Pulmonary DiseaseHolo-lungsNCT04227444
Preoperative Evaluation of Pulmonary Vascular Anatomy by Holograms
An observational study of Pulmonary Disease and Lung Cancer, run by European Institute of Oncology at 2 sites in Italy.
Trial summary
Pulmonary vascular anatomy represents a constant challenge during lung resection, because of its variability in terms of vascular branches and anatomical variations. Preoperative standard computed tomography is not always sufficient to foresee tricky abnormalities; augmented reality, thanks to holograms creation, may… Read more about this study
- Who is it for?
- Ages 18 to 90 years
- Conditions the study is for
- Pulmonary Disease, Lung Cancer
- What is being tested?
- Hologram
- How many people
- 50 participants
- Where
- 2 sitesItaly
- Study dates
- 1 Mar 2020to 1 Mar 2024
- 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 18 to 90 years
- All sexes
- Adult, Older adult
Study population: Patients suffering from (any) lung cancer scheduled for anatomical lung resection
Who may be able to join
- Planned anatomical resection for lung cancer
- Signed and dated informed consent indicating that the patient has been informed of all pertinent aspects of the study.
- Willingness and ability to comply with study procedures.
Who cannot join
- Age younger than 18 years
- Contraindications to general anesthesia
- Poor general clinical conditions ( ECOG PS >=2)
- Patients unable to provide informed consent
Trial locations and contacts
2 sites in 1 country.
Italy2 sites, 2 recruiting
- Recruiting
European Institute of Oncology
Milan, 20141
Francesco Petrella, MD, PhD
- Recruiting
European Institue of Oncology
Milan, 20143
Francesco Petrella, MD, Ph D, 00390294372921, francesco.petrella@ieo.it
About this study
Official title: Preoperative Evaluation of Pulmonary Vascular Anatomy by Augmented Reality (Holograms) in Patients Undergoing Lung Resection
Pulmonary vascular anatomy represents a constant challenge during lung resection, because of its variability in terms of vascular branches and anatomical variations.
Preoperative standard computed tomography is not always sufficient to foresee tricky abnormalities; augmented reality, thanks to holograms creation, may offer additional data on pulmonary vascular anatomy and its relation with neoplastic tissue. The aim of this study is to assess the possibility of correctly predict number, location and potential anomalies of pulmonary vascular anatomy of the lobe to be resected in patients undergoing lung resection for cancer.
Patients will receive standard preoperative oncologic and functional assessment. Preoperative computed tomography (CT) - performed according to a specific protocol - will be performed. CT images will be subsequently elaborated to generate 3D images (holograms). Two radiologists and two thoracic surgeons will analyze CT images and report number of artery and vein branches for the lobe to be resected. Moreover they will report every anatomical variation, according to the normal anatomy. After that, the same two radiologists and thoracic surgeons will analyze the holograms and perform the same analysis as quoted above. Patients will undergo to the planned surgical resection. The operating team will report the exact number of artery and vein branches of the resected lobe as well as every anatomical variation. Preoperative CT and holographic findings of the radiologists and the thoracic surgeons will be matched with the report of the operating team.
Read the detailed description
An augmented reality (AR) system provides the surgeon with computer processed imaging data in real-time via dedicated hardware and software. The projection of AR is made possible by using displays, projectors, cameras, trackers, or other specialized equipment.
At present, the applications of AR are limited by the essential requisite of preoperative 3D reconstructions of medical images. It is possible to create these reconstructions by using commercial or self-made software from the Digital Imaging and Communications in Medicine (DICOM) format . The quality of a reconstruction depends on the quality of input data and the accuracy of the reconstruction system. Such reconstructions can be used for virtual exploration of target areas, planning an elective surgical approach in advance, and for better orientation and navigation in the operative field. AR is especially useful in visualizing critical structures such as major vessels, nerves, or other vital tissues. By projecting these structures directly onto the patient, AR increases safety and reduces the time required to complete the procedure. Moreover Augmented reality proved to be an effective tool for training and skill assessment of surgery residents, other medical staff, or students. Augmented reality can be used effectively for preoperative planning and completion of the actual surgery in timely fashion. The preoperative 3D reconstructed images can be modified and prepared for display in AR systems. Commonly, AR is used for tailoring individually preferred incisions and cutting planes, optimal placement of trocars, or to generally improve safety by displaying positions of major organ components. Another benefit of AR is the ability to aid surgeons in difficult terrain after a neoadjuvant chemotherapy or radiotherapy.
