scholarly journals Impact of FilmArray Pneumonia Panel on Early Targeted Antibiotic Therapy

2020 ◽  
Vol 41 (S1) ◽  
pp. s260-s261
Author(s):  
Cindy Hou ◽  
Shereef Ali ◽  
Nikunj Vyas
Keyword(s):  
Staphylococcus Aureus ◽  
Influenza A ◽  
Primary Objective ◽  
Inpatient Mortality ◽  
Infectious Disease Physician ◽  
Comfort Care ◽  
Resistance Patterns ◽  
Secondary Objective ◽  
Resistance Rates ◽  
Care Culture

Background: Patients with pneumonia are frequently recipients of broad-spectrum antibiotics while awaiting maturation of respiratory cultures. FilmArray pneumonia panel (FPP) is an option for more expeditious identification of pathogen(s). We evaluated the utility of FPP in early de-escalation or escalation of antibiotics. Methods: FPP tests were performed on adults hospitalized with pneumonia. The microbiologist directly communicated the organisms, colony counts, and resistance patterns to the infectious disease physician or pharmacist. These results were also compared with pathogen identification and resistance patterns from a VITEK-2 system. The primary objective of this analysis was to evaluate the rates of de-escalation, escalation, and discontinuation of therapy and their impact on inpatient mortality. The secondary objective of the analysis was to evaluate the confirmation of detected organisms and resistance patterns by FPP. Results: In total, 26 patients included in the analysis. The median age was 70 years and 62% of patients were men; 50% of these patients were critically ill. In the cohort, the most commonly identified organisms were Pseudomonas aeruginosa (31%) and Staphylococcus aureus (30%). Other common organisms were Moraxella catarrhalis (23%) and influenza A (15%). The CTX-M resistance gene was seen in 30% of Enterobacteriaceae cultures, and the MecA/C and MREJ genes were detected in 75% of Staphylococcus aureus cultures. As a result of FPP, de-escalation occurred at a rate of 62%; discontinuation occurred at 42%; and escalation occurred 23%. Inpatient mortality was similar among the 3 groups: de-escalation, 37.5%; discontinuation, 45.5%; escalation, 50%. Notably, 82% of patients received comfort care. Organisms and resistance rates were confirmed with respiratory cultures in 54% of patients. Conclusions: Utilizing FPP yielded high rates of de-escalation, discontinuation, and escalation of antibiotics. No impact noted on inpatient mortality was noted; most of these patients were managed by comfort care. Culture confirmation rates were low due to the variety of sample types. We believe that the use of FPP for bronchoscopy and endotracheal cultures would have the highest impact on antibiotic stewardship efforts.Funding: NoneDisclosures: None

scholarly journals Molecular analysis of methicillin-resistant Staphylococcus aureus isolates from four teaching hospitals in Iran: The emergence of Novel MRSA ST- SCCmec clones

2020 ◽  
Author(s):  
Farzaneh Firoozeh ◽  
Mitra Omidi ◽  
Mahmood Saffari ◽  
Hossein Sedaghat ◽  
Mohammad Zibaei
Keyword(s):  
Staphylococcus Aureus ◽  
Methicillin Resistant Staphylococcus Aureus ◽  
Teaching Hospitals ◽  
Diffusion Method ◽  
Methicillin Resistant ◽  
Resistance Patterns ◽  
Mrsa Strains ◽  
Type V ◽  
Resistance Rates ◽  
Antibiotic Resistance Patterns

