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Shehab ME, Isa HM, Saleh LM, Alafeya ZA. Satisfaction and Quality of Life in Patients Who Underwent Post Massive Weight Loss Body Contouring Procedures: A Tertiary Center Experience in Bahrain. World J Plast Surg 2024; 13:71-82. [PMID: 38742039 PMCID: PMC11088735 DOI: 10.61186/wjps.13.1.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 09/03/2024] [Indexed: 05/16/2024] Open
Abstract
Background Incidence of body contouring surgeries (BCS) rose significantly to overcome problems resulted from post-Bariatric Surgery (BS). We aimed to evaluate satisfaction level and quality of life (QOL) in patients' post-BCS. Methods In this retrospective prospective study, patients who underwent BCS in Plastic Surgery Department, Salmaniya Medical Complex, Bahrain, in 2017-2018, were enrolled. Demographic and anthropometric data were collected. BS-group's QOL and satisfaction level were assessed using a questionnaire. Results Of 929 plastic surgery admissions, 316 (34%) were for BCS (249 patients). Fifty-eight (28%) patients underwent 82 BS were recruited, mostly females (n=42, 72.4%). The mean age was 37.4±9.6 years. Excess abdominal skin was the most area of concern (n=50, 86.2%). Median pre-BCS body mass index was 26.9 (interquartile range: 25.6-29.8) kg/m2. Most patients were overweight (n=26, 44.8%). Abdominoplasty was the commonest BCS (n=172, 50.6%). This was also the case in 82 BCS in post-BS group (n=38, 46.3%). In post-BS group, post-operative complications were noted in 25/82 (30.5%) patients with wound problems being the most frequent (n=14, 17.1%). Most patients rated their experience as better in all questionnaire domains and most (n=45, 54.9%) rated their satisfaction level as excellent. Older age gave better overall satisfaction (P<0.001) while employed patients had better overall QOL (P=0.012) and self-confidence (P=0.048). Females had better satisfaction with body appearance (P<0.001) while those underwent abdominoplasty or breast surgeries had lower physical activity (P=0.042). Conclusion This study showed improvement in patient's QOL post-BCS with excellent overall satisfaction, findings that could be affected by age, sex, and occupation.
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Affiliation(s)
- Mohamed E. Shehab
- Burn, Plastic and Reconstructive Surgery Department, Salmaniya Medical Complex; Manama, Bahrain
| | - Hasan M. Isa
- Pediatric Department, Salmaniya Medical Complex; Manama, Bahrain
| | - Lana M. Saleh
- ENT Department, Salmaniya Medical Complex; Manama, Bahrain
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Wan Makhtar WR, Mohamad Shah NS, Rusli SM, Mat Saad AZ, Wan Sulaiman WA. The Impact of Abdominoplasty vs Non-abdominoplasty on Weight Loss in Bariatric and Non-bariatric Malaysian Patients: A Multicentre Retrospective Study. Cureus 2022; 14:e23996. [PMID: 35547419 PMCID: PMC9085712 DOI: 10.7759/cureus.23996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background and aims Weight loss associated with abdominoplasty remains controversial as to whether it is contributed by the procedure alone, or if there are other patient factors. Therefore, we evaluated the relationship between weight loss in pre- and post-abdominoplasty and compared the weight loss of those who do not undergo abdominoplasty in bariatric and non-bariatric patients. Methods This study measured weight changes at designated time points in four different groups comprising 98 patients. The groups were abdominoplasty after bariatric surgery (group A), patients with abdominoplasty alone (B), bariatric surgery alone (group C), and diet alone (group D). Results are compared within and between the groups. Results Patients in groups A and B (patients who had abdominoplasty regardless with or without bariatric surgery) had a significant weight loss after six months (mean difference=10.70kg, 95% CI=4.05, 17.34, p<0.001) compared to pre abdominoplasty weight. Patients in group B were statistically significant (mean difference=4.01kg, 95% CI=0.92, 7.10, p=0.007) with 3.60kg weight reduction (4.59%). Patients in group A had clinically significant weight reduction (4.45kg, 5.14%) but it was not statistically significant (p>0.05) and had no significant additional weight reduction as compared to non-abdominoplasty (group C) patients (p=0.650). Patients in group C had a statistically significant difference from those in group D (F [1.00, 48.00] = 8.56, p=0.005) with an average weight loss of 3.60kg (4.59%) vs 2.56kg (2.8%) respectively. Conclusions All patients with abdominoplasty had significant weight loss after six months. Bariatric patients did not experience significant additional weight loss with abdominoplasty. Weight reduction after abdominoplasty alone was greater than diet alone.
