scholarly journals P096: Prospective pilot implementation of a clinical decision aid for acute aortic syndrome

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S98
Author(s):  
R. Ohle ◽  
N. Fortino ◽  
O. Montpellier ◽  
M. Ludgate ◽  
S. McIsaac ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Length Of Stay ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome ◽  
Pilot Implementation ◽  
Test Probability ◽  
D Dimer

Introduction: The RAPID RIP clinical decision aid was developed to identify patients at high-risk for acute aortic syndrome (AAS) who require investigations. It stratifies patients into low (no further testing) intermediate (D-dimer if no alternative diagnosis) and High risk (Computed tomography (CT) aorta). Our objectives were to assess its impact on: a) Documentation of high risk features/pre test probability for AAS b) D-dimers ordered c) CT ordered and d) Emergency department length of stay. Methods: We conducted a prospective pilot before/after study at a single tertiary-care emergency department between August and September 2018. Consecutive alert adults with chest, abdominal, flank, back pain or stroke like symptoms were included. Patients with pain >14 days or secondary to trauma were excluded. Results: We enrolled 1,340 patients, 656 before and 684 after implementation, including 0 AAS. Documentation of pre test probability assessment increased (0% to 3%, p < 0.009) after implementation. The proportion who had D-dimer performed increased (5.8% to 9.2% (p < 0.2), while the number of CT to rule out AAS remained stable (0.59% versus 0.58%; p = 0.60). The mean length of ED stay was stable (2.31+/−2.0 to 2.28+/−1.5 hours; p = 0.45) and slightly decreased in those with pre test probability documented (2.1+/−1.4 p < 0.09). The specificity of the decision aid for CT was 100%( 95%CI 71.5- 100%). If it were applied to all patients with high-risk clinical features of AAS the specificity would be 92.6% (95%CI 90.1-94.6%). Conclusion: Implementation of the RAPID RIP increased documentation of important high-risk features for AAS. The RAPID RIP strategy increased use of D-dimer without increasing the number of CT and had a trend towards decreased length of stay.

scholarly journals MP05: Validation of the Canadian clinical practice guideline clinical decision aid for acute aortic syndrome

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S43-S44
Author(s):  
B. Paige ◽  
A. Maeng ◽  
D. Savage ◽  
R. Ohle ◽  
MBBCh MA
Keyword(s):  
Computed Tomography ◽  
Clinical Practice ◽  
High Risk ◽  
Confidence Intervals ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.

National survey of emergency physicians on the risk stratification and acceptable miss rate of acute aortic syndrome

CJEM ◽  
2020 ◽  
Vol 22 (3) ◽  
pp. 309-312
Author(s):  
Robert Ohle ◽  
Sarah McIsaac ◽  
Justin Yan ◽  
Krishan Yadav ◽  
Debra Eagles ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
National Survey ◽  
Decision Aid ◽  
Electronic Mail ◽  
Clinical Decision ◽  
Acute Aortic Syndrome ◽  
Emergency Physicians ◽  
Canadian Association ◽  
Academic Teaching Hospital

ABSTRACTObjectivesOne in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.MethodsWe surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is requiredResultsWe had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.ConclusionsOur national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.

scholarly journals P114: Barriers and facilitators affecting implementation of a decision aid for the diagnosis of acute aortic syndrome: a qualitative study

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S106-S106
Author(s):  
C. Dmitriew ◽  
R. Ohle
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Practice Guidelines ◽  
Resource Use ◽  
Decision Aid ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Acute Aortic Syndrome ◽  
D Dimer

Introduction: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed in order to reduce the frequency of misdiagnoses and number of diagnostic tests. As part of the guidelines, a clinical decision aid was developed in order to facilitate clinician decision-making based on practice recommendations. The objective of this study was to identify barriers and facilitators among physicians to implementation of the decision aid. Methods: We conducted semi-structured interviews with emergency room physicians working at 5 sites distributed between urban academic and rural settings. We used purposive sampling, contacting ED physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators affecting the probability of decision aid uptake and accurate application of the tool. Two independent raters coded interview transcripts using an integrative approach to theme identification, combining an inductive approach to identification of themes within an organizing framework (Theoretical Domains Framework), discrepancies in coding were resolved through discussion until consensus was reached. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification while reducing resource use and missed diagnoses. Facilitators identified included validation and publication of the guidelines as well as adoption by peers. Barriers to implementation and application of the tool included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. Furthermore, scoring components were, at times, out of alignment with clinician practices and understanding of risk factors. The complexity of the decision aid was also identified as a potential barrier to accurate use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use, particularly within rural contexts. Key barriers identified included the complexity of scoring and inclusion criteria, and the variable acceptance of D-dimer among clinicians. These barriers should be addressed prior to implementation of the decision aid during validation studies of the clinical practice guidelines.