Abstract Background: The global spread of methicillin-resistant Staphylococcus aureus (MRSA) infections necessitates the use of validated methods for the identification and typing of this bacterium. This study aimed to determine the distribution of main molecular types of MRSA strain circulating among hospitalized patients in teaching hospitals in Isfahan and Kashan. Methods: A total of 146 Staphylococcus aureus strains were isolated from patients in four teaching hospitals in Isfahan and Kashan during June 2017 to September 2018. The antibiotic resistance patterns of Staphylococcus aureus strains were performed by disc diffusion method. The MRSA strains were identified phenotypically and confirmed by PCR assay. The prevalence of microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) genes among MRSA strains was evaluated by multiplex PCR. The genotypes of MRSA strains were determined by multi-locus sequence type and SCC mec typing. Results: Of 146 Staphylococcus aureus isolates 24 (16.4%) isolates identified as MRSA strains. According to antibiotic susceptibility testing the highest resistance rates were seen to erythromycin, cefoxitin and clindamycin. All of Staphylococcus aureus isolates were sensitive to vancomycin whereas 3 (2.1%) isolates were resistant to linezolid. Three different SCC mec types were obtained among MRSA strains including 16 (66.7%) SCC mec type V, 3 (12.5%) SCC mec type III and 5 (20.8%) SCC mec type II. Of 24 MRSA isolates 20 (83.3%) carried MSCRAMMs genes including eno (70.8%), fib (54.1%) , cna (25.0%), fnbB (16.6%) , ebps 5 (20.8%), and fnbA , bbp and clfA genes were not detected. MLST analysis revealed 11 sequence types among MRSA isolates as follows: ST239, ST239, ST291, ST22, ST861, ST 889, ST8, ST59, ST343, ST772, ST6 and ST1465. Also seven MLST-based clonal complexes (CCs) were identified among MRSA strains including: CC8, CC7, CC398, CC59, CC22, CC1 and CC5. Conclusions: A relatively high diversity was found in MRSA genotypes in Kashan and Isfahan hospitals, and seven clonal complexes were identified. Pandemic MRSA clones including CC8 and CC22 were the most prevalent clones and the novel ST types including ST1465, ST861, ST 889 and ST772 are reported for the first time in Iran in the present study. In addition the high prevalence of MSCRAMMs genes in MRSA isolates demonstrates the high potential of these strains for pathogenicity.

scholarly journals Antibiotic Resistance Pattern of Staphylococcus Aureus Isolated From Pediatrics With Ocular Infections: A 6-Year Hospital-Based Study in China

2021 ◽  
Vol 9 ◽  
Author(s):  
Xiao-Yu Zheng ◽  
Bonnie Nga Kwan Choy ◽  
Ming-Ming Zhou ◽  
Zheng-Yan Zhao
Keyword(s):  
Staphylococcus Aureus ◽  
Antibiotic Resistance ◽  
Resistance Rate ◽  
Resistance Pattern ◽  
Ocular Infection ◽  
Ocular Infections ◽  
Resistance Patterns ◽  
Mrsa Infection ◽  
Resistance Rates ◽  
Antibiotic Resistance Patterns

Staphylococcus aureus (S. aureus) is an important pathogen of ocular infections in pediatrics. The study aimed to identify the prevalence and resistance pattern of S. aureus, especially methicillin-resistant S. aureus (MRSA), in Chinese children with ocular infections. All patients with S. aureus infections were reviewed at a tertiary children's hospital during 2015–2020, and those with ocular infections were investigated for susceptibility results. Of 1,668 S. aureus strains, there were 177 unique isolates from ocular infection. Among them, 45 (25.4%) were MRSA and 132 (74.6%) were methicillin-sensitive S. aureus (MSSA). The proportion of MRSA did not change over time. Most of the strains were obtained from the neonate ward and ophthalmology department (n = 88, 49.7%, and n = 85, 48.0%, respectively), while eye secretion and pus were the main specimen types (n = 128, 72.3%, and n = 37, 20.9%, respectively). MRSA was significantly resistant against penicillin class (97.8%), erythromycin (71.1%), clindamycin (71.1%), and tetracycline (32.1%), with a high multidrug resistance (MDR) rate of 71.1%. However, MRSA was highly sensitive to levofloxacin. Resistance rates against erythromycin and ciprofloxacin as well as MDR percentage all increased among MSSA in children above 1 year of age, ophthalmology department, and outpatient population and decreased in eye secretion specimen. The mean resistance percentage remained stable for MRSA and MSSA during the study period. The survey of ocular S. aureus pathogens in pediatrics and their antibiotic resistance patterns helps in clinical treatment. MRSA with many strains demonstrating MDR is highly prevalent in children with ocular infections in Southeast China. Levofloxacin is an effective topical antibiotic for ocular MRSA infection, while erythromycin has a high resistance rate. The antibiotic resistance patterns of MRSA and MSSA differs and varies by different stratifications. A cautious use of antibiotics should be considered.

scholarly journals Molecular analysis of methicillin-resistant Staphylococcus aureus isolates from four teaching hospitals in Iran: The emergence of novel MRSA clones

