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  • S. Karger AG  (32)
  • Eberhardt, Ralf  (32)
  • 1
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    Online Resource
    Transbronchial Cryobiopsies for Diagnosing Interstitial Lung Disease: Real-Life Experience from a Tertiary Referral Center for Interstitial Lung Disease
    S. Karger AG ; 2019
    In:  Respiration Vol. 97, No. 4 ( 2019), p. 348-354
    Details
    In: Respiration, S. Karger AG, Vol. 97, No. 4 ( 2019), p. 348-354
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Transbronchial cryobiopsy (cTBB) may offer an alternative to surgical lung biopsy (SLB) for histopathological diagnosis of interstitial lung diseases (ILDs). However, real-life experience is limited, although case series are increasingly reported. 〈 b 〉 〈 i 〉 Objectives: 〈 /i 〉 〈 /b 〉 We aimed to evaluate the value of cTBB performed under real-life conditions in a tertiary care center for ILDs. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 Data on all patients undergoing a cTBB for evaluation of suspected ILD between October 2015 and January 2017 were included in this retrospective case series. Procedure details, complication rates, histopathological results, and diagnostic consensus reached by a multidisciplinary team (MDT) discussion were collated and evaluated. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 A total of 109 patients (mean age 64 years, range 19–85; 66% male, 38% never smokers) referred to our center with features suggestive of ILD underwent cTBB. The mean FVC% predicted was 77% (range 41–131), with a mean DLCO of 51% (range 20–86), and a 6-min walking test (6MWT) of 402 m (range 100–642). On average, 4 samples were taken from each patient (range 1–8), with a mean biopsy diameter of 5 mm (range 2–12). Complications included pneumothorax (11.9%), all treated with chest drain. Moderate bleeding occurred in 28.4% (all resolved without active measures). No acute disease exacerbations and no deaths occurred. A histopathological pattern diagnosis was possible in 80 cases (73.4%), and 26.6% of cases were considered nonspecific. An MDT consensus diagnosis was reached in 83.5% of cases. Subsequent SLB was proposed in 13 cases and performed in 8 cases. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 In the real-world setting, cTBB has a meaningful diagnostic value in the context of a MDT approach and may enable histopathological assessment even in patients with more advanced disease unsuitable for SLB.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000493428
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2019
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  • 2
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    Lung Sequestration: A Rare Cause for Pulmonary Symptoms in Adulthood
    S. Karger AG ; 2011
    In:  Respiration Vol. 82, No. 5 ( 2011), p. 445-450
    Details
    In: Respiration, S. Karger AG, Vol. 82, No. 5 ( 2011), p. 445-450
    Abstract: 〈 i 〉 Background: 〈 /i 〉 Lung sequestration is a rare congenital pulmonary disorder and is usually diagnosed in children with recurrent pulmonary infections. Lung sequestrations are not commonly found to be a cause of respiratory symptoms in adults. 〈 i 〉 Objectives: 〈 /i 〉 It was the aim of this study to show that pulmonary sequestration is rare in advanced age and can be accompanied by severe pulmonary symptoms. 〈 i 〉 Methods: 〈 /i 〉 We conducted a case series analysis of patient characteristics, symptoms, diagnosis and treatment of 11 adults with a lung sequestration at the Thoraxklinik Heidelberg between 2001 and 2009. 〈 i 〉 Results: 〈 /i 〉 From 2001 to 2009, intralobar lung sequestration was diagnosed and treated in 11 adults aged 19 to 58 years with an average age of 39.9 ± 11.3 years and a male:female distribution of 5:6. In 3 patients (27.3%), the predominant symptom was hemoptysis. Recurrent pulmonary infections occurred in 1 patient (9.1%); pneumonia and lung abscess were detected in 2 patients (18.2%). In 3 cases (27.3%), dry cough was the predominant symptom, and in only 2 cases (18.2%), lung sequestration was asymptomatic. Eight patients (72.7%) were diagnosed by imaging techniques prior to surgery. In 3 cases (27.3%), diagnosis was made intraoperatively and by pathological examination. Surgical intervention included 7 lobectomies (63.6%), 3 wedge resections (27.3%) and 1 (9.1%) segmentectomy. 〈 i 〉 Conclusion: 〈 /i 〉 Lung sequestration in adults is rare, but it can cause severe pulmonary symptoms. In cases of recurrent pulmonary infections of identical localization or recurrent hemoptysis, lung sequestration should be considered in order for the diagnosis to be made rapidly. Surgical resection is the treatment of choice.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000323562