Studies suggest that AR systems are becoming comparable to traditional navigation techniques, with precision and safety sufficient for routine clinical practice. Most problems faced presently will be solved by further medical and technological research. Augmented reality appears to be a powerful tool possibly capable of changing the field of surgery through a rational use. In the future, AR will likely serve as an advanced human-computer interface, working in symbiosis with surgeons, allowing them to achieve even better results. Nevertheless, further advancement is much needed to achieve maximum potential and cost-effectiveness of augmented reality.
- Conditions
- Pulmonary Disease, Lung Cancer
- Being tested
- Hologram
- Medical subject headings
- Lung Diseases, Lung Neoplasms
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
HologramDiagnostic test
Patient undergoing elective anatomical resection for lung cancer will receive standard preoperative CT scan of the chest (as usual); CT images will be subsequently elaborated by a Holographic computer to generate 3D images (holograms).Two radiologists and two thoracic surgeons will analyze CT images in a standard modality and report number of artery and vein branches for the lobe to be resected, moreover they will report every anatomical variation, according to the normal anatomy.
After that, the same two radiologists and thoracic surgeons will analyze 3D images by the use of Microsoft Hololens and perform the same analysis as quoted above.
For each review of the exam performed will be written a digitally signed clinical report to certify the timing of the evaluation and to be able to trace the analysis and any subsequent modifications of the interpretation of the CT images results.
What is being measured
The primary outcome is the main question the study is designed to answer.
Prediction of the exact number of pulmonary arteries and veins of the lobe to be resected.
Two different investigator (1 senior radiologist and 1 senior thoracic surgery) evaluate standard preoperative CT scan and indicate the number of pulmonary artery and veins of the lobe to be resected; this will be reported in a dedicated registry. After that, the same investigators will evaluate holograms of the same patients and will report the number of arteries and veins of the lobe to be resected; they will then register these data in the same registry. After the operation, the operating surgeon will report - as usual - the number of the arteries and veins resected during the procedure. Finally the prediction of the investigators obtained only by CT scan evaluation or bay CT scan + holograms evaluation, will be compared with the operatory report.
Measured: 2020 - 2022
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted13 Jan 2020
- Study start1 Mar 2020
- Primary completion1 Mar 2022
- Study completion1 Mar 2024 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (11)Papers the sponsor has linked to this study.
- Other trials for Pulmonary DiseaseStudies of the same condition, open and under way.
- More trials run by European Institute of OncologyThe 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
- Case only
- Time perspective
- Prospective
- Enrolment
- 50 participants (estimated)
Sponsor and investigators
- Lead sponsor
- European Institute of Oncology
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT04227444
- Sponsor's protocol ID
- R1033/19-IEO1088
- Acronym
- Holo-lungs
- Status last verified
- Jun 2023
- First submitted
- 7 Jan 2020
- Last updated
- 28 Jun 2023
- Results posted
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Vavra P, Roman J, Zonca P, Ihnat P, Nemec M, Kumar J, Habib N, El-Gendi A. Recent Development of Augmented Reality in Surgery: A Review. J Healthc Eng. 2017;2017:4574172. doi: 10.1155/2017/4574172. Epub 2017 Aug 21.
PubMed 29065604Pessaux P, Diana M, Soler L, Piardi T, Mutter D, Marescaux J. Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy. Langenbecks Arch Surg. 2015 Apr;400(3):381-5. doi: 10.1007/s00423-014-1256-9. Epub 2014 Nov 13.
PubMed 25392120Inoue D, Cho B, Mori M, Kikkawa Y, Amano T, Nakamizo A, Yoshimoto K, Mizoguchi M, Tomikawa M, Hong J, Hashizume M, Sasaki T. Preliminary study on the clinical application of augmented reality neuronavigation. J Neurol Surg A Cent Eur Neurosurg. 2013 Mar;74(2):71-6. doi: 10.1055/s-0032-1333415. Epub 2013 Feb 12.
PubMed 23404553Pessaux P, Diana M, Soler L, Piardi T, Mutter D, Marescaux J. Robotic duodenopancreatectomy assisted with augmented reality and real-time fluorescence guidance. Surg Endosc. 2014 Aug;28(8):2493-8. doi: 10.1007/s00464-014-3465-2. Epub 2014 Mar 8.
