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Gupta S, Ritzl EK, Husari KS. Lateralized Rhythmic Delta Activity and Lateralized Periodic Discharges in Critically Ill Pediatric Patients. J Clin Neurophysiol 2024:00004691-990000000-00121. [PMID: 38194635 DOI: 10.1097/wnp.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
PURPOSE To evaluate the clinical and electrographic characteristics of critically ill pediatric patients with lateralized rhythmic delta activity (LRDA) and compare them with patients with lateralized periodic discharges (LPDs). METHODS This was a retrospective study examining consecutive critically ill pediatric patients (1 month-18 years) with LRDA or LPDs monitored on continuous electroencephalography. Clinical, radiologic, and electrographic characteristics; disease severity; and acute sequelae were compared between the two groups. RESULTS Of 668 pediatric patients monitored on continuous electroencephalography during the study period, 12 (1.79%) patients had LRDA and 15 (2.24%) had LPDs. The underlying etiologies were heterogeneous with no difference in the acuity of brain MRI changes between both groups. Lateralized rhythmic delta activity and LPDs were concordant with the side of MRI abnormality in most patients [85.7% (LRDA) and 83.3% (LPD)]. There was no difference in the measures of disease severity between both groups. Seizures were frequent in both groups (42% in the LRDA group and 73% in the LPD group). Patients in the LPD group had a trend toward requiring a greater number of antiseizure medications for seizure control (median of 4 vs. 2 in the LRDA group, p = 0.09), particularly those patients with LPDs qualifying as ictal-interictal continuum compared with those without ictal-interictal continuum (p = 0.02). CONCLUSIONS Lateralized rhythmic delta activity and LPDs are uncommon EEG findings in the pediatric population. Seizures occur commonly in patients with these patterns. Seizures in patients with LPDs, especially those qualifying as ictal-interictal continuum, showed a trend toward being more refractory. Larger studies are needed in the future to further evaluate these findings.
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Affiliation(s)
- Siddharth Gupta
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Welte TM, Ernst S, Stritzelberger J, Gollwitzer S, Lang JD, Reindl C, Sprügel MI, Olmes D, Schwab S, Blinzler C, Hamer HM. Trends in the neurological emergency room, focusing on persons with seizures. Eur J Neurol 2023; 30:3008-3015. [PMID: 37422921 DOI: 10.1111/ene.15976] [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: 04/28/2023] [Revised: 06/15/2023] [Accepted: 07/04/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND PURPOSE Previous studies in neurological emergency rooms (nERs) have reported many non-acute, self-presenting patients, patients with delayed presentation of stroke, and frequent visits of persons with seizures (PWS). The aim of this study was to evaluate trends during the last decade, with special focus on PWS. METHODS We retrospectively analyzed patients who presented to our specialized nER during the course of 5 months in 2017 and 2019, and included information on admission/referral, hospitalization, discharge diagnosis, and diagnostic tests/treatment in the nER. RESULTS A total of 2791 patients (46.6% male, mean age 57 ± 21 years) were included. The most common diagnoses were cerebrovascular events (26.3%), headache (14.1%), and seizures (10.5%). Most patients presented with symptoms lasting >48 h (41.3%). The PWS group included the largest proportion of patients presenting within 4.5 h of symptom onset (171/293, 58.4%), whereas only 37.1% of stroke patients presented within this time frame (273/735). Self-presentation was the most common admission pathway (31.1%), followed by emergency service referral (30.4%, including the majority of PWS: 197/293, 67.2%). Despite known diagnosis of epilepsy in 49.2%, PWS more often underwent accessory diagnostic testing including cerebral imaging, compared to the overall cohort (accessory diagnostics 93.9% vs. 85.4%; cerebral imaging 70.1% vs. 64.1%). Electroencephalography in the nER was only performed in 20/111 patients (18.0%) with a first seizure. Nearly half of the patients (46.7%) were discharged home after nER work-up, including most self-presenters (632/869, 72.7%) and headache patients (377/393, 88.3%), as well as 37.2% (109/293) of PWS. CONCLUSION After 10 years, nER overuse remains a problem. Stroke patients still do not present early enough, whereas PWS, even those with known epilepsy, often seek acute and extensive assessment, indicating gaps in pre-hospital management and possible over-assessment.
