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Li J, Zhang Y, Huang Z, Jiang Y, Ren Z, Liu D, Zhang J, La Piana R, Chen Y. Cortical and subcortical morphological alterations in motor subtypes of Parkinson's disease. NPJ Parkinsons Dis 2022; 8:167. [PMID: 36470900 PMCID: PMC9723125 DOI: 10.1038/s41531-022-00435-3] [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: 08/02/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Parkinson's disease (PD) can be classified into an akinetic-rigid (AR) and a tremor-dominant (TD) subtype based on predominant motor symptoms. Patients with different motor subtypes often show divergent clinical manifestations; however, the underlying neural mechanisms remain unclear. This study aimed to characterize the cortical and subcortical morphological alterations in motor subtypes of PD. T1-weighted MRI images were obtained for 90 patients with PD (64 with the AR subtype and 26 with the TD subtype) and 56 healthy controls (HCs). Cortical surface area, sulcal depth (measured by Freesurfer's Sulc index), and subcortical volume were computed to identify the cortical and subcortical morphological alterations in the two motor subtypes. Compared with HCs, we found widespread surface area reductions in the AR subtype yet sparse surface area reductions in the TD subtype. We found no significant Sulc change in the AR subtype yet increased Sulc in the right supramarginal gyrus in the TD subtype. The hippocampal volumes in both subtypes were lower than those of HCs. In PD patients, the surface area of left posterior cingulate cortex was positively correlated with Mini-Mental State Examination (MMSE) score, while the Sulc value of right middle frontal gyrus was positively correlated with severity of motor impairments. Additionally, the hippocampal volumes were positively correlated with MMSE and Montreal Cognitive Assessment scores and negatively correlated with severity of motor impairments and Hoehn & Yahr scores. Taken together, these findings may contribute to a better understanding of the neural substrates underlying the distinct symptom profiles in the two PD subtypes.
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Affiliation(s)
- Jianyu Li
- grid.54549.390000 0004 0369 4060Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054 P. R. China
| | - Yuanchao Zhang
- grid.54549.390000 0004 0369 4060Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054 P. R. China
| | - Zitong Huang
- grid.54549.390000 0004 0369 4060Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054 P. R. China
| | - Yihan Jiang
- grid.54549.390000 0004 0369 4060Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054 P. R. China
| | - Zhanbing Ren
- grid.263488.30000 0001 0472 9649Department of Physical Education, Shenzhen University, Shenzhen, 518060 China
| | - Daihong Liu
- grid.452285.cDepartment of Radiology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, 400030 P. R. China
| | - Jiuquan Zhang
- grid.452285.cDepartment of Radiology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, 400030 P. R. China
| | - Roberta La Piana
- grid.14709.3b0000 0004 1936 8649Department of Neurology & Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC H3A 0G4 Canada
| | - Yifan Chen
- grid.54549.390000 0004 0369 4060Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054 P. R. China
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Palermo G, Giannoni S, Bellini G, Siciliano G, Ceravolo R. Dopamine Transporter Imaging, Current Status of a Potential Biomarker: A Comprehensive Review. Int J Mol Sci 2021; 22:11234. [PMID: 34681899 PMCID: PMC8538800 DOI: 10.3390/ijms222011234] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022] Open
Abstract
A major goal of current clinical research in Parkinson's disease (PD) is the validation and standardization of biomarkers enabling early diagnosis, predicting outcomes, understanding PD pathophysiology, and demonstrating target engagement in clinical trials. Molecular imaging with specific dopamine-related tracers offers a practical indirect imaging biomarker of PD, serving as a powerful tool to assess the status of presynaptic nigrostriatal terminals. In this review we provide an update on the dopamine transporter (DAT) imaging in PD and translate recent findings to potentially valuable clinical practice applications. The role of DAT imaging as diagnostic, preclinical and predictive biomarker is discussed, especially in view of recent evidence questioning the incontrovertible correlation between striatal DAT binding and nigral cell or axon counts.
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Affiliation(s)
- Giovanni Palermo
- Unit of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (G.P.); (S.G.); (G.B.); (G.S.)
| | - Sara Giannoni
- Unit of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (G.P.); (S.G.); (G.B.); (G.S.)
- Unit of Neurology, San Giuseppe Hospital, 50053 Empoli, Italy
| | - Gabriele Bellini
- Unit of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (G.P.); (S.G.); (G.B.); (G.S.)
| | - Gabriele Siciliano
- Unit of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (G.P.); (S.G.); (G.B.); (G.S.)
| | - Roberto Ceravolo
- Unit of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (G.P.); (S.G.); (G.B.); (G.S.)
