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Prinz N, Stingl J, Dapp A, Denkinger MD, Fasching P, Jehle PM, Merger S, Mühldorfer S, Pieper U, Schuler A, Zeyfang A, Holl RW. High rate of hypoglycemia in 6770 type 2 diabetes patients with comorbid dementia: A multicenter cohort study on 215,932 patients from the German/Austrian diabetes registry. Diabetes Res Clin Pract 2016; 112:73-81. [PMID: 26563590 DOI: 10.1016/j.diabres.2015.10.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/13/2015] [Accepted: 10/20/2015] [Indexed: 12/14/2022]
Abstract
AIMS Dementia and type 2 diabetes (T2D) are two major phenomena in older people. To compare anti-hyperglycemic therapy and diabetes-related comorbidities between elderly T2D patients with or without comorbid dementia. METHODS 215,932 type 2 diabetes patients aged ≥ 40 years (median [Q1;Q3]: 70.4 [61.2;77.7] years) from the standardized, multicenter German/Austrian diabetes patient registry, DPV, were studied. To identify patients with comorbid dementia, the registry was searched by ICD-10 codes, DSM-IV/-5 codes, respective search terms and/or disease-specific medication. For group comparisons, multiple hierarchic regression modeling with adjustments for age, sex, and duration of diabetes was applied. RESULTS 3.1% (n=6770; 57% females) of the eligible T2D patients had clinically recognized comorbid dementia. After adjustment for demographics, severe hypoglycemia (insulin group: 14.8 ± 0.6 vs. 10.4 ± 0.2 events per 100 patient-years, p<0.001), hypoglycemia with coma (insulin group: 7.6 ± 0.4 vs. 3.9 ± 0.1 events per 100 patient-years, p<0.001), depression (9.9 vs. 4.7%, p<0.001), hypertension (74.7 vs. 72.2%, p<0.001), stroke (25.3 vs. 6.5%, p<0.001), diabetic foot syndrome (6.0 vs. 5.2%, p=0.004), and microalbuminuria (34.7 vs. 32.2%, p<0.001) were more common in dementia patients compared to T2D without dementia. Moreover, patients with dementia received insulin therapy more frequently (59.3 vs. 54.7%, p<0.001), but metabolic control (7.7 ± 0.1 vs. 7.7 ± 0.1%) was comparable to T2D without dementia. CONCLUSIONS In T2D with dementia, higher rates of hypoglycemia and other diabetes-related comorbidities were observed. Hence, the risks of a glucocentric and intense diabetes management with insulin and a focus on tight glycemic control without considering other factors may outweigh the benefits in elderly T2D patients with comorbid dementia.
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Zeyfang A, Bahrmann A, Wernecke J. Diabetes mellitus im Alter. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1553883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zeyfang A. Diabetes im Alter: HbA1c und wie weiter? Dtsch Med Wochenschr 2015; 140:879-81. [DOI: 10.1055/s-0041-102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zeyfang A, Sieber C. Der geriatrische Patient mit Diabetes mellitus. DER DIABETOLOGE 2015; 11:193-193. [DOI: 10.1007/s11428-014-1302-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Scheuing N, Stingl J, Dapp A, Denkinger MD, Fasching P, Jehle PM, Merger S, Mühldorfer S, Pieper U, Schuler A, Zeyfang A, Holl RW. Glukozentrische Diabetestherapie bei geriatrischen Patienten mit Demenz sinnvoll? Multizentrische DPV-Daten von insgesamt 215.932 Typ-2-Diabetespatienten zeigen signifikant erhöhte Hypoglykämierate bei 6.771 Patienten mit komorbider Demenz. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1549772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Bahrmann A, Wilhelm B, Zeyfang A. Insulin degludec bei speziellen Patientengruppen. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0034-1399266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zeyfang A, Patzelt-Bath A. Importance of Geriatric Syndromes in Older Patients with Diabetes with de novo Insulin Treatment: The VEGAS Study. Drugs Real World Outcomes 2015; 2:73-79. [PMID: 27747621 PMCID: PMC4883201 DOI: 10.1007/s40801-015-0014-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aims The VEGAS study was conducted to evaluate representative data of de novo insulin-treated older patients with type 2 diabetes in the outpatient setting in Germany. Methods In this prospective, multicenter, non-interventional observational study, a nationwide written survey was carried out among practitioners (02/2011–06/2011). Older patients, aged ≥70 years, starting de novo insulin therapy, were documented. Results Data from 4,858 patients from about 500 centers (mean age: 78.2 ± 5.4 years; mean glycosylated hemoglobin [HbA1c]: 70 ± 14.2 mmol/mol [8.6 ± 1.3 %]) were collected. The mean target HbA1c value was 55 ± 6.6 mmol/mol (7.2 ± 0.6 %). 91.1 % of geriatric patients were multi-morbid. 96.2 % showed at least one physical or psychological geriatric syndrome. Most of the patients were notably impaired according to their age. Conventional insulin therapy and basal-supported oral therapy were the most frequently planned treatment regimens (39.1 and 31.1 %). Important factors in the selection of the insulin treatment regimen were an efficient HbA1c decrease (65.6 %), easy administration (55.7 %), and also a patient’s ability to self-administer insulin (38.5 %). De novo insulin treatment increased care requirements (22.7 %). 22.3 % of the relatives were scheduled to receive special training. Specific training programs for older patients with diabetes were planned in only 7.3 % of cases. Conclusions The data demonstrate the high prevalence of geriatric syndromes during de novo insulin treatment. Individual therapeutic goals and regimes are based on practicability, in particular, the receipt of autonomy and the care requirement. Diabetes education with adapted programs is currently under-represented. Important factors for the choice of an insulin treatment regimen were an efficient HbA1c decrease, easy administration, and a patient’s ability for self-administration. Electronic supplementary material The online version of this article (doi:10.1007/s40801-015-0014-9) contains supplementary material, which is available to authorized users.
