1
|
Demoré B, Humbert P, Boschetti E, Bevilacqua S, Clerc-Urmès I, May T, Pulcini C, Thilly N. Evaluation of effects of an operational multidisciplinary team on antibiotic use in the medium to long term at a French university hospital. Int J Clin Pharm 2017; 39:1061-1069. [PMID: 28756579 DOI: 10.1007/s11096-017-0516-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/19/2017] [Indexed: 11/30/2022]
Abstract
Background Antibiotic-resistant bacteria are a major public health problem throughout the world. In 2006, in accordance with the national guidelines for antibiotic use, the CHRU of Nancy created an operational multidisciplinary antibiotic team at one of its sites. In 2011, a cluster-controlled trial showed that the operational multidisciplinary antibiotic team (the intervention) had a favourable short-term effect on antibiotic use and costs. Objective Our objective was to determine whether these effects continued over the medium to long term (that is, 2-7 years after creation of the operational multidisciplinary antibiotic team, 2009-2014). Setting The 1800-bed University Hospital of Nancy (France). Method The effect in the medium to long term is measured according to the same criteria and assessed by the same methods as the first study. A cluster controlled trial was performed on the period 2009-2014. The intervention group comprised 11 medical and surgical wards in settings where the operational multidisciplinary antibiotic team was implemented and the control group comprised 6 wards without this operational team. Main outcome measure Consumption of antibiotics overall and by therapeutic class (in defined daily doses per 1000 patient-days) and costs savings (in €). Results The reduction in antibiotic use and costs continued, but at a lower rate than in the short term (11% between 2009 and 2014 compared with 33% between 2007 and 2009) at the site of the intervention. The principal decreases concerned fluoroquinolones and glycopeptides. At the site without an operational multidisciplinary antibiotic team (the control group), total antibiotic use remained stable. Between 2009 and 2014, costs fell 10.5% in the intervention group and 5.7% in the control group. Conclusion This study shows that it is possible to maintain the effectiveness over time of such an intervention and demonstrates its role in defining a hospital's antibiotic policy.
Collapse
Affiliation(s)
- Béatrice Demoré
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France.
- Faculté de Pharmacie, UMR 7565, SRSMC, CNRS - Lorraine University, Rue Albert Lebrun, 54001, Nancy Cedex, France.
| | - Pauline Humbert
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Emmanuelle Boschetti
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Sibylle Bevilacqua
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Isabelle Clerc-Urmès
- Unité ESPRI-BIOBASE, Plateforme d'Aide à la Recherche Clinique, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Thierry May
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- Host-Environment Relation, EA 4369, Lorraine University, Nancy, France
| | - Céline Pulcini
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- EA 4360 Apemac, Lorraine University, Nancy, France
| | - Nathalie Thilly
- Plateforme d'Aide à la Recherche Clinique, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- EA 4360 Apemac, Lorraine University, Nancy, France
| |
Collapse
|
2
|
Oreagba IA, Oshikoya KA, Ogar C, Adefurin AO, Ibrahim A, Awodele O, Oni Y. Adverse reactions to fluoroquinolones in the Nigerian population: an audit of reports submitted to the National Pharmacovigilance Centre from 2004 to 2016. Pharmacol Res Perspect 2017; 5:e00297. [PMID: 28357123 PMCID: PMC5368961 DOI: 10.1002/prp2.297] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 01/07/2017] [Indexed: 11/13/2022] Open
Abstract
Adverse drug reactions (ADRs) recorded in national pharmacovigilance databases in developed countries have been analyzed. However, adverse reactions to fluoroquinolones were observed globally despite their wide use and safety concerns. We provided information on the pattern of adverse reactions to fluoroquinolones reported spontaneously to the National Pharmacovigilance Centre (NPC), Nigeria. ADRs to fluoroquinolones reported to the NPC, over a period of 12 years, were analyzed. Evaluation was done for annual reports, age and gender of patients, type of reporter, suspected fluoroquinolones and adverse reactions, onset and outcome of ADRs, and causality. A total of 18527 ADR reports were received by the NPC. Antibiotics accounted for 1371(7.4%) of the total reports and fluoroquinolones accounted for 256 (18.7%) cases. A total of 540 ADRs due to fluoroquinolones was experienced by the patients. Multiple ADRs were experienced by 165 (65%) patients. Norfloxacin (2; 0.8%), moxifloxacin (3; 1.2%), ofloxacin (10; 3.9%), ciprofloxacin (112; 43.8%), and levofloxacin (129; 50.4%) were responsible for the ADRs. Neurological disorders (121; 22.4%), gastrointestinal disorders (118; 21.9%), and skin‐appendage disorders (116; 21.5%) were the most reported ADRs, while pruritus (41; 7.6%), abdominal pain (34; 6.3%), vomiting (34; 6.3%), and skin rash (27; 5.0%) were the most frequently reported specific ADRs. Thirty‐four (6.4%) patients experienced serious ADRs. Fluoroquinolones accounted for a small but significant proportion of ADRs spontaneously reported to the NPC in Nigeria. Ciprofloxacin and levofloxacin were the two most culpable fluoroquinolones due to their inappropriate use or increased use in multi‐drug resistant tuberculosis (MDR‐TB) treatment.