- Center for Neurodegenerative Diseases, Unit of Neurology, Parkinson’s Disease and Movement Disorders, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Chung SJ, Lee S, Yoo HS, Lee YH, Lee HS, Choi Y, Lee PH, Yun M, Sohn YH. Association of the Non-Motor Burden with Patterns of Striatal Dopamine Loss in de novo Parkinson's Disease. JOURNAL OF PARKINSONS DISEASE 2020; 10:1541-1549. [PMID: 32925098 DOI: 10.3233/jpd-202127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Striatal dopamine deficits play a key role in the pathogenesis of Parkinson's disease (PD), and several non-motor symptoms (NMSs) have a dopaminergic component. OBJECTIVE To investigate the association between early NMS burden and the patterns of striatal dopamine depletion in patients with de novo PD. METHODS We consecutively recruited 255 patients with drug-naïve early-stage PD who underwent 18F-FP-CIT PET scans. The NMS burden of each patient was assessed using the NMS Questionnaire (NMSQuest), and patients were divided into the mild NMS burden (PDNMS-mild) (NMSQuest score <6; n = 91) and severe NMS burden groups (PDNMS-severe) (NMSQuest score >9; n = 90). We compared the striatal dopamine transporter (DAT) activity between the groups. RESULTS Patients in the PDNMS-severe group had more severe parkinsonian motor signs than those in the PDNMS-mild group, despite comparable DAT activity in the posterior putamen. DAT activity was more severely depleted in the PDNMS-severe group in the caudate and anterior putamen compared to that in the PDMNS-mild group. The inter-sub-regional ratio of the associative/limbic striatum to the sensorimotor striatum was lower in the PDNMS-severe group, although this value itself lacked fair accuracy for distinguishing between the patients with different NMS burdens. CONCLUSION This study demonstrated that PD patients with severe NMS burden exhibited severe motor deficits and relatively diffuse dopamine depletion throughout the striatum. These findings suggest that the level of NMS burden could be associated with distinct patterns of striatal dopamine depletion, which could possibly indicate the overall pathological burden in PD.
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Affiliation(s)
- Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin, South Korea
| | - Sangwon Lee
- Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Han Soo Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Yang Hyun Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Yonghoon Choi
- Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Mijin Yun
- Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Young H Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
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Chung SJ, Lee JJ, Lee PH, Sohn YH. Emerging Concepts of Motor Reserve in Parkinson's Disease. J Mov Disord 2020; 13:171-184. [PMID: 32854486 PMCID: PMC7502292 DOI: 10.14802/jmd.20029] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/05/2020] [Indexed: 01/18/2023] Open
Abstract
The concept of cognitive reserve (CR) in Alzheimer's disease (AD) explains the differences between individuals in their susceptibility to AD-related pathologies. An enhanced CR may lead to less cognitive deficits despite severe pathological lesions. Parkinson's disease (PD) is also a common neurodegenerative disease and is mainly characterized by motor dysfunction related to striatal dopaminergic depletion. The degree of motor deficits in PD is closely correlated to the degree of dopamine depletion; however, significant individual variations still exist. Therefore, we hypothesized that the presence of motor reserve (MR) in PD explains the individual differences in motor deficits despite similar levels of striatal dopamine depletion. Since 2015, we have performed a series of studies investigating MR in de novo patients with PD using the data of initial clinical presentation and dopamine transporter PET scan. In this review, we summarized the results of these published studies. In particular, some premorbid experiences (i.e., physical activity and education) and modifiable factors (i.e., body mass index and white matter hyperintensity on brain image studies) could modulate an individual's capacity to tolerate PD pathology, which can be maintained throughout disease progression.
