scholarly journals Hypercoagulation and Hypermetabolism of Fibrinogen in Severely Burned Adults

2019 ◽  
Author(s):  
Wenjun Z Martini ◽  
John B Holcomb ◽  
Yong-Ming Yu ◽  
Steven E Wolf ◽  
Leopoldo C Cancio ◽  
...  
Keyword(s):  
Stable Isotope ◽  
Vital Signs ◽  
Institutional Review Board ◽  
Control Group ◽  
Clot Strength ◽  
Blood Samples ◽  
Respiration Rates ◽  
Institutional Review ◽  
Production And Consumption ◽  
D Dimer

Abstract This study investigated changes in plasma fibrinogen metabolism and changes in coagulation in severely burned adults. Ten patients (27 ± 3 years; 91 ± 6 kg) with 51 ± 3% TBSA were consented and enrolled into an institutional review board–approved prospective study. On the study day, stable isotope infusion of 1-13C-phenylalanine and d5-phenylalanine was performed to quantify fibrinogen production and consumption. During the infusion, vital signs were recorded and blood samples were drawn every hour. Coagulation was measured by thromboelastograph (TEG). Ten normal healthy volunteers (37 ± 7 years; 74 ± 4 kg) were included as the control group. Burned adults had elevated heart rates (120 ± 2 vs 73 ± 5 [control] beats/minute), respiration rates (23 ± 2 vs 15 ± 1 breaths/minute), plasma glucose (127 ± 10 vs 89 ± 2 mg/dl), and fibrinogen levels (613 ± 35 vs 239 ± 17 mg/dl); and decreased albumin (1.3 ± 0.2 vs 3.7 ± 0.1 g/dl) and total protein (4.4 ± 0.2 vs 6.8 ± 0.1 g/dl, all P < .05). Fibrinogen breakdown was elevated in the burn group (2.3 ± 0.4 vs. 1.0 ± 0.3 µmol/kg/minute); and fibrinogen synthesis was further enhanced in the burn group (4.4 ± 0.7 vs 0.7 ± 0.2 µmol/kg/minute, both P < .05). Clotting speed (TEG-alpha) and clot strength (TEG-MA) were increased in the burn group (62 ± 4 vs 50 ± 4°, and 76 ± 2 vs 56 ± 2 mm, respectively, both P < .05). Fibrinolysis of TEG-LY60 was accelerated in the burn group (16 ± 6 vs 3 ± 1) and so was the increase in D-dimer level in the burn group (4.5 ± 0.4 vs 1.9 ± 0.3 mg/l, both P < .05). The hypercoagulable state postburn is in part a result of increased fibrinogen synthesis, over and above increased fibrinogen breakdown.

scholarly journals Suitability of Placental Blood Samples of Newborns for Pre-Transfusion Testing

2021 ◽  
Vol 9 ◽  
Author(s):  
Rana Alissa ◽  
Patty D. Williams ◽  
Erika L. Baker ◽  
Jennifer A. Hipp ◽  
Jinous Saremian ◽  
...  
Keyword(s):  
Informed Consent ◽  
Categorical Data ◽  
Institutional Review Board ◽  
Abo Blood Group ◽  
Blood Samples ◽  
Rhesus Factor ◽  
Institutional Review ◽  
Antiglobulin Test ◽  
Placental Blood ◽  
Antibody Screen

Objective: To show concordance between heel stick and placental blood sample pairs for newborns' pre-transfusion testing and to validate placental blood's tube and gel methodology.Methods: Placental samples were collected for pre-transfusion testing at birth from 78 singleton and twin newborns admitted to our Mother–Baby Unit to compare with the results of heel stick samples taken from same newborns. Gestational age ≥35 weeks, weight ≥2,000 g. The study was approved by the Institutional Review Board (IRB). Informed consent was obtained from newborn parents. ABO blood group, Rhesus factor (Rh), direct antiglobulin test (DAT), and antibody screen were performed. Ortho ProVue Analyzer was used for tube and gel methods. McNemar's test for paired categorical data was performed.Results: One hundred percent concordance in 78 pairs for ABO and Rh. Seventy-four pairs were tested for antibodies, 72 were both negative, 1 was both positive, and 1 gave discordant result. Ninety-nine percent concordance, p = 0.999. Sixty-five pairs were both DAT negative, seven were both DAT positive, and six gave discordant results. Ninety-two percent concordance, p = 0.68. Placental blood gave identical results comparing tube with gel methods.Conclusions: Placental blood is suitable for pre-transfusion testing and can replace heel sticks. Placental blood tube and gel methods are validated.