2020 ◽  
Author(s):  
Farzaneh Firoozeh ◽  
Mitra Omidi ◽  
Mahmood Saffari ◽  
Hossein Sedaghat ◽  
Mohammad Zibaei
Keyword(s):  
Staphylococcus Aureus ◽  
Teaching Hospitals ◽  
Diffusion Method ◽  
Methicillin Resistant ◽  
High Prevalence ◽  
Resistance Patterns ◽  
Mrsa Strains ◽  
Type V ◽  
Resistance Rates ◽  
First Time

Abstract Background: The global spread of methicillin-resistant Staphylococcus aureus (MRSA) infections necessitates the use of validated methods for the identification and typing of this bacterium. This study aimed to determine the distribution of main molecular types of MRSA strain circulating among hospitalized patients in teaching hospitals in Isfahan and Kashan. Methods: A total of 146 Staphylococcus aureus strains were isolated from patients in four teaching hospitals in Isfahan and Kashan during June 2017 to September 2018. The antimicrobial resistance patterns of Staphylococcus aureus strains were performed by disc diffusion method. The MRSA strains were identified phenotypically and confirmed by PCR assay. The prevalence of microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) genes among MRSA strains was evaluated by multiplex PCR. The genotypes of MRSA strains were determined by multilocus sequence typing and SCCmec typing. Results: Of 146 Staphylococcus aureus isolates, 24 (16.4%) isolates were identified as MRSA strains. According to antimicrobial susceptibility testing the highest resistance rates were seen for tetracycline, erythromycin, ciprofloxacin and gentamicin. All of Staphylococcus aureus isolates were susceptible to vancomycin whereas 3 (2.1%) isolates were resistant to linezolid. Three different SCCmec types were obtained among MRSA strains including 16 (66.7%) SCCmec type V, 3 (12.5%) SCCmec type III and 5 (20.8%) SCCmec type II. Of 24 MRSA isolates 20 (83.3%) carried MSCRAMMs genes including eno (70.8%), fib (54.1%), cna (25.0%), fnbB (16.6%), ebps 5 (20.8%), and the fnbA, bbp and clfA genes were not detected in any MRSA isolate. MLST analysis revealed 11 sequence types among MRSA isolates as follows: ST239, ST291, ST22, ST861, ST889, ST8, ST59, ST343, ST772, ST6 and ST1465. Also seven MLST-based clonal complexes (CCs) were identified among MRSA strains including: CC8, CC7, CC398, CC59, CC22, CC1 and CC5. Conclusions: A relatively high diversity was found in MRSA genotypes in Kashan and Isfahan hospitals, and seven clonal complexes were identified. Pandemic MRSA clones including CC8 and CC22 were the most prevalent clones and the novel ST types including ST1465, ST861, ST 889 and ST772 are reported for the first time in Iran in the present study. In addition the high prevalence of MSCRAMMs genes in MRSA isolates demonstrates the high potential of these strains for pathogenicity.

Cancer-Related Pain Is an Independent Predictor of In-Hospital Opioid Overdose: A Propensity-Matched Analysis

Pain Medicine ◽  
2019 ◽  
Vol 20 (12) ◽  
pp. 2552-2561 ◽  
Author(s):  
Nnaemeka E Onyeakusi ◽  
Fahad Mukhtar ◽  
Semiu O Gbadamosi ◽  
Adebamike Oshunbade ◽  
Adeyinka C Adejumo ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Postoperative Pain Management ◽  
Hospital Charge ◽  
Primary Objective ◽  
Hospital Charges ◽  
Opioid Overdose ◽  
Inpatient Mortality ◽  
Total Hospital ◽  
Total Hospital Charge ◽  
Secondary Objective