scholarly journals Barriers and Facilitators Affecting Implementation of a Clinical Decision aid for the Diagnosis of Acute Aortic Syndrome: A Qualitative Study

2020 ◽  
Author(s):  
Caitlin Dmitriew ◽  
Robert Ohle
Keyword(s):  
Decision Making ◽  
Decision Aid ◽  
Clinical Decision Making ◽  
Theoretical Domains Framework ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Acute Aortic Syndrome ◽  
Structured Interviews ◽  
Potential Barriers ◽  
D Dimer

Abstract Background: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed to improve patient outcomes and include a clinical decision aid designed to facilitate clinician decision-making. The objective of this study was to prospectively identify barriers and facilitators among physicians prior to implementation of the decision aid.Methods: We conducted semi-structured interviews with emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to decision aid uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification. Potential facilitators identified included guideline validation and publication and endorsement by peers. Barriers to implementation and application of the aid included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the decision aid and insufficient specificity of D-dimer were also identified as potential barriers to use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use. The barriers identified should be addressed prior to implementation in order to support decision aid uptake and use.

scholarly journals LO051: Validation of a clinical decision rule to detect patients with adverse drug events in the emergency department

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S47-S48
Author(s):  
C.M. Hohl ◽  
K. Badke ◽  
M.E. Wickham ◽  
A. Zhao ◽  
M. Sivilotti ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Decision Rule ◽  
Adverse Drug Events ◽  
Medical Condition ◽  
Tertiary Care ◽  
Risk Groups ◽  
Clinical Decision ◽  
Clinical Decision Rule ◽  
Management Interventions

Introduction: Adverse drug events (ADE) are a leading cause of emergency department (ED) visits, yet are missed in up to 50% of presentations. In 2014, Accreditation Canada, a not-for-profit organization that evaluates healthcare institutions based on quality of care, introduced a requirement for EDs to identify patients at high-risk for drug-related morbidity, so that medication management interventions can be targeted to high-risk groups. We derived a clinical decision rule to identify patients at high-risk for ADEs using 4 variables. Our objective was to validate the rule by determining its sensitivity and specificity in a new sample. Methods: We conducted a prospective observational study in two tertiary care and one urban community hospital in British Columbia and Ontario. We used a systematic selection algorithm to generate a representative sample, and enrolled adults who reported taking at least one medication during the prior two weeks. Nurses completed the clinical decision rule and evaluated patients for standardized clinical findings. Each patient was assessed by a research pharmacist and a physician who were blinded to data collected by nurses. Any disagreement was subsequently adjudicated by an independent committee. The primary outcome was an ADE, defined as an unintended and harmful event related to medication use resulting a change in medical management, hospital admission or causing death. We calculated the rule’s sensitivity, specificity, and the proportion of patients screening positive with 95% confidence intervals (CI). Results: Among 1529 enrolled patients, 196 (12.8%, 95% CI 11.2-14.6%) were deemed to have experienced an ADE. The rule, consisting of the variables (i) having a pre-existing medical condition or having taken antibiotics within one week, and (ii) age ≥ 80 or having a medication change within 28 days, had a sensitivity of 92.9% (95%CI 88.3%-96.0%) and a specificity of 35.0% (95%CI 32.5%-37.7%) for ADEs. The proportion of patients screening positive was 41.7%. Conclusion: Among adults presenting to EDs, the rule was sensitive for ADEs while maintaining reasonable specificity. If implemented, the rule may help identify those patients at high-risk for ADEs who may benefit from evaluation by a clinical pharmacist in the ED, and will help institutions meet current Accreditation Canada standards.

scholarly journals LO083: Outcomes and resource utilization among syncope patients transported by emergency medical services

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S58-S59
Author(s):  
L. Yau ◽  
M.A. Mukarram ◽  
S. Kim ◽  
K. Arcot ◽  
K. Thavorn ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Emergency Medical Services ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Medical Services ◽  
Care Pathways ◽  
Alternative Care ◽  
Total Cost ◽  
Emergency Medical

