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  • 1.
    Eliason, Gabriella
    Örebro University, School of Health and Medical Sciences.
    Sceletal muscle characteristics and physical activity patterns in COPD2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. Besides abnormities within the respiratory system COPD is also associated with effects outside the lungs, so called systemic effects. One systemic effect that has been highlighted is skeletal muscle dysfunction which has also been associated with reduced exercise capacity. Apart from changes in muscle morphology, low levels of physical activity have also been suggested as a plausible mediator of reduced exercise capacity in COPD. The aim of this thesis was to study muscle morphology and physical activity patterns in patients with different degrees of COPD and to examine the associations between muscle morphology, physical activity and exercise capacity in these patients. Skeletal muscle morphology was found to shift towards a more glycolytic muscle profile in COPD patients and changes in muscle morphology were found to be correlated to disease severity and to exercise capacity. Muscle capillarization was also found to be lower in COPD compared with healthy subjects and to be correlated to disease severity and exercise capacity. When studying signalling pathways involved in muscle capillarization, an overexpression of VHL was found in patients with mild and moderate COPD compared with healthy subjects. Furthermore, COPD patients were found to be less physically active compared with healthy subjects and the level of physical activity was associated with exercise capacity.In conclusion, changes in skeletal muscle morphology and low levels of physical activity are present in COPD patients and may partly explain the lower exercise capacity observed in these patients. The more glycolytic muscle profile in COPD is suggested to be mediated by hypoxia and low levels of physical activity in this patient group. Furthermore, increased levels of VHL may lead to impaired transduction of the hypoxic signalling pathway, which may contribute to the decreased muscle capillarization observed in COPD.

    List of papers
    1. Physical performance and muscular characteristics in different stages of COPD
    Open this publication in new window or tab >>Physical performance and muscular characteristics in different stages of COPD
    Show others...
    2009 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 19, no 6, p. 865-870Article in journal (Refereed) Published
    Abstract [en]

    This study has examined exercise capacity and muscle morphology in patients with different severities of chronic obstructive pulmonary disease (COPD). Twenty-three patients and 12 healthy matched controls were recruited. Based on the severity of airflow obstruction, patients were divided into two subgroups. Exercise capacity was determined using a 6-min walk test. Muscle fiber composition, fiber area and number of satellite cells/muscle fiber were determined in muscle biopsies using immunohistochemistry. A progressive decline in exercise capacity was noted with ascending disease severity. Furthermore, a correlation between reduction in exercise capacity and changes in muscle fiber composition was observed in COPD. The group with severe and very severe COPD had a lower proportion of type I and a higher proportion of type IIa fibers compared with the other groups. In severe and very severe COPD, a reduction in fiber area of type IIa fibers was also seen. The number of satellite cells/muscle fiber did not differ between the groups. In conclusion, a decline in exercise capacity occurs already in mild and moderate COPD, indicating that the 6-min walk test is a reliable indicator of disease severity. Furthermore, changes in skeletal muscle morphology are associated with disease severity while muscle regenerative capacity is not altered.

    Place, publisher, year, edition, pages
    Wiley-Blackwell Publishing Inc., 2009
    Keywords
    Activities of Daily Living/*psychology, Adaptation; Psychological, Aged, Aged; 80 and over, Attitude to Health, Body Image, Dependency (Psychology), Female, Health Services Needs and Demand, Humans, Interpersonal Relations, Male, Middle Aged, Models; Psychological, Neoplasms/psychology, Nursing Methodology Research, Palliative Care/methods/*psychology, Power (Psychology), Quality of Life/psychology, Questionnaires, Respite Care/psychology, Self Concept, Social Support, Sweden
    National Category
    Medical and Health Sciences Physiology Respiratory Medicine and Allergy Sport and Fitness Sciences
    Research subject
    Physiology; Sports Science
    Identifiers
    urn:nbn:se:oru:diva-3417 (URN)10.1111/j.1600-0838.2008.00858.x (DOI)000272132200014 ()18980606 (PubMedID)2-s2.0-70450260481 (Scopus ID)
    Available from: 2008-12-04 Created: 2008-12-04 Last updated: 2018-01-13Bibliographically approved
    2. Overexpression of von Hippel-Lindau protein in skeletal muscles of patients with chronic obstructive pulmonary disease
    Open this publication in new window or tab >>Overexpression of von Hippel-Lindau protein in skeletal muscles of patients with chronic obstructive pulmonary disease
    Show others...
    2009 (English)In: Journal of Clinical Pathology, ISSN 0021-9746, E-ISSN 1472-4146, Vol. 62, no 1, p. 70-76Article in journal (Refereed) Published
    Abstract [en]