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Iljin A, Antoszewski B, Zieliński T, Skulimowski A, Szymański D, Strzelczyk J. Sublay or onlay incisional hernia repair along with abdominoplasty: which is better? Long-term results. Hernia 2019; 23:757-765. [PMID: 30805828 PMCID: PMC6661021 DOI: 10.1007/s10029-019-01914-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 02/19/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Estimation and comparison of results after incisional hernia repair (IHR) modo onlay or sublay with abdominoplasty in patients who lost the weight following Roux-en-Y Gastric Bypass (RYGB). Analysis and comparison of changes in quality of life (QL) of these patients prior to RYGB, before and after simultaneous IHR and abdominoplasty. METHODS Clinical analysis involved 40 patients with abdominal disfigurement (following RYGB and massive weight loss) after one-time IHR sublay method with abdominoplasty-group 1 or IHR onlay method with abdominoplasty-group 2. We evaluated postoperative results and long-term QL changes (DAS24, SF-36 scales). RESULTS We noted abnormal wound healing (2), pneumonia (3) and dysesthesia (3) in patients from group 1, and abnormal wound healing (2), seroma (2), pneumonia (2), and dysesthesia (4) in group 2. Quality of life was improved in the functional, esthetic and psychological aspects. CONCLUSIONS One stage incisional hernia repair by onlay as well as sublay method with abdominoplasty are safe surgical methods improving the functioning of patients after major weight loss following RYGB. Sublay hernia repair and abdominoplasty was connected with longer time of the: operation, drainage, analgesic agents use, time to mobilization and to full oral diet than the onlay method. Significant improvement of the quality of life was noted after every subsequent step of surgical treatment in both groups. Reduction of the risk of BMI re-growth after bariatric surgery is related to the need for constant, specialized care for these patients at every stage of follow-up after bariatric surgery.
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Affiliation(s)
- A Iljin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland
| | - B Antoszewski
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland
| | - T Zieliński
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland.
| | - A Skulimowski
- Department of General and Transplant Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland
| | - D Szymański
- Department of General and Transplant Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland
| | - J Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland
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Psychometric Validation of the BODY-Q in Danish Patients Undergoing Weight Loss and Body Contouring Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1529. [PMID: 29184741 PMCID: PMC5682177 DOI: 10.1097/gox.0000000000001529] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022]
Abstract
Background A well-developed patient-reported outcome instrument is needed for use in Danish bariatric and body contouring patients. The BODY-Q is designed to measure changes in important patient outcomes over the entire patient journey, from obesity to post-body contouring surgery. The current study aims to psychometrically validate the BODY-Q for use in Danish patients. Methods The process consisted of 3 stages: translation and linguistic validation, field-test, and data analysis. The translation was performed in accordance with the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines, and field-test data were collected in 4 departments in 2 different hospitals. Field-test data were analyzed using Rasch Measurement Theory. Results A total of 495 patients completed the Danish BODY-Q field-test 1-4 times, leading to a total of 681 assessments with an overall response rate at 76%. Cronbach α values were ≥ 0.90, and person separation index values were in general high. The Rasch Measurement Theory analysis provided broad support for the reliability and validity of the Danish version of the BODY-Q scales. Item fit was outside the criteria for 34 of 138 items, and of these, 21 had a significant chi-square P value after Bonferroni adjustment. Most items (128 of 138) had ordered thresholds, indicating that response options worked as intended. Conclusion The Danish version of the BODY-Q is a reliable and valid patient-reported outcome instrument for use in Danish bariatric and body contouring patients.