Abstract Background About 50% of patients with cancer who have undergone surgery suffer from cancer-related pain (CP). The use of opioids for postoperative pain management presents the potential for overdose, especially among these patients. Objective The primary objective of this study was to determine the association between CP and postoperative opioid overdose among inpatients who had undergone major elective procedures. The secondary objective was to assess the relationship between CP and inpatient mortality, total hospital charge, and length of stay in this population. Methods Data of adults 18 years and older from the National Inpatient Sample (NIS) were analyzed. Variables were identified using ICD-9 codes. Propensity-matched regression models were employed in evaluating the association between CP and outcomes of interest. Results Among 4,085,355 selected patients, 0.8% (N = 2,665) had CP, whereas 99.92% (N = 4,082,690) had no diagnosis of CP. We matched patients with CP (N = 2,665) and no CP (N = 13,325) in a 1:5 ratio. We found higher odds of opioid overdose (adjusted odds ratio [aOR] = 4.82, 95% confidence interval [CI] = 2.68–8.67, P < 0.0001) and inpatient mortality (aOR = 1.39, 95% CI = 1.11–1.74, P = 0.0043) in patients with CP vs no CP. Also, patients with CP were more likely to stay longer in the hospital (12.76 days vs 7.88 days) with higher total hospital charges ($140,220 vs $88,316). Conclusions CP is an independent risk factor for opioid overdose, increased length of stay, and increased total hospital charges.

scholarly journals 539. Impact of Corticosteroids when Combined with Tocilizumab or Remdesivir for the Treatment of Severe SARS-CoV-2

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S371-S371
Author(s):  
Michael Rosati ◽  
Nikunj M Vyas ◽  
Cindy Hou
Keyword(s):  
Statistical Difference ◽  
Primary Objective ◽  
Nasal Cannula ◽  
Ordinal Scale ◽  
Inpatient Mortality ◽  
High Flow Nasal Cannula ◽  
Primary Endpoints ◽  
Secondary Objective ◽  
Oxygen Requirements ◽  
Oxygenation Status

Abstract Background Tocilizumab (TCZ) and remdesivir (RDV) have both shown benefit for patients with SARS-CoV-2. However, there have been no head to head studies comparing the efficacy of the two therapies. The purpose of this study is to compare clinical outcomes of patients who have received corticosteroids (CS) along with TCZ or RDV. Methods This is an IRB approved retrospective observational study completed in a three hospital health system in New Jersey. Patients were included if age was ≥ 18, admitted with SARS-CoV2 infection requiring oxygen. Patients were stratified into two treatment arms; CS + TCZ and CS + RDV. The primary objective was to compare all-cause inpatient mortality (ACIM) based on oxygenation status; nasal cannula (NC), high-flow nasal cannula (HFNC), and invasive mechanical intubation (IMV). Secondary objectives was a snapshot analysis with a focus on clinical improvement (CI) defined as improvement in clinical ordinal scale by 2 or more at end of stay. Additional endpoint included progression to IMV after therapy initiation. Results There were total of 1053 patients included (123 in the CS+TCZ arm, 930 in the CS+RDV arm). Oxygen requirements were as follows: In the CS+TCZ arm (NC n=57, HFNC n=26, IMV n=40), and the RD+CS arm (NC n=669, HFN n=159, and IMV n=102). Results from the primary endpoints can be found in Table 1. No statistically significant differences were observed between the two treatment arms. For the secondary objective there were 214 patients included (70 in the CS+TCZ arm and 105 in the CS+RDV arm). For patients receiving NC, no difference seen in CI between two treatment arms (81.4% CS+RDV vs. 81.5% CS+TCZ). In HFNC group more patients in the CS+TCZ group observed CI compared to CS+RDV (68.8% vs. 40%). Less patients requiring HFNC progressed to IMV in CS+TCZ group (25%) compared to CS+RDV (40%). Conclusion No statistical difference in ACIM was detected between the two treatment arms regardless of baseline oxygenation requirements. There was a trend towards lower ACIM for IMV patients in the CS+TCZ arm compared to the CS+RDV arm. More patients experienced CI in CS+TCZ group compared to CS+RDV in HFNC group. Less HFNC patients also required new IMV in the CS+TCZ arm. Larger studies need to be performed to evaluate a true statistical difference between the two treatment arms. Disclosures All Authors: No reported disclosures

scholarly journals The Increasing Prevalence of Clindamycin Resistance inStaphylococcus aureusIsolates in Children with Head and Neck Abscesses