Investigation the Effects of Adding Intravenous Transoxalic Acid and Its Complications in the Prevention of Postpartum Hemorrhage after Vaginal Delivery in Patients Admitted to Ali-ibn-Abitaleb Hospital in Zahedan

2021 ◽  
Author(s):  
Tahereh Hajian ◽  
Maryam Razavi ◽  
Ali Dashipour
Keyword(s):  
Side Effects ◽  
Postpartum Hemorrhage ◽  
Intervention Group ◽  
Vital Signs ◽  
Control Group ◽  
Drug Side Effects ◽  
Blood Samples ◽  
Significant Difference ◽  
The Mean ◽  
Uterine Fundus

Background: This study was designed to investigate the effect of tranexamic acid and its side effects in preventing postpartum hemorrhage in patients referred to Ali ibn Abitaleb Hospital in Zahedan during 2020-2021. Methods: Patients were divided into two groups of 85 patients. Vital signs as well as drug side effects related to tranexamicity are monitored and recorded every15 minutes in the first hour and every 30 minutes in the second hour. Also, blood samples are taken from patients to measure hemoglobin and hematocrit within6 hours after delivery. The number and weight difference of droschitis used during 2 hours after delivery are also measured. In addition, PPH (Postpartum hemorrhage) cases in both groups were checked by repeated examination of the uterine fundus during the first 2 hours and after 6 weeks. Results: There was no statistically significant difference between the two groups in terms of the number of deliveries and further decrease in hemoglobin levels in the control group compared to the intervention group. Nausea, vomiting, and dizziness were observed in the intervention group and thrombosis was not observed in any group. According to the independent samples t-test, there was a statistically significant difference between the mean blood volume lost between the two groups. The mean hematocrit drop was statistically significant between the two groups. No blood transfusion was observed in any of the patients. Conclusion: Tranxamic acid injections can effectively reduce postpartum hemorrhage and reduce maternal hemoglobin and hematocrit following this complication.

Changes in blood acid-base balance parameters and coagulation profile during diarrhea in calves

2013 ◽  
Vol 16 (3) ◽  
pp. 543-549 ◽  
Author(s):  
P. Sobiech ◽  
W. Rękawek ◽  
M. Ali ◽  
R. Targoński ◽  
K. Żarczyńska ◽  
...  
Keyword(s):  
Control Group ◽  
Thrombin Time ◽  
Acid Base Balance ◽  
Acid Base ◽  
Blood Samples ◽  
Coagulation Profile ◽  
At Iii ◽  
Base Balance ◽  
Diarrheic Calves ◽  
D Dimer

Abstract The purpose of this study was to investigate possible alterations in acid-base balance parameters and the coagulation profile in neonatal diarrheic calves. Twenty neonatal diarrheic and 20 clinically healthy neonatal calves aged between 1 week to 10 days were used. All blood samples were taken on the third day from the onset of diarrhea symptom. Venous blood samples were collected from each animal to determine platelet numbers, pH, pCO2, pO2, HCO3-, BE, O2SAT, ctCO2 and electrolytes (K+, Na+ and Cl-). Plasma samples were collected from each animal for the measurement of prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), the concentrations of fibrinogen, D-dimer and the activity of antithrombin III (AT III). Blood pH (7.19), BE (-10.6 mmol/l), HCO3 - (25.15 mmol/l), pO2 (3.33 kPa), O2SAT (24.12 %) were significantly lower and serum concentration of K+ (6.55 mmol/l) was significantly higher in diarrheic calves. These changes indicate the state of uncompensated metabolic acidosis with accompanying hyperkalemia. TT (32.05s) and APTT (39.9s) values were more prolonged in calves with diarrhea than in the control group. D-dimer (587.25 μg/l) concentrations were significantly increased while a visible drop in AT III (103.75%) activity and platelets counts (598 x109/l) were observed in diarrheic group of calves. The results suggest that a consumptive type of disseminated intravascular coagulation (DIC) developed in diarrheic calves.