Introduction: Syncope accounts for 1% of all annual emergency department (ED) visits in Canada with only 10.3% suffering serious adverse event (SAE) within 30-days. However, 66% are transported to ED by Emergency Medical Services (EMS). Our objectives were to assess 30 day SAE among syncope patients transported by Emergency medical services (EMS), assess the need to develop an EMS clinical decision aid, and estimate anticipated health care savings by diverting patients from the ED to alternative care pathways. Methods: We conducted a prospective cohort study at four tertiary care EDs from Feb 2012 to Feb 2013. We included patients ≥16 years of age with syncope and who arrived to the ED via EMS. We collected patient demographics, medical history, 30 day SAE, EMS time points (call received, EMS arrival on scene, EMS departure from scene, time of transfer of care in the ED), critical EMS interventions, and ED length of stay. We assessed for the occurrence of any SAE (death, arrhythmia, other cardiac and non-cardiac conditions) within 30 days of ED disposition. We used descriptive analysis, unpaired two-tailed t-test and chi-square test. Ethics approval was obtained at all study sites. Results: Of 1,475 ED patients with syncope during the study period, 992 (67.3%) arrived by EMS. Mean times (SD) for EMS arrival to the scene, patient assessment at the scene and transfer of patient from scene to the ED were 10.1 (6.4), 18.9 (8.3), and 14.6 (11.5) minutes respectively. Only two patients had critical interventions enroute (pacing and defibrillation). Overall 138 (13.9%) patients suffered a SAE; 32 (3.2%) detected by EMS, 58 (5.8%) detected during ED evaluation, 48 (4.8%) after ED disposition. The average ED length of stay was 5.9(4.2) hours. Based on average of cost from two sites, we estimated that total cost of transporting syncope patients from the scene to the ED to be $4 million in Canada. The total cost of ED care for syncope patients transported by EMS in Canada was calculated at $21.5 million. Conclusion: A substantial proportion of patients arriving to the ED via EMS suffer no SAE within 30 days. Correspondingly, our results suggest a need for an EMS clinical decision aid to divert low-risk syncope patients to alternative care pathways such as family physicians or rapid access clinics. If developed and implemented, this tool can potentially reduce EMS burden, ED crowding, and reduce healthcare costs.

scholarly journals Diagnostic test utilization in the emergency department for alert headache patients with possible subarachnoid hemorrhage

CJEM ◽  
2002 ◽  
Vol 4 (05) ◽  
pp. 333-337 ◽  
Author(s):  
Jeffrey J. Perry ◽  
Ian Stiell ◽  
George Wells ◽  
Alena Spacek
Keyword(s):  
Emergency Department ◽  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Tertiary Care ◽  
Diagnostic Testing ◽  
Clinical Decision ◽  
Lengths Of Stay ◽  
Level Of Consciousness ◽  
The Mean ◽  
Acute Headache

ABSTRACT: Objectives: This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache. Methods: Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay. Results: The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8–4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7–5.4) if CT was performed and 7.1 hours (95% CI, 6.3–7.9) if LP was performed (p = 0.001). Conclusions: Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache.

Analysis of the Effects of Applying Federal Diagnosis-Related Grouping (DRG) Guidelines to a Population of High-Risk Newborn Infants

PEDIATRICS ◽  
1985 ◽  
Vol 76 (1) ◽  
pp. 104-109
Author(s):  
Ronald L. Poland ◽  
Robert O. Bollinger ◽  
Mary P. Bedard ◽  
Sanford N. Cohen
Keyword(s):  
High Risk ◽  
Length Of Stay ◽  
Geometric Mean ◽  
Tertiary Care ◽  
Newborn Infants ◽  
Frequency Distributions ◽  
Federal Register ◽  
Children's Hospital ◽  
Lengths Of Stay ◽  
Children’S Hospital

Length of stay data collected for high-risk newborn infants admitted to a tertiary care children's hospital neonatal unit over a 6-year period were compared with mean and outlier lengths of stay published in the Federal Register as part of a proposed system for prospective payment of hospital cost by diagnosis-related groupings (DRGs). We found that the classification system for newborns markedly underestimated the number of days required for the treatment of these infants. The use of the geometric mean instead of the arithmetic mean as the measure of central tendency was a significant contributor to the discrepancy, especially in those sub-groups with bimodal frequency distributions of lengths of stay. Another contributor to the discrepancy was the lack of inborn patients in the children's hospital cohort. The system of prospective payments, as outlined, does not take into account several factors that have a strong influence on length of stay such as birth weight (which requires more than three divisions to serve as an effective predictor), surgery, outborn status, and ventilation. Implementation of the system described in the Federal Register would severely discourage tertiary care referral hospitals from providing neonatal intensive care.

