (94%), vomiting (10.9%), and abdominal distension (6.9%). In another study by Grzybowska-Chlebowczyk et al.,[] symptoms were largely abdominal pain in 73 of 76 (96%) patients, vomiting in 31 (40.8%), and fever in 3 (3.8%). When the etiology was examined in the current study, idiopathic cases were determined most often at the rate of 19.4%. The known etiologies were observed to be hyperlipidemia at 19.4%, cholelithiasis at 15.7%, malnutrition at 12%, and choledocholithiasis at 7.4%. Acute pancreatitis was determined to have developed as a result of drug use in 5.6% of patients. In a study by Sweeny et al.,[] the etiology in 115 children with AP was reported as 31% idiopathic, 23% drug use, 18% biliary or gallstones, and 17% viral infection or systemic diseases. In the study by Grzybowska-Chlebowczyk et al.,[] the causes were reported as idiopathic in 22 (43.1%) of 76 patients, biliary in 15 (29.4%), and genetic factors in 8 (15.8%). The complications that developed in the current study were observed radiologically as inferior vena cava compression in 3 (2.8%) patients, necrosis of the pancreas in 3 (2.8%), pancreatic pseudocyst in 2 (1.9%), and choledochal cyst in 2 (1.9%). Birimberg-Schwartz et al.[] examined complications in a study of 312 patients; pseudocyst was determined in 9% of the patients, organ failure in 7%, and necrotizing pancreatitis in 5%. In another study of 130 patients, Zhong et al.[] reported peripancreatic fluid accumulation in 23 (17%), pancreatic pseudocyst in 14 (10.7%), and SIRS in 12 (9.2%). Amylase and lipase levels are important as part of the laboratory evaluation in the diagnosis of AP. The diagnostic value of amylase is more significant in the first 24 hours. The serum levels of lipase remain high for longer periods than amylase. Therefore, lipase values are more meaningful in respect of the diagnosis of AP. Increases of 3-fold or more in the amylase and/or lipase values are significant in the diagnosis of AP. In the current study, a ≥3-fold increase in serum levels, which is a diagnostic criterion for amylase and lipase, was not observed on the first presentation of 16 (14.8%) patients. In the remaining 92 (85.2%) patients, the increase in amylase and/or lipase was found to be significant as a diagnostic criterion. In the first presentation, the amylase values were normal in 37 (34%) patients and the lipase values were normal in 17 (15%). In 44 (40%) patients, both the amylase and lipase values were ≥3-fold higher than normal. Of the 11 (10.2%) patients admitted to ICU, the amylase and lipase levels were determined to have increased >3-fold in 6 (5.5%). In one patient, only the amylase value was normal; similarly, in another one, only the lipase value was normal. Furthermore, in 2 (1.8%) patients both the amylase and lipase values were reported as normal. In a study of 101 children by Lal et al.,[] the amylase values were reported to be normal in 22.8% of the patients, and the lipase values in 24.8%. Chlebowczyk et al.[] reported amylase values >3-fold higher than normal in 63 (82.9%) of 76 patients. In 28 of those patients, the lipase values were examined, and the lipase value was determined to be ≥3-fold higher than normal in 19 (25%). When the patients with AP were examined according to the Atlanta classification, the clinical condition of the cases with moderate-severe pancreatitis was confirmed by radiological image findings of pancreatic-peripancreatic fluid collection and pancreatic necrosis and severe pancreatitis by organ failure lasting longer than 48 hours. From this information, when the USG findings were examined, USG was applied to 102 (94.4%) patients, of which the findings were observed to be normal in 20 (18.5%), increased pancreas size was observed in 22 (20.4%), fluid in the abdomen in 18 (16.7%), hepatomegaly in 17 (15.7%), focal pancreatitis in 11 (10.2%), and cholelithiasis in 10 (9.3%). All the patients were evaluated radiologically. Mild pancreatitis was determined to have developed in 73 (67.6%) patients. In the remaining 22 (20.4%) patients, peripancreatic fluid and pancreatic necrosis were seen radiologically. These patients were evaluated for moderate-severe pancreatitis. In a