Knowledge and Competence Retention Among Mid-Level Health Providers After Intensive One-On-One Clinical Mentorship in TB and HIV Management

2020 ◽  
Author(s):  
Dan Kaggwa Senjovu ◽  
Sarah Naikoba ◽  
Pallen Mugabe ◽  
Damazo T. Kadengye ◽  
Carey McCarthy ◽  
...  
Keyword(s):  
Clinical Competence ◽  
Clinical Care ◽  
Institutional Review Board ◽  
Control Group ◽  
National Council ◽  
Task Sharing ◽  
Health Providers ◽  
Research Committee ◽  
Institutional Review ◽  
Clinical Mentorship

Abstract Introduction : Clinical mentorship is effective in improving knowledge and competence of health providers and may be a useful task sharing approach for improving antiretroviral therapy. However, the endurance of the effect of clinical mentorship is uncertain. Methods : The midlevel health providers who participated in a cluster-randomized trial of one-on-one, on-site, clinical mentorship in tuberculosis and HIV for 8 hours a week, every 6 weeks over 9 months were followed to determine if the gains in knowledge and competence that occurred after the intervention were sustained 6- and 12-months post-intervention. In December 2014 and June 2015, their knowledge and clinical competence were respectively assessed using vignettes and a clinical observation tool of patient care. Multilevel mixed effects regression analysis was used to compare the differences in mean scores for knowledge and clinical competence between times 0, 1, 2, and 3 by arm.Results: At the end of the intervention phase of the trial, the mean gain in knowledge scores and clinical competence scores in the intervention arm was 13.4% (95% confidence interval ([CI]: 7.2, 19.6), and 27.8% (95% CI: 21.1, 34.5) respectively, with no changes seen in the control arm. Following the end of the intervention; knowledge mean scores in the intervention arm did not significantly decrease at 6 months (0.6% [95% CI -1.4, 2.6]) or 12 months (-2.8% [95% CI: -5.9, 0.3]) while scores in the control arm significantly increased at 6 months (6.6% [95% CI: 4.4, 8.9]) and 12 months (7.9% [95% CI: 5.4, 10.5]). Also, no significant decrease in clinical competence mean scores for intervention arm was seen at 6 month (2.8% [95% CI: -1.8, 7.5] and 12 months (3.7% [95% CI: -2.4, 9.8]) while in the control arm, a significant increase was seen at 6 months (5.8% [95% CI: 1.2, 10.3] and 12 months (11.5% [95% CI: 7.6, 15.5]).Conclusions : Mentees sustained the competence and knowledge gained after the intervention for a period of one year. Although, there was an increase in knowledge in the control group over the follow-up period, MLP in the intervention arm experienced earlier and sustained gains. One-on-one clinical mentorship should be scaled-up as a task-sharing approach to improve clinical care.Trial Registration : The study received ethics approvals from 3 institutions – the US Centers for Disease Control and Prevention Institutional Review Board (USA), the Institutional Review Board “JCRC’s HIV/AIDS Research Committee” IRB#1-IRB00001515 with Federal Wide Assurance number (FWA00009772) based in Kampala and the Uganda National Council of Science and Technology (Uganda) which approves all scientific protocols to be implemented in Uganda.