Collapse
Affiliation(s)
- Ibrahim A Oreagba
- Pharmacology, Therapeutics and Toxicology Department College of Medicine University of Lagos Idiaraba Lagos Nigeria
| | - Kazeem A Oshikoya
- Pharmacology Department Lagos State University College of Medicine Ikeja Lagos Nigeria
| | - Comfort Ogar
- National Pharmacovigilance Centre National Agency for Food and Drug Administration and Control Abuja Nigeria
| | - Abiodun O Adefurin
- Department of Internal Medicine Meharry Medical College 1005 Dr. D.B. Todd Jr. Blvd. Nashville Tennessee
| | - Ali Ibrahim
- National Pharmacovigilance Centre National Agency for Food and Drug Administration and Control Abuja Nigeria
| | - Olufunsho Awodele
- Pharmacology, Therapeutics and Toxicology Department College of Medicine University of Lagos Idiaraba Lagos Nigeria
| | - Yetunde Oni
- National Pharmacovigilance Centre National Agency for Food and Drug Administration and Control Abuja Nigeria
| |
Collapse
|
3
|
Amoxicillin-clavulanic acid prescriptions at the Greater Paris University Hospitals (AP-HP). Med Mal Infect 2016; 47:42-49. [PMID: 27765474 DOI: 10.1016/j.medmal.2016.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 04/01/2016] [Accepted: 09/13/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We aimed to document amoxicillin-clavulanic acid prescription to improve the proper use of antibiotics in hospital settings. We used three criteria: quality of medical charts, adequacy of indications, and adequacy of treatment duration. METHOD This study was designed as a one-day point prevalence survey carried out by antibiotic lead specialists. RESULTS We included 387 prescriptions from 32 hospitals. Immunodeficiency was recorded as a risk factor in 30% of patients. Computerized prescriptions were observed in 79% of cases. The indication was mentioned in 73% of cases and a 48/78-hour re-assessment of the antibiotic therapy was performed in 54% of cases. The antibiotic indication was primarily for pneumonia and was deemed appropriate in 75% of patients. Adult mean treatment duration was 11.1 days. Use of dual combination therapy and/or treatment duration exceeding two weeks accounted for the main reasons for an inappropriate use of antibiotics. Prescriptions recorded as having been made by senior physicians were of the shortest treatment duration (P=0.0163). CONCLUSION Medical charts should be better filled in. Reinforcing the role of senior physicians in supervising antibiotic prescriptions is likely to result in a better control of treatment duration and ultimately in a reduced antibiotic consumption. By reinforcing the collaboration between pharmacists and antibiotic lead specialists, the improvement of computerized prescriptions at hospital level should help better detect the "at risk" prescriptions, namely those exceeding seven days or those combining antibiotics.
