Airway Closure Delay: The Predominant Pathophysiology in Reflux-Associated Dysphagia

2019 ◽  
Vol 160 (5) ◽  
pp. 885-890 ◽  
Author(s):  
Katherine A. Kendall
Keyword(s):  
Tertiary Care ◽  
Oropharyngeal Dysphagia ◽  
Retrospective Chart Review ◽  
Upper Esophageal Sphincter ◽  
Barium Swallow ◽  
Airway Closure ◽  
Swallowing Function ◽  
Pharyngeal Transit ◽  
Pharyngeal Swallowing ◽  
The Impact

Objective Reflux disease is common in patients with oropharyngeal dysphagia, but the impact of reflux on oropharyngeal swallowing physiology is not known. This study uses objective measures of swallowing function from modified barium swallow studies to describe the pathophysiology of dysphagia in a group of patients whose only associated condition is reflux. Study Design Retrospective chart review. Setting Tertiary care voice and swallowing clinic. Subjects and Methods The Swallowing Database at the University of Utah was queried for patients with a diagnosis of reflux without additional conditions known to affect swallowing function. Pharyngeal transit time (TPT), distance of hyoid elevation (Hmax), maximum opening size of the upper esophageal sphincter (UESmax), area of pharynx at maximum constriction (PAmax), airway closure timing relative to the arrival of the bolus at the UES, and penetration/aspiration (Pen/Asp) score were assessed. Results Of the 122 patients who met inclusion criteria for the study, 42% had normal pharyngeal swallowing function, 57% had at least 1 abnormal swallowing measure, and 47.5% demonstrated a delay in airway closure relative to arrival of the bolus at the UES on at least 1 swallow. The incidence of prolonged TPT, diminished Hmax, poor UESmax, and enlarged PAmax were 2.5%, 8%, 4%, and 11.5%, respectively. Sixty percent with a delay in airway closure had a normal Pen/Asp score. Conclusion A delay in airway closure relative to the arrival of the bolus at the UES is the most common abnormality of swallowing function found in patients with reflux-associated dysphagia but may not be identified using the Pen/Asp score.

scholarly journals The Impact of COVID-19 on Adolescents with Eating Disorders: A Cohort Study

2021 ◽  
Author(s):  
Wendy Spettigue ◽  
Nicole Obeid ◽  
Madison Erbach ◽  
Stephen Feder ◽  
Natalie Finner ◽  
...  
Keyword(s):  
Eating Disorders ◽  
Chart Review ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Time Frame ◽  
Lower Percentage ◽  
Average Percentage ◽  
Psychological Measures ◽  
One Year ◽  
The Impact

Abstract Background: There is a noticeable lack of evidence regarding the impact of COVID-19 and the associated lockdown on young people with eating disorders. The goals of this study were 1) to examine characteristics of adolescents presenting for eating disorder (ED) assessment since the onset of the COVID-19 pandemic; 2) to compare adolescents presenting for ED assessment since the onset of the COVID-19 pandemic to those that presented for assessment one year previously; 3) to examine implications of the pandemic on the system of care. Methods: A retrospective chart review was completed on all patients assessed at a pediatric tertiary care ED program during the pandemic between April 1 and October 31, 2020, and on youth assessed during the same time frame one year previously. Data including body measurements and results of psychological measures was extracted from patients’ charts. Clinician reports were utilized for accounts of ED symptoms. Referrals to our program were also compared for the two time periods.Results: Of the 48 youth assessed between April and October 2020, average age was 14.6 years and average percentage of treatment goal weight was 77.7%. 40% cited the pandemic as a trigger for their ED; of these youth, 78.9% were medically unstable compared to 55.2% of those whose ED was not triggered by the pandemic. When comparing the 2020 cohort to those assessed in 2019, youth who presented for assessment during the pandemic trended towards having lower percentage of goal weights and higher rates of self-reported impairment, and were significantly more likely to be medically unstable and to require hospitalization. Higher rates of inpatient admissions, emergency room consultation requests and outpatient referrals deemed “urgent” were likewise associated with the pandemic period.