The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study

Vascular ◽  
2016 ◽  
Vol 25 (2) ◽  
pp. 163-169 ◽  
Author(s):  
Ali Kagan Coskun ◽  
Zekai Halici ◽  
Akgun Oral ◽  
Yasin Bayir ◽  
Ferhat Deniz ◽  
...  
Keyword(s):  
Experimental Study ◽  
Superior Mesenteric Artery ◽  
Mesenteric Artery ◽  
Mesenteric Ischemia ◽  
Early Stage ◽  
Acute Mesenteric Ischemia ◽  
Artery Occlusion ◽  
Control Group ◽  
Blood Samples ◽  
D Dimer

Background The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates. Aim This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery. Methods The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured. Results The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L. Conclusions In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.

Molecular Alterations in Pulmonary Adenocarcinoma of African Americans

2019 ◽  
Vol 152 (2) ◽  
pp. 237-242
Author(s):  
Erika F Rodriguez ◽  
Robert Jones ◽  
C Paul Morris ◽  
David Ettinger ◽  
Sayanan Chowsilpa ◽  
...  
Keyword(s):  
Overall Survival ◽  
African American ◽  
African Americans ◽  
Pulmonary Adenocarcinoma ◽  
Institutional Review Board ◽  
Control Group ◽  
Molecular Alterations ◽  
Molecular Tests ◽  
Institutional Review Board Approval ◽  
Institutional Review

ABSTRACT Objectives Identify molecular alterations in pulmonary adenocarcinoma (ADC) in African American (AA) patients diagnosed on cytology specimens. Methods After institutional review board approval, we searched our database from 2013 to 2017 for AA patients with a diagnosis of pulmonary ADC. Molecular and clinical data were reviewed. White patients also diagnosed with pulmonary ADC on cytology samples formed a control group. Results A total of 113 patients were identified. Mean age was 63.4 years. Molecular tests were available for 91 patients. Mutations were identified in 53 (58.2%) cases. The most common mutations were EGFR (n = 19 cases, 36%) and KRAS (n = 24 cases, 45%). When compared with whites, AA patients were diagnosed at higher stages (P = .045) and demonstrated shorter overall survival (17 vs 47 months, P = .0150). No differences were noted regarding distribution of molecular alterations. Conclusion AA patients have similar molecular alterations in ADCs as their white counterparts. However, they have worse outcomes.

scholarly journals Multicentre randomised double-blinded placebo-controlled trial of favipiravir in adults with mild COVID-19

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e047495
Author(s):  
Mohammad Bosaeed ◽  
Ahmad Alharbi ◽  
Mohammad Hussein ◽  
Mohammed Abalkhail ◽  
Khizra Sultana ◽  
...  
Keyword(s):  
Randomised Trial ◽  
Disease Onset ◽  
Dropout Rate ◽  
Institutional Review Board ◽  
Research Centre ◽  
Control Group ◽  
Ministry Of Health ◽  
Link Type ◽  
Institutional Review ◽  
Novel Coronavirus

IntroductionA novel coronavirus, designated SARS-CoV-2, caused an international outbreak of a respiratory illness, termed COVID-19 in December 2019. There is a lack of specific therapeutic agents based on evidence for this novel coronavirus infection; however, several medications have been evaluated as a potential therapy. Therapy is required to treat symptomatic patients and decrease the virus carriage duration to limit the communitytransmission.Methods and analysisWe hypothesise that patients with mild COVID-19 treated with favipiravir will have a shorter duration of time to virus clearance than the control group. The primary outcome is to evaluate the effect of favipiravir on the timing of the PCR test conversion from positive to negative within 15 days after starting the medicine.Adults (>18 years, men or nonpregnant women, diagnosed with mild COVID-19 within 5 days of disease onset) are being recruited by physicians participating from the Ministry of National Guard Health Affairs and the Ministry of Health ethics committee approved primary healthcare centres. This double-blind, randomised trial comprises three significant parts: screening, treatment and a follow-up period. The treating physician and patients are blinded. Eligible participants are randomised in a 1:1 ratio to either the therapy group (favipiravir) or a control group (placebo) with 1800 mg by mouth two times per day for the first day, followed by 800 mg two times per day for 4–7 days. Serial nasopharyngeal/oropharyngeal swab samples are obtained on day 1 (5 days before therapy). On day5±1 day, 10±1 day, 15±2 days, extra nasopharyngeal/oropharyngeal PCR COVID-19 samples are requested.The primary analysis population for evaluating both the efficacy and safety outcomes will be a modified intention to treat population. Anticipating a 10% dropout rate, we expect to recruit 288 subjects per arm. The results assume that the hazard ratio is constant throughout the study and that the Cox proportional hazard regression is used to analyse the data.Ethics and disseminationThe study was approved by the King Abdullah International Medical Research Centre Institutional Review Board (28 April 2020) and the Ministry of Health Institutional Review Board (1 July 2020). Protocol details and any amendments will be reported to https://clinicaltrials.gov/ct2/show/NCT04464408. The results will be published in peer-reviewed journals.Trial registration numberNational Clinical Trial Registry (NCT04464408).

