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Thiermann H, Worek F. Oximes should be used routinely in organophosphate poisoning. Br J Clin Pharmacol 2022; 88:5064-5069. [PMID: 35023196 DOI: 10.1111/bcp.15215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
In poisoning with organophosphorus compounds, patients can only profit from the regeneration of acetylcholinesterase, when the poison load has dropped below a toxic level. Every measure that allows an increase of synaptic AChE activity at the earliest is essential for timely termination of the cholinergic crisis. Only a drug induced reactivation allows to achieve fast restoration of the inhibited AChE. Obidoxime and pralidoxime have proved to be able to reactivate inhibited cholinesterase thereby saving life of poisoned animals. A plasma level of obidoxime or pralidoxime allowing reactivation in humans poisoned by OP can be adjusted. There is no doubt that obidoxime and pralidoxime are able to reactivate OP inhibited AChE activity in poisoned patients thereby increasing AChE activity and contributing substantially to terminate cholinergic crisis. Hence, a benefit may be expected when substantial reactivation is achieved. A test system allowing determination of red blood cell AChE activity, reactivatability, inhibitory equivalents and BChE activity is available for relatively low cost. If any reactivation is possible while inhibiting equivalents are present, oxime therapy should be maintained. In particular, when balancing the benefit risk assessment, obidoxime or palidoxime should be given as soon as possible and as long as a substantial reactivation may be expected.
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Affiliation(s)
- Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Brittain MK, McGarry KG, Moyer RA, Babin MC, Jett DA, Platoff GE, Yeung DT. Efficacy of Recommended Prehospital Human Equivalent Doses of Atropine and Pralidoxime Against the Toxic Effects of Carbamate Poisoning in the Hartley Guinea Pig. Int J Toxicol 2016; 35:344-57. [PMID: 27102179 DOI: 10.1177/1091581816638086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Aldicarb and methomyl are carbamate pesticides commonly implicated in human poisonings. The primary toxic mechanism of action for carbamate poisoning is cholinesterase (ChE) inhibition. As such, it is logical to assume that the currently accepted therapies for organophosphate poisoning (muscarinic antagonist atropine and the oxime acetylcholinesterase reactivator pralidoxime chloride [2-PAM Cl]) could afford therapeutic protection. However, oximes have been shown to be contraindicated for poisoning by some carbamates. METHODS A protective ratio study was conducted in guinea pigs to evaluate the efficacy of atropine and 2-PAM Cl. The ChE activity was determined in both the blood and the cerebral cortex. RESULTS Coadministration of atropine free base (0.4 mg/kg) and 2-PAM Cl (25.7 mg/kg) demonstrated protective ratios of 2 and 3 against aldicarb and methomyl, respectively, relative to saline. The data reported here show that this protection was primarily mediated by the action of atropine. The reactivator 2-PAM Cl had neither positive nor negative effects on survival. Both blood acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activities were significantly reduced at 15 minutes postchallenge but gradually returned to normal within 24 hours. Analysis of cerebral cortex showed that BChE, but not AChE, activity was reduced in animals that succumbed prior to 24 hours after challenge. CONCLUSION The results suggest that coadministration of atropine and 2-PAM Cl at the currently recommended human equivalent doses for use in the prehospital setting to treat organophosphorus nerve agent and pesticide poisoning would likely also be effective against aldicarb or methomyl poisoning.
