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Reijneveld JC, Thijs RD, van Thuijl HF, Appelhof BA, Taphoorn MJB, Koekkoek JAF, Visser GH, Dirven L. Clinical outcome assessment in patients with epilepsy: The value of health-related quality of life measurements. Epilepsy Res 2024; 200:107310. [PMID: 38330675 DOI: 10.1016/j.eplepsyres.2024.107310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/20/2023] [Accepted: 01/22/2024] [Indexed: 02/10/2024]
Abstract
This narrative review provides an overview of the current knowledge on health-related quality of life (HRQOL), a relevant clinical outcome in patients with epilepsy. It shows that the most important factor determining HRQOL in this patient group is seizure frequency. In particular, seizure-freedom is associated with better HRQOL scores. Many other factors may impact perceived HRQOL aspects, but their interrelation is complex and requires further research. Novel analytical approaches, such as hierarchical cluster and symptom network analyses might shed further light on this, and may result in recommendations for interventions on the most 'central' factors influencing different aspects of HRQOL in patients with epilepsy. Next, an overview of the HRQOL tools and analytical methods currently used in epilepsy care, with a focus on clinical trials, is provided. The QOLIE-31 is the most frequently applied and best validated tool. Several other questionnaires focusing on specific aspects of HRQOL (e.g., mood, social impact) are less frequently used. We show some pitfalls that should be taken into account when designing study protocols including HRQOL endpoints. This includes standardized statistical analysis approaches and predefined reporting methods for HRQOL in epilepsy populations. It has been shown in other patient groups that the lack of such standardisation negatively impacts the quality and comparability of results. We conclude with a number of recommendations for future research.
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Affiliation(s)
- Jaap C Reijneveld
- Department of Neurology, SEIN, Heemstede, the Netherlands; Department of Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Roland D Thijs
- Department of Neurology, SEIN, Heemstede, the Netherlands; Department of Neurology, University College, London, United Kingdom
| | | | | | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Peeters MC, Zwinkels H, Koekkoek JA, Vos MJ, Dirven L, Taphoorn MJ. The Impact of the Timing of Health-Related Quality of Life Assessments on the Actual Results in Glioma Patients: A Randomized Prospective Study. Cancers (Basel) 2020; 12:cancers12082172. [PMID: 32764261 PMCID: PMC7465107 DOI: 10.3390/cancers12082172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 11/21/2022] Open
Abstract
Background: The aim of this study was to explore the impact of the timing of Health-Related Quality of Life (HRQoL) measurements in clinical care on the obtained HRQoL scores in glioma patients, and the association with feelings of anxiety or depression. Methods: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC)’s Quality of Life Questionnaires (QLQ-C30 and QLQ-BN20), and the Hospital Anxiety and Depression Scale (HADS) twice. All patients completed the first measurement on the day of the Magnetic Resonance Imaging (MRI) scan (t = 0), but the second measurement (t = 1) depended on randomization; Group 1 (n = 49) completed the questionnaires before and Group 2 (n = 51) after the consultation with the physician. Results: median HRQoL scale scores on t0/t1 and change scores were comparable between the two groups. Between 8–58% of patients changed to a clinically relevant extent (i.e., ≥10 points) on the evaluated HRQoL scales in about one-week time, in both directions, with only 3% of patients remaining stable in all scales. Patients with a stable role functioning had a lower HADS anxiety change score. The HADS depression score was not associated with a change in HRQoL. Conclusions: Measuring HRQoL before or after the consultation did not impact HRQoL scores on a group level. However, most patients reported a clinically relevant difference in at least one HRQoL scale between the two time points. These findings highlight the importance of standardized moments of HRQoL assessments, or patient-reported outcomes in general, during treatment and follow-up in clinical trials.
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Affiliation(s)
- Marthe C.M. Peeters
- Department of Neurology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (J.A.F.K.); (L.D.); (M.J.B.T.)
- Correspondence: ; Tel.: +31-071-526-2547
| | - Hanneke Zwinkels
- Department of Neurology, Haaglanden Medical Center, 2262 BA The Hague, The Netherlands; (H.Z.); (M.J.V.)
| | - Johan A.F. Koekkoek
- Department of Neurology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (J.A.F.K.); (L.D.); (M.J.B.T.)
- Department of Neurology, Haaglanden Medical Center, 2262 BA The Hague, The Netherlands; (H.Z.); (M.J.V.)
| | - Maaike J. Vos
- Department of Neurology, Haaglanden Medical Center, 2262 BA The Hague, The Netherlands; (H.Z.); (M.J.V.)
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (J.A.F.K.); (L.D.); (M.J.B.T.)
