Deep SedationNCT06436638
Comparison of Nasal Continuous Positive Airway Pressure (CPAP) Mask and Nasal Airway in Molar Tooth Extraction Under Deep Sedation
An observational study of Deep Sedation and Non-invasive Ventilation Support, run by Gözde Nur Erkan at 2 sites in Turkey (Türkiye).
Trial summary
In patients with high levels of fear and anxiety, it is recommended to perform dental procedures under sedation or general anesthesia depending on the nature of the procedure. In dental treatment under anesthesia, it is important that the procedure is comfortable and well tolerated by the patient. Read more about this study
- Who is it for?
- Ages 18 to 60 years
- Conditions the study is for
- Deep Sedation, Non-invasive Ventilation Support, Nasal Airway
- What is being tested?
- Non-invasive ventilation support equipment
- Type of treatment
- Medical device
- How many people
- 60 participants
- Where
- 2 sitesTurkey (Türkiye)
- Study dates
- 2 Jul 2024to Jun 2026
- Phase
- Observational
- Are there results?
- Not yet: the study is under way
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 60 years
- All sexes
- No healthy volunteers
- Adult
Study population: It is planned to investigate patients with a diagnosis of impacted molars, who have an indication for dental extraction, and who are scheduled for dental extraction under sedation.
Who may be able to join
- Volunteer adult patients aged 18-60 years
- Patients scheduled for impacted tooth extraction
- Cases with surgical time ≥20 minutes and ≤60 minutes
- American Society of Anaesthesiologists (ASA) physical status I and II patients
- Patients with BMI≤30
Who cannot join
- Patients under 18 years old-over 60 years old
- Surgeries with a procedure time over 1 hour or less than 20 minutes
- American Society of Anaesthesiologists (ASA) physical status III and higher patients
- Presence of conditions such as mental retardation that impair the patient's ability to make decisions about himself/herself
- Patients with respiratory system diseases such as asthma, chronic obstructive pulmonary disease (COPD) or airway hyperreactivity
- Patients with a condition that severely narrows the nasal passage opening (e.g. adenoid hypertrophy, etc.)
- Patients with BMI>30
- Patients who refused to participate in the study
Trial locations and contacts
2 sites in 1 country. Contact the study team or a site near you to ask about taking part.
Turkey (Türkiye)2 sites, 2 recruiting
- Recruiting
Erciyes University Faculty of Dentistry
Kayseri
Dilek Günay Canpolat, dgcanpolat@gmail.com
- Recruiting
Kırıkkale University Faculty of Dentistry
Kirikkale
Gözde Nur Erkan, +903182244927 ext. 7140, dr.gozdenur@gmail.com
About this study
Official title: Comparison of Nasal Continuous Positive Airway Pressure (CPAP) Mask and Nasal Airway in Terms of Intraoperative Anesthesia Quality and Postoperative Associated Complications in Impacted Molar Tooth Extraction Patients Under Deep Sedation; A Multi-Center Study
In patients with high levels of fear and anxiety, it is recommended to perform dental procedures under sedation or general anesthesia depending on the nature of the procedure. In dental treatment under anesthesia, it is important that the procedure is comfortable and well tolerated by the patient. In addition, patient comfort is important in all dental procedures to prevent the development of avoidance behavior.
During dental procedures performed under anesthesia, the oral cavity is completely within the scope of the surgical or procedure field. In this respect, sedation and general anesthesia in dental procedures and operations have specific risks and challenges.Since there is a risk of respiratory depression, hypoxia and hypercarbia during deep sedation, non-invasive ventilation support provided to patients with airway devices would be beneficial. In the research clinics where the study will be conducted, deep sedation with non-invasive mechanical ventilation support using a nasal CPAP (Continuous Positive Airway Pressure) mask or nasal airway is applied during the extraction of impacted molars. Thus, many dental procedures are routinely performed under deep sedation without the need for general anesthesia. There are very limited data in the literature on the use of a nasal CPAP mask during sedation for different procedures in patients with obstructive sleep apnea or obesity. However, no study comparing ventilation support during deep sedation with nasal CPAP mask and nasal airway has been found in the literature.
