Mechanical VentilationPhase 2FenHydroNCT07224620
Fentanyl Versus Hydromorphone in Patients on Mechanical Ventilation
A Phase 2 study testing fentanyl and Hydromorphone in people with Mechanical Ventilation and Sedation and Analgesia, run by Beth Israel Deaconess Medical Center at 1 site in United States.
Trial summary
Patients with respiratory failure who require mechanical ventilation are not only at risk of death, but also of complications of prolonged ICU stay. Patients may have significant functional decline, impact in quality of life, develop psychiatric disorders and at long-term can lead to significant cost to society. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Mechanical Ventilation, Sedation and Analgesia, Critical Care, Intensive Care
- What is being tested?
- fentanyl and Hydromorphone
- Type of treatment
- Injection or infusion
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 319 participants
- Where
- 1 siteUnited States
- Study dates
- 3 Nov 2025to 30 Jun 2026
- Phase
- Phase 2
- 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 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Admitted to either MICU A, B, C or FICU at Beth Israel Deaconess Medical Center
- Requiring mechanical ventilation
- Felt by primary team to require opioid infusion for analgosedation
Who cannot join
- Age < 18 years old
- Do not intubate orders prior to enrollment
- Comfort measures only
- Contraindication to fentanyl or hydromorphone
Trial locations and contacts
1 site in 1 country.
United States1 site
Beth Israel Deaconess Medical Center
Boston, Massachusetts, 02215
About this study
Official title: Fentanyl Versus Hydromorphone as First Line Strategy in Patients on Mechanical Ventilation, a Pilot Pragmatic Randomized Superiority Clinical Trial: the FenHydro Trial
Patients with respiratory failure who require mechanical ventilation are not only at risk of death, but also of complications of prolonged ICU stay. Patients may have significant functional decline, impact in quality of life, develop psychiatric disorders and at long-term can lead to significant cost to society. Although sedation and analgesia are considered only supportive therapy, several studies have shown that in patients on mechanical ventilation, different approaches can have significant impact on patient centered outcomes. However, to date, randomized clinical trials on critically ill patients have mostly evaluated the sedative agent but not the analgesic agent. Although morphine and its derivates are the most common used opioid analgesic agents in the critical care setting, only some retrospective studies and some prospective studies compared them head-to-head (ramifentanyl versus morphine and fentanyl versus morphine). Current guidelines recommend choosing the analgesic agent based on pharmacokinectics, physician experience and side-effects profile. To evaluate the differences of two standard-of-care analgosedation agents, the FenHydro trial will be a cluster randomized, pragmatic, pilot and feasibility superiority clinical trial in mechanically ventilated patients in the ICU. The main question the study hopes to answer is whether there is any difference in morphine milligram equivalents administered during mechanical ventilation.
Read the detailed description
Fentanyl is a synthetic derivate of morphine that is 100 times more potent than morphine, has a great lipid solubility leading to fast onset (one to two minutes), has a short half-life (up to three hours) and limited histamine release. It is metabolized by the liver and its excretion is not affected by the kidneys. Those characteristics allow fentanyl to be versatile and be used in many different scenarios in the ICU. Despite those advantages, concerns have been raised regarding adipose tissue accumulation, tachyphylaxis, CYP3A4 interaction and chest wall rigidity, particularly when on high doses.
Hydromorphone is an alternative analgesic agent. It is a semisynthetic morphine derivate that can be five to ten times more potent than morphine. It also has a fast onset (up to 10 minutes), a short half-life (up to three hours) and is less renally excreted than morphine. Some concerns have been raised regarding the accumulation of hydromorphone metabolites including hydromorphone-3-glucuronide, which can lead to neuroexcitatory effects and delirium. A few retrospective studies compared fentanyl and hydromorphone in the critical care setting. Due to the retrospective nature, small size of the studies and several imbalances in the groups, no significant conclusion can be drawn regarding the benefits and risks of fentanyl versus hydromorphone. However, the largest and most recent retrospective study, showed no difference in 28-day mechanical ventilation free days and death during mechanical ventilation.
Opioids currently used for analgosedation in mechanically ventilated ICU patients include morphine, fentanyl and hydromorphone. The selection of a specific agent as standard-of-care is determined by primary ICU team preference, logistics, patient characteristics and experience. Although small differences may affect the decision of one over the other, dosage reduction and close monitoring are used rather than switching to an alternative in most cases. Whether or not either of these agents afford additional meaningful clinical benefits, advantages or contribute to meaningful clinical outcomes has not been fully established in available literature and represents the basis for performing this clinical pilot study. Therefore, the investigators propose to study the use of fentanyl and hydromorphone in the critically ill population on mechanical ventilation due to the paucity of data comparing both medications head-to-head and their widespread use.