- Department of Neurology, Haaglanden Medical Center, 2262 BA The Hague, The Netherlands; (H.Z.); (M.J.V.)
| | - Martin J.B. Taphoorn
- Department of Neurology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (J.A.F.K.); (L.D.); (M.J.B.T.)
- Department of Neurology, Haaglanden Medical Center, 2262 BA The Hague, The Netherlands; (H.Z.); (M.J.V.)
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Sanghera S, Coast J. Measuring Quality-Adjusted Life-Years When Health Fluctuates. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:343-350. [PMID: 32197730 DOI: 10.1016/j.jval.2019.09.2753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 09/12/2019] [Accepted: 09/20/2019] [Indexed: 05/26/2023]
Abstract
Recurrent fluctuations in health states can occur as a result of long-term conditions with episodic symptoms or through side effects of cycles of treatment. Fluctuations and associated duration of symptoms can be predictable (eg, side effects of chemotherapy treatment) or unpredictable (eg, relapse in multiple sclerosis). Such recurrent fluctuations in health states can have an important impact on a person's health-related quality of life. When symptoms vary by time of day, day of the week, or during the month, it is challenging to obtain reliable health-related quality of life estimates for use in assessing cost-effectiveness of interventions. The adequacy of the quality of life estimate will be affected by (1) the standard recall period associated with the chosen measure (eg, "health today" EQ-5D, "past 4 weeks" for SF-36/SF-6D) and the way that respondents understand and make judgments about these recall periods, (2) the chosen time points for assessing health-related quality of life in relation to the fluctuations in health, and (3) the assumptions used to interpolate between measurement time points and thus calculate the quality-adjusted life-years. These issues have not received sufficient methodological attention and instead remain poorly accounted for in economic analyses. There is potential for these issues to considerably distort treatment decisions away from the optimal allocation. This article brings together evidence from health economics, psychology, and behavioral economics to explore these challenges in depth; presents the solutions that have been applied to date; and details a methodological research agenda for measuring quality-adjusted life-years in recurrent fluctuating health states.
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Affiliation(s)
- Sabina Sanghera
- Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Joanna Coast
- Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Quality of life of patients with gastrointestinal cancers undergoing chemotherapy. Qual Life Res 2018; 27:1865-1876. [PMID: 29679368 DOI: 10.1007/s11136-018-1860-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Findings regarding changes in the quality of life (QOL) of patients with gastrointestinal cancers (GI) undergoing chemotherapy (CTX) are inconclusive. Purpose was to evaluate for changes in QOL scores of patients with GI cancers over two cycles of CTX. METHODS Patients (n = 397) completed disease-specific [i.e., Quality of Life-Scale-Patient Version (QOL-PV)] and generic [12-item Medical Outcomes Study Short Form Survey (SF-12)] measures of QOL a total of six times over two cycles of CTX. Changes in these QOL scores were evaluated using bootstrapped multilevel regression with full information maximum likelihood estimation. Treatment group (i.e., with or without targeted therapy), age, number of metastatic sites, time from cancer diagnosis, number of prior cancer treatments, GI cancer diagnosis (i.e., colon/rectum/anal vs. other), and CTX regimen were evaluated as covariates in the conditional models for each of the QOL scores. RESULTS During the second cycle of CTX, QOL-PV scores decreased in the week following CTX administration, and then increased the following week. For both cycles of CTX, the physical component summary and mental component summary scores of the SF-12 decreased in the week following CTX administration and then increased the following week. Increased time from cancer diagnosis and a higher number of prior cancer treatments resulted in worse QOL-PV and SF-12 scores at enrollment. CONCLUSIONS While changes in QOL scores over the two CTX cycles were statistically significant, the differences were not clinically meaningful. Future studies need to determine the optimal timing of QOL assessments to assess changes associated with cancer treatments.
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Kristensen A, Solheim TS, Amundsen T, Hjelde HH, Kaasa S, Sørhaug S, Grønberg BH. Measurement of health-related quality of life during chemotherapy - the importance of timing. Acta Oncol 2017; 56:737-745. [PMID: 28117614 DOI: 10.1080/0284186x.2017.1279748] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Side effects of chemotherapy may occur at different time-points in the treatment cycle, and the exact assessment time relative to chemotherapy may affect HRQoL scores. The current study examined the variation of HRQoL during chemotherapy cycles, and whether differences in HRQoL scores varied at selected time-points between patients allocated to two different chemotherapy regimens. MATERIAL AND METHODS Patients with stage IIIB or IV non-small-cell lung cancer (NSCLC) were randomly assigned to receive three cycles of carboplatin plus vinorelbine (VC) or gemcitabine (GC) every 3 weeks. HRQoL was reported on the EORTC QLQ-C30 and LC13 on days 1, 4, 8, 11 and 15 of every cycle. Global health status, nausea/vomiting, fatigue and dyspnea (LC13) were defined as the HRQoL scales of primary interest. RESULTS Fifty-two patients were enrolled. Variation of mean scores of global health status, nausea/vomiting and fatigue showed a consistent pattern during chemotherapy. Day 4 appeared to be the time-point when chemotherapy influenced HRQoL the most. The differences in mean HRQoL scores between the two treatment arms varied at the different time-points, especially for nausea/vomiting. CONCLUSION There was a clinically relevant variation of HRQoL during chemotherapy cycles, with increased symptom burden the first week following treatment. Our results suggest that timing of HRQoL assessment can influence the chances of detecting differences between the treatment regimens.