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Poulsen L, Rose M, Klassen A, Roessler KK, Sørensen JA. Danish translation and linguistic validation of the BODY-Q: a description of the process. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016; 40:29-38. [PMID: 28179749 PMCID: PMC5258793 DOI: 10.1007/s00238-016-1247-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/20/2016] [Indexed: 11/28/2022]
Abstract
Background Patient-reported outcome (PRO) instruments are increasingly being included in research and clinical practice to assess the patient point of view. Bariatric and body contouring surgery has the potential to improve or restore a patient’s body image and health-related quality of life (HR-QOL). A new PRO instrument, called the BODY-Q, has recently been developed specifically for this patient group. The aim of the current study was to translate and perform a linguistic validation of the BODY-Q for use in Danish bariatric and body contouring patients. Methods The translation was performed in accordance with the International Society For Pharmacoeconomics and Outcomes Research (ISPOR) and the World Health Organization (WHO) recommendations. Main steps taken included forward and backward translations, an expert panel meeting, and cognitive patient interviews. All translators aimed to conduct a conceptual translation rather than a literal translation and used a simple and clear formulation to create a translation understandable for all patients. Results The linguistic translation process led to a conceptually equivalent Danish version of the BODY-Q. The comparison between the back translation of the first Danish version and the original English version of the BODY-Q identified 18 items or instructions requiring re-translation. The expert panel helped to identify and resolve inadequate expressions and concepts of the translation. The panel identified 31 items or instructions that needed to be changed, while the cognitive interviews led to seven major revisions. Conclusions The impact of weight loss methods such as bariatric surgery and body contouring surgery on patients’ HR-QOL would benefit from input from the patient perspective. A thorough translation and linguistic validation must be considered an essential step when implementing a PRO instrument to another language and/or culture. A combination of the ISPOR and WHO guidelines contributed to a straightforward and thorough translation methodology well suited for a Danish translation of the BODY-Q. The described method of translation and linguistic validation can be recommended for future translations of PRO instruments in the field of plastic surgery. Level of Evidence: Not ratable.
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Affiliation(s)
- Lotte Poulsen
- Department of Plastic Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark
| | - Michael Rose
- Department of Plastic Surgery, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Anne Klassen
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | | | - Jens Ahm Sørensen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
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Iljin A, Antoszewski B, Durczyński A, Lewandowicz E, Strzelczyk J. Long-Term Results of Incisional Hernia Repair with Concomitant Abdominoplasty in Postbariatric Patients. POLISH JOURNAL OF SURGERY 2016; 88:147-54. [PMID: 27428836 DOI: 10.1515/pjs-2016-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Indexed: 11/15/2022]
Abstract
UNLABELLED The aim of the study was evaluation of long-term results after simultaneous incisional hernia repair and abdominoplasty in patients following RYGB (Roux-en-Y Gastric By-pass) and estimation of quality of life before and after this complex operation. MATERIAL AND METHODS We analyzed long-term results in 18 patients who underwent complex anterior abdominal wall surgery after massive weight loss, following previous RYGB. The patients were followed-up for at least 8 years. We compared the quality of life before and after hernia repair combined with abdominoplasty. RESULTS Observed wide postoperative scar in 4 persons, permanent dysesthesia in one, and flaccidity of the anterior abdominal wall in three cases. Estimation of the quality of life revealed significant improvement in functional, aesthetic and psychological aspects after complex surgery. CONCLUSIONS 1. Simultaneous incisional hernia repair and abdominoplasty resulted in satisfactory long-term postoperative results, which confirms the efficiency of complex anterior abdominal wall surgery in patients following RYGB after massive weight loss. 2. Surgery in patients afflicted with disfigurements of the anterior abdominal wall contributed to significant improvement in their life quality in functional, aesthetic and psychological aspects, as compared with preoperative estimations. 3. All persons confirmed positive influence of abdominal wall surgery on their possibility to take challenges in life, and fulfill plans. 4. Surgery of the anterior abdominal wall deformities, if needed after massive weight loss, should become an integral part of complex multidisciplinary treatment in postbariatric individuals.
