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Eustachio JHPP, Filho WL, Baars C, Barbosa-Silva J, Lourenção M, Barbir J, Röseler J, Büddig S, de Lima PQ, Bandos MC. Fostering the discussion of planetary health in occupational therapy and physiotherapy. Aust Occup Ther J 2024; 71:423-442. [PMID: 38720015 DOI: 10.1111/1440-1630.12959] [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: 10/04/2023] [Revised: 04/09/2024] [Accepted: 04/14/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Occupational therapists and physiotherapists aim to promote health, prevent various diseases and help people in their rehabilitation processes. So far, there is a paucity of understanding of the big picture of how the new paradigm of planetary health (PH) is connected to the education and practice of these professionals. METHODS This research aimed to address this gap by investigating and deploying a bibliometric analysis to elucidate the pivotal role of occupational therapists and physiotherapists in addressing PH challenges. The ultimate goal is to construct a comprehensive framework crosschecking the bibliometric analysis and the collection of 10 case studies selected by experts to outline how best practices in occupational therapy and physiotherapy, related to the three pillars of sustainability and the UN's Sustainable Development Goals (SDGs), can contribute to increasing PH. RESULTS The bibliometric analysis revealed four major research strands: 1) enhancing patient care and quality of life; 2) integrating sustainability in health care and rehabilitation; 3) professional development and clinical competence; and 4) evidence-based practice and quality improvement. Moreover, further temporal analysis revealed how the topic evolved, from advancing evidence-based practice and clinical effectiveness, exploring the strengthening of health care and person-centred practices, to connecting the topic to aspects also predicted by the SDGs, such as integrating environmental and climate concerns in therapy and addressing psychological and self-care impacts on health. The case studies confirmed this trend, and a framework of PH in occupational therapy and physiotherapy through the lens of the SDGs was developed to support future research and practitioners in advancing this research field. CONCLUSIONS Occupational therapists and physiotherapists are essential players in public health and can integrate sustainability at every level of practice, from using resources during therapy sessions to advocating for more sustainable lifestyles.
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Affiliation(s)
- João Henrique Paulino Pires Eustachio
- Faculty of Life Sciences, Research and Transfer Centre Sustainability & Climate Change Management (FTZ-NK), Hamburg University of Applied Sciences, Hamburg, Germany
| | - Walter Leal Filho
- European School of Sustainability Science and Research (ESSSR), Hamburg University of Applied Sciences, Germany
- Department of Natural Sciences, Manchester Metropolitan University, Manchester, UK
| | - Caterina Baars
- Faculty of Life Sciences, Research and Transfer Centre Sustainability & Climate Change Management (FTZ-NK), Hamburg University of Applied Sciences, Hamburg, Germany
| | - Jordana Barbosa-Silva
- Women's Health Research Laboratory, Physical Therapy Department, Federal University of São Carlos (UFSCar), Sao Carlos, Brazil
| | - Marina Lourenção
- School of Economics, Business Administration and Accounting at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Jelena Barbir
- Faculty of Life Sciences, Research and Transfer Centre Sustainability & Climate Change Management (FTZ-NK), Hamburg University of Applied Sciences, Hamburg, Germany
| | - Jasmin Röseler
- Faculty of Life Sciences, Research and Transfer Centre Sustainability & Climate Change Management (FTZ-NK), Hamburg University of Applied Sciences, Hamburg, Germany
| | - Swantje Büddig
- Faculty of Life Sciences, Research and Transfer Centre Sustainability & Climate Change Management (FTZ-NK), Hamburg University of Applied Sciences, Hamburg, Germany
| | - Priscilla Queiroz de Lima
- School of Physiotherapy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Melissa Cavalcanti Bandos
- Uni-FACEF, Post-Graduation Program in Regional Development, Municipal University Center, Franca, SP, Brazil
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Masini G, Bertocchi E, Barugola G, Guerriero M, Ruffo G. Sexual, urinary, and intestinal dysfunction after rectal surgery: pre-, intra-, and post-operative predictors and trends over time in a single high-volume center. Updates Surg 2023; 75:599-609. [PMID: 36795321 DOI: 10.1007/s13304-023-01462-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