Read more
The aim of this study is to compare the non-invasive ventilation support provided with 2 different airway devices during the procedure in terms of intraoperative and postoperative related complications, ventilation parameters, patient and surgeon satisfaction.
The hypothesis of the study is that two different ventilation support methods during deep sedation may be superior to each other in terms of anesthesia quality, postoperative complications related to airway devices, patient and surgeon satisfaction.
In the study, a total of 60 patients (Group airway, n;30, Group Mask, n;30) from 2 centers are planned to be included in the study by performing power analysis with a statistical power of the trial >0.8.
The permutation method will be applied within the scope of the restricted randomization method to determine the group of patients to be included.
Read the detailed description
In the study to be conducted in two dental faculties, it is planned to use a total of 60 patient data, 30 patients with nasal CPAP mask and 30 patients with nasal airway. In the centers where the study will be conducted, deep sedation during dental procedures with ventilatory support via nasal airway and nasal CPAP mask, which will be compared in the study, is applied in routine practice. In this context, anxiolysis with 2 mg IV midazolam is administered to the patients before they are taken to the operating room on the day of the procedure. Patients are administered 1.5 mg/kg propofol and 0.5 mcg/kg fentanyl intravenously for sedation induction. Non-invasive ventilation support is then applied with a nasal airway or nasal CPAP mask and ventilation parameters are screened. Sevoflurane at 1 MAC (minimum alveolar concentration) level is administered inhalationally for sedation maintenance and the level of sedation is evaluated using the Ramsey sedation scale. Surgical dental extraction procedures between 20-60 minutes will be included in the study. For postoperative analgesia, paracetamol 1 g and dexketoprofen trometamol 50 mg are administered intravenously. The data planned to be collected within the scope of the study are blood pressure, heart rate, peripheral oxygen saturation (number of desaturation episodes), respiratory rate, ventilation parameters (Tidal volume (TV); set and actual, minute volume , end tidal CO2-EtCO2, and Peak pressure (Peak P). The total dose of agents used for sedation will also be recorded. During the post-operative follow-up period, the presence of nausea-vomiting, nasal pain, dryness in the nasal mucosa, epistaxis, sore throat, and dryness in the throat will be evaluated. Patient and surgeon satisfaction scores will be recorded.
- Conditions
- Deep Sedation, Non-invasive Ventilation Support, Nasal Airway, Nasal CPAP Mask, Impacted Molar
- Being tested
- Non-invasive ventilation support equipment
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Non-invasive ventilation support equipmentDevice
Non-invasive ventilation support is provided by nasal airway and nasal CPAP mask to avoid respiratory complications such as hypoxia, desaturation, hypercarbia, respiratory depression etc. during extraction of impacted molars under deep sedation.
| Study group | Role | What they receive |
|---|---|---|
| Group Airway | Group to receive non-invasive ventilation support via nasal airway during dental extraction under deep sedation. Receives: Device: Non-invasive ventilation support equipment | |
| Group Mask | Group to receive non-invasive ventilation support via nasal CPAP mask during dental extraction under deep sedation Receives: Device: Non-invasive ventilation support equipment |
What is being measured
The primary outcome is the main question the study is designed to answer.
Non-invasive blood pressure
It is planned to record non-invasive blood pressure values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Changes in blood pressure above 20% from baseline will be recorded additionally.
Measured: Intraoperative period and for 4 hours after surgery
ECG
It is planned to record heart rate values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Changes in heart rate greater than 20% of baseline will be recorded additionally.
Measured: Intraoperative period and for 4 hours after surgery
Peripheral oxygen saturation
It is planned to record peripheral oxygen saturation values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Hypoxia (SpO2<90%) will be recorded additionally.
Measured: Intraoperative period and for 4 hours after surgery
Respiratory rate
It is planned to record respiratory rate values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Respiratory depression will be recorded additionally.
Measured: Intraoperative period and for 4 hours after surgery
Number of interruptions for an anesthesia-related reason
Number of episodes during deep sedation when the procedure has to be interrupted due to desaturation or patient movement will be recorded
Measured: Intraoperative period
Tidal volume
During non-invasive ventilatory support, set and actual tidal volume values will be recorded at regular intervals during the operation.