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Patient Expectations of Bariatric and Body Contouring Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e694. [PMID: 27200256 PMCID: PMC4859253 DOI: 10.1097/gox.0000000000000677] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/23/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patient expectations are important in bariatric and body contouring surgery because the goals include improvements in health-related quality of life, appearance, and body image. The aim of this study was to identify patient expectations along the weight loss journey and/or body contouring surgery. METHODS This qualitative study took an interpretive description approach. Between September 2009 and February 2012, 49 patients were interviewed postbody contouring surgery. Data were analyzed using a line-by-line approach whereby expectations were identified and labeled as expected, unexpected, or neutral. Constant comparison was used to ensure coding was done consistently. Interviews continued until no new themes emerged. RESULTS Participants described expectations according to appearance, health-related quality of life, and patient experience of care. Two areas stood out in terms of unmet expectations and included appearance and physical health, ie, recovery from body contouring surgery. Most participants, who underwent bariatric surgery, expected neither the extent of excess skin after weight loss nor how the excess skin would make them look and feel. For recovery, participants did not expect that it would be as long or as hard as it was in reality. CONCLUSIONS A full understanding of outcomes and expectations for this patient population is needed to enhance patient education and improve shared medical decision making. Education materials should be informed by the collection of evidence-based patient-reported outcome information using measures such as the BODY-Q. A patient-reported outcome scale measuring patient expectations is needed for obese and bariatric patients.
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Ellison JM, Steffen KJ, Sarwer DB. Body Contouring After Bariatric Surgery. EUROPEAN EATING DISORDERS REVIEW 2015; 23:479-87. [PMID: 26395601 DOI: 10.1002/erv.2408] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/25/2015] [Indexed: 11/11/2022]
Abstract
Individuals who undergo bariatric surgery generally experience rapid and dramatic weight loss. While the weight loss typically confers significant health benefits, an undesirable consequence is often excessive quantities of hanging, surplus skin. Some patients undergo body-contouring surgery (BCS) in order to improve health, mobility, appearance and psychological adjustment. While the majority of post-bariatric patients desire BCS in one or more body regions, a small percentage of patients receive such surgeries. Lack of knowledge about procedures, cost and (in the USA and several other countries) difficulty obtaining insurance reimbursement likely prevents many patients from undergoing BCS. Those who do undergo BCS appear to be at heightened risk for wound-healing complications. Despite these complications, the majority of patients report satisfactory BCS outcomes. The extant literature in this area provides a great deal of information about these issues; nevertheless, additional research is needed to further inform clinical management and improve patient outcomes.
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Affiliation(s)
- Jo M Ellison
- Neuropsychiatric Research Institute, Fargo, ND, USA
| | | | - David B Sarwer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Terwee CB, Prinsen CAC, Ricci Garotti MG, Suman A, de Vet HCW, Mokkink LB. The quality of systematic reviews of health-related outcome measurement instruments. Qual Life Res 2015; 25:767-79. [PMID: 26346986 PMCID: PMC4830864 DOI: 10.1007/s11136-015-1122-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Systematic reviews of outcome measurement instruments are important tools for the selection of instruments for research and clinical practice. Our aim was to assess the quality of systematic reviews of health-related outcome measurement instruments and to determine whether the quality has improved since our previous study in 2007. METHODS A systematic literature search was performed in MEDLINE and EMBASE between July 1, 2013, and June 19, 2014. The quality of the reviews was rated using a study-specific checklist. RESULTS A total of 102 reviews were included. In many reviews the search strategy was considered not comprehensive; in only 59 % of the reviews a search was performed in EMBASE and in about half of the reviews there was doubt about the comprehensiveness of the search terms used for type of measurement instruments and measurement properties. In 41 % of the reviews, compared to 30 % in our previous study, the methodological quality of the included studies was assessed. In 58 %, compared to 55 %, the quality of the included instruments was assessed. In 42 %, compared to 7 %, a data synthesis was performed in which the results from multiple studies on the same instrument were somehow combined. CONCLUSION Despite a clear improvement in the quality of systematic reviews of outcome measurement instruments in comparison with our previous study in 2007, there is still room for improvement with regard to the search strategy, and especially the quality assessment of the included studies and the included instruments, and the data synthesis.