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Affiliation(s)
- Tamara M Welte
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Sebastian Ernst
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Jenny Stritzelberger
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Stephanie Gollwitzer
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Johannes D Lang
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Caroline Reindl
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Maximilian I Sprügel
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - David Olmes
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Schwab
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Christian Blinzler
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Hajo M Hamer
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
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deCampo D, Husari KS, Bembea MM, Habela CW, Ritzl EK. Continuous Electroencephalography (EEG) Protocol Improves Seizure Detection in Children on Extracorporeal Membrane Oxygenation. J Child Neurol 2023; 38:581-589. [PMID: 37624689 PMCID: PMC11060699 DOI: 10.1177/08830738231190145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
BACKGROUND / OBJECTIVE Seizures are a complication for pediatric patients requiring extracorporeal membrane oxygenation (ECMO). There are no standardized guidelines regarding continuous electroencephalography (EEG) monitoring to detect seizures in these patients, and the impact of protocolized monitoring has not been evaluated. Here we examined the effects of continuous EEG protocol implementation in our pediatric ECMO population. METHODS Retrospective chart reviews were conducted on 57 patients who underwent extracorporeal membrane oxygenation and concurrent continuous EEG out of 165 patients supported on extracorporeal membrane oxygenation. Timing of continuous EEG initiation and seizures detected by continuous EEG was determined for 5 years prior to and 15 months after protocol implementation. RESULTS Protocol implementation was associated with increased ECMO-supported patients who were concurrently monitored by continuous EEG. Time from ECMO cannulation to continuous EEG initiation was shorter (median 7 hours after versus 16.2 hours before; P < .001). Patients who had ongoing seizures at the start of continuous EEG recording decreased from 64% preprotocol to 0% postprotocol (P < .001), and there was an associated earlier time to break in status epilepticus postprotocol. Seizures were detected past 48 hours after cannulation in 50% of patients in the postprotocol group. CONCLUSIONS Protocol implementation resulted in earlier continuous EEG initiation and more EEGs initiated before seizure onset with evidence of altered seizure dynamics. Although current recommendations suggest that continuous EEG duration of 24-48 hours results in seizure detection for >90% of critically ill adults, longer monitoring may be needed to reliably detect seizures in children supported with ECMO, particularly if monitoring is initiated earlier in the post-cannulation period.
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Affiliation(s)
- Danielle deCampo
- Departments of Neurology, Johns Hopkins Hospital, Baltimore, MD
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Melania M. Bembea
- Department of Anesthesiology and Critical Care, Johns Hopkins Hospital, Baltimore, MD
| | | | - Eva K. Ritzl
- Departments of Neurology, Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care, Johns Hopkins Hospital, Baltimore, MD
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Chang BA, Cassim TZ, Mittel AM, Brambrink AM, García PS. Frontal Electroencephalography Findings in Critically Ill COVID-19 Patients. J Neurosurg Anesthesiol 2023; 35:322-326. [PMID: 35249987 PMCID: PMC10249398 DOI: 10.1097/ana.0000000000000837] [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: 10/31/2021] [Accepted: 01/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) negatively impacts the central nervous system, and studies using a full montage of electroencephalogram (EEG) electrodes have reported nonspecific EEG patterns associated with coronavirus disease 2019 (COVID-19) infection. The use of this technology is resource-intensive and limited in its implementation. In this descriptive pilot study, we report neurophysiological patterns and the potential prognostic capability of an abbreviated frontal EEG electrode montage in critically ill COVID-19 patients. MATERIALS AND METHODS Patients receiving mechanical ventilation for SARS-CoV-2 respiratory failure were monitored with Sedline Root Devices using EEG electrodes were placed over the forehead. Qualitative EEG assessments were conducted daily. The primary outcome was mortality, and secondary outcomes were duration of endotracheal intubation and lengths of intensive care and hospitalization stay. RESULTS Twenty-six patients were included in the study, and EEG discontinuity was identified in 22 (84.6%) patients. The limited sample size and patient heterogeneity precluded statistical analysis, but certain patterns were suggested by trends in the data. Survival was 100% (4/4) for those patients in which a discontinuous EEG pattern was not observed. The majority of patients (87.5%, 7/8) demonstrating activity in the low-moderate frequency range (7 to 17 Hz) survived compared with 61.1% (11/18) of those without this observation. CONCLUSIONS The majority of COVID-19 patients showed signs of EEG discontinuity during monitoring with an abbreviated electrode montage. The trends towards worse survival among those with EEG discontinuity support the need for additional studies to investigate these associations in COVID-19 patients.