Collapse
|
4
|
Demonchy E, Dufour JC, Gaudart J, Cervetti E, Michelet P, Poussard N, Levraut J, Pulcini C. Impact of a computerized decision support system on compliance with guidelines on antibiotics prescribed for urinary tract infections in emergency departments: a multicentre prospective before-and-after controlled interventional study. J Antimicrob Chemother 2014; 69:2857-63. [DOI: 10.1093/jac/dku191] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
5
|
Mondain V, Lieutier F, Dumas S, Gaudart A, Fosse T, Roger PM, Bernard E, Farhad R, Pulcini C. An antibiotic stewardship program in a French teaching hospital. Med Mal Infect 2013; 43:17-21. [DOI: 10.1016/j.medmal.2012.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 09/24/2012] [Accepted: 10/31/2012] [Indexed: 12/01/2022]
|
6
|
Rughoo L, Doco-Lecompte T, Henard S, Burty C, Desmots E, Letranchant L, Rabaud C, May T, Demoré B. Relevance of fluoroquinolone use in a French teaching hospital. Med Mal Infect 2012; 42:608-14. [DOI: 10.1016/j.medmal.2012.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/18/2012] [Accepted: 08/08/2012] [Indexed: 10/27/2022]
|
7
|
Approaching the quality of antibiotic prescriptions in primary care using reimbursement data. Eur J Clin Microbiol Infect Dis 2012; 32:325-32. [PMID: 22983401 DOI: 10.1007/s10096-012-1743-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
Our objectives for this investigation were: (i) to design quality measures of outpatient antibiotic use that could be calculated at the individual general practitioner (GP) level using reimbursement data only; and (ii) to analyse the variability in antibiotic prescriptions between GPs regarding these measures in south-eastern France. Based on the literature and international therapeutic guidelines, we designed a set of quality measures in an exploratory attempt to assess the quality of antibiotic prescriptions. We performed a cross-sectional study of antibiotic prescriptions in adults in south-eastern France in 2009, using data from the outpatient reimbursement database of the French National Health Insurance (NHI). We carried out a cluster analysis to group GPs according to their antibiotic prescribing behaviour. Six quality measures were calculated at the GP level, with wide variations in practice regarding all these measures. A six-cluster solution was identified, with one cluster grouping 56 % of the sample and made up of GPs having the most homogeneous pattern of prescription for all six quality measures, probably reflecting better antibiotic prescribing. Total pharmaceutical expenses (per patient), penicillin combinations use, quinolone use and seasonal variation of quinolone use were all positively associated with a more heterogeneous and possibly less appropriate use of antibiotics in a multivariate analysis. These quality measures could be useful to assess GPs' antibiotic prescribing behaviour in countries where no information system provides easy access to data linking drug use to a clinical condition.
Collapse
|
8
|
Doco-Lecompte T, Demore B, Hénard S, Rughoo L, Burty C, Rondelot G, Frentiu E, Desmots E, Letranchant L, Robert C, Rabaud C, May T. Relevance of fluoroquinolone use in hospitals in the Lorraine region of France before and after corrective measures: an investigation by the Antibiolor Network. ACTA ACUST UNITED AC 2011; 44:86-92. [PMID: 22074400 DOI: 10.3109/00365548.2011.616222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This study of fluoroquinolone use was carried out before and after an educational intervention run by Antibiolor, a regional network to all hospitals in the Lorraine region of France. METHODS The relevance of fluoroquinolone prescription according to regional guidelines was assessed using a standard card filled out by physicians and pharmacists at the voluntarily participating hospitals. A therapeutic index of adequacy was established for each card. The initial survey took place in January 2008, with feedback and proposals for corrective measures in January 2009. The second survey was organized in June 2009. The results of the 2 surveys were compared. RESULTS Twenty-four hospitals completed a total of 1336 cards in the first survey (S1) and 944 cards in the second (S2). The appropriateness of indications for fluoroquinolone use improved by 57% between the 2 surveys. All the criteria analyzed (choice of drug, dosage, treatment duration) were significantly improved in S2 compared to S1, as was the adequacy index (70% improvement). CONCLUSIONS In view of the consequences of fluoroquinolone use, many hospitals in Lorraine were keen to participate in this study, confirming its feasibility over a large area. In view of the study results, the book of guidelines was re-examined and republished at the conclusion of S2. Greater adherence to guidelines was noted in S2, demonstrating the benefit of assessing the situation thoroughly before proposing corrective measures and evaluating their impact.