2011 ◽  
Vol 22 (2) ◽  
pp. 49-51 ◽  
Author(s):  
Ashlin J. Alexander ◽  
Susan E. Richardson ◽  
Alok Sharma ◽  
Paolo Campisi
Keyword(s):  
Staphylococcus Aureus ◽  
Head And Neck ◽  
Methicillin Resistance ◽  
Neck Region ◽  
Empirical Therapy ◽  
Resistance Rate ◽  
Head And Neck Region ◽  
Resistance Patterns ◽  
The Mean ◽  
Resistance Rates

OBJECTIVE: To retrospectively review trends in clindamycin resistance amongStaphylococcus aureushead and neck abscesses between January 2000 and June 2008.METHODS: Between January 2000 and June 2008, inpatient and out-patientS aureusisolates were reviewed for antibiotic susceptibility. In particular, cultures from 153 abscesses in the head and neck region were assessed for clindamycin and methicillin resistance patterns.RESULTS: Annual clindamycin resistance rates for allS aureusisolates, and specifically forS aureushead and neck abscesses, revealed concerning levels of clindamycin and methicillin resistance. After 2002, the mean clindamycin resistance rate in head and neck abscesses was approximately 27%. The number of new cases of methicillin-resistantS aureusper year increased from four cases in 2000 to 44 cases in 2007.CONCLUSION: Antibiotic resistance should be considered following failed empirical therapy of head and neck abscesses with clindamycin.

The Student Room Survey: Changes in the Post Graduate Study for Cardiothoracic Surgery

2020 ◽  
Vol 23 (2) ◽  
pp. 71-74
Author(s):  
Md Faizus Sazzad ◽  
Mohammed Moniruzzaman ◽  
Dewan Iftakher Raza Choudhury ◽  
Arif Ahmed Mohiuddin ◽  
Raafi Rahman ◽  
...  
Keyword(s):  
Thoracic Surgery ◽  
Retrospective Analysis ◽  
Primary Objective ◽  
Graduate Study ◽  
Postgraduate Students ◽  
Depth Interview ◽  
Secondary Objective ◽  
Cardio Vascular ◽  
The University ◽  
Day By Day

Background: The number of postgraduate students in Cardiac surgical discipline is increasing day by day with incremental proportion are measurably suffering from the unnecessary lingering of the present course curriculum. The primary objective of this study was to find out the last 5 years’ of results of Masters in Surgery course under the University of Dhaka from a student room survey. A secondary objective was to find out positive changes that could show us the way of a step toward up-gradation. Methods: It is a retrospective analysis of all examination results of Cardio-vascular & Thoracic Surgery published since January 2008 to January 2013 from the University of Dhaka with in depth interview of 11 participants. Results: 85.24% students failed to pass part-I of Masters in Surgery for Cardio-vascular & Thoracic Surgery course while, 82.18% in part-II and 71.28% failed to pass the final part. Average 2.51 attempts needed to complete each part of the designed course resulted into lingering of course duration for 42.18 months/student. In the thoracic surgery discipline the number of students alarmingly reduced up to 0% in the recent academic sessions. Conclusions: Masters in Surgery is resulting in unnecessary prolongation of the course. We should step forward to meet the next generation challenge. Journal of Surgical Sciences (2019) Vol. 23(2): 71-74

Epidemiology of pheochromocytoma and paraganglioma: population-based cohort study

2021 ◽  
Vol 184 (1) ◽  
pp. 19-28
Author(s):  
Alexander A Leung ◽  
Janice L Pasieka ◽  
Martin D Hyrcza ◽  
Danièle Pacaud ◽  
Yuan Dong ◽  
...  
Keyword(s):  
Cohort Study ◽  
Administrative Data ◽  
Laboratory Data ◽  
Population Based ◽  
Incidence Rates ◽  
Primary Objective ◽  
Administrative Databases ◽  
Secondary Objective ◽  
True Frequency ◽  
Clinical Records