Between November 2025 and April 2026, all patients on mechanical ventilation admitted to the medical intensive care units (MICU) and Finard intensive care unit (FICU - medical and surgical ICU) at Beth Israel Deaconess Medical Center who are 18 years or older will be enrolled. The study will be pragmatic and randomization will be in two clusters. The MICU and the FICU will be randomized to an initial opioid (fentanyl or hydromorphone) in three-months blocks. The assigned opioid will be used as the first line agent of choice for analgosedation. The assigned opioid will be switched at the end of the three-months block. Since the study has a 6 months duration, each ICU will have 3 months with each opioid as first line for analgosedation. The investigators anticipate that 300 patients will be required for sample size.
- Being tested
- fentanyl, Hydromorphone
- Keywords
- Fentanyl, Hydromorphone, Mechanical ventilation, Intensive Care Unit, ICU, Analgosedation, Analgesia, Sedation
- Medical subject headings
- Agnosia
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
fentanylDrug
Suggested initial continuous infusion
- Route: Intravenous
- Dose: 0-200 mcg/hr (max 1,440 MME/day)
- Initial dose: 50mcg/hr
- Concentration: 50 mcg/mL
- Bolus: 50-200mcg up to every 5 minutes as needed
- Continuous infusion adjustment: Increase in the continuous infusion if sedation not at goal after 3 bolus doses, increase by 25 mcg/hr every 60 minutes
Titration of dose, initial dose, adjustments and bolus are just suggested. The primary team is allowed to modify them based on clinical judgement.
HydromorphoneDrug
Also called Dilaudid
Suggested initial continuous infusion
- Route: Intravenous
- Dose: 0-3 mg/hr (max 1,440 MME/day)
- Initial dose: 0.5mg/hr
- Concentration: 0.2 mg/mL
- Bolus: 0.5-2mg up to every 5 minutes as needed
- Continuous infusion adjustment: Increase in the continuous infusion if sedation not at goal after 3 bolus doses, increase by 0.25 mg/hr every 60 minutes
Titration of dose, initial dose, adjustments and bolus are just suggested. The primary team is allowed to modify them based on clinical judgement.
| Study group | Role | What they receive |
|---|---|---|
| Fentanyl as first line agent | Experimental | Patients in an ICU on a three-month period randomized to Fentanyl will have Fentanyl used as suggested first-line therapy for analgosedation, when clinically warranted. Receives: Drug: fentanyl |
| Hydromorphone as first line agent | Experimental | Patients in an ICU on a three-month period randomized to Hydromorphone will have Hydromorphone used as suggested first-line therapy for analgosedation, when clinically warranted. Receives: Drug: Hydromorphone |
What is being measured
The primary outcome is the main question the study is designed to answer.
Difference in daily MME dose received during mechanical ventilation period.
The daily MME dose will be calculated using all the opioid doses received during the day. The outcome will be obtained from the days patients were on mechanical ventilation. It will include not only the intervention medication, but also the additional boluses and alternate opioids, including cross-over drug. The doses will be converted into MME.
Measured: Assessed from enrollment (baseline) censored at day 28
Secondary outcomes (10)
All cause 28-day hospital mortality
Death before hospital discharge. Patients who were discharged prior to 28 days will be assumed to be alive.
Measured: 28 days after enrollment censored at hospital discharge
Days alive and free of mechanical ventilation at day 28
The ventilator free days will be counted as 28 minus the duration of mechanical ventilation in days for those patients who survived the 28 days. Patients discharged prior to 28 days will be assumed to be free of mechanical ventilation. Patients who died before 28 days will be assumed to have zero ventilation free days
Measured: 28 days after enrollment censored at hospital discharge
Days alive and free of ICU at day 28
Counted as 28 minus the days alive in the ICU. Patients discharged prior to 28 days will be assumed to be out of the ICU. Patients who died before 28 days will be assumed as zero ICU free days
Measured: 28 days after enrollment censored at hospital discharge
Days alive and free of vasopressors at day 28
Counted as 28 minus the days alive with intravenous vasopressors. Patients discharged prior to 28 days will be assumed to be off of vasopressors. Patients who die before 28 days will be assumed as zero vasopressors free days
Measured: 28 days after enrollment censored at hospital discharge
Difference in average daily dose of morphine milligram equivalent required during the first 28 days
Will be calculated based on daily average dose through 28 days of the intervention drug and other opioids received during hospital admission. The dose of opioids used on the comfort measures period for those patients that were transitioned to comfort measures will not be considered for the outcome analysis. Patients discharged prior to 28 days of enrollment will be considered to have 0 morphine milligram equivalent per day after discharge.