Collapse
Affiliation(s)
- Thanh Doco-Lecompte
- Department of Infectious Diseases, CHU Nancy, allée du Morvan, Vandoeuvre les Nancy, France.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Gendrin V, Letranchant L, Hénard S, Frentiu E, Demore B, Burty C, May T, Doco-Lecompte T. [Impact of corrective measures on fluoroquinolones prescriptions for urinary tract infections during a 2-round relevance study]. Presse Med 2011; 41:e10-4. [PMID: 21763098 DOI: 10.1016/j.lpm.2011.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 04/13/2011] [Accepted: 05/02/2011] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Evaluating the impact of corrective measures on fluoroquinolones (FQ) prescriptions for urinary tract infections (UTI) during a 2-round relevance study on a regional scale. METHODS FQ prescriptions of voluntary hospitals were checked by an infectious diseases physician and a pharmacist according to regional guidelines. A first round (R1) took place in January 2008, with feedback and proposal for personalized corrective measures in January 2009. A second round (R2) was organized in June 2009. UTI data were extracted and the results of the two rounds were compared. RESULTS Four hundred and thirty-five and 302 FQ prescriptions for UTI, coming from 28 and 24 different hospitals, were analyzed at R1 and R2, respectively. Thirty-six percent and 55% of these prescriptions were entirely in accordance with regional guidelines, at respectively R1 and R2 (P<0.001). All the analyzed criteria (choice of the molecule, dosage, duration of the treatment) significantly improved between R1 and R2. The route of administration non-significantly deteriorated. The rate of FQ prescriptions for non conform indications decreased from 24% to 12% between R1 and R2 (P<0.05). CONCLUSION Most hospitals of Lorraine took part in this study, confirming its feasibility on a regional scale. The regional guidelines were reviewed at the end of R2, taking into account the last national guidelines. There was a significant improvement of FQ prescriptions for UTI through better adhesion to the regional guidelines between the two rounds. This is probably due to first turn results feedback, and corrective measures suggestion.
Collapse
Affiliation(s)
- V Gendrin
- CHU de Nancy, hôpitaux de Brabois, maladies infectieuses et tropicales, 54500 Vandoeuvre-lès Nancy, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Naqvi A, Pulcini C. [Bacterial resistance and antibiotic prescription: a survey of hospital physician perception, attitude, and knowledge]. Med Mal Infect 2011; 40:625-31. [PMID: 20554141 DOI: 10.1016/j.medmal.2010.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 02/23/2010] [Accepted: 04/21/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The authors' goal was to assess physicians' perception of antibiotic prescribing practice and of bacterial resistance. DESIGN We questioned 503 interns and senior physicians in the Nice University Hospital. RESULTS Three hundred and twenty-two out of five hundred and three (64 %) physicians answered the questionnaire. Antibiotic resistance was perceived as a national problem by 98 % of physicians, but only 74 % rated the problem as important in their own daily practice. Fifty-nine percent of interns and 34 % of senior physicians respectively had received some training on antibiotic prescribing in the past 12 months. Only 33 % of physicians knew the exact prevalence of MRSA in their hospital. Senior physicians were more confident than interns when prescribing an antibiotic. The three issues they were the less confident with were: indications of antibiotic combinations, reassessment, and duration of antibiotic treatment. They were aware that antibiotic overuse, prescription of broad-spectrum molecules, or subtherapeutic doses of antibiotics were the three major causes of antibiotic resistance. They believed that the most useful measures to improve antibiotic prescription were: availability of guidelines, specific courses, readily accessible advice from an infectious diseases specialist, and audit plus feedback. CONCLUSIONS The collected data provides useful information for the implementation of strategies to optimize adherence to good antimicrobial stewardship.
