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Mausbach S, van Spankeren T, Hudel H, Schirotzik I, Viard M, Struffert T, Kaps M. TCCD Fusion Imaging to Estimate Intracranial Pressure and Tissue Displacement with Large Hemispheric Infarction. Neurocrit Care 2024; 40:562-567. [PMID: 37415022 DOI: 10.1007/s12028-023-01784-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Despite breakthroughs in stroke treatment, some patients still experience large infarctions of the cerebral hemispheres resulting in mass effect and tissue displacement. The evolution of mass effect is currently monitored using serial computed tomography (CT) imaging. However, there are patients who are ineligible for transport, and there are limited options for bedside monitoring of unilateral tissue shift. METHODS We used fusion imaging for overlaying transcranial color duplex with CT angiography. This method allows overlay of live ultrasound on top of CT or magnetic resonance imaging scans. Patients with large hemispheric infarctions were eligible to participate. Position data from the source files were used and matched with live imaging and correlation to magnetic probes on the patient's forehead and ultrasound probe. Shift of cerebral parenchyma, displacement of the anterior cerebral arteries, basilary artery and third ventricle were analyzed, as well as pressure on the midbrain, and the displacement of the basilar artery on the head were analyzed. Patients received multiple examinations in addition to standard care of treatment with CT imaging. RESULTS The sensitivity for diagnosing a shift of 3 mm with fusion imaging was 100%, with a specificity of 95%. No side effects or interactions with critical care equipment were recorded. CONCLUSIONS Fusion imaging is an easy method to access and acquire measurements for critical care patients and follow-up of tissue and vascular displacement after stroke. Fusion imaging may be a decisive support for indicating hemicraniectomy.
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Affiliation(s)
- Stefan Mausbach
- Department of Neurology and Neurocritical Care Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
- , Shmuel Bait Street, 9103102, Jerusalem, Israel.
| | - Teresa van Spankeren
- Department of Neurology, Justus-Liebig University Hospital Giessen, Giessen, Germany
| | - Helge Hudel
- Institute for Medical Informatics, Justus-Liebig University Hospital Giessen, Giessen, Germany
| | - Ingo Schirotzik
- Department of Neurology, Justus-Liebig University Hospital Giessen, Giessen, Germany
| | - Maxime Viard
- Department of Neurology, Justus-Liebig University Hospital Giessen, Giessen, Germany
| | - Tobias Struffert
- Department for Neuroradiology, Justus-Liebig University Hospital Giessen, Giessen, Germany
| | - Manfred Kaps
- Department of Neurology, Justus-Liebig University Hospital Giessen, Giessen, Germany
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Itsekson Hayosh Z, Abu Bandora E, Shelestovich N, Nulman M, Bakon M, Yaniv G, Khaitovitch B, Balan S, Gerasimova A, Drori T, Mausbach S, Schwammenthal Y, Afek A, Chapman J, Shavit Stein E, Orion D. In-thrombus thrombin secretion: a new diagnostic marker of atrial fibrillation in cryptogenic stroke. Isr Med Assoc J 2022; 25:853-854. [PMID: 37584409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Endovascularly retrieved clots may be a potential resource for diagnosing stroke etiology. This method may influence secondary prevention treatment. We measure thrombin activity eluted by serially washing clots. We concluded that an assay measuring the change in thrombin in clots retrieved during acute stroke endovascular thrombectomy procedures may serve as a diagnostic marker of the origin of the clot. The suggested mechanism for these differences may be the clot location before its retrieval, with high blood flow causing thrombin washout in atherosclerotic clots, in contrast to atrium appendage low blood flow retaining high thrombin levels.
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Affiliation(s)
- Ze'ev Itsekson Hayosh
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Maya Nulman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mati Bakon
- Institute of Medical Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Gal Yaniv
- Institute of Medical Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Boris Khaitovitch
- Institute of Medical Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Shmuel Balan
- Institute of Medical Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | | | - Tali Drori
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel
| | - Stefan Mausbach
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel, Neurology, Märkische Kliniken Lüdenscheid, Lüdenscheid, Germany
| | | | - Arnon Afek
- General Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Joab Chapman
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit Stein
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Orion
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Braun T, Juenemann M, Viard M, Meyer M, Reuter I, Mausbach S, Doerr JM, Schirotzek I, Prosiegel M, Schramm P, Kaps M, Tanislav C. Flexible endoscopic evaluation of swallowing (FEES) to determine neurological intensive care patients' oral diet. Int J Speech Lang Pathol 2021; 23:83-91. [PMID: 32245331 DOI: 10.1080/17549507.2020.1744727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation. METHOD FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy. RESULT This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (p = 0.009). Patients without oral diet had higher need for intubation (p = 0.007), tracheotomy (p = 0.032) and higher mortality (p < 0.001) in comparison to patients with at least small amounts of oral intake. CONCLUSION As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.
