AsthmaACT2NCT02662413
To Determine the Validity of the ACT in an Adolescent Population With Persistent Asthma
An observational study of Asthma, run by University of North Carolina, Chapel Hill at 2 sites in United States.
Trial summary
To determine the measurement profiles of the asthma control test (ACT) in an adolescent population with persistent asthma. Read more about this study
- Who is it for?
- Ages 12 to 18 years
- Conditions the study is for
- Asthma
- How many people
- 37 participants
- Where
- 2 sitesUnited States
- Study dates
- Jan 2016to 27 Sep 2017
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 12 to 18 years
- All sexes
- No healthy volunteers
- Child, Adult
Study population: Children ages 12-18 with a physician diagnosis of persistent asthma living in a defined geographical area
Who may be able to join
- Physician diagnosis of persistent asthma
- Current treatment with appropriate therapy for persistent asthma symptoms per the NHLBI guidelines including daily controller medication with at least low dose inhaled corticosteroids
- Must live within convenient driving distance of the North Carolina Children's Specialty Clinic in Raleigh North Carolina or the EPA Human Studies Facility on University of North Carolina Campus in Chapel Hill North Carolina.
Who cannot join
- Unable to perform spirometry
- Other medical history or underlying health problems that would preclude participation.
Trial locations and contacts
2 sites in 1 country.
United States2 sites
UNC Center for Environmental Medicine, Asthma and Lung Biology
Chapel Hill, North Carolina, 27599-7310
NC Children's Specialty Clinic, 4414 Lake Boone Trail, Suite 505
Raleigh, North Carolina, 27607
About this study
Official title: To Determine the Measurement Properties of the ACT in an Adolescent Population With Persistent Asthma Followed at a Subspecialty Clinic.
To determine the measurement profiles of the asthma control test (ACT) in an adolescent population with persistent asthma.
Read the detailed description
Asthma is the most common chronic illness of childhood, and adolescents represent a group that is typically difficult to engage in self-management strategies. Adolescent asthmatics tend to have poor perception of symptoms and experience a higher rate of asthma deaths compared to younger children. Studies have shown that perceived severity of asthma symptoms is related to self-management in adolescents, who were less likely to receive appropriate treatment for asthma exacerbation's. This poor perception of asthma control is likely one cause of the disproportionate asthma mortality rates seen in adolescent patients.
Because asthma control is now the focus of asthma care, assessment of control is the critical step in appropriate management. The two domains of asthma control, impairment and risk, evaluate the role asthma plays in a patient's quality of life and functional capacity on an ongoing basis and the risk their asthma presents for future adverse events. Although the National Asthma Education and Prevention Program guidelines contain a rubric for asthma control based on these domains, thus representing the "gold standard" for asthma care, their utilization may be time-consuming and cumbersome to implement in primary care offices, and primary care providers may be unfamiliar with their use. For primary care practices following adolescent patients, it remains imperative that the tools being used to gauge asthma control be evaluated and validated in this at-risk population.
At this time, there are approximately 17 questionnaires available for use in the assessment of asthma control, although most are not well validated. Of these, the most widely validated and most commonly used instrument is the Asthma Control Test (ACT). The ACT is a self-administered questionnaire intended to assess the impairment domain over the past four weeks and is completed by patients starting at age 12 years. The ACT has five questions with an overall best score of 25. For primarily adult Caucasian populations, the ACT has been found to be a valid, reliable, and responsive instrument of asthma control, and cut-offs for controlled and not well controlled asthma (< 19) as well as minimal clinically important (MIC) differences (3 points) have been identified. The measurement properties of validity, reliability, and responsiveness are critical to the usefulness of any questionnaire in both clinical and research settings. However, measurement properties of the ACT are lacking in the adolescent asthma population.The landmark validation study for the ACT by Schatz et al was comprised of a large sample size of over 300 patients that showed that a cut-off score of 19 as distinguishing well-controlled versus not well-controlled asthmatics. However, the mean age was 35 for that study population, and concerns have been raised as to whether this cut-off is appropriate for adolescents in general. Recent studies examining use of the ACT in Caucasian and Hispanic adolescent populations have found higher optimal cut points to distinguish control classifications.