    Background/aim: A Significant number of patients with chronic obstructive pulmonary disease (COPD) exhibit skeletal muscle wasting and decreased capillary area formation which have been correlated to increased mortality. The current study aimed to determine the molecular mechanisms mediating decreased capillary formation in COPD.

    Methods: Twenty-four COPD patients and twelve matching controls were recruited. COPD patients were divided into mild, moderate and severe groups according to GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria. Skeletal muscle biopsies were obtained from the tibialis anterior muscle. Fibre typing and capillary formation together with messenger RNA (mRNA) expression of hypoxia-inducible factors (HIF-1á and HIF-3á ), vascular endothelial growth factors (VEGF-A, -B and -C isoforms) and von Hippel Lindau (VHL) were determined. VHL expression and localization was further studied by immunohistochemistry.

    Results: Skeletal muscle capillary formation was significantly decreased with ascending disease severity. Compared to controls, a tendency to mRNA overexpression of HIF-1á, HIF-3á and VEGF isoforms was observed at mild and moderate COPD that decreased at the severe stage. By contrast, skeletal muscle biopsies from COPD patients exhibited significant overexpression of VHL both on the mRNA and protein levels by immunohistochemistry. VHL protein was further determined to be localized to satellite cells.

    Conclusions: Overexpression of VHL was identified in the skeletal muscle of patients with COPD. Increased VHL activity may exert a negative impact on transducing the hypoxic signal and may contribute to decreased capillarization in skeletal muscles of patients with COPD.

    Place, publisher, year, edition, pages
    London: BMJ Publishing Group Ltd, 2009
    National Category
    Medical and Health Sciences Cell and Molecular Biology
    Research subject
    Pathology; Medicine
    Identifiers
    urn:nbn:se:oru:diva-3418 (URN)10.1136/jcp.2008.057190 (DOI)000262420400018 ()18818266 (PubMedID)2-s2.0-58349102711 (Scopus ID)
    Available from: 2008-12-04 Created: 2008-12-04 Last updated: 2018-01-13Bibliographically approved
    3. Alterations in the muscle-to-capillary interface in patients with different degrees of chronic obstructive pulmonary disease
    Open this publication in new window or tab >>Alterations in the muscle-to-capillary interface in patients with different degrees of chronic obstructive pulmonary disease
    2010 (English)In: Respiratory research (Online), ISSN 1465-9921, E-ISSN 1465-993X, Vol. 11, article id 97Article in journal (Refereed) Published
    Abstract [en]

    Background: It is hypothesized that decreased capillarization of limb skeletal muscle is implicated in the decreased exercise tolerance in COPD patients. We have recently demonstrated decreased number of capillaries per muscle fibre (CAF) but no changes in CAF in relation to fibre area (CAFA), which is based on the diffusion distance between the capillary and muscle fibre. The aim of the current study is to investigate the muscle-to-capillary interface which is an important factor involved in oxygen supply to the muscle that has previously been suggested to be a more sensitive marker for changes in the capillary bed compared to CAF and CAFA.

    Methods: 23 COPD patients and 12 age-matched healthy subjects participated in the study. Muscle-to-capillary interface was assessed in muscle biopsies from the tibialis anterior muscle using the following parameters:

    1) The capillary-to-fibre ratio (C:Fi) which is defined as the sum of the fractional contributions of all capillary contacts around the fibre

    2) The ratio between C:Fi and the fibre perimeter (CFPE-index)

    3) The ratio between length of capillary and fibre perimeter (LC/PF) which is also referred to as the index of tortuosity.