Measured: 28 days after enrollment censored at hospital discharge
Percentage of time without coma and delirium during the ICU stay
Assessed daily by RASS and CAM-ICU by nurses at the bedside during ICU stay. A positive day for coma is RASS of -3 or less and delirium is considered as RASS of 3 or more or positive CAM-ICU. Percentage will be obtained by dividing the number of days without coma and delirium by the numbers of ICU days.
Measured: Assessed from enrollment (baseline) censored at day 28
Days alive and free of restraints at 28 days
Counted as 28 minus the days alive with need for restraints. Patients discharged prior to 28 days will be assumed to be off of restraints. Patients who die before 28 days will be assumed as zero restraints free days.
Measured: 28 days after enrollment censored at hospital discharge
Daily Average number of Bowel Movements through ICU stay
Will be measured by the number of bowel movements per day during the ICU stay. In patients with rectal tube, 1 bowel movement will be considered to have least 100mL and a maximum of 250mL of stools.
Measured: Assessed from enrollment (baseline) censored at day 28
Need for tracheostomy during hospital stay or 28 days
Incidence of tracheostomy required during hospital stay or 28 days
Measured: Hospital stay or 28 days (whichever comes first)
Days alive and out of hospital
Counted as 28 minus the days alive in the hospital. Patients who died before 28 days will be assumed as zero ICU free days
Measured: 28 days after enrollment censored at hospital discharge
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted4 Nov 2025
- Study start3 Nov 2025
- Primary completion30 May 2026
- Study completion30 Jun 2026
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Mechanical VentilationStudies of the same condition, open and under way.
- More trials run by Beth Israel Deaconess Medical CenterThe 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
- Interventional
- Phase
- Phase 2
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Crossover
- Model description
- Randomization will occur at the level of the ICU, rather than for each individual patient. Cluster I (MICU A, B, C) and cluster II (FICU) will be randomized to start from a period with fentanyl or hydromorphone and after 3 months will be crossed over to the other group. The process will be repeated during the study period. Cluster cross-over are planned to be 3 months to avoid seasonal variability. The investigators plan to start the enrollment in the middle of a season, so that the clusters have 1.5 months of each season. No washout period is planned.
- Masking
- Single blind
- Who is masked
- Outcomes assessor
- Enrolment
- 319 participants (actual)
Sponsor and investigators
- Lead sponsor
- Beth Israel Deaconess Medical Center
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Elias Baedorf Kassis, Beth Israel Deaconess Medical Center
- Investigators
- Elias N Baedorf-Kassis, MD, Principal investigator, Beth Israel Deaconess Medical Center
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07224620
- Sponsor's protocol ID
- 2025P000456
- Acronym
- FenHydro
- Status last verified
- May 2026
- First submitted
- 28 Oct 2025
- Last updated
- 14 Jul 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- Yes
- FDA-regulated device
- No
- Individual data sharing
- Yes: Requests for secondary use of the dataset can be made by emailing Dr. Eduardo Padrao. The data available will be identified.
Study at a glance
From the registry record, last updated by the sponsor on 14 Jul 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Fentanyl Versus Hydromorphone as First Line Strategy in Patients on Mechanical Ventilation, a Pilot Pragmatic Randomized Superiority Clinical Trial: the FenHydro Trial
- ClinicalTrials.gov ID
- NCT07224620
- Acronym / sponsor ID
- FenHydro / 2025P000456
- Keywords
- Fentanyl, Hydromorphone, Mechanical ventilation, Intensive Care Unit, ICU, Analgosedation, Analgesia, Sedation
- Phase
- Phase 2
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 319 participants (actual)
- Lead sponsor
- Beth Israel Deaconess Medical CenterUniversity, hospital or other
- Study start
- 3 Nov 2025 (actual)
- Primary completion
- 30 May 2026 (actual)
- Study completion
- 30 Jun 2026 (actual)
- First posted
- 4 Nov 2025 (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.