Botulinum Toxin Injection of the Cricopharyngeus Muscle for the Treatment of Dysphagia

2000 ◽  
Vol 122 (5) ◽  
pp. 691-695 ◽  
Author(s):  
Syed F. Ahsan ◽  
Robert J. Meleca ◽  
James Paul Dworkin
Keyword(s):  
Botulinum Toxin ◽  
Rating Scale ◽  
Botulinum Toxin Injection ◽  
Retrospective Chart Review ◽  
Muscle Spasm ◽  
Barium Swallow ◽  
Patient Questionnaire ◽  
Therapeutic Effects ◽  
Swallowing Function ◽  
Botox Injection

OBJECTIVE: This study was conducted to evaluate, subjectively and objectively, the diagnostic and therapeutic effects of botulinum toxin (Botox) in patients with dysphagia caused by cricopharyngeus (CP) muscle spasm and/or hypertonicity. METHODS: A retrospective chart review was done of 5 patients with normally functioning larynges treated with CP Botox injection for dysphagia caused by perceived spasm. Subjective measures of swallowing function after injection were obtained with a patient questionnaire. Objective data were obtained both before and after surgery by one or more of the following tests: modified barium swallow study, manometry, videostroboscopy, and fiberoptic endoscopic evaluation of swallowing. Quality-of-life measures were obtained with a swallowing rating scale. RESULTS: Overall, all patients had initial improvement in swallowing after Botox injection. The duration of benefit was from 2 to 14 months. There were no complications. Four of 5 patients had long-term benefits, as evidenced by decreased or eliminated aspiration symptoms, removal of tracheotomy, ability to eat solid foods, and weight gain. One patient continues to have poor swallowing function. CONCLUSION: Botox injection of the CP muscle to treat dysphagia is effective in patients with underlying muscle spasm or hypertonicity. A positive response to Botox can also help confirm the diagnosis of CP muscle spasm.

scholarly journals Implementation of Two-Step Clostridioides difficile Testing Algorithm and Management of Possible Carriers

2020 ◽  
Vol 41 (S1) ◽  
pp. s269-s270
Author(s):  
J. Daniel Markley ◽  
Daniel Tassone ◽  
Melanie Christian ◽  
Leroy Vaughan ◽  
Michael P. Stevens ◽  
...  
Keyword(s):  
Medical Center ◽  
Tertiary Care ◽  
Significant Proportion ◽  
Previous History ◽  
Retrospective Chart Review ◽  
Healthcare Facility ◽  
Nucleic Acid Amplification ◽  
Considerable Proportion ◽  
Testing Algorithm ◽  
The Impact