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Swingle N, Vuppala A, Datta P, Pedavally S, Swaminathan A, Kedar S, Samson KK, Wichman CS, Myers J, Taraschenko O. Limited-Montage EEG as a Tool for the Detection of Nonconvulsive Seizures. J Clin Neurophysiol 2022; 39:85-91. [PMID: 32604191 DOI: 10.1097/wnp.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Prefabricated arrays with a limited number of electrodes offer an opportunity to hasten the diagnosis of seizures; however, their accuracy to detect seizures is unknown. We examined the utility of two limited-montage EEG setups for the detection of nonconvulsive seizures. METHODS Thirty previously interpreted EEG segments with nonconvulsive seizures from 30 patients and 60 segments with background slowing or normal EEG from 60 patients were rendered in a bipolar "double banana" montage, a double distance "neonatal" montage, and a circumferential "hatband" montage. Experts reviewed 60 to 180 seconds long segments to determine whether seizures were present and if the EEG data provided were sufficient to make a decision on escalation of clinical care by ordering an additional EEG or prescribing anticonvulsants. The periodic patterns on the ictal-interictal continuum were specifically excluded for this analysis to keep the focus on definite electrographic seizures. RESULTS The sensitivities for seizure of the neonatal and hatband montages were 0.96 and 0.84, respectively, when compared with full montage EEG, whereas the specificities were 0.94 and 0.98, respectively. Appropriate escalation of care was suggested for 96% and 92% of occurrences of seizure patterns in neonatal and hatband montages, respectively. When compared with clinical EEG, the sensitivities of the neonatal and hatband montages for seizure diagnosis were 0.85 and 0.69, respectively. CONCLUSIONS Nonconvulsive seizures were detected with high accuracy using the limited electrode array configuration in the neonatal and hatband montages. The sensitivity of the neonatal montage EEG in detecting seizures was superior to that of a hatband montage. These findings suggest that in some patients with nonconvulsive seizures, limited-montage EEG may allow to differentiate ictal and slow patterns.
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Affiliation(s)
- Nicholas Swingle
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Aditya Vuppala
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Proleta Datta
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Swetha Pedavally
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Arun Swaminathan
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Sachin Kedar
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Kaeli K Samson
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A.; and
| | - Christopher S Wichman
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A.; and
| | - Jacob Myers
- Clinical Neurophysiology Laboratory, Nebraska Medicine, Omaha, Nebraska, U.S.A
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
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Virtual EEG-electrodes: Convolutional neural networks as a method for upsampling or restoring channels. J Neurosci Methods 2021; 355:109126. [PMID: 33711358 DOI: 10.1016/j.jneumeth.2021.109126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/21/2021] [Accepted: 03/04/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND In clinical practice, EEGs are assessed visually. For practical reasons, recordings often need to be performed with a reduced number of electrodes and artifacts make assessment difficult. To circumvent these obstacles, different interpolation techniques can be utilized. These techniques usually perform better for higher electrode densities and values interpolated at areas far from electrodes can be unreliable. Using a method that learns the statistical distribution of the cortical electrical fields and predicts values may yield better results. NEW METHOD Generative networks based on convolutional layers were trained to upsample from 4 or 14 channels or to dynamically restore single missing channels to recreate 21-channel EEGs. 5,144 h of data from 1,385 subjects of the Temple University Hospital EEG database were used for training and evaluating the networks. COMPARISON WITH EXISTING METHOD The results were compared to spherical spline interpolation. Several statistical measures were used as well as a visual evaluation by board certified clinical neurophysiologists. Overall, the generative networks performed significantly better. There was no difference between real and network generated data in the number of examples assessed as artificial by experienced EEG interpreters whereas for data generated by interpolation, the number was significantly higher. In addition, network performance improved with increasing number of included subjects, with the greatest effect seen in the range 5-100 subjects. CONCLUSIONS Using neural networks to restore or upsample EEG signals is a viable alternative to spherical spline interpolation.