Objective Despite the significant morbidity and mortality associated with pheochromocytoma and paraganglioma, little is known about their epidemiology. The primary objective was to determine the incidence of pheochromocytoma and paraganglioma in an ethnically diverse population. A secondary objective was to develop and validate algorithms for case detection using laboratory and administrative data. Design Population-based cohort study in Alberta, Canada from 2012 to 2019. Methods Patients with pheochromocytoma or paraganglioma were identified using linked administrative databases and clinical records. Annual incidence rates per 100 000 people were calculated and stratified according to age and sex. Algorithms to identify pheochromocytoma and paraganglioma, based on laboratory and administrative data, were evaluated. Results A total of 239 patients with pheochromocytoma or paraganglioma (collectively with 251 tumors) were identified from a population of 5 196 368 people over a period of 7 years. The overall incidence of pheochromocytoma or paraganglioma was 0.66 cases per 100 000 people per year. The frequency of pheochromocytoma and paraganglioma increased with age and was highest in individuals aged 60–79 years (8.85 and 14.68 cases per 100 000 people per year for males and females, respectively). An algorithm based on laboratory data (metanephrine >two-fold or normetanephrine >three-fold higher than the upper limit of normal) closely approximated the true frequency of pheochromocytoma and paraganglioma with an estimated incidence of 0.54 cases per 100 000 people per year. Conslusion The incidence of pheochromocytoma and paraganglioma in an unselected population of western Canada was unexpectedly higher than rates reported from other areas of the world.

Incidência da utilização de protetores bucais em diversos esportes de contato

2020 ◽  
Vol 12 (45) ◽  
pp. 118-122
Author(s):  
Victor Paes Dias Gonçalves ◽  
Hugo Leonardo Matias Nahmias ◽  
Marcus Menezes Alves Azevedo
Keyword(s):  
Martial Arts ◽  
Rio De Janeiro ◽  
Dental Trauma ◽  
Primary Objective ◽  
Type Ii ◽  
Contact Sports ◽  
The Face ◽  
Secondary Objective ◽  
The City

Among contact sports, the practice of martial arts offers a greater risk of causing dental trauma and fractures as contact with the face is more frequent. The primary objective of the research is to evaluate the incidence of mouthguard use, and the secondary objective is to verify which type has a greater predominance and the difficulties in its use correlating to the type of mouthguard used. A documentary study was carried out with 273 athletes of different contact sports, among them: MMA, Boxing, Muay Thai, Jiu-Jitsu, and Taekwondo of the city of Campos dos Goytacazes, Rio de Janeiro, Brazil. It was concluded that the most commonly used mouthguard is PB Boils and Bites - Type II and its level of approval is poor, interfering with the athletes’ performance, mainly in relation to the breathing factor.

scholarly journals Use of Ceftaroline in Hospitalized Patients with and without COVID-19: A Descriptive Cross-Sectional Study

Antibiotics ◽  
2021 ◽  
Vol 10 (7) ◽  
pp. 763
Author(s):  
Daniele Roberto Giacobbe ◽  
Chiara Russo ◽  
Veronica Martini ◽  
Silvia Dettori ◽  
Federica Briano ◽  
...  
Keyword(s):  
Bacterial Infections ◽  
Bloodstream Infections ◽  
Cross Sectional Study ◽  
Primary Objective ◽  
Sectional Study ◽  
Cross Sectional ◽  
First Line Therapy ◽  
Large Teaching Hospital ◽  
Secondary Objective ◽  
Medical Wards

A single-center cross-sectional study was conducted to describe the use of ceftaroline in a large teaching hospital in Northern Italy, during a period also including the first months of the coronavirus disease 2019 (COVID-19) pandemic. The primary objective was to describe the use of ceftaroline in terms of indications and characteristics of patients. A secondary objective was to describe the rate of favorable clinical response in patients with bloodstream infections (BSI) due to methicillin-resistant Staphylococcus aureus (MRSA-BSI) receiving ceftaroline. Overall, 200 patients were included in the study. Most of them had COVID-19 (83%, 165/200) and were hospitalized in medical wards (78%, 155/200). Included patients with COVID-19 pneumonia were given empirical ceftaroline in the suspicion of bacterial co-infection or superinfection. Among patients with MRSA-BSI, ceftaroline was used as a first-line therapy and salvage therapy in 25% (3/12) and 75% (9/12) of cases, respectively, and as a monotherapy or in combination with daptomycin in 58% (7/12) and 42% (5/12) of patients, respectively. A favorable response was registered in 67% (8/12) of patients. Improving etiological diagnosis of bacterial infections is essential to optimize the use of ceftaroline in COVID-19 patients. The use of ceftaroline for MRSA-BSI, either as a monotherapy or in combination with other anti-MRSA agents, showed promising rates of favorable response.

Sign in / Sign up

Export Citation Format

Share Document