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Affiliation(s)
- Are Kristensen
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tora S. Solheim
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tore Amundsen
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Harald H. Hjelde
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Sveinung Sørhaug
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bjørn H. Grønberg
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Singer S, Jordan S, Locati LD, Pinto M, Tomaszewska IM, Araújo C, Hammerlid E, Vidhubala E, Husson O, Kiyota N, Brannan C, Salem D, Gamper EM, Arraras JI, Ioannidis G, Andry G, Inhestern J, Grégoire V, Licitra L. The EORTC module for quality of life in patients with thyroid cancer: phase III. Endocr Relat Cancer 2017; 24:197-207. [PMID: 28223365 DOI: 10.1530/erc-16-0530] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 02/21/2017] [Indexed: 12/23/2022]
Abstract
The purpose of the study was to pilot-test a questionnaire measuring health-related quality of life (QoL) in thyroid cancer patients to be used with the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire EORTC QLQ-C30. A provisional questionnaire with 47 items was administered to patients treated for thyroid cancer within the last 2 years. Patients were interviewed about time and help needed to complete the questionnaire, and whether they found the items understandable, confusing or annoying. Items were kept in the questionnaire if they fulfilled pre-defined criteria: relevant to the patients, easy to understand, not confusing, few missing values, neither floor nor ceiling effects, and high variance. A total of 182 thyroid cancer patients in 15 countries participated (n = 115 with papillary, n = 31 with follicular, n = 22 with medullary, n = 6 with anaplastic, and n = 8 with other types of thyroid cancer). Sixty-six percent of the patients needed 15 min or less to complete the questionnaire. Of the 47 items, 31 fulfilled the predefined criteria and were kept unchanged, 14 were removed, and 2 were changed. Shoulder dysfunction was mentioned by 5 patients as missing and an item covering this issue was added. To conclude, the EORTC quality of life module for thyroid cancer (EORTC QLQ-THY34) is ready for the final validation phase IV.
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Affiliation(s)
- Susanne Singer
- Institute of Medical Biostatistics Epidemiology and Informatics (IMBEI)University Medical Center Mainz, Mainz, Germany
- University Cancer CentreMainz, Germany
| | - Susan Jordan
- QIMR Berghofer Medical Research InstituteHerston, Australia
| | - Laura D Locati
- Head & Neck Medical Oncology UnitFondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Pinto
- Rehabilitation UnitDepartment of Quality of Life, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS, Naples, Italy
| | - Iwona M Tomaszewska
- Department of Medical EducationJagiellonian University Medical College, Krakow, Poland
| | - Cláudia Araújo
- Service of Surgical OncologyInstituto Português do Oncologia do Porto Francisco Gentil, Porto, Portugal
| | - Eva Hammerlid
- Department of Otolaryngology and Head and Neck SurgerySahlgrenska University Hospital, Gothenburg, Sweden
| | - E Vidhubala
- Department of Psycho-OncologyResource Centre for Tobacco Control, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Olga Husson
- Department of Medical PsychologyRadboud University Medical Center, Nijmegen, The Netherlands
| | - Naomi Kiyota
- Department of Medical Oncology and HematologyKobe University Hospital, Kobe, Japan
| | - Christine Brannan
- Mount Vernon Cancer CentreEast & North Herts NHS Trust, Northwood, London, UK
| | - Dina Salem
- Clinical OncologyFaculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eva M Gamper
- Department of Nuclear MedicineMedical University of Innsbruck, Innsbruck Institute of Patient-Centred Outcome Research, Innsbruck, Austria
| | | | | | - Guy Andry
- Surgery DepartmentJules Bordet Institute, Brussels, Belgium
| | - Johanna Inhestern
- Clinic of OtorhinolaryngologyJena University Hospital, Jena, Germany
| | - Vincent Grégoire
- Department of Radiation OncologyInstitut de Recherche Experimentale et Clinique, Université Catholique de Louvain, St-Luc University Hospital, Brussels, Belgium
| | - Lisa Licitra
- Head & Neck Medical Oncology UnitFondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Zikos E, Coens C, Quinten C, Ediebah DE, Martinelli F, Ghislain I, King MT, Gotay C, Ringash J, Velikova G, Reeve BB, Greimel E, Cleeland CS, Flechtner H, Taphoorn MJB, Weis J, Schmucker-von Koch J, Sprangers MAG, Bottomley A. The Added Value of Analyzing Pooled Health-Related Quality of Life Data: A Review of the EORTC PROBE Initiative. J Natl Cancer Inst 2015; 108:djv391. [DOI: 10.1093/jnci/djv391] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/20/2015] [Indexed: 11/15/2022] Open
