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Sun Y, Wang Y, Li W, Li C. Real-time dual-modal photoacoustic and fluorescence small animal imaging. PHOTOACOUSTICS 2024; 36:100593. [PMID: 38352643 PMCID: PMC10862394 DOI: 10.1016/j.pacs.2024.100593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
By combining optical absorption contrast and acoustic resolution, photoacoustic imaging (PAI) has broken the barrier in depth for high-resolution optical imaging. Meanwhile, Fluorescence imaging (FLI), owing to advantages of high sensitivity and high specificity with abundant fluorescence agents and proteins, has always been playing a key role in live animal studies. Based on different optical contrast mechanisms, PAI and FLI can provide important complementary information to each other. In this work, we uniquely designed a Photoacoustic-Fluorescence (PA-FL) imaging system that provides real-time dual modality imaging, in which a half-ring ultrasonic array is employed for high quality PA tomography and a specially designed optical window allows simultaneous whole-body fluorescence imaging. The performance of this dual modality system was demonstrated in live animal studies, including real-time monitoring of perfusion and metabolic processes of fluorescent dyes. Our study indicates that the PA-FL imaging system has unique potential for live small animal research.
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Affiliation(s)
- Yu Sun
- Department of Biomedical Engineering, School of Future Technology, Peking University, Beijing 100871, China
| | - Yibing Wang
- Department of Biomedical Engineering, School of Future Technology, Peking University, Beijing 100871, China
| | - Wenzhao Li
- Department of Biomedical Engineering, School of Future Technology, Peking University, Beijing 100871, China
| | - Changhui Li
- Department of Biomedical Engineering, School of Future Technology, Peking University, Beijing 100871, China
- National Biomedical Imaging Center, Peking University, Beijing 100871, China
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2
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Yoon C, Kang J, Song TK, Chang JH. Elevational Synthetic Aperture Focusing for Three-Dimensional Photoacoustic Imaging Using a Clinical One-Dimensional Array Transducer. IEEE Trans Biomed Eng 2022; 69:2817-2825. [PMID: 35226597 PMCID: PMC9520468 DOI: 10.1109/tbme.2022.3154754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Two-dimensional (2D) photoacoustic (PA) imaging based on array transducers provide high spatial resolution in the lateral direction by adopting receive dynamic focusing. However, the quality of PA image is often deteriorated by poor elevational resolution which is achieved by an acoustic lens. To overcome this limitation, we present a three-dimensional (3D) image reconstruction method using a commercial one-dimensional (1D) array transducer. METHODS In the method, the elevational resolution is improved by applying synthetic aperture focusing (SAF) technique along the elevational direction. For this, a commercially available 1D array transducer with an acoustic lens is modeled and appropriate synthetic focusing delay that can minimize the effect of the acoustic lens is derived by mathematical analysis. RESULTS From the simulation and experiment results, it was demonstrated that the proposed method can enhance the image quality of PA imaging, i.e., elevational resolution and signal-to-noise ratio (SNR). CONCLUSION 3D PA images with improved elevational resolution were achieved using a clinical 1D array transducer. SIGNIFICANCE The presented method may be useful for clinical application such as detecting microcalcification, imaging of tumor vasculature and guidance of biopsy in real time.