The incidence of long-term complications after rectal surgery varies widely among studies, and data regarding functional sequelae after transanal surgery are lacking. The aim of this study is to describe the incidence and change over time of sexual, urinary, and intestinal dysfunction in a single-center cohort, identifying independent predictors of dysfunction. A retrospective analysis of all rectal resections performed between March 2016 and March 2020 at our institution was conducted. Validated questionnaires were administered to assess post-operative function. Predictors of dysfunction were assessed by univariate and multivariate analysis. Latent class analysis was used to distinguish different risk profile classes. One hundred and forty-five patients were included. Sexual dysfunction at 1 month rose to 37% for both sexes, whereas urinary dysfunction reached 34% in males only. A significant (p < 0.05) improvement in urogenital function was observed between 1 and 6 months only. Intestinal dysfunction increased at 1 month, with no significant improvement between 1 and 12 months. Independent predictors of genitourinary dysfunction were post-operative urinary retention, pelvic collection, and Clavien-Dindo score ≥ III (p < 0.05). Transanal surgery resulted an independent predictor of better function (p < 0.05). Transanal approach, Clavien-Dindo score ≥ III, and anastomotic stenosis were independent predictors of higher LARS scores (p < 0.05). Maximum dysfunction was found at 1 month after surgery. Improvement was earlier for sexual and urinary dysfunction, whereas intestinal dysfunction improved slower and depended on pelvic floor rehabilitation. Transanal approach was protective for urinary and sexual function, although associated with a higher LARS score. Prevention of anastomosis-related complications resulted protective of post-operative function.
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Affiliation(s)
- Gaia Masini
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy.
| | - Elisa Bertocchi
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Giuliano Barugola
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Massimo Guerriero
- Clinical Research Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
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Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet? Clin Oncol (R Coll Radiol) 2023; 35:e110-e120. [PMID: 36443138 DOI: 10.1016/j.clon.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/14/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022]
Abstract
Rectal cancer is a common cancer and shows an increased incidence with older age. Although the gold standard treatment is surgical excision, minimally invasive approaches are increasingly used and organ preservation is becoming a reasonable approach. The conservative treatment approach includes local excision, external beam radiotherapy and brachytherapy. However, these all carry a risk of side-effects. It is crucial to provide patients with information to quantify the improvement or detriment in quality of life with their cancer treatment. This can only be done with patient-reported outcome measures (PROMs) as tools within current and future trials. Colorectal cancer has numerous publications with specific PROMs. However, PROMs reporting in rectal cancer is more sparse; PROMs are generally extrapolated from colorectal cancer. Rectal PROMs trials hold small population samples and PROMs as an end point is scarce. We present a review of recent literature based on the PROMs reporting of quality of life for rectal cancer patients and introduce the CITRuS trial as an innovative feasibility study related to electronic PROMs data collection.
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Experiences of bowel symptoms in patients with rectal cancer after sphincter-preserving surgery: a qualitative meta-synthesis. Support Care Cancer 2022; 31:23. [PMID: 36513893 DOI: 10.1007/s00520-022-07473-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE This study is to identify and synthesize the available evidence of bowel symptom experiences of patients with rectal cancer after sphincter-preserving surgery (SPS). METHODS This qualitative meta-synthesis was conducted following the Joanna Briggs Institute (JBI) qualitative systematic review methodology and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Seven databases were searched on 22 December 2021. The selected studies were reviewed by two independent reviewers, and disagreements were resolved by discussion or with a third reviewer. RESULTS Seven qualitative articles were included in the meta-synthesis with 192 total rectal cancer patients. The review summarized 53 qualitative findings into three synthesized findings: (a) Patients experienced bowel symptoms and triggered additional physiological problems, and they underestimated bowel symptoms; (b) patients had many negative emotions, and their daily life and social interaction were disturbed; and (c) patients adopted strategies to adapt or control their bowel symptoms. According to the ConQual evidence grading approach, the confidence of the synthesized findings was rated as moderate to low. CONCLUSIONS The bowel symptoms of patients with rectal cancer after SPS have troubled their lives. Timely acquisition of symptom-related knowledge and enhancement of their coping abilities are important for the control and management of bowel symptoms. Healthcare professionals should clearly understand the bowel symptoms that patients may experience after SPS and provide supportive care for patients to improve patients' self-management abilities and quality of life. TRIAL REGISTRATION PROSPERO: CRD42021242610.