Background: Updated IDSA-SHEA guidelines recommend different diagnostic approaches to C. difficile depending on whether There are pre-agreed institutional criteria for patient stool submission. If stool submission criteria are in place, nucleic acid amplification testing (NAAT) alone may be used. If not, a multistep algorithm is suggested, incorporating various combinations of toxin enzyme immunoassay (EIA), glutamate dehydrogenase (GDH), and NAAT, with discordant results adjudicated by NAAT. At our institution, we developed a multistep algorithm leading with NAAT with reflex to EIA for toxin testing if NAAT is positive. This algorithm resulted in a significant proportion of patients with discordant results (NAAT positive and toxin EIA negative) that some experts have categorized as possible carriers or C. difficile colonized. In this study, we describe the impact of a multistep algorithm on hospital-onset, community-onset, and healthcare-facility–associated C. difficile infection (HO-CDI, CO-CDI, and HFA-CDI, respectively) rates and the management of possible carriers. Methods: The study setting was a 399-bed, tertiary-care VA Medical Center in Richmond, Virginia. A retrospective chart review was conducted. The multistep C. difficile testing algorithm was implemented June 4, 2019 (Fig. 1). C. difficile testing results and possible carriers were reviewed for the 5 months before and 4 months after implementation (January 2019 to September 2019). Results: In total, 587 NAATs were performed in the inpatient and outpatient setting (mean, 58.7 per month). Overall, 123 NAATs (21%) were positive: 59 in the preintervention period and 63 in the postintervention period. In the postintervention period, 23 positive NAATs (26%) had a positive toxin EIA. Based on LabID events, the mean rate of HO+CO+HCFA CDI cases per 10,000 bed days of care (BDOC) decreased significantly from 9.49 in the preintervention period to 1.15 in the postintervention period (P = .019) (Fig. 2). Also, 9 of the possible carriers (22%) were treated for CDI based on high clinical suspicion, and 6 of the possible carriers (14%) had a previous history of CDI. Of these, 5 (83%) were treated for CDI. In addition, 1 patient (2%) converted from possible carrier to positive toxin EIA within 14 days. The infectious diseases team was consulted for 11 possible carriers (27%). Conclusions: Implementation of a 2-step C difficile algorithm leading with NAAT was associated with a lower rate of HO+CO+HCFA CDI per 10,000 BDOC. A considerable proportion (22%) of possible carriers were treated for CDI but did not count as LabID events. Only 2% of the possible carriers in our study converted to a positive toxin EIA.Funding: NoneDisclosures: None

scholarly journals Effect of Capsaicinoids on Neurophysiological, Biochemical, and Mechanical Parameters of Swallowing Function

2021 ◽  
Author(s):  
Sonja Suntrup-Krueger ◽  
Paul Muhle ◽  
Isabella Kampe ◽  
Paula Egidi ◽  
Tobias Ruck ◽  
...  
Keyword(s):  
Substance P ◽  
Time Course ◽  
Randomized Study ◽  
Oropharyngeal Dysphagia ◽  
Cortical Activation ◽  
Swallowing Function ◽  
P Release ◽  
Age Related ◽  
The Impact ◽  
Substance P Release

AbstractOropharyngeal dysphagia is prevalent in age-related neurological disorders presenting with impaired efficacy and safety of swallowing due to a loss of muscle force and sensory deficits. Stimulating the oropharynx with capsaicin that mediates Substance P release is an emerging pharmacological treatment option which needs further scientific evidence. Our aim was to comprehensively evaluate the effect of capsaicin on biochemical, neurophysiological, and biomechanical parameters of swallowing function. In a randomized study on healthy individuals, the impact of orally administered capsaicinoids at different dosages and application durations in comparison to non-carbonated water was evaluated. Time course and magnitude of salivary Substance P increase were monitored. Magnetoencephalography was used to detect cortical swallowing network alterations. Modifications in swallowing biomechanics were measured applying high-resolution pharyngeal manometry. Capsaicinoids at 10 μmol/L improved swallowing efficacy as seen by a significant increase of pharyngeal contractile integral and upper esophageal sphincter activation and relaxation times in manometry. Significant improvement of precision in a challenging swallow task accompanied by a reduction in swallowing-related submental electromyographic power was observed with capsaicinoids preconditioning at 10 μmol/L over 5 min, but not with continuous stimulation. The cortical activation pattern remained unchanged after any intervention. A significant increase of salivary Substance P was not detected with 10 μmol/L but with 50 μmol/L and lasted for 15 min after application. Capsaicinoids mediate dose-dependent Substance P release and positively alter swallowing biomechanics in healthy subjects. The results provide supportive evidence for the value of natural capsaicinoids to improve swallowing function.

scholarly journals The Clinical Characteristics and Outcomes of COVID-19 Infections in Patients with Diabetes at a Tertiary Care Center in the UAE