    Exercise capacity was determined using the 6-min walking test.

    Results: A positive correlation was found between CFPE-index and ascending disease severity with CFPE-index for type I fibres being significantly lower in patients with moderate and severe COPD. Furthermore, a positive correlation was observed between exercise capacity and CFPE-index for both type I and type IIa fibres.

    Conclusion: It can be concluded that the muscle-to-capillary interface is disturbed in the tibialis anterior muscle in patients with COPD and that interface is strongly correlated to increased disease severity and to decreased exercise capacity in this patient group.

     

    Place, publisher, year, edition, pages
    London, United Kingdom: BioMed Central, 2010
    Keywords
    COPD, muscle-capillary interface, CFPE-index, LC/PF, tortuosity
    National Category
    Physiology Medical and Health Sciences
    Research subject
    Physiology; Medicine
    Identifiers
    urn:nbn:se:oru:diva-12493 (URN)10.1186/1465-9921-11-97 (DOI)000282550500002 ()20633289 (PubMedID)2-s2.0-77956692758 (Scopus ID)
    Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2018-09-11Bibliographically approved
    4. Physical activity patterns in patients with different degrees of chronic obstructive pulmonary disease
    Open this publication in new window or tab >>Physical activity patterns in patients with different degrees of chronic obstructive pulmonary disease
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: It has previously been suggested that exercise capacity is decreased in COPD patients and that it is associated with degree of disease. The reduced exercise capacity may plausibly be due to low levels of physical activity in this patient group. In the present study we aimed to assess exercise capacity and physical activity in different stages of COPD and to examine the associations between exercise capacity, pulmonary function and degree of physical activity.

    Methods: 44 COPD patients and 17 healthy subjects participated in the study. Exercise capacity was assessed using the 6 minute walking test and physical activity was assessed using a uniaxial accelerometer worn all waking hours during seven days.

    Results: Mean exercise capacity was significantly lower in COPD patients compared to healthy subjects. Mean physical activity level and time spent at least moderately active were significantly lower in patients with moderate and severe COPD compared to healthy subjects while no differences in time spent sedentary were observed between the study groups. Pulmonary function, mean physical activity level and time spent at least moderately physically active were significantly associated with exercise capacity in the patients.

    Conclusions: Patients with moderate and severe COPD are significantly less physically active compared to healthy subjects. Furthermore, mean physical activity level as well as physical activity of at least moderate intensity are positively associated with exercise capacity in COPD patients while time spent sedentary is not which stresses an important role of physical activity on exercise capacity in this patient group. 

    National Category
    Physiology Medical and Health Sciences
    Research subject
    Physiology; Medicine
    Identifiers
    urn:nbn:se:oru:diva-12495 (URN)
    Available from: 2010-11-18 Created: 2010-11-18 Last updated: 2018-01-12Bibliographically approved
  • 2.
    Eliason, Gabriella
    et al.
    Örebro University, School of Health and Medical Sciences.
    Abdel-Halim, S.
    Örebro University, School of Health and Medical Sciences.
    Arvidsson, B.
    Kadi, Fawzi
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Piehl-Aulin, Karin
    Örebro University, School of Health and Medical Sciences.
    Physical performance and muscular characteristics in different stages of COPD2009In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 19, no 6, p. 865-870Article in journal (Refereed)
    Abstract [en]

    This study has examined exercise capacity and muscle morphology in patients with different severities of chronic obstructive pulmonary disease (COPD). Twenty-three patients and 12 healthy matched controls were recruited. Based on the severity of airflow obstruction, patients were divided into two subgroups. Exercise capacity was determined using a 6-min walk test. Muscle fiber composition, fiber area and number of satellite cells/muscle fiber were determined in muscle biopsies using immunohistochemistry. A progressive decline in exercise capacity was noted with ascending disease severity. Furthermore, a correlation between reduction in exercise capacity and changes in muscle fiber composition was observed in COPD. The group with severe and very severe COPD had a lower proportion of type I and a higher proportion of type IIa fibers compared with the other groups. In severe and very severe COPD, a reduction in fiber area of type IIa fibers was also seen. The number of satellite cells/muscle fiber did not differ between the groups. In conclusion, a decline in exercise capacity occurs already in mild and moderate COPD, indicating that the 6-min walk test is a reliable indicator of disease severity. Furthermore, changes in skeletal muscle morphology are associated with disease severity while muscle regenerative capacity is not altered.