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2011
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  • 3
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    Efficacy of Bronchoscopic Thermal Vapor Ablation and Lobar Fissure Completeness in Patients with Heterogeneous Emphysema
    S. Karger AG ; 2012
    In:  Respiration Vol. 83, No. 5 ( 2012), p. 400-406
    Details
    In: Respiration, S. Karger AG, Vol. 83, No. 5 ( 2012), p. 400-406
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Bronchoscopic thermal vapor ablation (BTVA) ablates emphysematous tissue through a localized inflammatory response followed by contractive fibrosis and tissue shrinkage leading to lung volume reduction that should not be influenced by collateral ventilation. 〈 b 〉 〈 i 〉 Objectives: 〈 /i 〉 〈 /b 〉 To determine the correlation of clinical data from a trial of BTVA with fissure integrity visually assessed by computed tomography (CT). 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We conducted a single-arm study of patients with upper lobe-predominant emphysema (n = 44). Patients received BTVA either to the right upper lobe or left upper lobe, excluding the lingula. Primary efficacy outcomes were forced expiratory volume in 1 s (FEV 〈 sub 〉 1 〈 /sub 〉 ) and St. George’s Respiratory Questionnaire (SGRQ) at 6 months. Lobar volume reduction from CT was another efficacy outcome measurement. The fissure of the treated lobe was analyzed visually on preinterventional CT. Incompleteness of the small fissure, the upper half of the right large fissure and the whole left large fissure were estimated visually in 5% increments, and the relative amount of fissure incompleteness was calculated. Pearson correlation coefficients were calculated for the association between fissure incompleteness and change in efficacy outcomes (baseline to 6 months) of BTVA. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 A total of 38 out of 44 patients (86%) had incompleteness in the relevant fissure. Calculated relevant fissure incompleteness was a mean of 13% of fissure integrity (range 0–63). Correlation coefficients for the association of incompleteness with outcomes were as follows: FEV 〈 sub 〉 1 〈 /sub 〉 = 0.17; lung volume reduction = –0.27; SGRQ score = –0.10; 6-min walk distance = 0.0; residual volume (RV) = –0.18, and RV/total lung capacity = –0.14. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 Lobar fissure integrity has no or minimal influence on BTVA-induced lung volume reduction and improvements in clinical outcomes.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000336239
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2012
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  • 4
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    Endoscopic Valve Removal 〉180 Days since Implantation in Patients with Severe Emphysema
    S. Karger AG ; 2018
    In:  Respiration Vol. 96, No. 4 ( 2018), p. 348-354
    Details
    In: Respiration, S. Karger AG, Vol. 96, No. 4 ( 2018), p. 348-354
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Valve implantation provides a reversible effective therapy in a selected group of emphysema patients. Knowing predictors for successful therapy, the rate of treatment failure has decreased. Some patients, however, do not benefit, so that the valves may have to be removed. 〈 b 〉 〈 i 〉 Objectives: 〈 /i 〉 〈 /b 〉 To assess implant-related events, complications during valve removal, and clinical outcome after endoscopic procedure. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 The data of 76 consecutive emphysema patients who underwent valve removal & #x3e; 6 months since implantation were collected. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Seventy-six patients (mean age 62 years, 54% male) underwent removal of all valves after a mean time of 624 days (193–3,043 days) since implantation. Granulation tissue was observed in 39.5% (30/76) and significant secretion in 34.2% (26/76). In 5.3% (4/76), valve removal was complicated requiring another bronchoscopy in 2 of them. In 5.3% (4/76) of the patients, one valve could not be removed and remained in situ. Bleeding requiring intervention occurred in 3.9% (3/76) during valve removal. Following bronchoscopy, there was a need for antibiotics in 34.2% (26/76), glucocorticosteroids in 1.3% (1/76), and both in 6.6% (5/76) due to productive cough or chronic obstructive pulmonary disease (COPD) exacerbation. Due to respiratory failure, invasive ventilation or noninvasive ventilation was necessary in 2.6% (2/76) and 6.6% (5/76), respectively, following procedure. No statistical significant change in lung function was observed following valve removal. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 Valve removal after & #x3e; 6 months since implantation is feasible and associated with an acceptable safety profile. However, close monitoring of these patients with limited pulmonary reserve is recommended with particular attention to COPD exacerbations and respiratory failure.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000489887