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Jang J, Kim J, Lee HJ, Chang JH. Transrectal Ultrasound and Photoacoustic Imaging Probe for Diagnosis of Prostate Cancer. SENSORS 2021; 21:s21041217. [PMID: 33572287 PMCID: PMC7915711 DOI: 10.3390/s21041217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 12/27/2022]
Abstract
A combined transrectal ultrasound and photoacoustic (TRUS-PA) imaging probe was developed for the clear visualization of morphological changes and microvasculature distribution in the prostate, as this is required for accurate diagnosis and biopsy. The probe consisted of a miniaturized 128-element 7 MHz convex array transducer with 134.5° field-of-view (FOV), a bifurcated optical fiber bundle, and two optical lenses. The design goal was to make the size of the TRUS-PA probe similar to that of general TRUS probes (i.e., about 20 mm), for the convenience of the patients. New flexible printed circuit board (FPCB), acoustic structure, and optical lens were developed to meet the requirement of the probe size, as well as to realize a high-performance TRUS-PA probe. In visual assessment, the PA signals obtained with the optical lens were 2.98 times higher than those without the lens. Moreover, the in vivo experiment with the xenograft BALB/c (Albino, Immunodeficient Inbred Strain) mouse model showed that TRUS-PA probe was able to acquire the entire PA image of the mouse tight behind the porcine intestine about 25 mm depth. From the ex vivo and in vivo experimental results, it can be concluded that the developed TRUS-PA probe is capable of improving PA image quality, even though the TRUS-PA probe has a cross-section size and an FOV comparable to those of general TRUS probes.
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Affiliation(s)
- Jihun Jang
- Department of Electronic Engineering, Sogang University, Seoul 04107, Korea;
| | - Jinwoo Kim
- Department of Information and Communnication Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu 42988, Korea;
| | - Hak Jong Lee
- Department of Radiology, Seoul National University of Bundang Hospital, Seongnam-si 13620, Korea;
| | - Jin Ho Chang
- Department of Information and Communnication Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu 42988, Korea;
- Correspondence: ; Tel.: +82-53-785-6330
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Real-time, functional intra-operative localization of rat cavernous nerve network using near-infrared cyanine voltage-sensitive dye imaging. Sci Rep 2020; 10:6618. [PMID: 32313132 PMCID: PMC7171155 DOI: 10.1038/s41598-020-63588-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/27/2020] [Indexed: 12/02/2022] Open
Abstract
Despite current progress achieved in the surgical technique of radical prostatectomy, post-operative complications such as erectile dysfunction and urinary incontinence persist at high incidence rates. In this paper, we present a methodology for functional intra-operative localization of the cavernous nerve (CN) network for nerve-sparing radical prostatectomy using near-infrared cyanine voltage-sensitive dye (VSD) imaging, which visualizes membrane potential variations in the CN and its branches (CNB) in real time. As a proof-of-concept experiment, we demonstrate a functioning complex nerve network in response to electrical stimulation of the CN, which was clearly differentiated from surrounding tissues in an in vivo rat prostate model. Stimulation of an erection was confirmed by correlative intracavernosal pressure (ICP) monitoring. Within 10 minutes, we performed trans-fascial staining of the CN by direct VSD administration. Our findings suggest the applicability of VSD imaging for real-time, functional imaging guidance during nerve-sparing radical prostatectomy.
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Wu Y, Zhang HK, Kang J, Boctor EM. An economic photoacoustic imaging platform using automatic laser synchronization and inverse beamforming. ULTRASONICS 2020; 103:106098. [PMID: 32105781 PMCID: PMC7418056 DOI: 10.1016/j.ultras.2020.106098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 10/28/2019] [Accepted: 01/20/2020] [Indexed: 05/02/2023]
Abstract
We present a proof-of-concept of an automatic integration of photoacoustic (PA) imaging on clinical ultrasound (US) imaging platforms. Here we tackle two critical challenges: the laser synchronization and the inaccessibility to the beamformer core embedded in commercial US imaging platform. In particular, the line trigger frequency (LTF) estimation and the asynchronous synthetic aperture inverse beamforming (ASAIB) were developed and evaluated in both k-Wave simulation and phantom experiment. The proposed method is an economical solution to enable PA imaging on a greater number of US equipment to further thrive the PA imaging research community.
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Affiliation(s)
- Yixuan Wu
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD 21218, USA
| | - Haichong K Zhang
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jeeun Kang
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD 21218, USA; Russell H, Morgan Department of Radiology and Radiological Science, The Johns Hopkins University, Baltimore, MD 21218, USA.
| | - Emad M Boctor
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD 21218, USA; Russell H, Morgan Department of Radiology and Radiological Science, The Johns Hopkins University, Baltimore, MD 21218, USA; Department of Electrical and Computer Engineering, The Johns Hopkins University, Baltimore, MD 21218, USA.