  • 3.
    Eliason, Gabriella
    et al.
    Örebro University, School of Health and Medical Sciences.
    Abdel-Halim, Samy M.
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden.
    Piehl-Aulin, Karin
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Rheumatology, Danderyds hospital, Stockholm, Sweden.
    Kadi, Fawzi
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Alterations in the muscle-to-capillary interface in patients with different degrees of chronic obstructive pulmonary disease2010In: Respiratory research (Online), ISSN 1465-9921, E-ISSN 1465-993X, Vol. 11, article id 97Article in journal (Refereed)
    Abstract [en]

    Background: It is hypothesized that decreased capillarization of limb skeletal muscle is implicated in the decreased exercise tolerance in COPD patients. We have recently demonstrated decreased number of capillaries per muscle fibre (CAF) but no changes in CAF in relation to fibre area (CAFA), which is based on the diffusion distance between the capillary and muscle fibre. The aim of the current study is to investigate the muscle-to-capillary interface which is an important factor involved in oxygen supply to the muscle that has previously been suggested to be a more sensitive marker for changes in the capillary bed compared to CAF and CAFA.

    Methods: 23 COPD patients and 12 age-matched healthy subjects participated in the study. Muscle-to-capillary interface was assessed in muscle biopsies from the tibialis anterior muscle using the following parameters:

    1) The capillary-to-fibre ratio (C:Fi) which is defined as the sum of the fractional contributions of all capillary contacts around the fibre

    2) The ratio between C:Fi and the fibre perimeter (CFPE-index)

    3) The ratio between length of capillary and fibre perimeter (LC/PF) which is also referred to as the index of tortuosity.

    Exercise capacity was determined using the 6-min walking test.

    Results: A positive correlation was found between CFPE-index and ascending disease severity with CFPE-index for type I fibres being significantly lower in patients with moderate and severe COPD. Furthermore, a positive correlation was observed between exercise capacity and CFPE-index for both type I and type IIa fibres.

    Conclusion: It can be concluded that the muscle-to-capillary interface is disturbed in the tibialis anterior muscle in patients with COPD and that interface is strongly correlated to increased disease severity and to decreased exercise capacity in this patient group.

     

  • 4.
    Eliason, Gabriella
    et al.
    Örebro University, School of Health and Medical Sciences.
    Zakrisson, Ann-Britt
    Örebro University, School of Health and Medical Sciences.
    Piehl-Aulin, Karin
    Hurtig-Wennlöf, Anita
    Örebro University, School of Health and Medical Sciences.
    Physical activity patterns in patients in different stages of chronic obstructive pulmonary disease2011In: COPD: Journal of Chronic Obstructive Pulmonary Disease, ISSN 1541-2555, E-ISSN 1541-2563, Vol. 8, no 5, p. 369-374Article in journal (Refereed)
    Abstract [en]

    It has previously been suggested that exercise capacity is decreased in COPD and that it is associated with degree of disease. The reduced exercise capacity may plausibly be due to low levels of physical activity in this patient group. The aim of the present study was to assess exercise capacity and physical activity in different stages of COPD and to examine the associations between exercise capacity, pulmonary function and degree of physical activity. A total of 44 COPD patients and 17 healthy subjects participated in the study. Exercise capacity was assessed using the 6-minute walking test and physical activity was assessed using an accelerometer worn all waking hours during 7 days. Mean exercise capacity was significantly lower in COPD patients compared with healthy subjects. Mean physical activity level and time spent at least moderately active were significantly lower in patients with moderate and severe COPD compared with healthy subjects while no differences in time spent sedentary were observed between the study groups. Pulmonary function, mean physical activity level and time spent at least moderately physically active were significantly associated with exercise capacity in the patients. We conclude that patients with moderate and severe COPD are less physically active compared with healthy subjects. Furthermore, mean physical activity level and physical activity of at least moderate intensity are positively associated with exercise capacity in COPD, while time spent sedentary is not, which stresses an important role of physical activity on exercise capacity in these patients.