scholarly journals Driving After Total Ankle Arthroplasty

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0008
Author(s):  
Elizabeth McDonald ◽  
David Pedowitz ◽  
Rachel Shakked ◽  
Joseph Daniel ◽  
Kristen Nicholson ◽  
...  
Keyword(s):  
Total Ankle Arthroplasty ◽  
Institutional Review Board ◽  
Control Group ◽  
Analog Scale ◽  
Ankle Arthroplasty ◽  
Patient Demographics ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Age Range ◽  
Arthroplasty Surgery

Category: Ankle Introduction/Purpose: With the increase in number of total ankle arthroplasty surgery, physician guidelines on when to begin to consider patients’ return to driving is valuable. The ability to accurately and efficiently determine when a patient can return to driving is important both from a patient safety and a medicolegal perspective. The purpose of the study was to determine when patients’ brake reaction time (BRT) returns to a safe value after right total ankle arthroplasty. We also aimed to identify predictive factors that may identify those patients who may not be safe to drive. Methods: After institutional review board approval, fifty-five patients undergoing right total ankle arthroplasty were recruited prospectively. Patient demographics include an age range of 43 to 83 years (median 63 years), of which 31 were male (56%) and 24 were female (44%). BRT was tested at six weeks and repeated weekly until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish a passing BRT of 0.850 seconds. Patients were given a validated, novel driver readiness survey to complete of which a 10/15 point or higher score was considered passing. Results: At 6 weeks, 50 patients (91%) achieved a passing BRT and were considered safe to drive, and the passing group average BRT was 0.662 seconds. At 9 weeks, 52 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) for pain (p=0.037) and significantly diminished ankle plantarflexion (p=0.029). There is a significant (p<0.001) and large (r=-0.455) correlation between BRT and the validated driver readiness survey scores. 5/5 (100%) patients that failed the BRT also failed the driver readiness survey (p=0.049). Interestingly, males were more likely to think they were ready to drive based on their driver readiness survey but were no more likely to pass the BRT than females (p=0.002). Conclusion: Over 90% of patients may be eligible to return to driving as early as 6 weeks post-operatively. Indications that a patient is not safe to return to driving at 6 weeks are higher VAS, limited plantarflexion, and a failed driver readiness survey. Although many factors determine whether a patient may safely return to driving, patients may be informed that BRT normalizes 9 weeks after right total ankle arthroplasty.

scholarly journals Comparison of modern quantitative methods for determining level of D-dimer based on immunoturbidimetry

2019 ◽  
Vol 3 (22) ◽  
pp. 56-57
Author(s):  
A. N. Mamaev ◽  
M. V. Pykhteeva ◽  
S. S. Terekhov ◽  
A. V. Kudinov ◽  
D. A. Trukhina ◽  
...  
Keyword(s):  
Monoclonal Antibodies ◽  
Quantitative Methods ◽  
Research Study ◽  
Lower Limbs ◽  
Control Group ◽  
Blood Samples ◽  
Thrombotic Complications ◽  
D Dimer ◽  
Duration Of Gestation