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Development of an embedded multimodality imaging platform for onco-pharmacology using a smart anticancer prodrug as an example. Sci Rep 2020; 10:2661. [PMID: 32060400 PMCID: PMC7021674 DOI: 10.1038/s41598-020-59561-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/28/2020] [Indexed: 11/08/2022] Open
Abstract
Increasingly, in vivo imaging holds a strategic position in bio-pharmaceutical innovation. We will present the implementation of an integrated multimodal imaging setup enabling the assessment of multiple, complementary parameters. The system allows the fusion of information provided by: Near infrared fluorescent biomarkers, bioluminescence (for tumor proliferation status), Photoacoustic and Ultrasound imaging. We will study representative applications to the development of a smart prodrug, delivering a highly cytotoxic chemotherapeutic agent to cancer tumors. The results realized the ability of this embedded, multimodality imaging platform to firstly detect bioluminescent and fluorescent signals, and secondly, record ultrasound and photoacoustic data from the same animal. This study demonstrated that the prodrug was effective in three different models of hypoxia in human cancers compared to the parental cytotoxic agent and the vehicle groups. Monitoring by photoacoustic imaging during the treatments revealed that the prodrug exhibits an intrinsic capability to prevent the progression of tumor hypoxia. It is essential for onco-pharmacology studies to precisely document the hypoxic status of tumors both before and during the time course of treatments. This approach opens new perspectives for exploitation of preclinical mouse models of cancer, especially when considering associations between hypoxia, neoangiogenesis and antitumor activity.
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Kim H, Chang JH. Multimodal photoacoustic imaging as a tool for sentinel lymph node identification and biopsy guidance. Biomed Eng Lett 2018; 8:183-191. [PMID: 30603202 PMCID: PMC6208518 DOI: 10.1007/s13534-018-0068-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/14/2018] [Accepted: 04/15/2018] [Indexed: 02/06/2023] Open
Abstract
As a minimally invasive method, sentinel lymph node biopsy (SLNB) in conjunction with guidance methods is the standard method to determine cancer metastasis in breast. The desired guidance methods for SLNB should be capable of precise SLN localization for accurate diagnosis of micro-metastases at an early stage of cancer progression and thus facilitate reducing the number of SLN biopsies for minimal surgical complications. For this, high sensitivity to the administered dyes, high spatial and contrast resolutions, deep imaging depth, and real-time imaging capability are pivotal requirements. Currently, various methods have been used for SLNB guidance, each with their own advantages and disadvantages, but no methods meet the requirements. In this review, we discuss the conventional SLNB guidance methods in this perspective. In addition, we focus on the role of the PA imaging modality on real-time SLN identification and biopsy guidance. In particular, PA-based hybrid imaging methods for precise SLN identification and efficient biopsy guidance are introduced, and their unique features, advantages, and disadvantages are discussed.