2021 ◽  
pp. 1-6
Author(s):  
Khadija Hafidh ◽  
Saira Abbas ◽  
Arhsee Khan ◽  
Touseef Kazmi ◽  
Zufana Nazir ◽  
...  
Keyword(s):  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Tertiary Care Center ◽  
Newly Diagnosed ◽  
Patients With Diabetes ◽  
Diagnosed Diabetes ◽  
Age Range ◽  
Newly Diagnosed Diabetes ◽  
The Impact

<b><i>Introduction:</i></b> Uncontrolled glycemia is a well-recognized predictor of severity and deaths in previous respiratory viral outbreaks. We aimed to describe the characteristics and clinical course of patients with diabetes admitted with COVID-19 infection at a tertiary care center in the Emirate of Dubai, UAE, and assess the impact of hyperglycemia on the clinical outcomes. <b><i>Methods:</i></b> This study is a single-center, observational, retrospective chart review of 250 cases during the months of March to May 2020. <b><i>Results:</i></b> Among the 250 cases studied, 235 (94%) were male. The mean age of the study group was 49.6 ± 10.4 years, with an age range of 21–78 years. Diabetes was previously known in 166 (66.4%) of the patients. The mortality (<i>p</i> = 0.03) and requirement for mechanical ventilation (<i>p</i> = 0.02) were higher for the cases with newly diagnosed diabetes when compared to those with pre-existing diabetes. <b><i>Conclusion:</i></b> Uncontrolled hyperglycemia adversely affects patients with COVID-19 infection. Newly diagnosed and previously undiagnosed hyperglycemia poses an added risk for complications. In the context of the COVID-19 pandemic, optimizing glycemia in hospitalized patients is of paramount importance and screening to detect undiagnosed cases of diabetes may be particularly relevant.

scholarly journals The impact of COVID-19 on adolescents with eating disorders: a cohort study

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Wendy Spettigue ◽  
Nicole Obeid ◽  
Madison Erbach ◽  
Stephen Feder ◽  
Natalie Finner ◽  
...  
Keyword(s):  
Eating Disorders ◽  
Chart Review ◽  
Clinical Course ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Time Frame ◽  
Lower Percentage ◽  
Average Percentage ◽  
Psychological Measures ◽  
The Impact

Abstract Background There is a noticeable lack of evidence regarding the impact of COVID-19 and the associated lockdown on young people with eating disorders. The goals of this study were 1) to examine characteristics of adolescents presenting for eating disorder (ED) assessment since the onset of the COVID-19 pandemic; 2) to compare adolescents presenting for ED assessment since the onset of the COVID-19 pandemic to those that presented for assessment 1 year previously; 3) to examine implications of the pandemic on the system of care. Methods A retrospective chart review was completed on all patients assessed at a pediatric tertiary care ED program during the pandemic between April 1 and October 31, 2020, and on youth assessed during the same time frame 1 year previously. Data including body measurements and results of psychological measures was extracted from patients’ charts. Clinician reports were utilized for accounts of ED symptoms. Referrals to our program were also compared for the two time periods. Results Of the 48 youth assessed between April and October 2020, average age was 14.6 years and average percentage of treatment goal weight was 77.7%. 40% cited the pandemic as a trigger for their ED; of these youth, 78.9% were medically unstable compared to 55.2% of those whose ED was not triggered by the pandemic. When comparing the 2020 cohort to those assessed in 2019, youth who presented for assessment during the pandemic trended towards having lower percentage of goal weights and higher rates of self-reported impairment, and were significantly more likely to be medically unstable (p = 0.005) and to require hospitalization (p = 0.005). Higher rates of inpatient admissions, emergency room consultation requests and outpatient referrals deemed “urgent” were likewise associated with the pandemic period. Conclusions During the COVID-19 pandemic, youth assessed for an ED presented with high rates of medical instability and need for hospitalization. Caring for these youth may be more challenging during the pandemic, when access to services may be limited. Further research is required to better understand the impact of the pandemic on the clinical course and outcomes of EDs in adolescents.

