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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




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"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : UC20 - UC23 Full Version

Efficacy of Stroke Volume Variation-guided Fluid Management of Patients undergoing Off-pump Coronary Artery Bypass Grafting: An Observational Comparative Study between Open and Closed Chest


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59603.17275
Shilpa Durge, Nazmeen Imranali Sayed, Shakuntala Basantwani

1. Senior Resident, Department of Anaesthesiology, Apollo Hospital, Bilaspur, Chhattisgarh, India. 2. Associate Professor, Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. 3. Additional Professor, Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.

Correspondence Address :
Dr. Nazmeen Imranali Sayed,
B 1201, The Springs, Roadpali Road, Kalamboli, Sector 20, Panvel, Navi Mumbai-428108, Maharashtra, India.
E-mail: drnazmeensayed@gmail.com

Abstract

Introduction: Functional haemodynamic monitoring using dynamic parameter such as Stroke Volume Variation (SVV), based on pulse contour analysis, helps in predicting fluid responsiveness in off-pump Coronary Artery Bypass Grafting (CABG) surgery. This allows adequate volume replacement to achieve optimal cardiac performance.

Aim: To evaluate the efficacy of SVV in predicting volume responsiveness and effect on haemodynamic variable in patients undergoing off-pump CABG in both closed and open chest.

Materials and Methods: This single-centre, non randomised observational study was conducted at a tertiary medical college and hospital (LokmanyaTilak Municipal Medical College and General Hospital) Mumbai, Maharashtra, India, from December 2016 to December 2018. A total of 34 patients undergoing elective off-pump CABG were included. Haemodynamic measurements Stroke Volume (SV), Cardiac Output (CO), Cardiac Index (CI), and SVV, were recorded with the transducer positioned at the level of midaxillary line. If the SVV was equal to or higher than 12, 100 mL fluid aliquot was given to patients. Endpoints for fluid aliquots was increase in CO by 15%, decrease in SVV of less than 12 or an increase Central Venous Pressure (CVP) upto 15 millimetre of mercury (mmHg). Number of times SVV above 12 during the procedure was recorded. SVV was considered as fluid responsive “if there was an increase in SV by 5%”. Statistical analysis was done using Student’s t-test (two tailed, dependent) on continuous parameters. The p-value <0.05, was considered significant.

Results: Out of 103 events of rise in SVV, 65 (63.1%) occurred when chest was open and 38 (36.9%) while chest was closed. The SVV-guided fluid response was 76.3% in closed chest and 75.4% in open chest and there was no significant difference. (p-value=0.91). There was a significant increase in SV (p-value <0.01), CO (p-value=0.04), and significant decrease in SVV (p-value <0.01) and heart rate (p-value <0.01) after fluid loading in the responsive group when compared with non responsive group. There was no statistically significant difference between percentage change in SV, CO, CI, SBP, DBP, MAP and CVP between closed and open chest conditions after fluid replacement.

Conclusion: The SVV is not affected by open or closed chest conditions in mechanically ventilated patients undergoing CABG and can be used as a guide for fluid replacement. Weather open or closed chest conditions, few patients do not respond to fluid replacement when SVV are more than 12 by an increase in SV, cardiac output or CI, the cause of which remains to be determined.

Keywords

Dynamic parameter, Flotrac vigileo device, Preload variables

Adequate volume replacement to achieve optimal performance is a primary goal of haemodynamic management of patients undergoing cardiac surgery. In off-pump CABG the open chest causes evaporative loss of fluid. Blood loss occurs during sternotomy, harvesting of Internal Mammary Artery (IMA) and saphenous vein as well as during coronary anastomosis. Preoperative fasting, induction of general anaesthesia, diuretics, intraoperative bleeding may decrease intravascular volume. Hypotension can be caused by hypovolaemia or due to decrease ventricular function. Intraoperative CO may be very low if the negative fluid balance is not minimised whereas excessive fluid results in pulmonary oedema in a patient with weak heart. Judicial fluid replacement increases the CO, maintain tissue perfusion and provide haemodynamic stability during heart positioning and anastomosis (1). The positive intrathoracic pressure generated during inspiration in mechanically ventilated patients causes compression of the major blood vessels. Reduced preload due to venous compression added-on with aortic compression results in decreased SV. During expiration the compression on major blood vessel is reduced implying larger SV. This indicate that SVV occur within a respiratory cycle (2),(3).

Hypovolaemia increases the collapsibility of the venous system, thus increasing the SVV whereas adequate volume status or hypovolaemia makes veins non collapsible, negating the changes on CO with cyclic changes of respiration. Hypovolaemia also puts right ventricle and left ventricle on ascending portion of Frank-Starling curve. Thus changes in preload that occur with respiration have a more pronounced effect on SV and arterial pressure reflecting as higher SVV (4). Overall SVV variation can be an excellent continous parameter to monitor fluid status of a patient. After sternotomy when the pericardium is open, the heart is open to atmosphere thus negating the effect of intrathoracic pressure on venous return and ventricular preload and modifying the cardiopulmonary interactions (5).