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Joint modeling of longitudinal health-related quality of life data and survival. Qual Life Res 2014; 24:795-804. [DOI: 10.1007/s11136-014-0821-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2014] [Indexed: 01/22/2023]
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Giesinger JM, Wintner LM, Zabernigg A, Gamper EM, Oberguggenberger AS, Sztankay MJ, Kemmler G, Holzner B. Assessing quality of life on the day of chemotherapy administration underestimates patients' true symptom burden. BMC Cancer 2014; 14:758. [PMID: 25305067 PMCID: PMC4198707 DOI: 10.1186/1471-2407-14-758] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/03/2014] [Indexed: 12/02/2022] Open
Abstract
Background In chemotherapy trials quality of life (QOL) is assessed mostly at the days of chemotherapy administration (i.e. event-driven) during treatment and follows fixed time intervals in the aftercare phase (i.e. time-driven). Specific QOL impairments and treatment side-effects are known to be time dependent following different trajectories. Therefore, acute problems are likely to be missed if assessments are done infrequently or at inappropriate time points. Since the planning of supportive care interventions during chemotherapy depends on knowledge about symptom trajectories, such information may be of substantial importance to a clinician. Methods Cancer patients receiving chemotherapy at Kufstein County Hospital were assessed using an electronic version of the EORTC QLQ-C30 at the day of chemotherapy administration at the hospital. One and two weeks later assessments were repeated via the internet while patients were at home. Assessments at home and the hospital were conducted using the web-based software CHES. Data were analysed by means of linear mixed models. Results A sample of 54 chemotherapy outpatients participated in electronic QOL assessments at the hospital and at home. For 9 out of the 15 QOL domains of the EORTC QLQ-C30 patients reported increased burden one week after chemotherapy administration compared to the day of chemotherapy administration. Most pronounced differences were found for Fatigue, Constipation, and Appetite Loss. Conclusions Our results indicate that patients experience most severe QOL impairments in the week following chemotherapy administration. This is a period that is usually not covered by QOL assessments in chemotherapy trials which may result in underestimation of true treatment burden. Our findings suggest to conduct QOL assessments not only event- or time-driven, but to rely on specific hypotheses on symptom and functioning trajectories.
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Affiliation(s)
- Johannes M Giesinger
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Pesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Søreide K, Søreide AH. Using patient-reported outcome measures for improved decision-making in patients with gastrointestinal cancer - the last clinical frontier in surgical oncology? Front Oncol 2013; 3:157. [PMID: 23785670 PMCID: PMC3682158 DOI: 10.3389/fonc.2013.00157] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 06/03/2013] [Indexed: 11/18/2022] Open
Abstract
The genomic era has introduced concepts of “personalized medicine” and “targeted therapy” in the field of oncology. Medicine has become increasingly complex with a plethora of potential dilemmas in diagnosis, treatment, and management. The focus on classical outcomes for clinical decision-making is now increasingly being replaced by patient-reported outcome measures (PROMs). PROMs should increasingly now be in the center of patient-centered decision-making, based on valid, reliable, and clinically useful measures delivered directly by the patient to the caregiver. Surgeons’ ability to interpret and apply PROMs and quality of life results must improve by education and further research, and has an unreleased potential to contribute to a better understanding of the patients’ well-being. A number of caveats must be addressed before this can be brought to fruition; standardization for valid items; appropriate use of instruments; correct timing of the application; missing data handling, compliance, and respondent drop-outs are but a few issues to be addressed. Based on the apparent lack of use in both research and clinical work, it should call for an educational effort to address this among surgeons caring for patients with cancer.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital , Stavanger , Norway ; Department of Clinical Medicine, University of Bergen , Bergen , Norway
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Dirven L, Reijneveld JC, Aaronson NK, Bottomley A, Uitdehaag BMJ, Taphoorn MJB. Health-related Quality of Life in Patients with Brain Tumors: Limitations and Additional Outcome Measures. Curr Neurol Neurosci Rep 2013; 13:359. [DOI: 10.1007/s11910-013-0359-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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