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Affiliation(s)
- Tobias Braun
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Martin Juenemann
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Maxime Viard
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Marco Meyer
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Department of Neurology/Geriatrics, Diakonie Klinikum Jung-Stilling, Siegen, Germany
| | - Iris Reuter
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Stefan Mausbach
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Johanna M Doerr
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Ingo Schirotzek
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Mario Prosiegel
- Faculty of Languages and Literatures, Department I, Ludwig-Maximilians-University (LMU), Munich, Germany, and
| | - Patrick Schramm
- Department of Anaesthesiology, University Hospital Mainz, Mainz, Germany
| | - Manfred Kaps
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Christian Tanislav
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Department of Neurology/Geriatrics, Diakonie Klinikum Jung-Stilling, Siegen, Germany
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Itsekson Hayosh Z, Abu Bandora E, Shelestovich N, Nulman M, Bakon M, Yaniv G, Khaitovitch B, Balan S, Gerasimova A, Drori T, Mausbach S, Schwammenthal Y, Afek A, Chapman J, Shavit Stein E, Orion D. In-thrombus thrombin secretion: a new diagnostic marker of atrial fibrillation in cryptogenic stroke. J Neurointerv Surg 2020; 13:799-804. [PMID: 33055222 DOI: 10.1136/neurintsurg-2020-016484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/11/2020] [Accepted: 08/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endovascularly retrieved clots are a potential resource for diagnosing stroke etiology, which may influence secondary prevention treatment. In this study we measured thrombin activity eluted by serially washing clots. METHODS Clots were retrieved from 68 patients with acute ischemic stroke, freshly frozen and classified by standard criteria into proven atrial fibrillation (AF, 18 patients), atherosclerotic origin (AS, 15 patients), cryptogenic stroke (Cr, 17 patients) and other known causes (18 patients). Thawed clot samples were washed by transferring them into 1 mL buffer in seven hourly cycles and a fluorescent substrate assay was used to measure secreted thrombin activity. The clots were also examined histologically. Artificial fibrin and red blood cell-rich clots were similarly assayed for wash-eluted thrombin activity as an external control. RESULTS Thrombin activity eluted from clots of AF origin decreased significantly with time in contrast to steady levels eluted from AS origin thrombi (P<0.0001 by repeated measures ANOVA). The Cr stroke group was indistinguishable from the AF group and differed statistically from the AS group (P=0.017 by repeated measures ANOVA). In artificial clots we found a biphasic activity pattern, with initially decreasing levels of eluted thrombin (AF pattern) and then, with continuing washes, steady eluted thrombin levels (AS pattern). CONCLUSIONS An assay measuring the change in thrombin in clots retrieved during acute stroke endovascular thrombectomy procedures may serve as a diagnostic marker of the origin of the clot. The suggested mechanism for these differences may be the clot location before its retrieval, with high blood flow causing thrombin washout in atherosclerotic clots, in contrast to atrium appendage low blood flow retaining high thrombin levels.