study of 117 patients by Galai et al.,[] pancreatic edema, pancreas expansion, and a small amount of peripancreatic fluid accumulation on radiological imaging were accepted as non-specific findings of pancreas inflammation. These findings were determined in 74 (63%) patients, in 56% of mild AP patients, and in 100% of moderate-severe AP patients. Peripancreatic fluid collection was determined in 15.6% of all the patients and in 93.3% of the moderate-severe cases. Pancreatic necrosis was observed in 2.2% of all the patients and in 13.3% of the moderate-severe cases, while cholelithiasis was reported in 10% of all the patients. Orkin et al.,[] examined 112 patients and reported USG findings of pancreatic edema in 42 (56.8%) patients, peripancreatic edema in 35 (45.9%), peripancreatic fluid collection in 16 (22.2%), and pancreatic canal dilatation in 15 (20.5%). Abdominal USG is extremely useful in the diagnosis of AP and in the determination and evaluation of complications such as pancreatic pseudocyst, peripancreatic fluid accumulation, and abscess. However, USG has specific disadvantages including that it is operator-dependent and in conditions such as obesity or the presence of intense gas in the intestines, a good evaluation of the pancreas cannot be made in these circumstances, USG may also be insufficient in the evaluation of obese patients, those with trauma or anatomic malformations, or patients with severe or complicated pancreatitis. In such patients, contrast computed tomography (CT) may be more useful in diagnosis.[,] Contrast CT is used to show necrosis and peripancreatic inflammation in the differential diagnosis of necrotizing and edematous AP. Although CT has been determined to have 90% sensitivity, which is more sensitive than USG, it has the disadvantage of radiation exposure.[,] In the current study, CT was done in 41 (38%) patients, and the results were determined as 5 (4.6%) normal, an increase in pancreas size in 16 (14.8%), abdominal fluid in 11 (10.2%), focal pancreatitis in 9 (8.3%), edema of the pancreas in 5 (4.6%), and peripancreatic fluid in 5 (4.6%). In the study by Grzybowska-Chlebowczyk et al.,[] CT evaluation was made of 56 (73%) of the total 76 patients, and the findings were reported as pancreas edema in 29 (38%), pancreas necrosis in 5 (6%), cholecystitis, gallbladder stone, and cholelithiasis of biliary causes in 13 (17%). Orkin et al.[] evaluated 36 of 112 patients with CT, and determined pancreatic edema in 27 (75%), peripancreatic edema in 26 (72.2%), and peripancreatic fluid collection in 19 (52.8%). Magnetic resonance cholangiopancreatography (MRCP) is a non-interventional method, useful in the definition of abnormalities in the ductal system. It is superior to CT in the evaluation of damage in the pancreatic canal and fluid collections that require drainage without requiring surgery. In the evaluation before drainage, MRCP has higher sensitivity and specificity than CT and USG. In subacute pancreatic fluid accumulations, MRI should be applied before drainage to avoid infectious complications of undrained or disorganized necrotic debris with the use of traditional pseudocyst drainage techniques. In the determination of prognosis, MRI is more useful than CT.[] Examination with MRCP was applied to 77 (71%) of the current study patients. The MRCP result was normal in 14 (13%) and other findings were reported as focal pancreatitis in 25 (23.1%), increased pancreas size in 21 (19.4%), pancreatic edema in 16 (14.8%), cholelithiasis in 11 (10.2%), peripancreatic fluid in 11 (10.2%), and dilatation in the gall bladder duct in 10 (9.3%). Grzybowska-Chlebowczyk et al.[] evaluated 23 (45%) of 76 patients with MRCP and determined choledocolithiasis in 5 (9.8%) patients, cholelithiasis in 4 (7.8%), and type 4 biliary cyst in 1 female patient. Orkin et al.[] examined 17 of 112 patients with MRCP, and reported pancreatic edema in 15 (88.2%) patients, peripancreatic edema in 13 (76.5%), and peripancreatic fluid collection in 8 (47.1%). Following trauma in pediatric AP patients, endoscopic retrograde cholangiopancreatography (ERCP) is important for the examination of complications associated with pancreatitis and anatomic defects, and for treatment. The absence of improvement in AP and abscess formation are contra-indications for ERCP, and pancreatic pseudocyst is a relative contraindication.