Patients with respiratory failure who require mechanical ventilation are not only at risk of death, but also of complications of prolonged ICU stay. Patients may have significant functional decline, impact in quality of life, develop psychiatric disorders and at long-term can lead to significant cost to society. Although sedation and analgesia are considered only supportive therapy, several studies have shown that in patients on mechanical ventilation, different approaches can have significant impact on patient centered outcomes. However, to date, randomized clinical trials on critically ill patients have mostly evaluated the sedative agent but not the analgesic agent. Although morphine and its derivates are the most common used opioid analgesic agents in the critical care setting, only some retrospective studies and some prospective studies compared them head-to-head (ramifentanyl versus morphine and fentanyl versus morphine). Current guidelines recommend choosing the analgesic agent based on pharmacokinectics, physician experience and side-effects profile. To evaluate the differences of two standard-of-care analgosedation agents, the FenHydro trial will be a cluster randomized, pragmatic, pilot and feasibility superiority clinical trial in mechanically ventilated patients in the ICU. The main question the study hopes to answer is whether there is any difference in morphine milligram equivalents administered during mechanical ventilation.
Detailed description
Fentanyl is a synthetic derivate of morphine that is 100 times more potent than morphine, has a great lipid solubility leading to fast onset (one to two minutes), has a short half-life (up to three hours) and limited histamine release. It is metabolized by the liver and its excretion is not affected by the kidneys. Those characteristics allow fentanyl to be versatile and be used in many different scenarios in the ICU. Despite those advantages, concerns have been raised regarding adipose tissue accumulation, tachyphylaxis, CYP3A4 interaction and chest wall rigidity, particularly when on high doses.
Hydromorphone is an alternative analgesic agent. It is a semisynthetic morphine derivate that can be five to ten times more potent than morphine. It also has a fast onset (up to 10 minutes), a short half-life (up to three hours) and is less renally excreted than morphine. Some concerns have been raised regarding the accumulation of hydromorphone metabolites including hydromorphone-3-glucuronide, which can lead to neuroexcitatory effects and delirium. A few retrospective studies compared fentanyl and hydromorphone in the critical care setting. Due to the retrospective nature, small size of the studies and several imbalances in the groups, no significant conclusion can be drawn regarding the benefits and risks of fentanyl versus hydromorphone. However, the largest and most recent retrospective study, showed no difference in 28-day mechanical ventilation free days and death during mechanical ventilation.
Opioids currently used for analgosedation in mechanically ventilated ICU patients include morphine, fentanyl and hydromorphone. The selection of a specific agent as standard-of-care is determined by primary ICU team preference, logistics, patient characteristics and experience. Although small differences may affect the decision of one over the other, dosage reduction and close monitoring are used rather than switching to an alternative in most cases. Whether or not either of these agents afford additional meaningful clinical benefits, advantages or contribute to meaningful clinical outcomes has not been fully established in available literature and represents the basis for performing this clinical pilot study. Therefore, the investigators propose to study the use of fentanyl and hydromorphone in the critically ill population on mechanical ventilation due to the paucity of data comparing both medications head-to-head and their widespread use.
Between November 2025 and April 2026, all patients on mechanical ventilation admitted to the medical intensive care units (MICU) and Finard intensive care unit (FICU - medical and surgical ICU) at Beth Israel Deaconess Medical Center who are 18 years or older will be enrolled. The study will be pragmatic and randomization will be in two clusters. The MICU and the FICU will be randomized to an initial opioid (fentanyl or hydromorphone) in three-months blocks. The assigned opioid will be used as the first line agent of choice for analgosedation. The assigned opioid will be switched at the end of the three-months block. Since the study has a 6 months duration, each ICU will have 3 months with each opioid as first line for analgosedation. The investigators anticipate that 300 patients will be required for sample size.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Crossover
- Masking
- Single blind (outcomes assessor)
- Number of arms
- 2
- Model description
- Randomization will occur at the level of the ICU, rather than for each individual patient. Cluster I (MICU A, B, C) and cluster II (FICU) will be randomized to start from a period with fentanyl or hydromorphone and after 3 months will be crossed over to the other group. The process will be repeated during the study period. Cluster cross-over are planned to be 3 months to avoid seasonal variability. The investigators plan to start the enrollment in the middle of a season, so that the clusters have 1.5 months of each season. No washout period is planned.