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Affiliation(s)
- Haemin Kim
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 South Korea
| | - Jin Ho Chang
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 South Korea
- Department of Electronic Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 South Korea
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8
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Zheng PP, Li J, Kros JM. Breakthroughs in modern cancer therapy and elusive cardiotoxicity: Critical research-practice gaps, challenges, and insights. Med Res Rev 2017; 38:325-376. [PMID: 28862319 PMCID: PMC5763363 DOI: 10.1002/med.21463] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 12/16/2022]
Abstract
To date, five cancer treatment modalities have been defined. The three traditional modalities of cancer treatment are surgery, radiotherapy, and conventional chemotherapy, and the two modern modalities include molecularly targeted therapy (the fourth modality) and immunotherapy (the fifth modality). The cardiotoxicity associated with conventional chemotherapy and radiotherapy is well known. Similar adverse cardiac events are resurging with the fourth modality. Aside from the conventional and newer targeted agents, even the most newly developed, immune‐based therapeutic modalities of anticancer treatment (the fifth modality), e.g., immune checkpoint inhibitors and chimeric antigen receptor (CAR) T‐cell therapy, have unfortunately led to potentially lethal cardiotoxicity in patients. Cardiac complications represent unresolved and potentially life‐threatening conditions in cancer survivors, while effective clinical management remains quite challenging. As a consequence, morbidity and mortality related to cardiac complications now threaten to offset some favorable benefits of modern cancer treatments in cancer‐related survival, regardless of the oncologic prognosis. This review focuses on identifying critical research‐practice gaps, addressing real‐world challenges and pinpointing real‐time insights in general terms under the context of clinical cardiotoxicity induced by the fourth and fifth modalities of cancer treatment. The information ranges from basic science to clinical management in the field of cardio‐oncology and crosses the interface between oncology and onco‐pharmacology. The complexity of the ongoing clinical problem is addressed at different levels. A better understanding of these research‐practice gaps may advance research initiatives on the development of mechanism‐based diagnoses and treatments for the effective clinical management of cardiotoxicity.
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Affiliation(s)
- Ping-Pin Zheng
- Cardio-Oncology Research Group, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jin Li
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Johan M Kros
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
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Lee H, Kim H, Han H, Lee M, Lee S, Yoo H, Chang JH, Kim H. Microbubbles used for contrast enhanced ultrasound and theragnosis: a review of principles to applications. Biomed Eng Lett 2017; 7:59-69. [PMID: 30603152 PMCID: PMC6208473 DOI: 10.1007/s13534-017-0016-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 12/26/2016] [Accepted: 01/18/2017] [Indexed: 12/31/2022] Open
Abstract
Ultrasound was developed several decades ago as a useful imaging modality, and it became the second most popular diagnostic tool due to its non-invasiveness, real-time capabilities, and safety. Additionally, ultrasound has been used as a therapeutic tool with several therapeutic agents and in nanomedicine. Ultrasound imaging is often used to diagnose many types of cancers, including breast, stomach, and thyroid cancers. In addition, ultrasound-mediated therapy is used in cases of joint inflammation, rheumatoid arthritis, and osteoarthritis. Microbubbles, when used as ultrasound contrast agents, can act as echo-enhancers and therapeutic agents, and they can play an essential role in ultrasound imaging and ultrasound-mediated therapy. Recently, various types of ultrasound contrast agents made of lipid, polymer, and protein shells have been used. Air, nitrogen, and perfluorocarbon are usually included in the core of the microbubbles to enhance ultrasound imaging, and therapeutic drugs are conjugated and loaded onto the surface or into the core of the microbubbles, depending on the purpose and properties of the substance. Many research groups have utilized ultrasound contrast agents to enhance the imaging signal in blood vessels or tissues and to overcome the blood-brain barrier or blood-retina barrier. These agents are also used to help treat diseases in various regions or systems of the body, such as the cardiovascular system, or as a cancer treatment. In addition, with the introduction of targeted moiety and multiple functional groups, ultrasound contrast agents are expected to have a potential future in ultrasound imaging and therapy. In this paper, we briefly review the principles of ultrasound and introduce the underlying theory, applications, limitations, and future perspectives of ultrasound contrast agents.