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The Longitudinal Course of Low-anterior Resection Syndrome: An individual Patient Meta-analysis. Ann Surg 2022; 276:46-54. [PMID: 35185131 DOI: 10.1097/sla.0000000000005423] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to better understand the longitudinal course of low anterior resection syndrome (LARS) to guide patient expectations and identify those at risk of persisting dysfunction. SUMMARY BACKGROUND DATA LARS describes disordered bowel function after rectal resection that significantly impacts quality of life. METHODS MEDLINE, EMBASE, CENTRAL, and CINAHL databases were systematically searched for studies that enrolled adults undergoing anterior resection for rectal cancer and used the LARS score to assess bowel function at ≥2 postoperative time points. Regression analyses were performed on deidentified patient-level data to identify predictors of change in LARS score from baseline (3-6months) to 12-months and 18-24 months. RESULTS Eight studies with a total of 701 eligible patients were included. The mean LARS score improved over time, from 29.4 (95% confidence interval 28.6-30.1) at baseline to 16.6 at 36 months (95% confidence interval 14.2%-18.9%). On multivariable analysis, a greater improvement in mean LARS score between baseline and 12 months was associated with no ileostomy formation [mean difference (MD) -1.7 vs 1.7, P < 0.001], and presence of LARS (major vs minor vs no LARS) at baseline (MD -3.8 vs -1.7 vs 5.4, P < 0.001). Greater improvement in mean LARS score between baseline and 18-24 months was associated with partial mesorectal excision vs total mesorectal excision (MD-8.6 vs 1.5, P < 0.001) and presence of LARS (major vs minor vs no LARS) at baseline (MD -8.8 vs -5.3 vs 3.4, P < 0.001). CONCLUSIONS LARS improves by 18 months postoperatively then remains stable for up to 3 years. Total mesorectal excision, neoadjuvant radiotherapy, and ileostomy formation negatively impact upon bowel function recovery.
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Pelvic Floor Rehabilitation After Rectal Cancer Surgery: A Multicenter Randomized Clinical Trial (FORCE Trial). Ann Surg 2022; 276:38-45. [PMID: 34966064 DOI: 10.1097/sla.0000000000005353] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the effects of PFR after LAR compared to usual care without PFR. SUMMARY OF BACKGROUND DATA Functional complaints, including fecal incontinence, often occur after LAR for rectal cancer. Controversy exists about the effectiveness of PFR in improving such postoperative functional outcomes. METHODS This was a multicenter, randomized controlled trial involving 17 Dutch centers. Patients after LAR for rectal cancer were randomly assigned (1:1) to usual care or PFR and stratified by sex and administration of neoadjuvant therapy. Selection was not based on severity of complaints at baseline. Baseline measurements were taken 3 months after surgery without temporary stoma construction or 6 weeks after stoma closure. The primary outcome measure was the change in Wexner incontinence scores 3 months after randomization. Secondary outcomes were fecal incontinence-related quality of life, colorectal-specific quality of life, and the LARS scores. RESULTS Between October 2017 and March 2020, 128 patients were enrolled and 106 randomly assigned (PFR n = 51, control n = 55); 95 patients (PFR n = 44, control n = 51) were assessable for final analysis. PFR did not lead to larger changes in Wexner incontinence scores in nonselected patients after LAR compared to usual care [PFR: -2.3, 95% confidence interval (CI) -3.3 to -1.4, control: -1.3, 95% CI -2.2 to -0.4, P = 0.13]. However, PFR was associated with less urgency at follow-up (odds ratio 0.22, 95% CI 0.06-0.86). Patients without near-complete incontinence reported larger Wexner score improvements after PFR (PFR: -2.1, 95% CI -3.1 to -1.1, control: -0.7, 95% CI -1.6 to 0.2, P = 0.045). For patients with at least moderate incontinence PFR resulted in relevant improvements in all fecal incontinence-related quality of life domains, while the control group deteriorated. These improvements were even larger when patients with near-complete incontinence were excluded. No serious adverse PFR-related events occurred. CONCLUSION No benefit was found of PFR in all patients but several subgroups were identified that did benefit from PFR, such as patients with urgency or with at least moderate incontinence and no near-complete incontinence. A selective referral policy (65%-85% of all patients) is suggested to improve postoperative functional outcomes for patients after LAR for rectal cancer. TRIAL REGISTRATION Netherlands Trial Registration, NTR5469, registered on 3 September 2015.