Impact of 24/7/365 Attending Radiologist Coverage on the Turnaround Time in an Emergency and Trauma Radiology Department

2020 ◽  
pp. 084653711989932
Author(s):  
Sabeena Jalal ◽  
Hugue Ouellette ◽  
Zharmaine Ante ◽  
Peter Munk ◽  
Faisal Khosa ◽  
...  
Keyword(s):  
Chart Review ◽  
Emergency Radiology ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Turnaround Time ◽  
Radiology Department ◽  
Tertiary Care Center ◽  
Imaging Studies ◽  
The Impact

Objective: To study the impact of 24/7/365 attending radiologist coverage on the turnaround time (TAT) of trauma and nontrauma cases in an emergency and trauma radiology department. Patients and Methods: This was a retrospective chart review in which TAT of patients coming to the emergency department between 2 periods: (1) December 1, 2012, to September 30, 2013, and (2) January 1, 2017, to January 30, 2018, and whose reports were read by an attending emergency and trauma radiologist was noted. Results: The 24/7/365 radiology coverage was associated with a significant reduction in TAT of computed tomography reports, and the time reduction was comparable between trauma and nontrauma cases. In adjusted models, the extension of radiology coverage was associated with an average of 7.83 hours reduction in overall TAT (95% confidence interval [CI]: 7.44-8.22) for reports related to trauma, in which 2.73 hours were due to reduction in completion to transcription time (TC; 95% CI: 2.53-2.93), and 5.10 hours were due to reduction in transcription to finalization time (TF; 95% CI: 4.75-5.44). For reports related to nontrauma cases, 24/7/365 coverage was associated with an average of 6.07 hours reduction in overall TAT (95% CI: 3.54-8.59), 2.91 hours reduction in TC (95% CI: 1.55-4.26), and 3.16 hours reduction in TF (95% CI: 0.90-5.42). Conclusion: Our pilot study demonstrates that the implementation of on-site 24/7/365 attending emergency radiology coverage at a tertiary care center was associated with a reduced TAT for trauma and nontrauma patients imaging studies. Although the magnitude and precision of estimates were slightly higher for trauma cases as compared to nontrauma cases. Trauma examinations stand to benefit the most from 24/7/365 attending level radiology coverage.

scholarly journals 862. Impact of Caregiver Health on Pediatric Healthcare-Associated Viral Respiratory Infections (HAVRIs): A Retrospective Study

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S470-S470
Author(s):  
Maude Paquette ◽  
Allyson Shephard ◽  
Pat Bedard ◽  
Nisha Thampi ◽  
Nisha Thampi
Keyword(s):  
Respiratory Infections ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Prevention Measures ◽  
Poor Outcomes ◽  
Viral Respiratory Infections ◽  
Healthcare Associated ◽  
The Impact ◽  
Viral Respiratory

Abstract Background The burden of healthcare-associated viral respiratory infections (HAVRIs) in children is significant, with increased healthcare costs and risk of poor outcomes. However, while healthcare workers are the main target of infection prevention measures, little is known about the impact of sick contacts during hospitalization on the incidence of HAVRIs. The objective of our study was to determine the proportion of pediatric HAVRIs following contact with an ill caregiver or visitor. Secondary objectives were to describe the characteristics of affected patients as well as the complications associated with the HAVRI episodes. Methods This is a retrospective chart review that took place in a pediatric tertiary care center with both multiple and single-bed rooms. All cases of HAVRIs that occurred between December 2017 and July 2019 in patients aged less than 18 years old were included in the study. HAVRIs were defined as a laboratory confirmed respiratory viral illness occurring after 72 hours of admission. Results Forty-four HAVRIs were included in the analysis. The majority (n=32, 72.7%) were among patients aged less than 24 months. Only 2 patients had no comorbidities and almost half (n=21, 47.7%) had multiple complex medical conditions. Rhinovirus was the most frequently isolated virus (n=20, 45.5%). Nine patients (20.5%) had a documented contact with a sick caregiver (n=8, 88.9%) or sick visitor (n=2, 22.2%) in the 7 days prior to the onset of new respiratory symptoms and subsequent HAVRI diagnosis. In the 72 hours prior to HAVRI onset, 18 patients (40.9%) were in a single-bed room and 6 patients (13.6%) were already under droplet/contact precautions. Twelve patients (27.3%) had new or increased O2 requirements and 4 (9.1%) were transferred to the intensive care unit. There were no associated deaths. Conclusion Our study suggests that having a contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. This reinforces the relevance of a strict visitor-screening policy and of educating caregivers on the importance of appropriate hand hygiene when caring for their child. Of note, more than one third of HAVRI cases occurred in patients already in a single-bed room, with or without additional precautions, suggesting that those measures are not entirely protective. Disclosures All Authors: No reported disclosures

