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Tamblyn R, Moraga T, Girard N, Boulet J, Chan FKI, Habib B. Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing? BMC MEDICAL EDUCATION 2023; 23:821. [PMID: 37915014 PMCID: PMC10621187 DOI: 10.1186/s12909-023-04817-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/29/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis. METHODS A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics. RESULTS Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics. CONCLUSIONS Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue, H3A 1G1, Montreal, QC, Canada.
- Department of Medicine, McGill University Health Center, Montreal, QC, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - John Boulet
- Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, PA, USA
| | - Fiona K I Chan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue, H3A 1G1, Montreal, QC, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
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Zaidi TH, Zafar M, Baloch ZH, Shakeel A, Ali NM, Ahmed BN, Khan MA, Masood R, Fatima I, Shakeel S. Prevalence, determinants of chronic rhinosinusitis and its impact on quality of life among students in Karachi, Pakistan. Future Sci OA 2022; 8:FSO824. [PMID: 36788986 PMCID: PMC9912247 DOI: 10.2144/fsoa-2022-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/09/2022] [Indexed: 01/11/2023] Open
Abstract
Background Chronic rhinosinusitis (CRS) is a common public health issue among students. Methodology A total of 300 undergraduate students were selected through multistage cluster sampling from three public-sector universities. Sino-nasal Outcome Test (SNOT-22) and Rhinosinusitis Disability Index (RSDI) were used for determining the quality of life. Chi-square and independent t-test were used. Results About 46% and 54% (p = 0.001) of social science and health science students were suffering from CRS, respectively. Around 7% and 9% of CRS patients had poor quality of life according to SNOT-22 and RSDI, respectively (p = 0.042 and p = 0.032, respectively). Conclusion Quality of life was affected in all domains of SNOT-22 and RSDI.
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Affiliation(s)
- Tafazzul Hyder Zaidi
- Department of Community Medicine, Jinnah Sindh Medical University, Karachi, 75510, Pakistan,Author for correspondence:;
| | - Mubashir Zafar
- Department of Family & Community Medicine, College of Medicine, University of Hail, Hail, 2440, Kingdom of Saudi Arabia,Author for correspondence:;
| | - Zafar Haleem Baloch
- , Anatomy Department, Sind Medical College, Jinnah Sindh Medical University, Karachi,75510, Pakistan
| | - Alisha Shakeel
- Medical students, Sindh Medical College, Jinnah Sind Medical University, Karachi, 75510, Pakistan
| | - Nouman Mansoor Ali
- Medical students, Sindh Medical College, Jinnah Sind Medical University, Karachi, 75510, Pakistan
| | - Beenish Nisar Ahmed
- Otolaryngology Department, Khan Research Laboratory (KRL) Hospital, Islamabad, 44000, Pakistan
| | - Muhammad Amash Khan
- Medical students, Sindh Medical College, Jinnah Sind Medical University, Karachi, 75510, Pakistan
| | - Rafia Masood
- Medical students, Sindh Medical College, Jinnah Sind Medical University, Karachi, 75510, Pakistan
| | - Iman Fatima
- Medical students, Sindh Medical College, Jinnah Sind Medical University, Karachi, 75510, Pakistan
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Choosing the Right Patient for Biologic Therapy in Chronic Rhinosinusitis with Nasal Polyposis: Endotypes, Patient Characteristics, and Defining Failures of Standard Therapy. Otolaryngol Clin North Am 2021; 54:701-708. [PMID: 34116843 DOI: 10.1016/j.otc.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There are many phenotypes of chronic sinusitis and clinical variables that differ between patients. The ability to accurately diagnose, predict prognosis, and select the appropriate treatment depends on the understanding of disease endotypes. Chronic sinusitis is in the early stages of disease endotyping. The ability to identify endotypes is at the forefront of clinical research. Endotyping of chronic sinusitis uses clinical information, radiographic studies, and pathophysiologic data. Understanding of the full spectrum of chronic sinusitis is in its infancy. A personalized approach to treatment will consider standard medical therapies, sinus surgeries, and targeted use of biologic agents.