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Affiliation(s)
- Ze'ev Itsekson Hayosh
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Maya Nulman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mati Bakon
- Institute of Medical Imaging, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Gal Yaniv
- Institute of Medical Imaging, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Boris Khaitovitch
- Institute of Medical Imaging, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Shmuel Balan
- Institute of Medical Imaging, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | | | - Tali Drori
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Stefan Mausbach
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel.,Neurology, Märkische Kliniken Lüdenscheid, Lüdenscheid, Germany
| | | | - Arnon Afek
- General Hospital, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Joab Chapman
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit Stein
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Orion
- Neurology, Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Taliansky A, Bakon M, Schwammenthal Y, Mausbach S, Merzlyak O, Granbichler C, Tsabari R, Chapman J, Orion D. P05.71 Acute stroke in cancer patients: do they benefit from reperfusion treatment? Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy139.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A Taliansky
- Neuro-Oncology service, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat Gan, Israel
| | - M Bakon
- Department of Imaging, Neuro-interventional service, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
| | - Y Schwammenthal
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - S Mausbach
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
| | - O Merzlyak
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
| | - C Granbichler
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
| | - R Tsabari
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
| | - J Chapman
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - D Orion
- Department of Neurology, The Chaim Sheba Medical Center, Tel Ha Shomer, Ramat-Gan, Israel
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
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Mattyasovszky SG, Mausbach S, Ritz U, Wollstädter J, Schmidtmann I, Baranowski A, Drees P, Rommens PM, Hofmann A. Cytokine Interferon-γ suppresses the function of capsule myofibroblasts and induces cell apoptosis. J Orthop Res 2017; 35:2524-2533. [PMID: 28176370 DOI: 10.1002/jor.23538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/27/2017] [Indexed: 02/04/2023]
Abstract
Myofibroblasts (MFs), a contractile subset of fibroblasts, play a pivotal role in physiological wound healing and in the development of many fibroconnective disorders. The complex cytokine network regulating the function of MFs in joint stiffness is still poorly understood. In this in vitro study, we investigated the effect of the cytokine Interferon-gamma (IFN-γ) on MFs isolated from human joint capsules. MFs were cultivated either in the presence of increasing concentrations of IFN-γ alone or in combination with IFN-γ neutralizing antibodies. Cell viability, cytotoxicity, apoptosis, and mRNA gene expression of the MF markers alpha-smooth muscle actin (α-SMA) and collagen type I were analyzed in MF cultures. Contraction potential was analyzed in an established collagen gel contraction assay simulating the extracellular matrix. Using immunofluorescence staining, we could verify that MFs express IFN-γ-receptor (R)-1 on their membrane. IFN-γ decreased MF viability and significantly elevated the apoptosis rate in a dose-dependent manner. IFN-γ down-regulated α-SMA and collagen type I mRNA expression which was associated with a diminished MF mediated contraction of the gel matrices. These effects were suppressed by simultaneous treatment of cells with a neutralizing IFN-γ antibody. Our experiments confirm the hypothesis that the cytokine IFN-γ is a crucial component of the regulatory network of capsule MFs. IFN-γ notably influences the ability of MFs to contract collagen matrices by suppressing α-SMA gene expression. IFN-γ is toxic for MFs in high concentrations and may negatively regulate the number of pro-fibrotic MFs during the healing process via induction of cell apoptosis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2524-2533, 2017.
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Affiliation(s)
- Stefan G Mattyasovszky
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Stefan Mausbach
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Jochen Wollstädter
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biometry, Epidemiology and Computer Science, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Phillipp Drees
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Mainz, Germany
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Mattyasovszky SG, Mausbach S, Ritz U, Langendorf E, Wollstädter J, Baranowski A, Drees P, Rommens PM, Hofmann A. Influence of the anti-inflammatory cytokine interleukin-4 on human joint capsule myofibroblasts. J Orthop Res 2017; 35:1290-1298. [PMID: 27504740 DOI: 10.1002/jor.23386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/05/2016] [Indexed: 02/04/2023]
Abstract
Post-traumatic joint contracture was reported to be associated with elevated numbers of contractile myofibroblasts (MFs) in the healing capsule. During the physiological healing process, the number of MFs declines; however, in fibroconnective disorders, MFs persist. The manifold interaction of the cytokines regulating the appearance and persistence of MFs in the pathogenesis of joint contracture remains to be elucidated. The objective of our current study was to analyze the impact of the anti-inflammatory cytokine interleukin (IL)-4 on functional behavior of MFs. Cells were isolated from human joint capsule specimens and challenged with three different concentrations of IL-4 with or without its neutralizing antibody. MF viability, contractile properties, and the gene expression of both alpha-smooth muscle actin (α-SMA) and collagen type I were examined. Immunofluorescence staining revealed the presence of IL-4 receptor (R)-alpha (α) on the membrane of cultured MFs. The cytokine IL-4 promoted MF viability and enhanced MF modulated contraction of collagen gels. Moreover, IL-4 intervened in gene expression by up-regulation of α-SMA and collagen type I mRNA. These effects could be specifically lowered by the neutralizing IL-4 antibody. On the basis of our findings we conclude that the anti-inflammatory cytokine IL-4 specifically regulates viability and the contractile properties of MFs via up-regulating the gene expression of α-SMA and collagen type I. IL-4 may be a helpful target in developing anti-fibrotic therapeutics for post-traumatic joint contracture in human. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1290-1298, 2017.
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Affiliation(s)
- Stefan G Mattyasovszky
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Stefan Mausbach
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Eva Langendorf
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jochen Wollstädter
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Phillipp Drees
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Elkabetz N, Bracco D, Zlotnik G, Watad A, Mausbach S, Amital H. How Confusing Can an Acute Confusional State be? Isr Med Assoc J 2016; 18:301-303. [PMID: 27430090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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