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Affiliation(s)
- Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
| | - Jae Jung Lee
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young H Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Park SB, Kwon KY, Lee JY, Im K, Sunwoo JS, Lee KB, Roh H, Ahn MY, Park S, Kim SJ, Oh JS, Kim JS. Lack of association between dopamine transporter loss and non-motor symptoms in patients with Parkinson’s disease: a detailed PET analysis of 12 striatal subregions. Neurol Sci 2018; 40:311-317. [DOI: 10.1007/s10072-018-3632-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
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Lombardi VC, De Meirleir KL, Subramanian K, Nourani SM, Dagda RK, Delaney SL, Palotás A. Nutritional modulation of the intestinal microbiota; future opportunities for the prevention and treatment of neuroimmune and neuroinflammatory disease. J Nutr Biochem 2018; 61:1-16. [PMID: 29886183 PMCID: PMC6195483 DOI: 10.1016/j.jnutbio.2018.04.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 01/09/2023]
Abstract
The gut-brain axis refers to the bidirectional communication between the enteric nervous system and the central nervous system. Mounting evidence supports the premise that the intestinal microbiota plays a pivotal role in its function and has led to the more common and perhaps more accurate term gut-microbiota-brain axis. Numerous studies have identified associations between an altered microbiome and neuroimmune and neuroinflammatory diseases. In most cases, it is unknown if these associations are cause or effect; notwithstanding, maintaining or restoring homeostasis of the microbiota may represent future opportunities when treating or preventing these diseases. In recent years, several studies have identified the diet as a primary contributing factor in shaping the composition of the gut microbiota and, in turn, the mucosal and systemic immune systems. In this review, we will discuss the potential opportunities and challenges with respect to modifying and shaping the microbiota through diet and nutrition in order to treat or prevent neuroimmune and neuroinflammatory disease.
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Affiliation(s)
- Vincent C Lombardi
- Nevada Center for Biomedical Research, University of Nevada, Reno, 1664 N. Virginia St. MS 0552, Reno, NV, 89557, USA; University of Nevada, Reno, School of Medicine, Department of Pathology, 1664 N. Virginia St. MS 0357, Reno, NV, 89557, USA.
| | - Kenny L De Meirleir
- Nevada Center for Biomedical Research, University of Nevada, Reno, 1664 N. Virginia St. MS 0552, Reno, NV, 89557, USA.
| | - Krishnamurthy Subramanian
- Nevada Center for Biomedical Research, University of Nevada, Reno, 1664 N. Virginia St. MS 0552, Reno, NV, 89557, USA.
| | - Sam M Nourani
- University of Nevada, Reno, School of Medicine, Department of Internal Medicine, 1664 N. Virginia St. MS 0357, Reno, NV, 89557, USA; Advanced Therapeutic, General Gastroenterology & Hepatology Digestive Health Associates, Reno, NV, USA.
| | - Ruben K Dagda
- University of Nevada, Reno, School of Medicine, Department of Pharmacology, 1664 N. Virginia St. MS 0318, Reno, NV, 89557, USA.
| | | | - András Palotás
- Kazan Federal University, Institute of Fundamental Medicine and Biology, (Volga Region) 18 Kremlyovskaya St., Kazan, 420008, Republic of Tatarstan, Russian Federation; Asklepios-Med (private medical practice and research center), Kossuth Lajos sgt. 23, Szeged, H-6722, Hungary.
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Ishiki HM, Filho JMB, da Silva MS, Scotti MT, Scotti L. Computer-aided Drug Design Applied to Parkinson Targets. Curr Neuropharmacol 2018; 16:865-880. [PMID: 29189169 PMCID: PMC6080092 DOI: 10.2174/1570159x15666171128145423] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/24/2017] [Indexed: 12/01/2022] Open
Abstract
Background Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by debilitating motor deficits, as well as autonomic problems, cognitive declines, changes in affect and sleep disturbances. Although the scientific community has performed great efforts in the study of PD, and from the most diverse points of view, the disease remains incurable. The exact mechanism underlying its progression is unclear, but oxidative stress, mitochondrial dysfunction and inflammation are thought to play major roles in the etiology. Objective Current pharmacological therapies for the treatment of Parkinson’s disease are mostly inadequate, and new therapeutic agents are much needed. Methods In this review, recent advances in computer-aided drug design for the rational design of new compounds against Parkinson disease; using methods such as Quantitative Structure-Activity Relationships (QSAR), molecular docking, molecular dynamics and pharmacophore modeling are discussed. Results In this review, four targets were selected: the enzyme monoamine oxidase, dopamine agonists, acetylcholine receptors, and adenosine receptors. Conclusion Computer aided-drug design enables the creation of theoretical models that can be used in a large database to virtually screen for and identify novel candidate molecules.