[] Performing sphincterectomy during ERCP, and balloon dilatation and injections within the canal are risk factors for the development of pancreatitis after ERCP. Whether or not stent placement is a risk for the development of pancreatitis remains a matter of debate.[,] When the ERCP results of the current study patients were evaluated, of the 22 patients who had ERCP, the diagnosis of acute pancreatitis was determined in 12 (11%), acute recurrent pancreatitis in 5 (4.6%), and chronic pancreatitis in 5 (4.6%). The most common ERCP indications were cases with recurrent pancreatitis which developed bile duct stricture and blockage jaundice. The therapeutic interventions applied to the current study patients were sphincterectomy in 19 (17.6%), and stone excretion procedure in 17 (15.7%). Otto et al.[] applied a total of 231 ERCP procedures to 167 pediatric patients, and reported that acute pancreatitis was diagnosed in 88 patients, recurrent pancreatitis in 68, and chronic pancreatitis in 11. The most common finding at ERCP was gallstones, which were reported in 15 (6%) patients. Therapeutic interventions were applied to 159 (69%) patients, such as sphincterotomy in 96 (42%), stone removal in 55 (24%), and stent placement in 52 (23%). Keil et al.,[] applied 856 ERCP procedures to 656 pediatric patients and reported the therapeutic procedures as placement of biliary drainage catheter in 241 (38.44%), sphincterotomy in 195 (31.1%) and stone excretion in 113 (18.02%). The most common indication in patients for the application of endoscopic USG is the presence of complications leading to recurrent pancreatitis. Endoscopic USG is used for local treatment of pancreatic complications such as biliary pancreatitis, autoimmune pancreatitis, and pseudocyst.[] It is used in particular for the visualization and treatment of gallstones in children aged >5 years.[] There is no radiation exposure. However, there are disadvantages which include it being interventional, and the requirement for sedation: there is also no suitably sized device for infants and very young children, and a specialized team is required for children, all of which limit its use. When the endoscopic USG results of the current study were examined, endoscopic USG was applied to a total of 8 (7%) patients, of which acute recurrent pancreatitis was present in 2 (1.9%) and chronic pancreatitis in 3 (2.7%). In the endoscopic USG examinations, pancreatic edema was determined in 2 (1.9%) patients, increased pancreas size in 2 (1.9%), hyperechoic foci in 2 (1.9%) chronic pancreatitis in 2 (1.9%), and autoimmune hepatitis in 2 (1.9%). Cystogastrostomy procedure was performed in one patient because of pancreas pseudocyst. In a study by Varadarajulu et al.,[] endoscopic USG was applied 15 times to 14 patients, of which 6 (42%) were determined with acute or acute recurrent pancreatitis and 3 (21%) with chronic pancreatitis. The endoscopic USG results of the patients were reported as normal in 4, chronic pancreatitis in 3, idiopathic fibrotic pancreas in 2, carcinoid tumor in 1, pancreatic pseudocyst in 1, pancreas divisum in 1, choledocolithiasis in 1, and duodenal duplication cyst in 1. In a study of 101 children, Lal et al.[] determined pancreatic fluid collection in 62 (61.4%) patients. As the fluid collection was persistent in 39 patients, drainage was applied to 12, of which the percutaneous drainage catheter procedure was successful in 6. In the remaining 6, cystogastrostomy and stent placement were performed under endoscopic USG guidance. When the pathology results of the current study patients were examined, of the 8 patients with a sample sent to pathology, chronic cholecystitis was determined in 3 (2.8%), cholesterolosis in 3 (2.8%), chronic cholecystitis with stones in 2 (1.9%), and choledochal cyst in 2 (1.9%). When the CRP levels of the patients were examined, the mean value was determined to be 11 mg/L, in the range of 0.66-211 mg/L. In the 11 patients in ICU, CRP was observed in the range of 3.0-211 mg/L. When the patients were examined in two groups of mild or moderate-severe AP, the CRP value was determined as 0.66-141 mg/L in the mild pancreatitis group and as 3.2-211 mg/L in the moderate-severe group. In a study of 130 children by Izquierdo et al.,[] the CRP value was determined as 15.85-30.9 mg/L in 92 (70.7%) patients thought to have a diagnosis of mild pancreatitis, and as 58.5-172.1 mg/L in 38 (29.2%) thought to have a diagnosis of severe pancreatitis. Chlebowczyk et al.