Due to the fluid shifts, off-pump CABG may be pushing the patients towards the steeper Frank-Starling’s curve thus making SVV more pronounced. In other words, the effect of intrathoracic pressure on venous return in open chest may be overwhelmed by deficit (6).

Some studies have shown that SVV correlates with preload status in open chest as well (5),(6). Vigileo system is an automatic and continuous monitoring of CO based on pulse contour analysis. The Vigileo monitor with Flotrac sensor can display key flow parameter such as CO, SV, SVV, and CI (7),(8). In mechanically ventilated patients, the present prospective observational study was designed to compare efficacy of SVV (acquired from vigileo Flotrac device) guided fluid management of patients undergoing off-pump CABG in closed as well as open chest conditions. The primary aim of efficacy in the study was defined as the number of times SVV more than 12 responded to fluid replacement in patients by an increase in SV equal to or more than 5%. The secondary aim of the study was to evaluate the clinical benefits in terms of SV, CO, CI, and haemodynamic variable after SVV guided fluid replacement.

Material and Methods

This singe-centre non randomised comparative observational study was conducted at Lokmanya Tilak Municipal Medical College and General Hospital Mumbai Maharashtra India, from December 2016 to December 2018. Institutional Review Board and Human Research Ethic Committee approval was obtained. This trial has been registered in Clinical Trial Registry–India (CTRI/2017/04/0139995).

Inclusion criteria: Patients aged more than 18 years planned for elective off-pump CABG procedure under general anaesthesia were included in the study.

Exclusion criteria: Patients with American Society of Anaesthesiology (ASA) grade IV, Left ventricular ejection fraction less than 30%, preoperative dysrhythmias, valvular heart disease, intracardiac shunt, severe pulmonary artery hypertension, severe obstructive lung disease were excluded from the study. Withdrawal criterion were patients requiring Intra-Aortic Balloon Pump (IABP), patients requiring cardiopulmonary bypass and patients developing persistent arrhythmias.

Based on above assumptions a sample size of 103 completed cases was needed to assess the study objective at 80% power and 5% level of significance using formula:

N=4×Z21-a/2×S2/ W2

Study Procedure

After application of routine haemodynamic monitor according to institute protocol (pulse oximetry, 5 lead ECG, non invasive Blood Pressure (BP) monitoring) patient was sedated before securing arterial and central venous line. A transducer (Flo Trac Edward lifesciencesR) was connected to radial artery on one end and to vigileo system on the other hand. Haemodynamic variable CO, CI, SV and SVV were obtained. Vigileo monitor with Flotrac sensor was used for continuous monitoring of CO based on pulse contour analysis. After induction of anaesthesia and tracheal intubation, patients were mechanical ventilated with a tidal volume of 6-8 mL/kg to maintain end expiratory CO2 of 32-35 mmHg during the surgery. Crystalloids were started at 4 mL per kg per hour. SVV was monitored continuously. Number of times SVV rose above 12 during the procedure was recorded. If the SVV was equal to or higher than 12, fluid aliquots of 100 mL were given. Endpoint for fluid aliquots was increase in CO by 15%, decrease in SVV of less than 12 or increase in CVP up to 15 mmHg. SVV was considered fluid responsive if there was an increase in SV by 5% or more. Change in CO, CI, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) and SV after fluid aliquots was recorded.

Sample size calculation (9): Sample size for a descriptive study of a continuous variable with Confidence level=95%, W=6 (Desired total width of confidence interval), and S=15.5 (Standard deviation of the variable). W/S=0.39. Standard normal deviate for α=Z(1-α/2)=1.96.

Statistical Analysis

After data collection, data entry was done in Microsoft excel. Data analysis was done with the help of Statistical Package for Social Science (SPSS) software for window version 10.0. Student’s t-test used to find the significance of study parameters on continuous scale within each group.

Results

Total 50 patients were enrolled for study. Eight patients were excluded and eight patients were withdrawn from the study. Finally, data of 34 patients and 103 episodes of raised SVV (more than 12) were analysed. (Table/Fig 1) shows CONSORT flow diagram. (Table/Fig 2) show demographic data.

Out of 103 times that the fluid replacement was given, SVV was responsive in 78 (75.73%). The mean decrease in SVV was 49.86% (SD=13.77) in responsive group versus 12.96% (SD=13.13) in non responsive group (p-value <0.01). Responsive and non responsive after fluid loading differed significantly in their CO (p-value=0.04), SV (p-value <0.01), HR (p-value <0.01), but not in CVP, SBP, DBP, MAP, CI (Table/Fig 3).

Out of 103 events of rise in SVV, 65 (63.1%) occurred when chest was open and 38 (36.9%) while chest was closed. The SVV-guided fluid response was 76.3% in closed chest and 75.4% in open chest and there was no significant difference (p-value=0.91) (Table/Fig 4).