Lung function measures are included in the rubric of assessing asthma control by the NAEPP (National Asthma Education and Prevention Program). Per these recommendations, spirometry should be available to physicians caring for asthma patients and used with initiation of treatment, change in asthma control, and every one to two years. While sub-specialists often have access to spirometry, office-based spirometry is time-consuming, requires technical ability and staff training, equipment maintenance and calibration, and is not always available or feasible for use in primary care physician offices. Because spirometry may be of limited accessibility to primary care providers, questionnaires are quickly taking a leading role in asthma management. Studies of adolescent asthmatics reveal poor perception of asthma control leading to under-reporting of asthma symptoms and thus under-treatment of exacerbation's. This type of under-reporting reflects a false level of asthma control when queried by the ACT and leads to inappropriate medical management when spirometry is not utilized.
As exploratory endpoints, we will obtain fractional exhaled nitric oxide (FeNO) measurements shortly after spirometry is performed. Elevated FeNO indicates eosinophilic airway inflammation and assists in assigning the correct asthma phenotype, which can have implications for asthma management. We will also obtain nasal epithelial lining fluid (ELF) for collection of nasal cytokines and chemokines. This information is useful for expanding our current understanding of the inflammatory mediators involved in asthma-associated airway inflammation.
- Conditions
- Asthma
- Being tested
- Validation of Asthma Control Questionnaire
- Medical subject headings
- Asthma
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Validation of Asthma Control QuestionnaireOther
This is an observational study so there is no planned intervention.
What is being measured
The primary outcome is the main question the study is designed to answer.
Cohen's kappa
To determine the agreement of the ACT score at the standard cutpoint of >19 with physician assessment of control using Cohen's kappa.
Measured: Baseline visit
Secondary outcomes (3)
Sensitivity of ACT Questionnaire
A receiver-operating curve will be used to determine the best ACT cutpoint for assessment of control in this population. A logistic regression model will be used with 'control by physician' as the dependent variable and 'ACT score' as the independent variable. The model will include adjustment for repeated measures (baseline and 6 week visit).
Measured: follow-up visit (six weeks)
Specificity of ACT Questionnaire
A receiver-operating curve will be used to determine the best ACT cutpoint for assessment of control in this population. A logistic regression model will be used with 'control by physician' as the dependent variable and 'ACT score' as the independent variable. The model will include adjustment for repeated measures (baseline and 6 week visit).
Measured: follow-up visit (six weeks)
Cohen's kappa
To determine the agreement of the ACT score at the standard cutpoint of >19 with physician assessment of control using Cohen's kappa.
Measured: follow-up visit (six weeks)
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted25 Jan 2016 (estimated)
- Study startJan 2016
- Primary completion10 Aug 2017
- Study completion27 Sep 2017
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (13)Papers the sponsor has linked to this study.
- Other trials for AsthmaStudies of the same condition, open and under way.
- More trials run by University of North Carolina, Chapel HillThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 37 participants (actual)
Sponsor and investigators
- Lead sponsor
- University of North Carolina, Chapel Hill
- Sponsor type
- University, hospital or other
- Collaborators
- American Academy of Allergy, Asthma, and Immunology
- Responsible party
- Sponsor
- Investigators
- Allison Burbank, MD, Principal investigator, FellowMichelle Hernandez, MD, Study director, Assistant Professor
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT02662413
- Sponsor's protocol ID
- 15-1804
- Acronym
- ACT2
- Status last verified
- Mar 2018
- First submitted
- 5 Jan 2016
- Last updated
- 23 Mar 2018
- Results posted
- No
- Data monitoring committee
- No
Publications
Raherison C, Tunon-de-Lara JM, Vernejoux JM, Taytard A. Practical evaluation of asthma exacerbation self-management in children and adolescents. Respir Med. 2000 Nov;94(11):1047-52. doi: 10.1053/rmed.2000.0888.
PubMed 11127490Larsen GL. Asthma in children. N Engl J Med. 1992 Jun 4;326(23):1540-5. doi: 10.1056/NEJM199206043262306.