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Affiliation(s)
- Hamilton M Ishiki
- University of Western Sao Paulo (Unoeste), Presidente Prudente, SP, Brazil
| | | | | | - Marcus T Scotti
- Federal University of Paraiba, Campus I, Joao Pessoa-PB, Brazil
| | - Luciana Scotti
- Federal University of Paraiba, Campus I, Joao Pessoa-PB, Brazil
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Lee Y, Oh JS, Chung SJ, Lee JJ, Chung SJ, Moon H, Lee PH, Kim JS, Sohn YH. The presence of depression in de novo Parkinson's disease reflects poor motor compensation. PLoS One 2018; 13:e0203303. [PMID: 30231066 PMCID: PMC6145582 DOI: 10.1371/journal.pone.0203303] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 08/18/2018] [Indexed: 11/18/2022] Open
Abstract
Depression frequently accompanies Parkinson's disease and often precedes the onset of motor symptoms. This study aimed to evaluate the impact of depression on motor compensation in patients with de novo Parkinson's disease. This retrospective cohort study analyzed data from 474 non-demented patients with de novo Parkinson's disease (mean age, 64.6±9.8 years; 242 men) who underwent both dopamine transporter PET scan and depression assessment using the Beck Depression Inventory at baseline. Patients were classified into tertiles by Beck Depression Inventory score. At baseline, high-tertile group (Beck Depression Inventory score ≥15, n = 157) showed more severe motor deficits and lower cognitive function than low-tertile group (Beck Depression Inventory score ≤7, n = 158, P = 0.034 and P = 0.008, respectively). Greater motor deficits in high-tertile group than low-tertile group remained significant after controlling for dopamine transporter binding in the posterior putamen, as well as other confounding variables. During follow-up of a median duration of 47 months, high-tertile group received higher levodopa-equivalent doses for symptom control than did low-tertile group after controlling for age, gender, and initial motor deficit severity. These results demonstrate that depression in de novo Parkinson's disease is associated with motor deficit severity at baseline and dose of PD medications during follow-up, suggesting that the presence of depression in de novo Parkinson's disease represents poor motor compensation.
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Affiliation(s)
- Yoonju Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jungsu S. Oh
- Department of Nuclear Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Jung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Su Jin Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurology, Myongji Hospital, Goyang, South Korea
| | - Hyojeong Moon
- Department of Nuclear Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Young H. Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
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Shin C, Lee S, Lee JY, Rhim JH, Park SW. Non-Motor Symptom Burdens Are Not Associated with Iron Accumulation in Early Parkinson's Disease: a Quantitative Susceptibility Mapping Study. J Korean Med Sci 2018; 33:e96. [PMID: 29573246 PMCID: PMC5865060 DOI: 10.3346/jkms.2018.33.e96] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/21/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Quantitative susceptibility mapping (QSM) has been used to measure iron accumulation in the deep nuclei of patients with Parkinson's disease (PD). This study examined the relationship between non-motor symptoms (NMSs) and iron accumulation in the deep nuclei of patients with PD. METHODS The QSM data were acquired from 3-Tesla magnetic resonance imaging (MRI) in 29 patients with early PD and 19 normal controls. The Korean version of the NMS scale (K-NMSS) was used for evaluation of NMSs in patients. The patients were divided into high NMS and low NMS groups. The region-of-interest analyses were performed in the following deep nuclei: red nucleus, substantia nigra pars compacta, substantia nigra pars reticulata, dentate nucleus, globus pallidus, putamen, and head of the caudate nucleus. RESULTS Thirteen patients had high NMS scores (total K-NMSS score, mean = 32.1), and 16 had low NMS scores (10.6). The QSM values in the deep were not different among the patients with high NMS scores, low NMS scores, and controls. The QSM values were not correlated linearly with K-NMSS total score after adjusting the age at acquisition of brain MRI. CONCLUSION The study demonstrated that the NMS burdens are not associated with iron accumulation in the deep nuclei of patients with PD. These results suggest that future neuroimaging studies on the pathology of NMSs in PD should use more specific and detailed clinical tools and recruit PD patients with severe NMSs.
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Affiliation(s)
- Chaewon Shin
- Department of Neurology, Kyung Hee University Medical Center, Seoul, Korea
| | - Seon Lee
- Department of Mechanical and Aerospace Engineering, Seoul National University, Seoul, Korea
| | - Jee Young Lee
- Department of Neurology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Jung Hyo Rhim
- Department of Radiology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Sun Won Park
- Department of Radiology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
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Cardiac sympathetic denervation and dementia in de novo Parkinson's disease: A 7-year follow-up study. J Neurol Sci 2017; 381:291-295. [DOI: 10.1016/j.jns.2017.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 08/25/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023]
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