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Affiliation(s)
| | | | | | | | - David A Jett
- National Institute of Neurological Disorders and Stroke (NIH/NINDS), National Institutes of Health, Bethesda, MD, USA
| | - Gennady E Platoff
- National Institute of Allergy and Infectious Diseases (NIH/NIAID), National Institutes of Health, Bethesda, MD, USA
| | - David T Yeung
- National Institute of Neurological Disorders and Stroke (NIH/NINDS), National Institutes of Health, Bethesda, MD, USA
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Bierwisch A, Wille T, Thiermann H, Worek F. Kinetic analysis of interactions of amodiaquine with human cholinesterases and organophosphorus compounds. Toxicol Lett 2016; 246:49-56. [PMID: 26851641 DOI: 10.1016/j.toxlet.2016.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 01/30/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
Standard therapy of poisoning by organophosphorus compounds (OP) is a combined administration of an anti-muscarinic drug (e.g. atropine) and an oxime as reactivator of inhibited acetylcholinesterase (AChE). Limited efficacy of clinically used oximes against a variety of OPs was shown in numerous studies, calling for research on novel reactivators of OP-inhibited AChE. Recently, reactivation of OP-inhibited AChE by the antimalarial drug amodiaquine was reported. In the present study, amodiaquine and its interactions with human cholinesterases in presence or absence of OP nerve agents was investigated in vitro. Thereby, reversible inhibition of human cholinesterases by amodiaquine (AChE ≫ BChE) was observed. Additionally, a mixed competitive-non-competitive inhibition type of amodiaquine with human AChE was determined. Slow and partial reactivation of sarin-, cyclosarin- and VX-inhibited cholinesterases by amodiaquine was recorded, amodiaquine failed to reactivate tabun-inhibited human cholinesterases. Amodiaquine, being a potent, reversible AChE inhibitor, was tested for its potential benefit as a pretreatment to prevent complete irreversible AChE inhibition by the nerve agent soman. Hereby, amodiaquine failed to prevent phosphonylation and resulted only in a slight increase of AChE activity after removal of amodiaquine and soman. At present the molecular mechanism of amodiaquine-induced reactivation of OP-inhibited AChE is not known, nevertheless amodiaquine could be considered as a template for the design of more potent non-oxime reactivators.
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Affiliation(s)
- Anne Bierwisch
- Institut für Pharmakologie und Toxikologie der Bundeswehr, Neuherbergstraße 11, 80937 München, Germany
| | - Timo Wille
- Institut für Pharmakologie und Toxikologie der Bundeswehr, Neuherbergstraße 11, 80937 München, Germany
| | - Horst Thiermann
- Institut für Pharmakologie und Toxikologie der Bundeswehr, Neuherbergstraße 11, 80937 München, Germany
| | - Franz Worek
- Institut für Pharmakologie und Toxikologie der Bundeswehr, Neuherbergstraße 11, 80937 München, Germany.
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Application of a dynamic in vitro model with real-time determination of acetylcholinesterase activity for the investigation of tabun analogues and oximes. Toxicol In Vitro 2015; 30:514-20. [DOI: 10.1016/j.tiv.2015.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 08/22/2015] [Accepted: 09/01/2015] [Indexed: 11/17/2022]
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Worek F, Horn G, Wille T, Thiermann H. Adaptation of a dynamic in vitro model with real-time determination of butyrylcholinesterase activity in the presence of cyclosarin and an oxime. Toxicol In Vitro 2015; 29:162-7. [DOI: 10.1016/j.tiv.2014.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/29/2014] [Accepted: 10/06/2014] [Indexed: 02/03/2023]
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Brandhuber F, Zengerle M, Porwol L, Tenberken O, Thiermann H, Worek F, Kubik S, Reiter G. Detoxification of tabun at physiological pH mediated by substituted β-cyclodextrin and glucose derivatives containing oxime groups. Toxicology 2012; 302:163-71. [DOI: 10.1016/j.tox.2012.08.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/28/2012] [Accepted: 08/29/2012] [Indexed: 01/10/2023]
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Herkert NM, Freude G, Kunz U, Thiermann H, Worek F. Comparative kinetics of organophosphates and oximes with erythrocyte, muscle and brain acetylcholinesterase. Toxicol Lett 2012; 209:173-8. [PMID: 22230262 DOI: 10.1016/j.toxlet.2011.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 12/20/2011] [Accepted: 12/23/2011] [Indexed: 11/27/2022]
Abstract
There is an ongoing debate whether oximes can effectively counteract the effects of organophosphorus compounds (OP) on brain acetylcholinesterase (AChE) activity and whether there are differences in the kinetic properties of brain and erythrocyte AChE. In order to investigate the kinetics of AChE from different tissues and species the well established dynamically working in vitro model with real-time determination of membrane-bound AChE activity was adapted for use with brain AChE. The enzyme reactor, that was loaded with brain, erythrocyte or muscle AChE, was continuously perfused with substrate and chromogen while AChE activity was on-line analyzed in a flow-through detector. It was possible to determine the Michaelis-Menten constants of human erythrocyte, muscle and brain AChE which were almost identical. In addition, the inhibition kinetics of sarin and paraoxon as well as the reactivation kinetics of obidoxime and HI 6 were determined with human, swine and guinea pig brain and erythrocyte AChE. It was found that the inhibition and reactivation kinetics of brain and erythrocyte AChE were highly comparable in all tested species. These data support the view that AChE from different tissue has similar kinetic properties and that brain AChE is comparably susceptible toward reactivation by oximes.