PubMed 24609700Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853.
PubMed 26103444Lahanas V, Loukas C, Smailis N, Georgiou E. A novel augmented reality simulator for skills assessment in minimal invasive surgery. Surg Endosc. 2015 Aug;29(8):2224-34. doi: 10.1007/s00464-014-3930-y. Epub 2014 Oct 11.
PubMed 25303925Qu M, Hou Y, Xu Y, Shen C, Zhu M, Xie L, Wang H, Zhang Y, Chai G. Precise positioning of an intraoral distractor using augmented reality in patients with hemifacial microsomia. J Craniomaxillofac Surg. 2015 Jan;43(1):106-12. doi: 10.1016/j.jcms.2014.10.019. Epub 2014 Oct 29.
PubMed 25465484Muller M, Rassweiler MC, Klein J, Seitel A, Gondan M, Baumhauer M, Teber D, Rassweiler JJ, Meinzer HP, Maier-Hein L. Mobile augmented reality for computer-assisted percutaneous nephrolithotomy. Int J Comput Assist Radiol Surg. 2013 Jul;8(4):663-75. doi: 10.1007/s11548-013-0828-4. Epub 2013 Mar 23.
PubMed 23526436Volonte F, Pugin F, Bucher P, Sugimoto M, Ratib O, Morel P. Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion. J Hepatobiliary Pancreat Sci. 2011 Jul;18(4):506-9. doi: 10.1007/s00534-011-0385-6.
PubMed 21487758Souzaki R, Ieiri S, Uemura M, Ohuchida K, Tomikawa M, Kinoshita Y, Koga Y, Suminoe A, Kohashi K, Oda Y, Hara T, Hashizume M, Taguchi T. An augmented reality navigation system for pediatric oncologic surgery based on preoperative CT and MRI images. J Pediatr Surg. 2013 Dec;48(12):2479-83. doi: 10.1016/j.jpedsurg.2013.08.025.
PubMed 24314190Petrella F, Rizzo SMR, Rampinelli C, Casiraghi M, Bagnardi V, Frassoni S, Pozzi S, Pappalardo O, Pravettoni G, Spaggiari L. Assessment of pulmonary vascular anatomy: comparing augmented reality by holograms versus standard CT images/reconstructions using surgical findings as reference standard. Eur Radiol Exp. 2024 May 10;8(1):57. doi: 10.1186/s41747-024-00458-w.
PubMed 38724831
Study at a glance
From the registry record, last updated by the sponsor on 28 Jun 2023. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Preoperative Evaluation of Pulmonary Vascular Anatomy by Augmented Reality (Holograms) in Patients Undergoing Lung Resection
- ClinicalTrials.gov ID
- NCT04227444
- Acronym / sponsor ID
- Holo-lungs / R1033/19-IEO1088
- Conditions
- Pulmonary Disease, Lung Cancer
- Study type
- Observational
- Recruitment status
- Unknown status
- Enrolment
- 50 participants (estimated)
- Lead sponsor
- European Institute of OncologyUniversity, hospital or other
- Study start
- 1 Mar 2020 (actual)
- Primary completion
- 1 Mar 2022 (actual)
- Study completion
- 1 Mar 2024 (estimated)
- First posted
- 13 Jan 2020 (actual)
- 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.
Pulmonary vascular anatomy represents a constant challenge during lung resection, because of its variability in terms of vascular branches and anatomical variations.
Preoperative standard computed tomography is not always sufficient to foresee tricky abnormalities; augmented reality, thanks to holograms creation, may offer additional data on pulmonary vascular anatomy and its relation with neoplastic tissue. The aim of this study is to assess the possibility of correctly predict number, location and potential anomalies of pulmonary vascular anatomy of the lobe to be resected in patients undergoing lung resection for cancer.
Patients will receive standard preoperative oncologic and functional assessment. Preoperative computed tomography (CT) - performed according to a specific protocol - will be performed. CT images will be subsequently elaborated to generate 3D images (holograms). Two radiologists and two thoracic surgeons will analyze CT images and report number of artery and vein branches for the lobe to be resected. Moreover they will report every anatomical variation, according to the normal anatomy. After that, the same two radiologists and thoracic surgeons will analyze the holograms and perform the same analysis as quoted above. Patients will undergo to the planned surgical resection. The operating team will report the exact number of artery and vein branches of the resected lobe as well as every anatomical variation. Preoperative CT and holographic findings of the radiologists and the thoracic surgeons will be matched with the report of the operating team.