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2018
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  • 5
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    Endoscopic Valve Therapy in COPD Patients with Hypercapnia
    S. Karger AG ; 2022
    In:  Respiration Vol. 101, No. 10 ( 2022), p. 918-924
    Details
    In: Respiration, S. Karger AG, Vol. 101, No. 10 ( 2022), p. 918-924
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Endoscopic valve therapy has been established as a therapeutic option for patients with severe emphysema. Several randomized controlled trials confirmed the efficacy of this therapeutic approach in COPD patients without significant collateral ventilation. However, patients with clinical relevant hypercapnia were excluded from these trials. 〈 b 〉 〈 i 〉 Aims and Objectives: 〈 /i 〉 〈 /b 〉 Patients with hypercapnia who underwent endoscopic valve treatment were enrolled in this retrospective analysis. The efficacy of valve treatment and its impact on blood gases were analysed. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 COPD patients with mild to severe hypercapnia (pCO 〈 sub 〉 2 〈 /sub 〉 ≥45 mm Hg) who were treated by endoscopic valve placement at the Thoraxklinik, University of Heidelberg, were enrolled in this retrospective trial. Lung function test (vital capacity [VC], forced expiratory volume in 1 s [FEV 〈 sub 〉 1 〈 /sub 〉 ], residual volume [RV] ), blood gases (pO 〈 sub 〉 2 〈 /sub 〉 , pCO 〈 sub 〉 2 〈 /sub 〉 ), and 6-minute-walk test (6-MWT) were assessed prior to intervention and at 3 and 6 months following valve implantation. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 129 patients (mean age 64 ± 7 years) with severe COPD (mean FEV 〈 sub 〉 1 〈 /sub 〉 26 ± 12% of predicted, mean RV 285 ± 22% of predicted) with hypercapnia (pCO 〈 sub 〉 2 〈 /sub 〉 ≥45 mm Hg, mean pCO 〈 sub 〉 2 〈 /sub 〉 50 ± 5 mm Hg) underwent endoscopic valve treatment. 3 and 6 months following intervention, statistical significant improvement was observed in VC, FEV 〈 sub 〉 1 〈 /sub 〉 , RV, and 6-MWT (all 〈 i 〉 p 〈 /i 〉 & #x3c; 0.001). Blood gas analysis revealed a significant improvement of mean pCO 〈 sub 〉 2 〈 /sub 〉 at 3- and 6-month follow-up (both 〈 i 〉 p 〈 /i 〉 & #x3c; 0.001). 40% of the patients had normal pCO 〈 sub 〉 2 〈 /sub 〉 values 3 and 6 months following intervention. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 COPD patients with hypercapnia should not be excluded from valve treatment, as the hyperinflation reduction improves the respiratory mechanics and thus leading to improvement of hypercapnia.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000525729
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2022
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  • 6
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    Preparation of Cell Blocks for Lung Cancer Diagnosis and Prediction: Protocol and Experience of a High-Volume Center
    S. Karger AG ; 2014
    In:  Respiration Vol. 87, No. 5 ( 2014), p. 432-438
    Details
    In: Respiration, S. Karger AG, Vol. 87, No. 5 ( 2014), p. 432-438
    Abstract: Minimally invasive diagnostic techniques are increasingly being used to obtain specimens for pathological diagnosis and prediction. Referring to lung cancer, both endobronchial and endoesophageal ultrasound are used worldwide as diagnostic routine methods. Consequently, an increasing number of pathological samples are cytological and fewer are histological. On the other hand, the requirements for specific and sensitive tumor subtyping complemented by predictive analyses are steadily increasing and are an essential basis for evidence-based treatment decisions. In this article we focus on the cell block method as a helpful tool for diagnostic and predictive analyses in lung cancer and point out its advantages and disadvantages in comparison to conventional cytological and biopsy specimens. Furthermore, we retrospectively analyze the diagnostic results of the cell block method in a high-volume center over 5 years. The main advantages of cell blocks are the availability of established and validated protocols, archiving and the opportunity to have serial sections from the same specimens to provide or repeat molecular analyses. Actually, in case of tumor progression, even additional biomarkers can be tested using the original cell block when re-biopsies are not feasible. The cell block method should be considered as a reliable, complimentary approach to conventional cytological or biopsy procedures, which is helpful to fulfill the increasing requirements of high-quality diagnostics and prediction.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000357068