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Michalak AJ, Mendiratta A, Eliseyev A, Ramnath B, Chung J, Rasnow J, Reid L, Salerno S, García PS, Agarwal S, Roh D, Park S, Bazil C, Claassen J. Frontotemporal EEG to guide sedation in COVID-19 related acute respiratory distress syndrome. Clin Neurophysiol 2021; 132:730-736. [PMID: 33567379 PMCID: PMC7817418 DOI: 10.1016/j.clinph.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/08/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
Objective To study if limited frontotemporal electroencephalogram (EEG) can guide sedation changes in highly infectious novel coronavirus disease 2019 (COVID-19) patients receiving neuromuscular blocking agent. Methods 98 days of continuous frontotemporal EEG from 11 consecutive patients was evaluated daily by an epileptologist to recommend reduction or maintenance of the sedative level. We evaluated the need to increase sedation in the 6 h following this recommendation. Post-hoc analysis of the quantitative EEG was correlated with the level of sedation using a machine learning algorithm. Results Eleven patients were studied for a total of ninety-eight sedation days. EEG was consistent with excessive sedation on 57 (58%) and adequate sedation on 41 days (42%). Recommendations were followed by the team on 59% (N = 58; 19 to reduce and 39 to keep the sedation level). In the 6 h following reduction in sedation, increases of sedation were needed in 7 (12%). Automatized classification of EEG sedation levels reached 80% (±17%) accuracy. Conclusions Visual inspection of a limited EEG helped sedation depth guidance. In a secondary analysis, our data supported that this determination may be automated using quantitative EEG analysis. Significance Our results support the use of frontotemporal EEG for guiding sedation in patients with COVID-19.
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Affiliation(s)
- Andrew J Michalak
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Anil Mendiratta
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrey Eliseyev
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Jane Chung
- NewYork Presbyterian Hospital, New York, NY, USA
| | | | | | | | - Paul S García
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carl Bazil
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.
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Westover MB, Gururangan K, Markert MS, Blond BN, Lai S, Benard S, Bickel S, Hirsch LJ, Parvizi J. Diagnostic Value of Electroencephalography with Ten Electrodes in Critically Ill Patients. Neurocrit Care 2020; 33:479-490. [PMID: 32034656 PMCID: PMC7416437 DOI: 10.1007/s12028-019-00911-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In critical care settings, electroencephalography (EEG) with reduced number of electrodes (reduced montage EEG, rm-EEG) might be a timely alternative to the conventional full montage EEG (fm-EEG). However, past studies have reported variable accuracies for detecting seizures using rm-EEG. We hypothesized that the past studies did not distinguish between differences in sensitivity from differences in classification of EEG patterns by different readers. The goal of the present study was to revisit the diagnostic value of rm-EEG when confounding issues are accounted for. METHODS We retrospectively collected 212 adult EEGs recorded at Massachusetts General Hospital and reviewed by two epileptologists with access to clinical, trending, and video information. In Phase I of the study, we re-configured the first 4 h of the EEGs in lateral circumferential montage with ten electrodes and asked new readers to interpret the EEGs without access to any other ancillary information. We compared their rating to the reading of hospital clinicians with access to ancillary information. In Phase II, we measured the accuracy of the same raters reading representative samples of the discordant EEGs in full and reduced configurations presented randomly by comparing their performance to majority consensus as the gold standard. RESULTS Of the 95 EEGs without seizures in the selected fm-EEG, readers of rm-EEG identified 92 cases (97%) as having no seizure activity. Of 117 EEGs with "seizures" identified in the selected fm-EEG, none of the cases was labeled as normal on rm-EEG. Readers of rm-EEG reported pathological activity in 100% of cases, but labeled them as seizures (N = 77), rhythmic or periodic patterns (N = 24), epileptiform spikes (N = 7), or burst suppression (N = 6). When the same raters read representative epochs of the discordant EEG cases (N = 43) in both fm-EEG and rm-EEG configurations, we found high concordance (95%) and intra-rater agreement (93%) between fm-EEG and rm-EEG diagnoses. CONCLUSIONS Reduced EEG with ten electrodes in circumferential configuration preserves key features of the traditional EEG system. Discrepancies between rm-EEG and fm-EEG as reported in some of the past studies can be in part due to methodological factors such as choice of gold standard diagnosis, asymmetric access to ancillary clinical information, and inter-rater variability rather than detection failure of rm-EEG as a result of electrode reduction per se.
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Affiliation(s)
- M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | - Saien Lai
- Kaiser Permanente Medical Center, Panorama City, CA, USA
| | - Shawna Benard
- Keck Hospital of University of Southern California, Los Angeles, CA, USA
| | - Stephan Bickel
- Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, USA
| | | | - Josef Parvizi
- Stanford University Medical Center, Stanford, CA, USA
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Backman S, Cronberg T, Rosén I, Westhall E. Reduced EEG montage has a high accuracy in the post cardiac arrest setting. Clin Neurophysiol 2020; 131:2216-2223. [DOI: 10.1016/j.clinph.2020.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/18/2020] [Accepted: 06/08/2020] [Indexed: 10/23/2022]
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Jordan KG. Reduced Electrode Arrays for ICU-Continuous EEG Seizure Detection. J Clin Neurophysiol 2018; 35:519. [DOI: 10.1097/wnp.0000000000000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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