Detailed description
An augmented reality (AR) system provides the surgeon with computer processed imaging data in real-time via dedicated hardware and software. The projection of AR is made possible by using displays, projectors, cameras, trackers, or other specialized equipment.
At present, the applications of AR are limited by the essential requisite of preoperative 3D reconstructions of medical images. It is possible to create these reconstructions by using commercial or self-made software from the Digital Imaging and Communications in Medicine (DICOM) format . The quality of a reconstruction depends on the quality of input data and the accuracy of the reconstruction system. Such reconstructions can be used for virtual exploration of target areas, planning an elective surgical approach in advance, and for better orientation and navigation in the operative field. AR is especially useful in visualizing critical structures such as major vessels, nerves, or other vital tissues. By projecting these structures directly onto the patient, AR increases safety and reduces the time required to complete the procedure. Moreover Augmented reality proved to be an effective tool for training and skill assessment of surgery residents, other medical staff, or students. Augmented reality can be used effectively for preoperative planning and completion of the actual surgery in timely fashion. The preoperative 3D reconstructed images can be modified and prepared for display in AR systems. Commonly, AR is used for tailoring individually preferred incisions and cutting planes, optimal placement of trocars, or to generally improve safety by displaying positions of major organ components. Another benefit of AR is the ability to aid surgeons in difficult terrain after a neoadjuvant chemotherapy or radiotherapy.
Studies suggest that AR systems are becoming comparable to traditional navigation techniques, with precision and safety sufficient for routine clinical practice. Most problems faced presently will be solved by further medical and technological research. Augmented reality appears to be a powerful tool possibly capable of changing the field of surgery through a rational use. In the future, AR will likely serve as an advanced human-computer interface, working in symbiosis with surgeons, allowing them to achieve even better results. Nevertheless, further advancement is much needed to achieve maximum potential and cost-effectiveness of augmented reality.
Study design
- Observational model
- Case only
- Time perspective
- Prospective
Who may qualify
- Ages
- 18 to 90 years
- Sex
- All
- Age groups
- Adult, Older adult
- Study population
- Patients suffering from (any) lung cancer scheduled for anatomical lung resection
Key inclusion criteria (3 listed)
- Planned anatomical resection for lung cancer
- Signed and dated informed consent indicating that the patient has been informed of all pertinent aspects of the study.
- Willingness and ability to comply with study procedures.
Key exclusion criteria (4 listed)
- Age younger than 18 years
- Contraindications to general anesthesia
- Poor general clinical conditions ( ECOG PS >=2)
- Patients unable to provide informed consent
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 |
|---|---|---|
| HologramPatient undergoing elective anatomical resection for lung cancer will receive standard preoperative CT scan of the chest (as usual); CT images will be subsequently elaborated by a Holographic computer to generate 3D images (holograms).Two radiologists and two thoracic surgeons will analyze CT images in a standard modality and report number of artery and vein branches for the lobe to be resected, moreover they will report every anatomical variation, according to the normal anatomy. After that, the same two radiologists and thoracic surgeons will analyze 3D images by the use of Microsoft Hololens and perform the same analysis as quoted above. For each review of the exam performed will be written a digitally signed clinical report to certify the timing of the evaluation and to be able to trace the analysis and any subsequent modifications of the interpretation of the CT images results. | Diagnostic test | – |
Primary outcome
Prediction of the exact number of pulmonary arteries and veins of the lobe to be resected.
Time frame: 2020 - 2022
Two different investigator (1 senior radiologist and 1 senior thoracic surgery) evaluate standard preoperative CT scan and indicate the number of pulmonary artery and veins of the lobe to be resected; this will be reported in a dedicated registry. After that, the same investigators will evaluate holograms of the same patients and will report the number of arteries and veins of the lobe to be resected; they will then register these data in the same registry. After the operation, the operating surgeon will report - as usual - the number of the arteries and veins resected during the procedure. Finally the prediction of the investigators obtained only by CT scan evaluation or bay CT scan + holograms evaluation, will be compared with the operatory report.
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 28 Jun 2023.