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Affiliation(s)
- Hohyeon Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Haemin Kim
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hyounkoo Han
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Minji Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Sunho Lee
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hongkeun Yoo
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Jin Ho Chang
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
- Sogang Institute of Advanced Technology, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
| | - Hyuncheol Kim
- Department of Chemical and Biomolecular Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
- Department of Biomedical Engineering, Sogang University, 35 Baekbeom-ro, Mapo-gu, Seoul, 04107 Republic of Korea
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Kang J, Chang JH, Kim SM, Lee HJ, Kim H, Wilson BC, Song TK. Real-time sentinel lymph node biopsy guidance using combined ultrasound, photoacoustic, fluorescence imaging: in vivo proof-of-principle and validation with nodal obstruction. Sci Rep 2017; 7:45008. [PMID: 28327582 PMCID: PMC5361205 DOI: 10.1038/srep45008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/20/2017] [Indexed: 12/20/2022] Open
Abstract
Precise sentinel lymph node (SLN) identification is crucial not only for accurate diagnosis of micro-metastases at an early stage of cancer progression but also for reducing the number of SLN biopsies (SLNB) to minimize their severe side effects. Furthermore, it is desirable that an SLNB guidance should be as safe as possible in routine clinical use. Although there are currently various SLNB guidance methods for pre-operative or intra-operative assessment, none are ideal. We propose a real-time SLNB guidance method using contrast-enhanced tri-modal images (i.e., ultrasound, photoacoustic, and fluorescence) acquired by a recently developed hand-held tri-modal probe. The major advantage of tri-modal imaging is demonstrated here through an in vivo study of the technically-difficult case of nodal obstruction that frequently leads to false-negative results in patients. The results in a tumor model in rabbits and normal controls showed that tri-modal imaging is capable of clearly identifying obstructed SLNs and of indicating their metastatic involvement. Based on these findings, we propose an SLNB protocol to help surgeons take full advantage of the complementary information obtained from tri-modal imaging, including for pre-operative localization, intra-operative biopsy guidance and post-operative analysis.
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Affiliation(s)
- Jeeun Kang
- Department of Electronic Engineering, Sogang University, Seoul, 04107, South Korea
| | - Jin Ho Chang
- Department of Electronic Engineering, Sogang University, Seoul, 04107, South Korea.,Sogang Institute of Advanced Technology, Sogang University, Seoul, 04107, South Korea.,Department of Biomedical Engineering, Sogang University, Seoul, 04107, South Korea
| | - Sun Mi Kim
- Department of Radiology, Seoul National University of Bundang Hospital, Kyeonggi-do, 13620, South Korea
| | - Hak Jong Lee
- Department of Radiology, Seoul National University of Bundang Hospital, Kyeonggi-do, 13620, South Korea
| | - Haemin Kim
- Department of Biomedical Engineering, Sogang University, Seoul, 04107, South Korea
| | - Brian C Wilson
- Princess Margaret Cancer Centre, University Health Network, M5G 1L7, Canada.,Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Ontario M5G 1L7, Canada
| | - Tai-Kyong Song
- Department of Electronic Engineering, Sogang University, Seoul, 04107, South Korea
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A Dual-Modality System for Both Multi-Color Ultrasound-Switchable Fluorescence and Ultrasound Imaging. Int J Mol Sci 2017; 18:ijms18020323. [PMID: 28165390 PMCID: PMC5343859 DOI: 10.3390/ijms18020323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/29/2016] [Accepted: 01/24/2017] [Indexed: 12/21/2022] Open
Abstract
Simultaneous imaging of multiple targets (SIMT) in opaque biological tissues is an important goal for molecular imaging in the future. Multi-color fluorescence imaging in deep tissues is a promising technology to reach this goal. In this work, we developed a dual-modality imaging system by combining our recently developed ultrasound-switchable fluorescence (USF) imaging technology with the conventional ultrasound (US) B-mode imaging. This dual-modality system can simultaneously image tissue acoustic structure information and multi-color fluorophores in centimeter-deep tissue with comparable spatial resolutions. To conduct USF imaging on the same plane (i.e., x-z plane) as US imaging, we adopted two 90°-crossed ultrasound transducers with an overlapped focal region, while the US transducer (the third one) was positioned at the center of these two USF transducers. Thus, the axial resolution of USF is close to the lateral resolution, which allows a point-by-point USF scanning on the same plane as the US imaging. Both multi-color USF and ultrasound imaging of a tissue phantom were demonstrated.
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Effect of Acoustic Properties of Lens Materials on Performance of Capacitive Micromachined Ultrasonic Transducers. J Med Biol Eng 2016. [DOI: 10.1007/s40846-016-0150-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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