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Zeyfang A, Bahrmann A, Wernecke J. Diabetes mellitus im Alter. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0034-1385401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schröder F, Zeyfang A. [Insulin pens are no longer in reference price groups: Geriatric patients are not included!]. Z Gerontol Geriatr 2014; 47:700. [PMID: 25412804 DOI: 10.1007/s00391-014-0834-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bahrmann A, Abel A, Zeyfang A, Petrak F, Kubiak T, Hummel J, Oster P, Bahrmann P. Psychological insulin resistance in geriatric patients with diabetes mellitus. PATIENT EDUCATION AND COUNSELING 2014; 94:417-422. [PMID: 24341962 DOI: 10.1016/j.pec.2013.11.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 10/29/2013] [Accepted: 11/19/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine the extent to which geriatric patients with diabetes mellitus experience psychological insulin resistance (PIR). METHODS A total of 67 unselected geriatric patients with diabetes (mean age 82.8±6.7 years, diabetes duration 12.2 [0.04-47.2] years, 70.1% female) were recruited in a geriatric care center of a university hospital. A comprehensive geriatric assessment (CGA) was performed including WHO-5, Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE) and Barthel-Index. We assessed PIR using the Barriers of Insulin Treatment Questionnaire (BIT) and the Insulin Treatment Appraisal Scale in a face-to-face interview. RESULTS Insulin-naïve patients (INP) showed higher PIR scores than patients already on insulin therapy (BIT-sum score: 4.3±1.4 vs. 3.2±1.0; p<0.001). INP reported in the BIT increased fear of injection and self-testing (2.4±2.4 vs. 1.3±0.8; p=0.016), expect disadvantages from insulin treatment (2.7±1.6 vs. 1.9±1.4; p=0.04), and fear of stigmatization by insulin injection (5.2±2.3 vs. 3.6±2.6; p=0.008). Fear of hypoglycemia, however, did not differ significantly (6.3±2.8 vs. 5.1±3.1; p=0.11). Depression was not shown to be a barrier to insulin therapy. CONCLUSION INP with diabetes have a significantly more negative attitude toward insulin therapy in comparison to patients already on insulin. PRACTICE IMPLICATIONS Systematic assessment of barriers of insulin therapy, individualized diabetes treatment plans and information of patients may help to overcome such negative attitudes, leading to quicker initiation of therapy, improved adherence to treatment and a better quality of life.
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Rodríguez-Mañas L, Bayer AJ, Kelly M, Zeyfang A, Izquierdo M, Laosa O, Hardman TC, Sinclair AJ, Moreira S, Cook J. An evaluation of the effectiveness of a multi-modal intervention in frail and pre-frail older people with type 2 diabetes--the MID-Frail study: study protocol for a randomised controlled trial. Trials 2014; 15:34. [PMID: 24456998 PMCID: PMC3917538 DOI: 10.1186/1745-6215-15-34] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 12/11/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Diabetes, a highly prevalent, chronic disease, is associated with increasing frailty and functional decline in older people, with concomitant personal, social, and public health implications. We describe the rationale and methods of the multi-modal intervention in diabetes in frailty (MID-Frail) study. METHODS/DESIGN The MID-Frail study is an open, randomised, multicentre study, with random allocation by clusters (each trial site) to a usual care group or an intervention group. A total of 1,718 subjects will be randomised with each site enrolling on average 14 or 15 subjects. The primary objective of the study is to evaluate, in comparison with usual clinical practice, the effectiveness of a multi-modal intervention (specific clinical targets, education, diet, and resistance training exercise) in frail and pre-frail subjects aged ≥70 years with type 2 diabetes in terms of the difference in function 2 years post-randomisation. Difference in function will be measured by changes in a summary ordinal score on the short physical performance battery (SPPB) of at least one point. Secondary outcomes include daily activities, economic evaluation, and quality of life. DISCUSSION The MID-Frail study will provide evidence on the clinical, functional, social, and economic impact of a multi-modal approach in frail and pre-frail older people with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov: NCT01654341.