  • 5.
    Eliason, Gabriella
    et al.
    Örebro University, School of Health and Medical Sciences.
    Zakrisson, Ann-Britt
    Örebro University, School of Health and Medical Sciences.
    Piehl-Aulin, Karin
    Department of pheumatology, danderyds hospital, Stockholm, Sweden.
    Hurtig-Wennlöf, Anita
    Örebro University, School of Health and Medical Sciences.
    Physical activity patterns in patients with different degrees of chronic obstructive pulmonary diseaseManuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: It has previously been suggested that exercise capacity is decreased in COPD patients and that it is associated with degree of disease. The reduced exercise capacity may plausibly be due to low levels of physical activity in this patient group. In the present study we aimed to assess exercise capacity and physical activity in different stages of COPD and to examine the associations between exercise capacity, pulmonary function and degree of physical activity.

    Methods: 44 COPD patients and 17 healthy subjects participated in the study. Exercise capacity was assessed using the 6 minute walking test and physical activity was assessed using a uniaxial accelerometer worn all waking hours during seven days.

    Results: Mean exercise capacity was significantly lower in COPD patients compared to healthy subjects. Mean physical activity level and time spent at least moderately active were significantly lower in patients with moderate and severe COPD compared to healthy subjects while no differences in time spent sedentary were observed between the study groups. Pulmonary function, mean physical activity level and time spent at least moderately physically active were significantly associated with exercise capacity in the patients.

    Conclusions: Patients with moderate and severe COPD are significantly less physically active compared to healthy subjects. Furthermore, mean physical activity level as well as physical activity of at least moderate intensity are positively associated with exercise capacity in COPD patients while time spent sedentary is not which stresses an important role of physical activity on exercise capacity in this patient group. 

  • 6.
    Fernström, Maria
    et al.
    Örebro University, School of Health Sciences. Department of Medical Diagnostics, Medical Faculty, School of Health Sciences, Örebro University, Örebro, Sweden.
    Fernberg, Ulrika
    Örebro University, School of Medical Sciences. Medical Faculty, School of Medical Sciences, Örebro University, Örebro, Sweden .
    Eliason, Gabriella
    Örebro University, School of Health Sciences. Department of Medical Diagnostics, Medical Faculty, School of Health Sciences, Örebro University, Örebro, Sweden.
    Hurtig-Wennlöf, Anita
    Örebro University, School of Health Sciences. Department of Medical Diagnostics, Medical Faculty, School of Health Sciences, Örebro University, Örebro, Sweden.
    Aerobic fitness is associated with low cardiovascular disease risk: the impact of lifestyle on early risk factors for atherosclerosis in young healthy Swedish individuals - the Lifestyle, Biomarker, and Atherosclerosis study2017In: Vascular Health and Risk Management, ISSN 1176-6344, E-ISSN 1178-2048, Vol. 13, p. 91-99Article in journal (Refereed)
    Abstract [en]

    Background: The progression of cardiovascular disease (CVD) and atherosclerosis is slow and develops over decades. In the cross-sectional Swedish Lifestyle, Biomarker, and Atherosclerosis study, 834 young, self-reported healthy adults aged 18.0-25.9 years have been studied to identify early risk factors for atherosclerosis.

    Purpose: The aims of this study were to 1) assess selected cardiometabolic biomarkers, carotid intima-media thickness (cIMT) as a marker of subclinical atherosclerosis, and lifestyle-related indicators (food habits, handgrip strength, and oxygen uptake, VO(2)max);2) analyze the associations between cIMT and lifestyle factors; and 3) identify subjects at risk of CVD using a risk score and to compare the characteristics of subjects with and without risk of CVD.

    Method: Blood samples were taken in a fasting state, and food habits were reported through a questionnaire. cIMT was measured by ultrasound, and VO2 max was measured by ergometer bike test. The risk score was calculated according to Wildman.