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Affiliation(s)
- C B Terwee
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - C A C Prinsen
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | | | - A Suman
- Department of Public Health and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - H C W de Vet
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - L B Mokkink
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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Satisfaction and complications after lower body lift with autologous gluteal augmentation by island fat flap: 55 case series over 3 years. J Plast Reconstr Aesthet Surg 2015; 68:410-8. [DOI: 10.1016/j.bjps.2014.10.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 10/07/2014] [Accepted: 10/31/2014] [Indexed: 11/22/2022]
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de Zwaan M, Georgiadou E, Stroh CE, Teufel M, Köhler H, Tengler M, Müller A. Body image and quality of life in patients with and without body contouring surgery following bariatric surgery: a comparison of pre- and post-surgery groups. Front Psychol 2014; 5:1310. [PMID: 25477839 PMCID: PMC4235262 DOI: 10.3389/fpsyg.2014.01310] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/28/2014] [Indexed: 12/28/2022] Open
Abstract
Background: Massive weight loss (MWL) following bariatric surgery frequently results in an excess of overstretched skin causing physical discomfort and negatively affecting quality of life, self-esteem, body image, and physical functioning. Methods: In this cross-sectional study 3 groups were compared: (1) patients prior to bariatric surgery (n = 79), (2) patients after bariatric surgery who had not undergone body contouring surgery (BCS) (n = 252), and (3) patients after bariatric surgery who underwent subsequent BCS (n = 62). All participants completed self-report questionnaires assessing body image (Multidimensional Body-Self Relations Questionnaire, MBSRQ), quality of life (IWQOL-Lite), symptoms of depression (PHQ-9), and anxiety (GAD-7). Results: Overall, 62 patients (19.2%) reported having undergone a total of 90 BCS procedures. The most common were abdominoplasties (88.7%), thigh lifts (24.2%), and breast lifts (16.1%). Post-bariatric surgery patients differed significantly in most variables from pre-bariatric surgery patients. Although there were fewer differences between patients with and without BCS, patients after BCS reported better appearance evaluation (AE), body area satisfaction (BAS), and physical functioning, even after controlling for excess weight loss and time since surgery. No differences were found for symptoms of depression and anxiety, and most other quality of life and body image domains. Discussion: Our results support the results of longitudinal studies demonstrating significant improvements in different aspects of body image, quality of life, and general psychopathology after bariatric surgery. Also, we found better AE and physical functioning in patients after BCS following bariatric surgery compared to patients with MWL after bariatric surgery who did not undergo BCS. Overall, there appears to be an effect of BCS on certain aspects of body image and quality of life but not on psychological aspects on the whole.
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Affiliation(s)
- Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School Hannover, Germany
| | - Ekaterini Georgiadou
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School Hannover, Germany
| | - Christine E Stroh
- Department of General, Abdominal and Pediatric Surgery, SRH Wald-Klinikum Gera Gera, Germany
| | - Martin Teufel
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital, University of Tuebingen Tuebingen, Germany
| | - Hinrich Köhler
- Department of Surgery, Herzogin Elisabeth Hospital Braunschweig, Germany
| | - Maxi Tengler
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School Hannover, Germany
| | - Astrid Müller
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School Hannover, Germany
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