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Zeyfang A, Bahrmann A, Wernecke J. Erratum:Diabetes mellitus im Alter. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1356350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Zeyfang A, Bahrmann A, Wernecke J. Diabetes mellitus im Alter. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1356098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Zeyfang A, Bahrmann A. [Diabetes in old age--risk by over- and undertreatment]. MMW Fortschr Med 2013; 155:56-58. [PMID: 23964510 DOI: 10.1007/s15006-013-1142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Zeyfang A, Sorli C, Kienhöfer J, Oyer D, Warren M, Mersebach H, Johansen T. Ältere Patienten haben eine niedrigere Rate nächtlicher Hypoglykämien mit Insulin degludec als mit Insulin glargin: eine Metaanalyse von Phase-3a-Studien (MON-204). DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Scheuing N, Best F, Dapp A, Dreyhaupt I, Filz HP, Krakow D, Lang W, Siegel E, Zeyfang A, Holl RW. DPV-Analyse von 183.219 erwachsenen Typ 2 Diabetespatienten zeigt bei Patienten mit komorbider Parkinsonerkrankung eine bessere metabolische Kontrolle trotz erhöhten Raten für Hypertonie, Schlaganfall, Demenz und wiederholter stationärer Aufnahme. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bahrmann P, Zeyfang A. [Hypertension in older patients]. MMW Fortschr Med 2013; 155:67-68. [PMID: 23654137 DOI: 10.1007/s15006-013-0295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Scheuing N, Bayer C, Best F, Kerner W, Lenk T, Pfeifer M, Rühl D, Schütt M, Siegel E, Stadler M, Zeyfang A, Zimny S, Holl RW. Is there a benefit to use calculated percent body fat or age- and gender-adjusted BMI-SDS(LMS) to predict risk factors for cardiovascular disease? A German/Austrian multicenter DPV-Wiss analysis on 42 048 type 2 diabetic patients. Exp Clin Endocrinol Diabetes 2013; 121:67-74. [PMID: 23426699 DOI: 10.1055/s-0032-1333243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE In clinical practice Body Mass Index is generally used to evaluate overweight status in adults. The present multicenter study examines whether Body Mass Index (BMI), age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculated %body fat is a better predictor for cardiovascular disease risk factors, specifically hypertension and dyslipidemia, in a high-risk population. METHODS Data of 42 048 adult type 2 diabetic patients (median age: 67.1 years) from 161 centers in Germany (n=158) and Austria (n=3) registered in a standardized, prospective, computer-based documentation program, were included in the study. For each patient body weight, height, blood pressure and blood lipids were documented. Spearman correlation analyses as well as multivariable logistic regression models were used to examine the relationship between anthropometric measurements and cardiovascular disease risk factors. RESULTS Correlation and regression analyses revealed minor, non significant differences between the 3 anthropometric measurements (all p>0.05). In both genders, relationships between anthropometric measurements and hypertension or reduced HDL-cholesterol were nearly identical. Only for increased triglycerides, the relations with the 3 anthropometric measurements were significantly stronger in males than in females (p<0.0001, respectively). With increasing age, associations between anthropometric measurements and hypertension, reduced HDL-cholesterol or increased triglycerides became weaker. Spearman correlation coefficients for total cholesterol and LDL-cholesterol revealed weak associations with the 3 anthropometric measurements. CONCLUSION Compared to Body Mass Index, age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculation of %body fat, has no further benefit to predict cardiovascular disease risk factors in adult type 2 diabetic patients.