PubMed 1579137National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. doi: 10.1016/j.jaci.2007.09.043.
PubMed 17983880Cloutier MM, Schatz M, Castro M, Clark N, Kelly HW, Mangione-Smith R, Sheller J, Sorkness C, Stoloff S, Gergen P. Asthma outcomes: composite scores of asthma control. J Allergy Clin Immunol. 2012 Mar;129(3 Suppl):S24-33. doi: 10.1016/j.jaci.2011.12.980.
PubMed 22386507Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010 Dec;36(6):1410-6. doi: 10.1183/09031936.00117509. Epub 2010 Jun 7.
PubMed 20530041Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999 Oct;14(4):902-7. doi: 10.1034/j.1399-3003.1999.14d29.x.
PubMed 10573240Korn S, Both J, Jung M, Hubner M, Taube C, Buhl R. Prospective evaluation of current asthma control using ACQ and ACT compared with GINA criteria. Ann Allergy Asthma Immunol. 2011 Dec;107(6):474-9. doi: 10.1016/j.anai.2011.09.001. Epub 2011 Oct 5.
PubMed 22123375Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA, Kosinski M, Pendergraft TB, Jhingran P. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006 Mar;117(3):549-56. doi: 10.1016/j.jaci.2006.01.011.
PubMed 16522452Thomas M, Kay S, Pike J, Williams A, Rosenzweig JR, Hillyer EV, Price D. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009 Mar;18(1):41-9. doi: 10.4104/pcrj.2009.00010.
PubMed 19240948Leung TF, Ko FW, Sy HY, Wong E, Li CY, Yung E, Hui DS, Wong GW, Lai CK. Identifying uncontrolled asthma in young children: clinical scores or objective variables? J Asthma. 2009 Mar;46(2):130-5. doi: 10.1080/02770900802468533.
PubMed 19253117Koolen BB, Pijnenburg MW, Brackel HJ, Landstra AM, van den Berg NJ, Merkus PJ, Hop WC, Vaessen-Verberne AA. Comparing Global Initiative for Asthma (GINA) criteria with the Childhood Asthma Control Test (C-ACT) and Asthma Control Test (ACT). Eur Respir J. 2011 Sep;38(3):561-6. doi: 10.1183/09031936.00173710. Epub 2011 Mar 15.
PubMed 21406508Shi Y, Tatavoosian AV, Aledia AS, George SC, Galant SP. Cut points for Asthma Control Tests in Mexican children in Orange County, California. Ann Allergy Asthma Immunol. 2012 Aug;109(2):108-13. doi: 10.1016/j.anai.2012.06.002. Epub 2012 Jul 4.
PubMed 22840251Burbank AJ, Todoric K, Steele P, Rosen J, Zhou H, Frye M, Loughlin CE, Ivins S, Mills K, Massey LD, Reeve BB, Hernandez ML. Age and African-American race impact the validity and reliability of the asthma control test in persistent asthmatics. Respir Res. 2018 Aug 15;19(1):152. doi: 10.1186/s12931-018-0858-0.
PubMed 30111326
Study at a glance
From the registry record, last updated by the sponsor on 23 Mar 2018. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- To Determine the Measurement Properties of the ACT in an Adolescent Population With Persistent Asthma Followed at a Subspecialty Clinic.
- ClinicalTrials.gov ID
- NCT02662413
- Acronym / sponsor ID
- ACT2 / 15-1804
- Conditions
- Asthma
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 37 participants (actual)
- Lead sponsor
- University of North Carolina, Chapel HillUniversity, hospital or other
- Collaborators
- American Academy of Allergy, Asthma, and Immunology
- Study start
- Jan 2016
- Primary completion
- 10 Aug 2017 (actual)
- Study completion
- 27 Sep 2017 (actual)
- First posted
- 25 Jan 2016 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
To determine the measurement profiles of the asthma control test (ACT) in an adolescent population with persistent asthma.
Detailed description
Asthma is the most common chronic illness of childhood, and adolescents represent a group that is typically difficult to engage in self-management strategies. Adolescent asthmatics tend to have poor perception of symptoms and experience a higher rate of asthma deaths compared to younger children. Studies have shown that perceived severity of asthma symptoms is related to self-management in adolescents, who were less likely to receive appropriate treatment for asthma exacerbation's. This poor perception of asthma control is likely one cause of the disproportionate asthma mortality rates seen in adolescent patients.