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Affiliation(s)
- Nadja M Herkert
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Worek F, Eyer P, Thiermann H. Determination of acetylcholinesterase activity by the Ellman assay: a versatile tool for in vitro research on medical countermeasures against organophosphate poisoning. Drug Test Anal 2011; 4:282-91. [PMID: 21998030 DOI: 10.1002/dta.337] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 07/01/2011] [Accepted: 07/05/2011] [Indexed: 11/08/2022]
Abstract
Inhibition of acetylcholinesterase (AChE) is the main mechanism of action of organophosphorus compounds (OP), and AChE reactivators (oximes) are at present the only causal therapeutic approach. Being the key target of OP toxicity, AChE may serve as a valuable tool for diagnosis of OP exposure as well as for the investigation of the kinetics of interactions between OP and oximes. At present, the rapid, simple, and cheap spectrophotometric Ellman assay is widely used for diagnosis, therapeutic monitoring and in vitro kinetic investigations. Application of the assay for investigation of the interactions between AChE, inhibitors, and oximes requires the consideration of potential matrix effects (e.g. hemoglobin), side reactions (e.g. oximolysis of substrate) and other determinants (e.g. pH, temperature). By taking these factors into account, the Ellman assay allows the precise and reproducible determination of kinetic constants as a basis for the understanding of toxic OP effects and for the development of improved therapies against poisoning by OP. In addition, advanced applications of the Ellman assay, for example, in a dynamic in vitro model for the real-time activity determination of membrane-bound AChE, enables the proper investigation of relevant tissue, primarily respiratory muscle, and extends the applicability of this method.
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Affiliation(s)
- Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstrasse 11, Munich, Germany.
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Henderson JD, Glucksman G, Leong B, Tigyi A, Ankirskaia A, Siddique I, Lam H, DePeters E, Wilson BW. Pyridostigmine bromide protection against acetylcholinesterase inhibition by pesticides. J Biochem Mol Toxicol 2011; 26:31-4. [DOI: 10.1002/jbt.20410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 07/15/2011] [Accepted: 07/31/2011] [Indexed: 11/06/2022]
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Maselli RA, Henderson JD, Ng J, Follette D, Graves G, Wilson BW. Protection of human muscle acetylcholinesterase from soman by pyridostigmine bromide. Muscle Nerve 2011; 43:591-5. [PMID: 21404290 DOI: 10.1002/mus.21922] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pretreatment with pyridostigmine bromide (PB) of human intercostal muscle fibers exposed to the irreversible acetylcholinesterase (AChE) inhibitor soman was investigated. METHODS Muscles were pretreated with 3 × 10(-6) M PB or saline for 20 minutes, then exposed to 10(-7) M soman for 10 minutes. RESULTS AChE of muscles treated with soman alone was inhibited >95%. In contrast, PB pretreatment of soman-exposed bundles protected 20% of AChE activity. AChE of bundles exposed to PB alone recovered after 4 hours, but bundles exposed to both PB and soman did not. Soman-induced reduction of resting membrane potentials and increment of amplitudes and decay times of miniature endplate potentials (MEPPs) were partially corrected by PB pretreatment. CONCLUSIONS In vitro pretreatment of human muscles with PB protected up to 20% of muscle AChE and ameliorated some deleterious effects on endplate physiology induced by soman.