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2014
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  • 7
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    Effectiveness of Endobronchial Coil Treatment for Lung Volume Reduction in Patients with Severe Heterogeneous Emphysema and Bilateral Incomplete Fissures: A Six-Month Follow-Up
    S. Karger AG ; 2014
    In:  Respiration Vol. 88, No. 1 ( 2014), p. 52-60
    Details
    In: Respiration, S. Karger AG, Vol. 88, No. 1 ( 2014), p. 52-60
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Treatment with lung volume reduction coils (LVRC) may be effective in patients with severe heterogeneous emphysema and incomplete fissures. 〈 b 〉 〈 i 〉 Objective: 〈 /i 〉 〈 /b 〉 We hypothesized that LVRC placement improves pulmonary function, exercise tolerance and quality of life in these patients. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 Twenty-six patients with chronic obstructive pulmonary disease (COPD), 13 males and 13 females, aged 66 ± 8 years with heterogeneous emphysema and incomplete fissures were included in this retrospective analysis. The coils were implanted unilaterally in the upper or lower lobe. Patients were followed up at 30, 90 and 180 days after treatment and changes in pulmonary function test and 6-minute-walk-test (6MWT) values as well as scores for the modified Medical Research Council (mMRC) dyspnea scale and the St. George's Respiratory Questionnaire (SGRQ) were recorded. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 FEV 〈 sub 〉 1 〈 /sub 〉 improved significantly at 90 days and tended to decrease at the 180-day follow-up (0.67 ± 0.17 vs. 0.78 ± 0.25 vs. 0.73 ± 0.21 liters, respectively, p 〈 0.001). The 6MWT score had improved significantly at 90 days and had tended to decrease at the 180-day follow-up (216 ± 107 vs. 262 ± 97 vs. 262 ± 112 m, respectively, p = 0.001). SGRQ was significantly improved at 90 days. Multivariate analysis showed that worse 6MWT performance at baseline was independently associated with a greater improvement in 6MWT at the 90-day follow-up. The total complication rate was 54% (n = 14) and included light hemorrhage in 6 patients, COPD exacerbation in 6, pneumothorax in 1 and both COPD exacerbation and pneumothorax in 1 patient. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 This is the first study to show that LVRC in patients with heterogeneous emphysema and incomplete fissures improves exercise capacity, quality of life and lung function up to 90 days after the intervention. Further studies are needed to assess the long-term effects of LVRC in these patients.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000358441
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2014
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  • 8
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    Expert Statement: Pneumothorax Associated with Endoscopic Valve Therapy for Emphysema - Potential Mechanisms, Treatment Algorithm, and Case Examples
    S. Karger AG ; 2014
    In:  Respiration Vol. 87, No. 6 ( 2014), p. 513-521
    Details
    In: Respiration, S. Karger AG, Vol. 87, No. 6 ( 2014), p. 513-521
    Abstract: The use of endoscopically placed unidirectional valves for the treatment of emphysema is increasing. With better patient selection, there is also an increased likelihood of complications associated with the procedure, such as postprocedural pneumothorax. There is, however, little evidence of pneumothorax management in patients with severe COPD and emphysema. This report describes an expert recommendation that has been developed to outline pneumothorax management after valve placement to inform physicians and patients of the risk-benefit profile and to assist them in decision making. Skilled and aggressive pneumothorax management is necessary in this patient population, and by following these recommendations traumatic scenarios, prolonged drainage, extended hospitalizations, and/or surgery might be avoided in many cases.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000360642
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2014
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  • 9
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    Efficacy and Safety of the 9-mm Intrabronchial Valve in Patients with Advanced Emphysema
    S. Karger AG ; 2020
    In:  Respiration Vol. 99, No. 4 ( 2020), p. 333-343
    Details
    In: Respiration, S. Karger AG, Vol. 99, No. 4 ( 2020), p. 333-343