Collapse
Affiliation(s)
- A Naqvi
- Service d'infectiologie, hôpital l'Archet 1, CHU de Nice, route Saint-Antoine de Ginestière, BP 3079, 06202 Nice cedex 3, France
| | | |
Collapse
|
11
|
Pulcini C, Williams F, Molinari N, Davey P, Nathwani D. Junior doctors' knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland. Clin Microbiol Infect 2011; 17:80-7. [PMID: 20132254 DOI: 10.1111/j.1469-0691.2010.03179.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Our objective was to assess junior doctors' perceptions of their antibiotic prescribing practice and of bacterial resistance. We surveyed 190 postgraduate doctors still in training at two university teaching hospitals, in Nice (France) and Dundee (Scotland, UK), and 139 of them (73%) responded to the survey. The main results presented in this abstract are combined for Nice and Dundee, because there was no statistical difference for these points between the two hospitals. Antibiotic resistance was perceived as a national problem by 95% of the junior doctors, but only 63% rated the problem as important in their own daily practice. Their perceptions of the causes of antibiotic resistance were sometimes at variance with available medical evidence, with excessive duration of antibiotic treatment and poor hand hygiene practices rarely being perceived as important drivers for resistance. Only 31% and 26% of the doctors knew the correct prevalences of antibiotic misuse and of methicillin-resistant Staphylococcus aureus in hospitals, respectively. They preferred educational interventions, such as specific teaching sessions, availability of guidelines or readily accessible advice from an infectious diseases specialist, to improve antibiotic prescribing, rather than restricted prescription of antibiotics. These data provide helpful information for the design of strategies to optimize adherence to good antimicrobial stewardship.
Collapse
Affiliation(s)
- C Pulcini
- Centre Hospitalier Universitaire de Nice, Service d'Infectiologie, Hôpital l'Archet 1, Nice, France.
| | | | | | | | | |
Collapse
|
12
|
[Relevance of fluoroquinolone use in Nancy's hospital. Results of the first turn]. ACTA ACUST UNITED AC 2010; 59:122-6. [PMID: 20570055 DOI: 10.1016/j.patbio.2010.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 03/05/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The objective was to evaluate the good use of fluoroquinolones in a hospital with a relevance review in the context of an approach to evaluation of professional practices at the regional level initiated by the Antibiolor network. METHOD In February 2008, in each volunteer service, practitioners filled out a standardized form indicating indication, the name of the fluoroquinolone, route of administration and duration of treatment, retrospectively from 20 medical records on the last 3 months. Each one was analyzed by a binomial (doctors and pharmacists) according to the local Antibioguide. The degree of compliance requirements has been appreciated by a global index of adequacy of therapeutic consisting of six criteria. RESULTS Eighteen units of Nancy's hospital filled 475 cards. The most frequent indications were pulmonary infections (38 %; 181/475) and urinary (23 %; 111/475). The fluoroquinolone indication was non-conform for 28 % of the cards (133/475). When the fluoroquinolone indication was justified, the association with another antibiotic was considered non-compliant in 20 % of cases (70/342), the choice of the molecule in 18 % (62/342), duration of treatment in 17 % (57/342), the dose in 13 % (45/342) and route of administration in 9 % (30/342). The requirements were entirely conform in 34 % of cases (160/475). CONCLUSION The results were communicated to each participating service with corrective actions and then this experience has been repeated in May 2009.
Collapse
|
13
|
Roger PM, Brofferio P, Labate C, Barrière JR, Minguet JM, Foulon P, Zumbo C. Évaluation prospective des associations antibiotiques d’un centre hospitalier général. Med Mal Infect 2010; 40:165-71. [DOI: 10.1016/j.medmal.2009.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 08/31/2009] [Indexed: 10/20/2022]
|
14
|
Doco-Lecompte T, Demoré B, Burty C, Rondelot G, Scheid P, Zuck P, Simon L, Letranchant L, Robert C, Frentiu E, Petitfrère M, Simplot B, Bevilacqua S, Voltz C, Rabaud C, May T. Revue de pertinence des fluoroquinolones en Lorraine : résultats de la première évaluation. Med Mal Infect 2010; 40:106-11. [DOI: 10.1016/j.medmal.2009.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Accepted: 08/31/2009] [Indexed: 10/20/2022]
|