scholarly journals Cost-minimisation analysis alongside a pilot study of early Tissue Doppler Evaluation of Diastolic Dysfunction in Emergency Department Non-ST Elevation Acute Coronary Syndromes (TEDDy-NSTEACS)

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e023920 ◽  
Author(s):  
Vijay S Gc ◽  
Mohamad Alshurafa ◽  
David J Sturgess ◽  
Joseph Ting ◽  
Kye Gregory ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pilot Study ◽  
High Risk ◽  
Length Of Stay ◽  
Cost Saving ◽  
Risk Stratification ◽  
Diagnostic Tool ◽  
Tissue Doppler ◽  
Conventional Care ◽  
St Elevation

ObjectiveTo estimate the cost implications of early angiography for patients with suspected non-ST elevation acute coronary syndrome (NSTEACS) using tissue Doppler imaging (TDI).DesignA decision tree model was used to synthesise data from the pilot study and literature sources. Sensitivity analyses tested the impact of assumptions incorporated into the analysis.SettingEmergency department (ED), Brisbane, Australia.ParticipantsPatients with suspected NSTEACS.InterventionsTDI as a diagnostic tool for triaging patients within 4 hours of presentation in addition to conventional risk stratification, compared with conventional risk stratification alone.Data sourcesResource used for diagnosis and management were recorded prospectively and costed for 51 adults who had echocardiography within 24 hours of admission. Costs for conventional care were based on observed data. Cost estimates for the TDI intervention assumed patients classified as high risk at TDI (E/e’>14) progressed early to angiography with an associated 1-day reduction in length of stay.Primary outcome measuresCosts until discharge from the Australian healthcare perspective in 2016–2017 prices.ResultsFindings suggest that using TDI as a diagnostic tool for triaging patients with suspected NSTEACS is likely to be cost saving by $A1090 (95% credible interval: $A573 to $A1703) per patient compared with conventional care. The results are mainly driven by the assumed reduction in length of stay due to the inclusion of early TDI in clinical decision-making.ConclusionsThis pilot study indicates that compared with conventional risk stratification, triaging patients presenting with suspected NSTEACS with TDI within 4 hours of ED presentation has potential cost savings. Findings assume a reduction in hospital stay is achieved for patients considered to be high risk at TDI. Larger, comparative studies with longer follow-up are needed to confirm the clinical effectiveness of TDI as a diagnostic strategy for NSTEACS, the assumed reduction in hospital stay and any cost saving.

scholarly journals Prevalence and characteristics of venous thromboembolism in severe exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in India

2021 ◽  
Author(s):  
Soibam Pahel Meitei ◽  
Sudheer Tale ◽  
Arjun Kumar Negi ◽  
Ruchi Dua ◽  
Rohit Walia ◽  
...  
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Venous Thromboembolism ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Lower Limbs ◽  
Chronic Obstructive ◽  
Care Hospital ◽  
Obstructive Pulmonary Disease ◽  
Test Probability ◽  
D Dimer

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries a high risk of venous thromboembolism (VTE). Pulmonary embolism (PE) and AECOPD increase the mortality and morbidity risk associated with each other. Racial and ethnic differences in VTE risk have been documented in multiple studies. However, there is a dearth of reliable Indian data on the same. This study was planned to find the prevalence of VTE in the setting of severe AECOPD in a tertiary care hospital in India and to identify the clinical, laboratory and radiological characteristics of VTE in severe AECOPD. A total of 156 consecutive patients admitted with severe AECOPD and meeting the specified inclusion and exclusion criteria were recruited. Thorough workup of all patients was done including ABG, serum D dimer, ECG, compression ultrasound of lower limbs and 2-D echocardiography. Patients with high pre-test probability score, or intermediate pre-test probability score at presentation with serum D dimer above the age adjusted cut-off underwent computerised tomography pulmonary angiography (CTPA).  Results were analysed using SPSS version 23.  Sixteen (10.3%) patients had VTE, 15 (93.75%) of them being cases of isolated PE. Female gender, higher cumulative past exposure to corticosteroid, higher alveolar-arterial gradient, right ventricular dysfunction, and higher mean pulmonary artery pressure were associated with increased risk for VTE. The prevalence of VTE in AECOPD in this study among an Indian population is higher than among other Asians, but lower than among the Blacks, the Caucasians and the Middle-East ethnicities. Since a vast majority of VTE presents as PE without DVT in the setting of AECOPD, the absence of deep vein thrombosis of lower limbs does not rule PE in the setting.

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