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Zeyfang A, Bahrmann A, Wernecke J. Diabetes mellitus im Alter. DIABETOL STOFFWECHS 2012. [DOI: 10.1055/s-0032-1325571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Awa WL, Fach E, Krakow D, Welp R, Kunder J, Voll A, Zeyfang A, Wagner C, Schütt M, Boehm B, de Souza M, Holl RW. Type 2 diabetes from pediatric to geriatric age: analysis of gender and obesity among 120,183 patients from the German/Austrian DPV database. Eur J Endocrinol 2012; 167:245-54. [PMID: 22645200 DOI: 10.1530/eje-12-0143] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM To characterize the clinical phenotype of type 2 diabetes mellitus (T2DM) with respect to age, gender, and BMI. METHOD Anonymized data of 120,183 people with T2DM from the German/Austrian multicenter Diabetes Patienten Verlaufsdokumentation database were analyzed based on chronological age or age at diagnosis (0-19, 20-39, 40-59, 60-79, and ≥80 years). Age, gender, and BMI comparisons with clinical phenotype were made using χ(2) and Kruskal-Wallis tests (SAS V9.2). RESULTS Of all the patients, 51.3% were male, average age was 67.112.7 years, and average disease duration was 9.99.1 years. More girls than boys were diagnosed during adolescence and more men than women during adulthood (2060 years). No gender differences existed when age at diagnosis was 60 years. Patients were obese on average (BMI: 30.5±6.1 kg/m(2)) and had significantly higher BMI values than German population peers. The BMI gap was widest in the younger age categories and closed with increasing age. Adult women were significantly more obese than men. Obese patients more often had elevated HbA1c (≥7.5%), hypertension or dyslipidemia (irrespective of age), microalbuminuria (adults), or retinopathy (elderly) than nonobese patients. More men than women (20-60 years) had hypertension, dyslipidemia, or microalbuminuria while more women than men (≥60 years) had hypertension or dyslipidemia. CONCLUSION During puberty, more girls than boys were diagnosed with T2DM while during adulthood males predominated. T2DM manifested at comparatively lower BMI in males, and younger patients were more obese at diagnosis. Age, gender, and BMI were also associated with poor metabolic control and cardiovascular disease comorbidities/complications.
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Schütt M, Fach EM, Seufert J, Kerner W, Lang W, Zeyfang A, Welp R, Holl RW. Multiple complications and frequent severe hypoglycaemia in 'elderly' and 'old' patients with Type 1 diabetes. Diabet Med 2012; 29:e176-9. [PMID: 22506989 DOI: 10.1111/j.1464-5491.2012.03681.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Elderly and old patients with Type 1 diabetes represent a growing population that requires thorough diabetes care. The increasing relevance of this subgroup, however, plays only a minor role in the literature. Here, we describe elderly patients with Type 1 diabetes on the basis of a large multi-centre database in order to point out special features of this population. METHOD Data of 64609 patients with Type 1 diabetes treated by 350 qualified diabetes treatment centres were assessed and analysed by age group. RESULTS Compared with the age group ≤ 60 years, patients aged >60 years (n=3610 61-80 years and n=377 >80 years old) were characterized by a longer diabetes duration (27.7 vs. 7.7 years), an almost double risk for severe hypoglycaemia (40.1 vs. 24.3/100 patient-years), a lower level of HbA(1c) [60 vs. 67 mmol/mol (7.6 vs. 8.3%)] and higher percentages of microalbuminuria (34.5 vs. 15.6%), diabetic retinopathy (45.2 vs. 8.3%), myocardial infarction (9.0 vs. 0.4%) or stroke (6.8 vs. 0.3%). Elderly patients used insulin pumps less frequently (12.2 vs. 23.8%), but more often used conventional premixed insulin treatment (10.8 vs. 3.8%). Differences between elderly and younger patient groups were significant, respectively. CONCLUSION Diabetes care of elderly patients with Type 1 diabetes involves individualized treatment concepts. Increased hypoglycaemia risk and functional impairment attributable to diabetes-associated and/or age-related disorders must be taken into account.
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Zeyfang A. [Frailty is not a must in the old age]. MMW Fortschr Med 2012; 154:44. [PMID: 22803240 DOI: 10.1007/s15006-012-0678-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Zeyfang A. [TUV (Technical Monitoring Association) in general practice.Is the senior citizen still competent to drive? (interview by Christine Starostzik)]. MMW Fortschr Med 2012; 154:6. [PMID: 22693748 DOI: 10.1007/s15006-012-0483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Zeyfang A, Rissmann U, Feucht I, Holl RW. Tele@myhome Pilotstudie zur telemedizinischen Versorgung von Pflegeheimbewohnern mit Diabetes mellitus. DIABETOL STOFFWECHS 2012. [DOI: 10.1055/s-0032-1314572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Zeyfang A, Molz E, Schütt M, Fach EM, Siegel EG, Holl RW. Wie wirkt sich die Nierenfunktion (Krea/eGFR) auf die Therapie betagter (>80-jähriger) Patienten mit Typ-2-Diabetes aus? - Eine Untersuchung an 142.417 Patienten. DIABETOL STOFFWECHS 2012. [DOI: 10.1055/s-0032-1314483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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