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Affiliation(s)
- Ricardo A Maselli
- Department of Neurology, University of California Davis, Davis, California, USA
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Herkert N, Schulz S, Wille T, Thiermann H, Hatz R, Worek F. Pre- and post-treatment effect of physostigmine on soman-inhibited human erythrocyte and muscle acetylcholinesterase in vitro. Toxicol Appl Pharmacol 2011; 253:7-13. [DOI: 10.1016/j.taap.2011.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/04/2011] [Accepted: 03/06/2011] [Indexed: 11/16/2022]
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Herkert NM, Thiermann H, Worek F. In vitro kinetic interactions of pyridostigmine, physostigmine and soman with erythrocyte and muscle acetylcholinesterase from different species. Toxicol Lett 2011; 206:41-6. [PMID: 21414391 DOI: 10.1016/j.toxlet.2011.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
Abstract
The low effectiveness of atropine and oxime treatment in soman poisoning may be enhanced by carbamates pre-treatment. For ethical reasons medical countermeasures can only be tested in animal models despite the fact of substantial species differences. With this kinetic in vitro study the interactions between pyridostigmine, physostigmine and soman with human, Rhesus monkey, swine and guinea pig erythrocyte AChE were investigated. In addition, the effect of the carbamates on the residual activity and enzyme recovery after soman inhibition was examined with erythrocyte and intercostal muscle AChE from these species with a dynamic in vitro model with real-time determination of AChE activity. Only small to moderate species differences of the inhibition and decarbamylation kinetics were recorded. It was possible to show that with erythrocyte and muscle AChE a similar level of protection by carbamates and reactivation after discontinuation of the carbamates and soman could be observed. Thus, these data indicate that carbamate pre-treatment is expected to protect a critical level of muscle AChE and confirm the presumption that erythrocyte AChE may serve as a surrogate for synaptic AChE. Hence, these and previous data fortify the notion that erythrocyte AChE is a proper tool for in vitro kinetic studies as well as for therapeutic monitoring in experimental and clinical studies.
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Affiliation(s)
- N M Herkert
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstrasse 11, 80937 Munich, Germany
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In vitro kinetic interactions of DEET, pyridostigmine and organophosphorus pesticides with human cholinesterases. Chem Biol Interact 2011; 190:79-83. [PMID: 21354413 DOI: 10.1016/j.cbi.2011.02.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 02/17/2011] [Accepted: 02/18/2011] [Indexed: 11/20/2022]
Abstract
The simultaneous use of the repellent DEET, pyridostigmine, and organophosphorus pesticides has been assumed as a potential cause for the Gulf War Illness and combinations have been tested in different animal models. However, human in vitro data on interactions of DEET with other compounds are scarce and provoked the present in vitro study scrutinizing the interactions of DEET, pyridostigmine and pesticides with human acetylcholinesterase (hAChE) and butyrylcholinesterase (hBChE). DEET showed to be a weak and reversible inhibitor of hAChE and hBChE. The IC(50) of DEET was calculated to be 21.7mM DEET for hAChE and 3.2mM DEET for hBChE. The determination of the inhibition kinetics of pyridostigmine, malaoxon and chlorpyrifos oxon with hAChE in the presence of 5mM DEET resulted in a moderate reduction of the inhibition rate constant k(i). The decarbamoylation velocity of pyridostigmine-inhibited hAChE was not affected by DEET. In conclusion, the in vitro investigation of interactions between human cholinesterases, DEET, pyridostigmine, malaoxon and chlorpyrifos oxon showed a weak inhibition of hAChE and hBChE by DEET. The inhibitory potency of the tested cholinesterase inhibitors was not enhanced by DEET and it did not affect the regeneration velocity of pyridostigmine-inhibited AChE. Hence, this in vitro study does not give any evidence of a synergistic effect of the tested compounds on human cholinesterases.