Because asthma control is now the focus of asthma care, assessment of control is the critical step in appropriate management. The two domains of asthma control, impairment and risk, evaluate the role asthma plays in a patient's quality of life and functional capacity on an ongoing basis and the risk their asthma presents for future adverse events. Although the National Asthma Education and Prevention Program guidelines contain a rubric for asthma control based on these domains, thus representing the "gold standard" for asthma care, their utilization may be time-consuming and cumbersome to implement in primary care offices, and primary care providers may be unfamiliar with their use. For primary care practices following adolescent patients, it remains imperative that the tools being used to gauge asthma control be evaluated and validated in this at-risk population.
At this time, there are approximately 17 questionnaires available for use in the assessment of asthma control, although most are not well validated. Of these, the most widely validated and most commonly used instrument is the Asthma Control Test (ACT). The ACT is a self-administered questionnaire intended to assess the impairment domain over the past four weeks and is completed by patients starting at age 12 years. The ACT has five questions with an overall best score of 25. For primarily adult Caucasian populations, the ACT has been found to be a valid, reliable, and responsive instrument of asthma control, and cut-offs for controlled and not well controlled asthma (< 19) as well as minimal clinically important (MIC) differences (3 points) have been identified. The measurement properties of validity, reliability, and responsiveness are critical to the usefulness of any questionnaire in both clinical and research settings. However, measurement properties of the ACT are lacking in the adolescent asthma population.The landmark validation study for the ACT by Schatz et al was comprised of a large sample size of over 300 patients that showed that a cut-off score of 19 as distinguishing well-controlled versus not well-controlled asthmatics. However, the mean age was 35 for that study population, and concerns have been raised as to whether this cut-off is appropriate for adolescents in general. Recent studies examining use of the ACT in Caucasian and Hispanic adolescent populations have found higher optimal cut points to distinguish control classifications.
Lung function measures are included in the rubric of assessing asthma control by the NAEPP (National Asthma Education and Prevention Program). Per these recommendations, spirometry should be available to physicians caring for asthma patients and used with initiation of treatment, change in asthma control, and every one to two years. While sub-specialists often have access to spirometry, office-based spirometry is time-consuming, requires technical ability and staff training, equipment maintenance and calibration, and is not always available or feasible for use in primary care physician offices. Because spirometry may be of limited accessibility to primary care providers, questionnaires are quickly taking a leading role in asthma management. Studies of adolescent asthmatics reveal poor perception of asthma control leading to under-reporting of asthma symptoms and thus under-treatment of exacerbation's. This type of under-reporting reflects a false level of asthma control when queried by the ACT and leads to inappropriate medical management when spirometry is not utilized.
As exploratory endpoints, we will obtain fractional exhaled nitric oxide (FeNO) measurements shortly after spirometry is performed. Elevated FeNO indicates eosinophilic airway inflammation and assists in assigning the correct asthma phenotype, which can have implications for asthma management. We will also obtain nasal epithelial lining fluid (ELF) for collection of nasal cytokines and chemokines. This information is useful for expanding our current understanding of the inflammatory mediators involved in asthma-associated airway inflammation.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
Who may qualify
- Ages
- 12 to 18 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Child, Adult
- Study population
- Children ages 12-18 with a physician diagnosis of persistent asthma living in a defined geographical area
Key inclusion criteria (3 listed)
- Physician diagnosis of persistent asthma
- Current treatment with appropriate therapy for persistent asthma symptoms per the NHLBI guidelines including daily controller medication with at least low dose inhaled corticosteroids
- Must live within convenient driving distance of the North Carolina Children's Specialty Clinic in Raleigh North Carolina or the EPA Human Studies Facility on University of North Carolina Campus in Chapel Hill North Carolina.