scholarly journals Oropharyngeal Dysphagia and Impaired Motility of the Upper Gastrointestinal Tract—Is There a Clinical Link in Neurocritical Care?

Nutrients ◽  
2021 ◽  
Vol 13 (11) ◽  
pp. 3879
Author(s):  
Paul Muhle ◽  
Karen Konert ◽  
Sonja Suntrup-Krueger ◽  
Inga Claus ◽  
Bendix Labeit ◽  
...  
Keyword(s):  
Gastrointestinal Tract ◽  
Neurological Disease ◽  
Oropharyngeal Dysphagia ◽  
Upper Gastrointestinal Tract ◽  
Swallowing Function ◽  
Neurological Condition ◽  
Gastrointestinal Dysmotility ◽  
Single Center Study ◽  
The Impact ◽  
Upper Gastrointestinal

Patients in the neurological ICU are at risk of suffering from disorders of the upper gastrointestinal tract. Oropharyngeal dysphagia (OD) can be caused by the underlying neurological disease and/or ICU treatment itself. The latter was also identified as a risk factor for gastrointestinal dysmotility. However, its association with OD and the impact of the neurological condition is unclear. Here, we investigated a possible link between OD and gastric residual volume (GRV) in patients in the neurological ICU. In this retrospective single-center study, patients with an episode of mechanical ventilation (MV) admitted to the neurological ICU due to an acute neurological disease or acute deterioration of a chronic neurological condition from 2011–2017 were included. The patients were submitted to an endoscopic swallowing evaluation within 72 h of the completion of MV. Their GRV was assessed daily. Patients with ≥1 d of GRV ≥500 mL were compared to all the other patients. Regression analysis was performed to identify the predictors of GRV ≥500 mL/d. With respect to GRV, the groups were compared depending on their FEES scores (0–3). A total of 976 patients were included in this study. A total of 35% demonstrated a GRV of ≥500 mL/d at least once. The significant predictors of relevant GRV were age, male gender, infratentorial or hemorrhagic stroke, prolonged MV and poor swallowing function. The patients with the poorest swallowing function presented a GRV of ≥500 mL/d significantly more often than the patients who scored the best. Conclusions: Our findings indicate an association between dysphagia severity and delayed gastric emptying in critically ill neurologic patients. This may partly be due to lesions in the swallowing and gastric network.

The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

2020 ◽  
Vol 129 (9) ◽  
pp. 886-893 ◽  
Author(s):  
Hannah J. Brown ◽  
Hannah N. Kuhar ◽  
Max A. Plitt ◽  
Inna Husain ◽  
Pete S. Batra ◽  
...  
Keyword(s):  
Chronic Rhinosinusitis ◽  
Laryngopharyngeal Reflux ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Reflux Symptom Index ◽  
Symptom Index ◽  
Patient Reported ◽  
The Impact ◽  
Snot 22

Objective: This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR. Methods: In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains. Results: A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003). Conclusion: Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

Sign in / Sign up

Export Citation Format

Share Document