    Result: cIMT (mean +/- standard deviation) was 0.50 +/- 0.06 mm, and VO2 max values were 37.8 +/- 8.5 and 42.9 +/- 9.9 mL/kg/min, in women and men, respectively. No correlation was found between aerobic fitness expressed as VO2 max (mL/kg/min) and cIMT. Using Wildman's definition, 12% of the subjects were classified as being at risk of CVD, and 15% had homeostasis model assessment of insulin resistance. A total of 35% of women and 25% of men had lower high-density lipoprotein cholesterol than recommended. Food habits did not differ between those at risk and those not at risk. However, aerobic fitness measured as VO2 max (mL/kg/min) differed; 47% of the subjects at risk had low aerobic fitness compared to 23% of the nonrisk subjects (P<0.001).

    Conclusion: High aerobic fitness is associated with low CVD risk in Swedish young adults. The high prevalence of young adults observed with unfavorable levels of high-density lipoprotein cholesterol and homeostasis model assessment of insulin resistance raises concerns about future CVD risk.

  • 7.
    Jatta, Ken
    et al.
    Örebro University, School of Health and Medical Sciences.
    Eliason, Gabriella
    Örebro University, School of Health and Medical Sciences.
    Portela-Gomes, Guida M.
    Grimelius, Lars
    Caro, Oscar
    Nilholm, Lennart
    Sirsjö, Allan
    Örebro University, School of Health and Medical Sciences.
    Piehl-Aulin, Karin
    Örebro University, School of Health and Medical Sciences.
    Abdel-Halim, Samy M.
    Örebro University, School of Health and Medical Sciences.
    Overexpression of von Hippel-Lindau protein in skeletal muscles of patients with chronic obstructive pulmonary disease2009In: Journal of Clinical Pathology, ISSN 0021-9746, E-ISSN 1472-4146, Vol. 62, no 1, p. 70-76Article in journal (Refereed)
    Abstract [en]

    Background/aim: A Significant number of patients with chronic obstructive pulmonary disease (COPD) exhibit skeletal muscle wasting and decreased capillary area formation which have been correlated to increased mortality. The current study aimed to determine the molecular mechanisms mediating decreased capillary formation in COPD.

    Methods: Twenty-four COPD patients and twelve matching controls were recruited. COPD patients were divided into mild, moderate and severe groups according to GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria. Skeletal muscle biopsies were obtained from the tibialis anterior muscle. Fibre typing and capillary formation together with messenger RNA (mRNA) expression of hypoxia-inducible factors (HIF-1á and HIF-3á ), vascular endothelial growth factors (VEGF-A, -B and -C isoforms) and von Hippel Lindau (VHL) were determined. VHL expression and localization was further studied by immunohistochemistry.

    Results: Skeletal muscle capillary formation was significantly decreased with ascending disease severity. Compared to controls, a tendency to mRNA overexpression of HIF-1á, HIF-3á and VEGF isoforms was observed at mild and moderate COPD that decreased at the severe stage. By contrast, skeletal muscle biopsies from COPD patients exhibited significant overexpression of VHL both on the mRNA and protein levels by immunohistochemistry. VHL protein was further determined to be localized to satellite cells.

    Conclusions: Overexpression of VHL was identified in the skeletal muscle of patients with COPD. Increased VHL activity may exert a negative impact on transducing the hypoxic signal and may contribute to decreased capillarization in skeletal muscles of patients with COPD.

  • 8.
    Zakrisson, Ann-Britt
    et al.
    Örebro University, School of Health Sciences. Örebro University Hospital. Universitetssjukvårdens Forskningscentrum.
    Anerös, Terese
    Örebro University, School of Health Sciences. Universitetssjukvårdens Forskningscentrum, Region Örebro Län, Örebro, Sweden.
    Eliason, Gabriella
    Örebro University, School of Health Sciences.
    Forsberg, Anette
    Örebro University, School of Health Sciences. Örebro University Hospital.
    Projekt Region Örebro län: Att använda en mobil app med larm för att motivera till fysisk aktivitet hos patienter med KOL – en mixed method pilot-studie2019In: Lung och Allergi Forum, ISSN 2000-5237, p. 32-39Article in journal (Other academic)
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