- Background: PubMed 29065604Vavra P, Roman J, Zonca P, Ihnat P, Nemec M, Kumar J, Habib N, El-Gendi A. Recent Development of Augmented Reality in Surgery: A Review. J Healthc Eng. 2017;2017:4574172. doi: 10.1155/2017/4574172. Epub 2017 Aug 21.
- Background: PubMed 25392120Pessaux P, Diana M, Soler L, Piardi T, Mutter D, Marescaux J. Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy. Langenbecks Arch Surg. 2015 Apr;400(3):381-5. doi: 10.1007/s00423-014-1256-9. Epub 2014 Nov 13.
- Background: PubMed 23404553Inoue D, Cho B, Mori M, Kikkawa Y, Amano T, Nakamizo A, Yoshimoto K, Mizoguchi M, Tomikawa M, Hong J, Hashizume M, Sasaki T. Preliminary study on the clinical application of augmented reality neuronavigation. J Neurol Surg A Cent Eur Neurosurg. 2013 Mar;74(2):71-6. doi: 10.1055/s-0032-1333415. Epub 2013 Feb 12.
- Background: PubMed 24609700Pessaux P, Diana M, Soler L, Piardi T, Mutter D, Marescaux J. Robotic duodenopancreatectomy assisted with augmented reality and real-time fluorescence guidance. Surg Endosc. 2014 Aug;28(8):2493-8. doi: 10.1007/s00464-014-3465-2. Epub 2014 Mar 8.
- Background: PubMed 26103444Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853.
- Background: PubMed 25303925Lahanas V, Loukas C, Smailis N, Georgiou E. A novel augmented reality simulator for skills assessment in minimal invasive surgery. Surg Endosc. 2015 Aug;29(8):2224-34. doi: 10.1007/s00464-014-3930-y. Epub 2014 Oct 11.
- Background: PubMed 25465484Qu M, Hou Y, Xu Y, Shen C, Zhu M, Xie L, Wang H, Zhang Y, Chai G. Precise positioning of an intraoral distractor using augmented reality in patients with hemifacial microsomia. J Craniomaxillofac Surg. 2015 Jan;43(1):106-12. doi: 10.1016/j.jcms.2014.10.019. Epub 2014 Oct 29.
- Background: PubMed 23526436Muller M, Rassweiler MC, Klein J, Seitel A, Gondan M, Baumhauer M, Teber D, Rassweiler JJ, Meinzer HP, Maier-Hein L. Mobile augmented reality for computer-assisted percutaneous nephrolithotomy. Int J Comput Assist Radiol Surg. 2013 Jul;8(4):663-75. doi: 10.1007/s11548-013-0828-4. Epub 2013 Mar 23.
- Background: PubMed 21487758Volonte F, Pugin F, Bucher P, Sugimoto M, Ratib O, Morel P. Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion. J Hepatobiliary Pancreat Sci. 2011 Jul;18(4):506-9. doi: 10.1007/s00534-011-0385-6.
- Background: PubMed 24314190Souzaki R, Ieiri S, Uemura M, Ohuchida K, Tomikawa M, Kinoshita Y, Koga Y, Suminoe A, Kohashi K, Oda Y, Hara T, Hashizume M, Taguchi T. An augmented reality navigation system for pediatric oncologic surgery based on preoperative CT and MRI images. J Pediatr Surg. 2013 Dec;48(12):2479-83. doi: 10.1016/j.jpedsurg.2013.08.025.
- Derived from this study: PubMed 38724831Petrella F, Rizzo SMR, Rampinelli C, Casiraghi M, Bagnardi V, Frassoni S, Pozzi S, Pappalardo O, Pravettoni G, Spaggiari L. Assessment of pulmonary vascular anatomy: comparing augmented reality by holograms versus standard CT images/reconstructions using surgical findings as reference standard. Eur Radiol Exp. 2024 May 10;8(1):57. doi: 10.1186/s41747-024-00458-w.
- Individual participant dataSharing planned: No
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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.
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 Pulmonary Disease and Lung Cancer, run by European Institute of Oncology at 2 sites in Italy.
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 4 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: status not confirmed, as of the sponsor's last update on 28 Jun 2023. 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 Italy. 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?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
Contact Francesco Petrella, MD, PhD (00390294372921, francesco.petrella@ieo.it), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Prediction of the exact number of pulmonary arteries and veins of the lobe to be resected. (time frame: 2020 - 2022). 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 NCT04227444, which also lists 11 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 28 Jun 2023.