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Pipolo C, Saibene AM, Felisati G. Prevalence of pain due to rhinosinusitis: a review. Neurol Sci 2018; 39:21-24. [DOI: 10.1007/s10072-018-3336-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Shen SA, Jafari A, Bracken D, Pang J, DeConde AS. Predictive value of SNOT-22 on additional opiate prescriptions after endoscopic sinus surgery. Int Forum Allergy Rhinol 2018; 8:1021-1027. [PMID: 29722922 DOI: 10.1002/alr.22137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) is generally well tolerated, yet a subset of patients require an additional opiate prescription in the postoperative period. The purpose of this study was to quantify differences in both preoperative and immediate postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores between patients with a single prescription and those requiring additional opiate prescriptions (AOPs). METHODS Patients undergoing ESS between November 2016 and August 2017 were reviewed retrospectively. The Medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed; patients requiring AOP within 60 days after surgery were identified. The primary and secondary outcomes of interest were the association of baseline and first postoperative visit SNOT-22 total and domain scores with AOP. RESULTS A total of 121 patients were reviewed, 22 (18.2%) required AOP. Baseline SNOT-22 scores were higher in aggregate (58.7 ± 16.0 vs 46.1 ± 22.5) and ear/facial domain (11.4 ± 4.8 vs 8.5 ± 5.4) in the AOP group (p < 0.01). AOP patients also demonstrated higher scores across all SNOT-22 domains (p < 0.001) at the immediate preoperative visit. There was no difference in the absolute improvement between groups (15.5 ± 18.30 vs 12.3 ± 23.9, p = 0.54). AOP patients experienced less relative improvement (20.2% vs 34.8%, p < 0.05) and smaller mean effect size (0.57 vs 0.70, p < 0.001) after ESS. CONCLUSION Patients reporting increased ear and facial symptoms at baseline have an increased risk of additional opiate prescription after surgery; preoperative SNOT-22 scores may provide utility in identifying these patients. Subjects in both cohorts report symptomatic improvement after ESS; however, relative, not absolute, improvement in SNOT-22 scores is more predictive of AOP.
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Affiliation(s)
- Sarek A Shen
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Aria Jafari
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, CA
| | - David Bracken
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, CA
| | - John Pang
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, CA
| | - Adam S DeConde
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, CA
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Kara N, Yao AC, Newton J, Deary V, O'Hara J, Wilson JA. General illness and psychological factors in patients with chronic nasal symptoms. Clin Otolaryngol 2017; 43:609-616. [PMID: 29150985 DOI: 10.1111/coa.13032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Only a minority of patients referred to specialists with sinonasal symptoms have clear evidence of chronic rhinosinusitis (CRS). This study aims to estimate the prevalence of and associations between (i) general illness factors (fatigue, autonomic dysfunction) and (ii) psychological factors (anxiety, depression, somatisation, personality traits) in patients presenting with sinonasal symptoms. DESIGN The following validated questionnaires were administered to patients: the Sino-Nasal Outcome Test-22 (SNOT-22) identifying symptom burden, Composite Autonomic Symptom Score-31 (COMPASS-31) measuring autonomic function, Chalder Fatigue Questionnaire, Patient Health Questionnaire-15 (PHQ-15) addressing somatisation symptoms, Hospital Anxiety and Depression Scale (HADS), and the International Personality Item Pool-50 (IPIP-50). Comparisons were made with normative and general population data, and relationships were analysed using nonparametric correlation. SETTING Secondary care ENT outpatients. PARTICIPANTS Adults referred with chronic sinonasal symptoms. MAIN OUTCOME MEASURES SNOT-22, COMPASS-31, Chalder, PHQ-15, HADS, and IPIP-50 questionnaire scores. RESULTS Sixty-one patients were included. There was a high prevalence of all general and psychological factors assessed compared with controls. Total SNOT-22 scores showed significant correlation with Chalder fatigue scores, total autonomic dysfunction score, anxiety, depression, somatisation tendencies and the emotionally unstable personality trait. Emotional instability and psychological dysfunction correlated significantly with sleep and psychological subscales of SNOT-22 but not the rhinological or ear/facial subscales. CONCLUSION Patients with sinonasal symptoms demonstrate high prevalence and complex associations of general illness factors, psychological distress and certain personality traits. The SNOT-22 is a valuable tool, but its utility is limited by correlations with these confounding factors (eg psychological factors) that may exaggerate the total score. The use of the SNOT-22 component subscales is likely to provide more clinically meaningful and discriminant information.