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Endoscopic valve therapy aims at lung volume reduction that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. The size of intrabronchial valves of the Spiration® Valve System (SVS) selected to achieve lobar occlusion may have an influence on treatment outcomes. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 49 severe emphysema patients (M/F: 24/25, age: 64 ± 7 years), with complete interlobar fissures on the side intended to be treated, underwent treatment with at least one 9-mm intrabronchial valve implantation at 3 centers and were followed up at 30, 90 and 180 days after intervention. Changes in pulmonary function tests (PFT), 6-min walk test (6MWT), modified Medical Research Council (mMRC) dyspnea scale and chronic obstructive pulmonary disease assessment test scores as well as possible complications were recorded. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Forced expiratory volume in 1 s (FEV 〈 sub 〉 1 〈 /sub 〉 ) improved significantly over the 6-month period of the study, and the proportion of patients achieving a minimal clinically important difference (MCID) for FEV 〈 sub 〉 1 〈 /sub 〉 was 46.4% at 6 months. Regarding the remaining PFT values, the changes were not statistically significant at 6 months, but when looking at the MCIDs, 44.4% of the patients achieved the MCID decrease for residual volume. The 6MWT distance also improved statistically significantly, and an MCID increase of ≥26 m was reached by 41.7% of the patients. Furthermore, there was a statistically significant improvement in the mMRC score. The incidence of pneumothoraxes requiring drainage was 26.5% while a valve dislocation rate of 24% was observed but only in the lower lobes. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 Endoscopic lung volume reduction with the 9-mm SVS valves was associated with statistically significant but modest improvement of FEV 〈 sub 〉 1 〈 /sub 〉 , mMRC and 6MWT up to 6 months after intervention. These results were accompanied by an anticipated and acceptable risk profile. The relative increased incidence of device dislocation observed needs to be further elucidated.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000506521
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2020
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  • 10
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    Endoscopic Lung Volume Reduction with Endobronchial Valves in Patients with Severe Emphysema and Established Pulmonary Hypertension
    S. Karger AG ; 2015
    In:  Respiration Vol. 89, No. 1 ( 2015), p. 41-48
    Details
    In: Respiration, S. Karger AG, Vol. 89, No. 1 ( 2015), p. 41-48
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 One of the most common forms of pulmonary hypertension (PH) is that associated with chronic obstructive pulmonary disease (COPD). So far, patients with severe emphysema and established PH have been excluded from endoscopic lung volume reduction (ELVR) therapy due to the risk of right heart decompensation. 〈 b 〉 〈 i 〉 Objective: 〈 /i 〉 〈 /b 〉 The aim of this pilot study was to evaluate the feasibility and efficacy of ELVR using one-way endobronchial valves (EBV) in this specific group of patients. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We prospectively included 6 patients with COPD, severe heterogeneous emphysema, and established PH who underwent right heart catheterization and clinical assessments before and 90 days after ELVR with unilateral EBV placement. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 This study was not powered to measure any statistical differences in endpoints. Ninety days after ELVR, the symptoms, lung function, and hemodynamics improved in 5 out of 6 patients (1 patient normalized and 1 slightly worsened). The mean hemodynamics improved from baseline to 90 days after ELVR as follows: mean pulmonary artery pressure, -2.5 ± 3.5 mm Hg; pulmonary arterial wedge pressure, -4.3 ± 8.3 mm Hg; cardiac index, +0.3 ± 0.6 l/min/m 〈 sup 〉 2 〈 /sup 〉 , and 6-min walk distance, +59 ± 99 m. ELVR was performed without PH-related complications in all patients. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 To our knowledge, this is the first prospective, single-center pilot study to evaluate the feasibility and efficacy of ELVR in patients with established PH. ELVR was feasible and resulted in an improvement of clinical and hemodynamic parameters in 5 out of 6 patients. These results have to be further confirmed in larger-scale controlled studies.
    Type of Medium: Online Resource
    ISSN: 0025-7931 , 1423-0356
    URL: Article
    DOI: 10.1159/000368369
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2015
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