| Arm | Type | Receives |
|---|---|---|
| Fentanyl as first line agent | Experimental | Drug: fentanylPatients in an ICU on a three-month period randomized to Fentanyl will have Fentanyl used as suggested first-line therapy for analgosedation, when clinically warranted. |
| Hydromorphone as first line agent | Experimental | Drug: HydromorphonePatients in an ICU on a three-month period randomized to Hydromorphone will have Hydromorphone used as suggested first-line therapy for analgosedation, when clinically warranted. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (3 listed)
- Admitted to either MICU A, B, C or FICU at Beth Israel Deaconess Medical Center
- Requiring mechanical ventilation
- Felt by primary team to require opioid infusion for analgosedation
Key exclusion criteria (4 listed)
- Age < 18 years old
- Do not intubate orders prior to enrollment
- Comfort measures only
- Contraindication to fentanyl or hydromorphone
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 |
|---|---|---|
| fentanylSuggested initial continuous infusion * Route: Intravenous * Dose: 0-200 mcg/hr (max 1,440 MME/day) * Initial dose: 50mcg/hr * Concentration: 50 mcg/mL * Bolus: 50-200mcg up to every 5 minutes as needed * Continuous infusion adjustment: Increase in the continuous infusion if sedation not at goal after 3 bolus doses, increase by 25 mcg/hr every 60 minutes Titration of dose, initial dose, adjustments and bolus are just suggested. The primary team is allowed to modify them based on clinical judgement. | Drug | Fentanyl as first line agent |
| HydromorphoneAlso: DilaudidSuggested initial continuous infusion * Route: Intravenous * Dose: 0-3 mg/hr (max 1,440 MME/day) * Initial dose: 0.5mg/hr * Concentration: 0.2 mg/mL * Bolus: 0.5-2mg up to every 5 minutes as needed * Continuous infusion adjustment: Increase in the continuous infusion if sedation not at goal after 3 bolus doses, increase by 0.25 mg/hr every 60 minutes Titration of dose, initial dose, adjustments and bolus are just suggested. The primary team is allowed to modify them based on clinical judgement. | Drug | Hydromorphone as first line agent |
Primary outcome
Difference in daily MME dose received during mechanical ventilation period.
Time frame: Assessed from enrollment (baseline) censored at day 28
The daily MME dose will be calculated using all the opioid doses received during the day. The outcome will be obtained from the days patients were on mechanical ventilation. It will include not only the intervention medication, but also the additional boluses and alternate opioids, including cross-over drug. The doses will be converted into MME.
10 secondary outcomes
All cause 28-day hospital mortality
Time frame: 28 days after enrollment censored at hospital discharge
Days alive and free of mechanical ventilation at day 28
Time frame: 28 days after enrollment censored at hospital discharge
Days alive and free of ICU at day 28
Time frame: 28 days after enrollment censored at hospital discharge
Days alive and free of vasopressors at day 28
Time frame: 28 days after enrollment censored at hospital discharge
Difference in average daily dose of morphine milligram equivalent required during the first 28 days
Time frame: 28 days after enrollment censored at hospital discharge
Percentage of time without coma and delirium during the ICU stay
Time frame: Assessed from enrollment (baseline) censored at day 28
Days alive and free of restraints at 28 days
Time frame: 28 days after enrollment censored at hospital discharge
Daily Average number of Bowel Movements through ICU stay
Time frame: Assessed from enrollment (baseline) censored at day 28
Need for tracheostomy during hospital stay or 28 days
Time frame: Hospital stay or 28 days (whichever comes first)
Days alive and out of hospital
Time frame: 28 days after enrollment censored at hospital discharge
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 14 Jul 2026.
- Individual participant dataSharing planned: Yes. Requests for secondary use of the dataset can be made by emailing Dr. Eduardo Padrao. The data available will be identified.
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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.
Elias N Baedorf-Kassis, MD principal investigator
Beth Israel Deaconess Medical Center
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 2 study testing fentanyl and Hydromorphone in people with Mechanical Ventilation and Sedation and Analgesia, run by Beth Israel Deaconess Medical Center at 1 site 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 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: finished, as of the sponsor's last update on 14 Jul 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site 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.
What does this phase mean?
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
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?
Difference in daily MME dose received during mechanical ventilation period. (time frame: Assessed from enrollment (baseline) censored at day 28). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
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 14 Jul 2026.