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Affiliation(s)
- N Kara
- ENT Department, County Durham & Darlington NHS Foundation Trust, Darlington, UK
| | - A C Yao
- ENT Department, Stockport NHS Foundation Trust, Stockport, UK
| | - J Newton
- Institute of Cellular Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - V Deary
- Psychology Department, Northumbria University, Newcastle upon Tyne, UK
| | - J O'Hara
- ENT Department, Institute of Health and Society, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - J A Wilson
- ENT Department, Institute of Health and Society, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
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Hirsch SD, Reiter ER, DiNardo LJ, Wan W, Schuman TA. Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis. Laryngoscope 2017; 127:1011-1016. [DOI: 10.1002/lary.26442] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/13/2016] [Accepted: 11/01/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Scott D. Hirsch
- Virginia Commonwealth University School of MedicineRichmond Virginia U.S.A
| | - Evan R. Reiter
- Department of Otolaryngology–Head & Neck SurgeryVirginia Commonwealth University Health SystemRichmond Virginia U.S.A
| | - Laurence J. DiNardo
- Department of Otolaryngology–Head & Neck SurgeryVirginia Commonwealth University Health SystemRichmond Virginia U.S.A
| | - Wen Wan
- Department of BiostatisticsUniversity of Chicago School of MedicineChicago Illinois U.S.A
| | - Theodore A. Schuman
- Department of Otolaryngology–Head & Neck SurgeryVirginia Commonwealth University Health SystemRichmond Virginia U.S.A
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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Kroll KE, Camacho MA, Gautam S, Levenson RB, Edlow JA. Findings of chronic sinusitis on brain computed tomography are not associated with acute headaches. J Emerg Med 2014; 46:753-9. [PMID: 24750900 DOI: 10.1016/j.jemermed.2013.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 06/27/2013] [Accepted: 08/07/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is "chronic sinusitis." Assuming that "chronic sinusitis" is the cause of the patient's headache is a potential source of mis-diagnosis. STUDY OBJECTIVE We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury. METHODS This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis. RESULTS We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of -2.5-11.6%). CONCLUSION Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache.
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Affiliation(s)
- Katherine E Kroll
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marc A Camacho
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shiva Gautam
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robin B Levenson
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Hsueh WD, Conley DB, Kim H, Shintani-Smith S, Chandra RK, Kern RC, Tan BK. Identifying clinical symptoms for improving the symptomatic diagnosis of chronic rhinosinusitis. Int Forum Allergy Rhinol 2012; 3:307-14. [PMID: 23129294 DOI: 10.1002/alr.21106] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 06/29/2012] [Accepted: 07/21/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current symptom criteria for identifying patients with chronic rhinosinusitis (CRS) has poor specificity. The objective of this study was to test the hypothesis that symptoms drawn from the Task Force on Rhinosinusitis (RSTF) criteria and the International Headache Society (IHS) criteria for primary headaches can differentiate CRS patients from those with CRS-symptoms but no evidence for inflammation (non-CRS). METHODS A retrospective cohort study from a total of 140 charts of patients who received a diagnostic computed tomography (CT) scan for CRS symptoms in a tertiary care clinic. The study was conducted in 2 phases: (1) using a retrospective review of otolaryngologist-documented symptoms (ODS) in the medical record; and (2) using patient-reported symptoms (PRS) on a prospectively collected customized review of systems form from a separate cohort. A radiographic gold standard differentiated CRS from non-CRS patients. RESULTS Subjects in the CRS and non-CRS group were matched for age and race and almost universally met symptomatic criteria as defined by the RSTF in both study phases. In both study phases, facial pain, but not facial pressure, was negatively predictive for CRS (p < 0.05). Similarly, hyposmia was positively predictive, whereas facial pain of a pulsating quality and photophobia were negatively predictive (p < 0.05), although analysis of PRS was significant only when symptom frequency was considered. Nonetheless, significant overlap exists between the prevalence and frequency of symptoms in both groups. CONCLUSION The symptom-based diagnosis of CRS is challenging but symptoms of hyposmia is positively predictive while facial pain, a throbbing quality, headaches and photophobia are negatively predictive and show promise for improving the specificity of CRS diagnosis. Further validation studies are needed.
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Affiliation(s)
- Wayne D Hsueh
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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T. K, N.S. J. 12 minute consultation: Evidence based management of a patient with facial pain. Clin Otolaryngol 2012; 37:207-12. [DOI: 10.1111/j.1749-4486.2012.02478.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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