Key exclusion criteria (2 listed)
- Unable to perform spirometry
- Other medical history or underlying health problems that would preclude participation.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Validation of Asthma Control QuestionnaireThis is an observational study so there is no planned intervention. | Other | – |
Primary outcome
Cohen's kappa
Time frame: Baseline visit
To determine the agreement of the ACT score at the standard cutpoint of >19 with physician assessment of control using Cohen's kappa.
3 secondary outcomes
Sensitivity of ACT Questionnaire
Time frame: follow-up visit (six weeks)
Specificity of ACT Questionnaire
Time frame: follow-up visit (six weeks)
Cohen's kappa
Time frame: follow-up visit (six weeks)
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 23 Mar 2018.
- Background: PubMed 11127490Raherison C, Tunon-de-Lara JM, Vernejoux JM, Taytard A. Practical evaluation of asthma exacerbation self-management in children and adolescents. Respir Med. 2000 Nov;94(11):1047-52. doi: 10.1053/rmed.2000.0888.
- Background: PubMed 1579137Larsen GL. Asthma in children. N Engl J Med. 1992 Jun 4;326(23):1540-5. doi: 10.1056/NEJM199206043262306.
- Background: PubMed 17983880National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. doi: 10.1016/j.jaci.2007.09.043.
- Background: PubMed 22386507Cloutier MM, Schatz M, Castro M, Clark N, Kelly HW, Mangione-Smith R, Sheller J, Sorkness C, Stoloff S, Gergen P. Asthma outcomes: composite scores of asthma control. J Allergy Clin Immunol. 2012 Mar;129(3 Suppl):S24-33. doi: 10.1016/j.jaci.2011.12.980.
- Background: PubMed 20530041Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010 Dec;36(6):1410-6. doi: 10.1183/09031936.00117509. Epub 2010 Jun 7.
- Background: PubMed 10573240Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999 Oct;14(4):902-7. doi: 10.1034/j.1399-3003.1999.14d29.x.
- Background: PubMed 22123375Korn S, Both J, Jung M, Hubner M, Taube C, Buhl R. Prospective evaluation of current asthma control using ACQ and ACT compared with GINA criteria. Ann Allergy Asthma Immunol. 2011 Dec;107(6):474-9. doi: 10.1016/j.anai.2011.09.001. Epub 2011 Oct 5.
- Background: PubMed 16522452Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA, Kosinski M, Pendergraft TB, Jhingran P. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006 Mar;117(3):549-56. doi: 10.1016/j.jaci.2006.01.011.
- Background: PubMed 19240948Thomas M, Kay S, Pike J, Williams A, Rosenzweig JR, Hillyer EV, Price D. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009 Mar;18(1):41-9. doi: 10.4104/pcrj.2009.00010.
- Background: PubMed 19253117Leung TF, Ko FW, Sy HY, Wong E, Li CY, Yung E, Hui DS, Wong GW, Lai CK. Identifying uncontrolled asthma in young children: clinical scores or objective variables? J Asthma. 2009 Mar;46(2):130-5. doi: 10.1080/02770900802468533.
- Background: PubMed 21406508Koolen BB, Pijnenburg MW, Brackel HJ, Landstra AM, van den Berg NJ, Merkus PJ, Hop WC, Vaessen-Verberne AA. Comparing Global Initiative for Asthma (GINA) criteria with the Childhood Asthma Control Test (C-ACT) and Asthma Control Test (ACT). Eur Respir J. 2011 Sep;38(3):561-6. doi: 10.1183/09031936.00173710. Epub 2011 Mar 15.
- Background: PubMed 22840251Shi Y, Tatavoosian AV, Aledia AS, George SC, Galant SP. Cut points for Asthma Control Tests in Mexican children in Orange County, California. Ann Allergy Asthma Immunol. 2012 Aug;109(2):108-13. doi: 10.1016/j.anai.2012.06.002. Epub 2012 Jul 4.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Allison Burbank, MD principal investigator
Fellow
Michelle Hernandez, MD study director
Assistant Professor
2 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Asthma, run by University of North Carolina, Chapel Hill at 2 sites in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 3 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 23 Mar 2018. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Cohen's kappa (time frame: Baseline visit). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT02662413, which also lists 13 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 23 Mar 2018; AzTrials last refreshed its copy on 7 Nov 2026.