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Thiermann H, Seeger T, Gonder S, Herkert N, Antkowiak B, Zilker T, Eyer F, Worek F. Assessment of neuromuscular dysfunction during poisoning by organophosphorus compounds. Chem Biol Interact 2010; 187:265-9. [DOI: 10.1016/j.cbi.2009.12.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 12/17/2009] [Accepted: 12/21/2009] [Indexed: 10/20/2022]
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Worek F, Aurbek N, Wille T, Eyer P, Thiermann H. Kinetic prerequisites of oximes as effective reactivators of organophosphate-inhibited acetylcholinesterase: a theoretical approach. J Enzyme Inhib Med Chem 2010; 26:303-8. [DOI: 10.3109/14756366.2010.504673] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Nadine Aurbek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Timo Wille
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Peter Eyer
- Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-University, Munich, Germany
| | - Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Wille T, Thiermann H, Worek F. Effect of different buffers on kinetic properties of human acetylcholinesterase and the interaction with organophosphates and oximes. Arch Toxicol 2010; 85:193-8. [PMID: 20669006 DOI: 10.1007/s00204-010-0578-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 07/14/2010] [Indexed: 12/01/2022]
Abstract
Acetylcholinesterase (AChE) is the primary target of organophosphorus compounds (OP). The investigation into interactions between AChE, OP and oximes in vitro may be affected by the experimental conditions, e.g. by the buffer system. Hence, it was tempting to investigate the Michaelis-Menten kinetics and the inhibition and reactivation kinetics of paraoxon-ethyl, sarin, soman and VX in the presence of phosphate, MOPS, Tyrode and TRIS buffer with human AChE. Compared to phosphate buffer, the inhibition and reactivation kinetics of human erythrocyte AChE were markedly changed by TRIS and in part by MOPS, whereas Tyrode showed similar results to phosphate buffer. These results indicate an effect of the tested buffers on the properties of AChE, and an interaction between OP and oximes has to be considered for the design of in vitro studies and may impair the comparison of data from different laboratories. In view of the comparability of human in vitro kinetic data determined with phosphate buffer with data from human OP poisoning, it seems to be a suitable buffer for the investigation into interactions between AChE, OP and oximes.
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Affiliation(s)
- T Wille
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Muscle force and acetylcholinesterase activity in mouse hemidiaphragms exposed to paraoxon and treated by oximes in vitro. Toxicology 2010; 272:46-51. [DOI: 10.1016/j.tox.2010.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 03/15/2010] [Accepted: 04/03/2010] [Indexed: 11/20/2022]
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Herkert NM, Aurbek N, Eyer P, Thiermann H, Worek F. Comparative study of oxime-induced reactivation of erythrocyte and muscle AChE from different animal species following inhibition by sarin or paraoxon. Toxicol Lett 2010; 194:94-101. [DOI: 10.1016/j.toxlet.2010.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 02/05/2010] [Accepted: 02/05/2010] [Indexed: 11/28/2022]
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Monitoring of neuromuscular transmission in organophosphate pesticide-poisoned patients. Toxicol Lett 2009; 191:297-304. [DOI: 10.1016/j.toxlet.2009.09.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 09/18/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022]
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Aurbek N, Thiermann H, Eyer F, Eyer P, Worek F. Suitability of human butyrylcholinesterase as therapeutic marker and pseudo catalytic scavenger in organophosphate poisoning: A kinetic analysis. Toxicology 2009; 259:133-9. [DOI: 10.1016/j.tox.2009.02.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 02/20/2009] [Accepted: 02/20/2009] [Indexed: 10/21/2022]
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