[] reported a CRP value of >10 mg/L in 29 (38.1%) of 76 patients. In the evaluation of the laboratory results, the amylase, lipase, and CRP parameters were determined to be significant in the determination of the severity and prognosis of AP. Of the parameters evaluated, leukocytes, Ca, GGT, total bilirubin, and direct bilirubin values were found not to be determinants of the severity and prognosis of AP. In the examination of the duration of hospitalizations, the length of stay on the ward of 97 (89.8%) patients ranged from 1-30 days, and for the 11 (10.1%) patients admitted to ICU, the mean length of hospital stay was 9.45 ± 8.81 days, ranging from 2-33 days. The length of stay in the hospital was a mean of 6.27 ± 5.20 days (range, 1-30 days) for those diagnosed with mild AP and a mean of 9.14 ± 7.92 days (range, 3-33 days) for patients diagnosed with moderate-severe AP. Galai et al.[] reported length of hospital stay as 4-8 days in a study of 117 patients and as 4-17 days for 15 (12.8%) patients evaluated as moderate-severe pancreatitis. In a study of 96 patients by Cole et al.,[] 42 (43.7%) patients were treated on the ward and 54 (56.2%) in ICU. Of these patients, 7 (7.2%) had mild pancreatitis, and 89 (92.7%) had moderate-severe pancreatitis. The length of hospital stay was reported as 8.3-45.3 days for all the patients and 2-35 days for those admitted to ICU. When the development of AP was examined as a side-effect of drugs being taken, a total of 9 (8.3%) patients reported drug use. There was a history of use of prednisolone in 2 (1.8%) patients, azathioprine in 2 (1.8%), furosemide in 1 (0.9%), valproic acid in 1 (0.9%), enalapril in 1 (0.9%), methylprednisolone in 1 (0.9%), and ibuprofen in 1 (0.9%). In a study of 1060 pediatric patients by Meczker et al.,[] drug-related causes of pancreatitis were reported as use of valproic acid in 81 (7.6%) patients, L-asparaginase in 68 (6.4%), meselamine in 28 (2.6%), azathioprine in 19 (1.8%), ciprofloxacin in 17 (1.6%), pegaspargase in 17, and prednisolone in 17. Zhong et al.[] reported the development of drug-related pancreatitis in 6 (4.6%) of 130 pediatric patients, of which 5 (3.8%) were associated with the use of dexamethasone, and 1 (0.76%) with cytarabine.

of this study are its retrospective design and that it was conducted in a single center. There is a need for further, multicenter studies using other scoring methods to determine disease prognosis. An increased awareness of acute pancreatitis together with easier access to laboratory and imaging methods has increased the frequency of diagnosis. Acute pancreatitis should be considered in the differential diagnosis, especially in patients with complaints of abdominal pain and vomiting. The clinical course is mild-moderate in most patients, and as a result of early treatment and follow-up, the mortality rate is not as high as has been assumed. In the blood tests, the determination of leukocytosis, hypocalcemia, hypoalbuminemia, and long-lasting hyperglycemia are poor prognostic factors. An elevated level of serum urea is a factor that can increase mortality. Early initiation of enteral nutrition in patients with AP reduces the complication rate and shortens the length of hospital stay. Financial support and sponsorship Nil. Conflict of interests There are no conflicts of interest. Author contributions Conception- planning: SKÜ, UD Design: SKÜ, UD Supervision- consultation: SKÜ, UD, YD Data Collection and/or processing: SKÜ, UD Analysis and/or interpretation SKÜ, UD Literature review: SKÜ, UD, YD Writing the manuscript: SKÜ, UD Critical examination: UD, YD Resources and Funding: SKÜ, UD

SKÜ, UD.

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