The object of this paper is the comparative analysis of the results of determination of the D-dimer level with the new home-produced reagent on the basis of original monoclonal antibodies with the results of the widespread diagnostic analogues. The research study included blood samples of 80 patients. 22 of these patients (27.5 %) were diagnosed venous thrombosises of the lower limbs, 28 patients (35.0 %) did not have any thrombotic complications (control group). Besides, the research included 30 pregnant women (37.5 %) with different duration of gestation. Despite some distinctions when determining the D-dimer level, contemporary quantitative methods of the D-dimer level study demonstrate comparability of the research results which is documented by the high rates of correlation. The new diagnostic kit Tech-D-dimer-auto, based on the use of original monoclonal antibodies, demonstrates good comparability with analogues and is suitable for detection of thrombosis.

scholarly journals Retention of knowledge and clinical competence among Ugandan mid-level health providers 1 year after intensive clinical mentorship in TB and HIV management

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Dan K. Senjovu ◽  
Sarah Naikoba ◽  
Pallen Mugabe ◽  
Damazo T. Kadengye ◽  
Carey McCarthy ◽  
...  
Keyword(s):  
Clinical Competence ◽  
Clinical Care ◽  
Institutional Review Board ◽  
Control Group ◽  
National Council ◽  
Task Sharing ◽  
Health Providers ◽  
Research Committee ◽  
Institutional Review ◽  
Clinical Mentorship

Abstract Introduction Clinical mentorship is effective in improving knowledge and competence of health providers and may be a useful task sharing approach for improving antiretroviral therapy. However, the endurance of the effect of clinical mentorship is uncertain. Methods The midlevel health providers who participated in a cluster-randomized trial of one-on-one, on-site, clinical mentorship in tuberculosis and HIV for 8 h a week, every 6 weeks over 9 months were followed to determine if the gains in knowledge and competence that occurred after the intervention were sustained 6- and 12-months post-intervention. In December 2014 and June 2015, their knowledge and clinical competence were respectively assessed using vignettes and a clinical observation tool of patient care. Multilevel mixed effects regression analysis was used to compare the differences in mean scores for knowledge and clinical competence between times 0, 1, 2, and 3 by arm. Results At the end of the intervention phase of the trial, the mean gain in knowledge scores and clinical competence scores in the intervention arm was 13.4% (95% confidence interval ([CI]: 7.2, 19.6), and 27.8% (95% CI: 21.1, 34.5) respectively, with no changes seen in the control arm. Following the end of the intervention; knowledge mean scores in the intervention arm did not significantly decrease at 6 months (0.6% [95% CI − 1.4, 2.6]) or 12 months (− 2.8% [95% CI: − 5.9, 0.3]) while scores in the control arm significantly increased at 6 months (6.6% [95% CI: 4.4, 8.9]) and 12 months (7.9% [95% CI: 5.4, 10.5]). Also, no significant decrease in clinical competence mean scores for intervention arm was seen at 6 month (2.8% [95% CI: − 1.8, 7.5] and 12 months (3.7% [95% CI: − 2.4, 9.8]) while in the control arm, a significant increase was seen at 6 months (5.8% [95% CI: 1.2, 10.3] and 12 months (11.5% [95% CI: 7.6, 15.5]). Conclusions Mentees sustained the competence and knowledge gained after the intervention for a period of one year. Although, there was an increase in knowledge in the control group over the follow-up period, MLP in the intervention arm experienced earlier and sustained gains. One-on-one clinical mentorship should be scaled-up as a task-sharing approach to improve clinical care. Trial Registration The study received ethics approvals from 3 institutions—the US Centers for Disease Control and Prevention Institutional Review Board (USA), the Institutional Review Board “JCRC’s HIV/AIDS Research Committee” IRB#1-IRB00001515 with Federal Wide Assurance number (FWA00009772) based in Kampala and the Uganda National Council of Science and Technology (Uganda) which approves all scientific protocols to be implemented in Uganda.

Sign in / Sign up

Export Citation Format

Share Document