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Ng KS, Gladman MA. LARS: A review of therapeutic options and their efficacy. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Qaderi SM, van der Heijden JAG, Verhoeven RHA, de Wilt JHW, Custers JAE. Trajectories of health-related quality of life and psychological distress in patients with colorectal cancer: A population-based study. Eur J Cancer 2021; 158:144-155. [PMID: 34666216 DOI: 10.1016/j.ejca.2021.08.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/16/2021] [Accepted: 08/29/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND The aim of this nationwide cohort study was to examine the course of symptoms and trajectories of health-related quality of life (HR-QoL) and psychological distress during follow-up and to identify vulnerable patients. METHODS Patients with pathological stage I-III colorectal cancer (CRC) between 2013 and 2018 were included. Baseline characteristics were collected from the Netherlands Cancer Registry, and patients completed the European Organisation for Research and Treatment of Cancer QLQ-C30/CR29, Hospital Anxiety and Depression Scale and low anterior resection syndrome (LARS) questionnaires at the baseline and subsequently at 3, 6, 12, 18 and 24 months. Latent class growth and multinomial logistic regression analyses were performed to outline 24-month trajectories in HR-QoL and distress and to identify predictive factors. RESULTS A total of 1535 patients with colon cancer or rectal cancer were included. Trajectory analysis of HR-QoL identified three patient classes: high HR-QoL (62.7%), improving HR-QoL (29.0%) and low HR-QoL (8.3%). The following patient groups were identified with having low distress (64.0%), moderate distress (26.9%) and high distress (9.1%). Around 13% of the total cohort had either persistent low HR-QoL or high psychological distress throughout follow-up. Patients belonging to this vulnerable group were significantly more likely to be female, to be younger aged, to have lower education, to have disease stage II-III or to have major LARS. CONCLUSIONS Although most patients treated for stage I-III CRC fared well, a small but significant proportion of around 13% did not recover during follow-up and reported low HR-QoL and/or high psychological distress levels throughout. This study's findings should be taken into account when organising and selecting patients for tailored follow-up.
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Affiliation(s)
- Seyed M Qaderi
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Surgical Oncology, Nijmegen, the Netherlands.
| | - Joost A G van der Heijden
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Surgical Oncology, Nijmegen, the Netherlands
| | - Rob H A Verhoeven
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Surgical Oncology, Nijmegen, the Netherlands; Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands; Amsterdam UMC, Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Johannes H W de Wilt
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Surgical Oncology, Nijmegen, the Netherlands
| | - Jose A E Custers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, Nijmegen, the Netherlands
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van der Heijden JAG, Qaderi SM, Verhoeven R, Custers JAE, Klarenbeek BR, Maaskant-Braat AJG, de Wilt JHW. Transanal total mesorectal excision and low anterior resection syndrome. Br J Surg 2021; 108:991-997. [PMID: 33837383 DOI: 10.1093/bjs/znab056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR). METHODS Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression. RESULTS Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group. CONCLUSIONS TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.
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Affiliation(s)
- J A G van der Heijden
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S M Qaderi
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.,Amsterdam UMC, Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - J A E Custers
- Department of Medical Psychology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B R Klarenbeek
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A J G Maaskant-Braat
- Department of Surgical Oncology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - J H W de Wilt
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
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Christensen P, IM Baeten C, Espín‐Basany E, Martellucci J, Nugent KP, Zerbib F, Pellino G, Rosen H. Management guidelines for low anterior resection syndrome - the MANUEL project. Colorectal Dis 2021; 23:461-475. [PMID: 33411977 PMCID: PMC7986060 DOI: 10.1111/codi.15517] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023]
Abstract
AIM Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS. METHOD The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project. RESULTS The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts. CONCLUSIONS The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.
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Affiliation(s)
- Peter Christensen
- Department of SurgeryDanish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic OrgansAarhus University HospitalAarhusDenmark
| | - Coen IM Baeten
- Department of SurgeryGroene Hart ZiekenhuisGoudaThe Netherlands
| | | | | | | | - Frank Zerbib
- Gastroenterology DepartmentCHU de BordeauxCentre Medico‐Chirurgical MagellanHôpital Haut‐LévêqueUniversité de BordeauxBordeauxFrance
| | - Gianluca Pellino
- Colorectal SurgeryVall d'Hebron University HospitalBarcelonaSpain,Department of Advanced Medical and Surgical SciencesUniversitá degli Studi della Campania ‘Luigi Vanvitelli’NaplesItaly
| | - Harald Rosen
- Department of Surgical OncologySigmund Freud UniversityViennaAustria
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