The baseline parameters including baseline CVP, were comparable among closed and open chest condition in responsive fluid loading except for prefluid loading SVV. Mean baseline SVV in responsive fluid loading was 19.10% (SD-6.13%) in closed chest as compared to 16.69% (SD-3.51%) in open chest (Table/Fig 5).

There was no statistically significant difference between percentage change in SV, CO, CI, SBP, DBP, MAP and CVP between open chest and open chest conditions (Table/Fig 6).

No significant correlation was found in amount of fluid required and increase in SV (p=0.062) in responsive group (Table/Fig 7).

Discussion

The SVV is preload dependent variable that occurs during the respiratory cycle which is estimated from arterial pressure waveform (10). In the present study, authors compared the SVV guided fluid responsiveness in closed and open chest condition. There is more evaporative fluid loss, leading to fluid deficit, in open than closed chest conditions and this was reflected by more episodes of rise in SVV (65) in open than closed (38) chest conditions. The response to SVV guided fluid replacement was not significantly different in open or closed chest conditions. The rise in SVV more than 12% was responsive to fluid replacement with increase in SV and CO in 76.3% in closed and 75.4% in open chest conditions. The results of this study showed that SVV can be a useful indicator of fluid deficit in closed as well as open chest conditions in patients undergoing off-pump CABG.

Two factors seem to be responsible for SVV, the cycling intrathoracic pressure and a low intravascular volume. Open heart conditions with sternotomy and pericardectomy reduces the effect cycling intrathoracic pressure on major blood vessels but does not obliterate it. This is reflected in present study by a lower mean prefluid SVV (16) in open as compared to closed (19) chest conditions. One can explain this from basic anatomy. 50 percent of SVC and the two brachiocephalic veins are extrapericardial (11). The short intrathoracic course of IVC is both intra and extrapericardial. The posterior aspect of intrapericardial inferior vena cava is not covered by the pericardium (12). Hence, open pericardectomy may not abolish the effect of cyclic intrathoracic pressure on these vessels.

Another explanation is that the decrease in preload conditions during inspiration may be simple compression of small pulmonary vessels and capillaries as a study has shown that application of peep resulted in similar fall in arterial pressure in closed-chest and lateral thoracotomy conditions (13). Hence, compression of these extrathoracic major veins and small pulmonary vasculature by the lungs during inspiration may be responsible for the decrease in venous return during ventilation in open chest (5).

On further analysis of present study there was no significant difference in prefluid bolus conditions (CVP, HR, SBP, DBP, MAP, SV, CO, CI) in the responsive group in closed as well as open chest conditions except the SVV value as discussed above. There was no significant difference in the percentage change in the above parameters in the closed and open chest group making the authors state that whatever be the reason for SVV, it was not affected by the chest being open or closed. Whereas, De Waal EE et al., found all static and dynamic preload indicators fail to predict fluid responsiveness under open chest conditions (14). They have given a fluid challenge immediately after sternotomy. Sternotomy with sternal retractors squeezes the pulmonary blood into the left atrium adding to preload and decreasing in SVV (14). This explains the low SVV before fluid challenge in the above study and their non responsive result in open chest.

Now coming to secondary aim, there was an increase in SBP, DBP, MAP, SV, CO, CI and decrease in HR and SVV after fluid replacement in both open and closed chest conditions in the responsive group. Change in SVV, SV, CO, was significantly different in responsive group than non responsive group. But the increase in SBP, DBP, MAP, and CI was not significantly different from non responsive group. Other studies have shown similar results with a percentage of raised SVV to respond to fluid replacement with increase in CO and CI but there were some non responders (15),(16). Though, SBP and DBP increased after fluid loading in responsive and non responsive group, the difference was statistically insignificant. As the blood pressure is not only a component of CO but also interplay of sympathetic system, the pressures in the non responsive group may have been maintained.

Limitation(s)

There was no difference in the change in CVP between fluid responders and non responders. Use of pulmonary artery capillary wedge pressure would have given a more precise difference in left ventricular preload.

Conclusion

The SVV, are not affected by open or closed chest conditions in mechanically ventilated patients undergoing CABG and can be used as a guide for fluid replacement. Weather open or closed chest conditions, few patients do not respond to fluid replacement when SVV are more than 12% by an increase in SV, cardiac output or CI, the cause of which remains to be determined.

References

1.
Heames RM, Gill RS, Ohri SK, Heat DA. Off-pump coronary artery surgery. Anaesthesia. 2002;57:676-85. [crossref] [PubMed]
2.
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DOI and Others

DOI: 10.7860/JCDR/2022/59603.17275

Date of Submission: Aug 10, 2022
Date of Peer Review: Sep 13, 2022
Date of Acceptance: Nov 17, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 24, 2022
• Manual Googling: Sep 19, 2022
• iThenticate Software: Oct 06, 2022 (5%)

ETYMOLOGY: Author Origin

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