Measured: Intraoperative period
Peak pressure
During non-invasive ventilatory support, peak pressure values will be recorded at regular intervals during the operation.
Measured: Intraoperative period
End tidal carbon dioxide level (EtCO2)
During non-invasive ventilatory support, end tidal carbon dioxide values will be recorded at regular intervals during the operation.
Measured: Intraoperative period
Minute ventilation
During non-invasive ventilatory support, minute ventilation values will be recorded.
Measured: Intraoperative period
Secondary outcomes (4)
Postoperative complications related non-invasive ventilation support devices and sedation
During the recovery unit and inpatient ward follow-up, patients will be monitored for the presence of nausea/vomiting, pain and/or itching/dryness in the nose and/or throat. A 10-point Likert scale would be used for nausea and vomiting assessment (0 points: No nausea, 1-2 points: Very mild nausea, 3-4 points: Mild nausea, 5-6 points: Moderate nausea, 7-8 points: Severe nausea and 9-10 points: worst nausea). For pain, a 10-point visual analog scale would be used. Additionally, the development of epistaxis will be recorded.
Measured: During the next 3 hours after the end of the operation
Patient and surgeon satisfaction
Using a 5-point Likert scale, the satisfaction level of the patients and the surgeon will be questioned and recorded. In the Likert scale, 5 indicates the highest level of satisfaction and 1 indicates the lowest level of satisfaction.
Measured: Perioperative period
Total dose of medications used for sedation during the procedure
The total dose of anesthetic medications required to provide a depth of sedation with a Ramsey sedation score of 5 or higher during the surgical procedure will be recorded
Measured: Intraoperative period
Recovery duration from anesthesia
The time until the Modified Aldrete Score is 9 or higher during the recovery period
Measured: From the end of the operation until discharge to the ward
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted31 May 2024
- Study start2 Jul 2024
- Primary completionMay 2026 (estimated)
- Study completionJun 2026 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (3)Papers the sponsor has linked to this study.
- Other trials for Deep SedationStudies of the same condition, open and under way.
- 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
- 60 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Gözde Nur Erkan
- Sponsor type
- University, hospital or other
- Collaborators
- TC Erciyes University, Kırıkkale University
- Responsible party
- Sponsor-investigator, Gözde Nur Erkan, Kırıkkale University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06436638
- Sponsor's protocol ID
- KU-ERKAN-001
- Status last verified
- Aug 2025
- First submitted
- 10 May 2024
- Last updated
- 20 Mar 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016 Mar 10;8:35-50. doi: 10.2147/CCIDE.S63626. eCollection 2016.
PubMed 27022303Cukierman DS, Perez M, Guerra-Londono JJ, Carlson R, Hagan K, Ghebremichael S, Hagberg C, Ge PS, Raju GS, Rhim A, Cata JP. Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial. J Clin Anesth. 2023 Oct;89:111196. doi: 10.1016/j.jclinane.2023.111196. Epub 2023 Jul 3.
PubMed 37406462Bai Y, Xu Z, Chandrashekar M, St Jacques PJ, Liang Y, Jiang Y, Kla K. Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial. Eur J Anaesthesiol. 2019 Sep;36(9):633-640. doi: 10.1097/EJA.0000000000001052.
PubMed 31313720
Study at a glance
From the registry record, last updated by the sponsor on 20 Mar 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Comparison of Nasal Continuous Positive Airway Pressure (CPAP) Mask and Nasal Airway in Terms of Intraoperative Anesthesia Quality and Postoperative Associated Complications in Impacted Molar Tooth Extraction Patients Under Deep Sedation; A Multi-Center Study
- ClinicalTrials.gov ID
- NCT06436638
- Acronym / sponsor ID
- KU-ERKAN-001
- Conditions
- Deep Sedation, Non-invasive Ventilation Support, Nasal Airway, Nasal CPAP Mask, Impacted Molar
- Study type
- Observational
- Recruitment status
- Recruiting
- Enrolment
- 60 participants (estimated)
- Lead sponsor
- Gözde Nur ErkanUniversity, hospital or other
- Collaborators
- TC Erciyes University, Kırıkkale University
- Study start
- 2 Jul 2024 (actual)
- Primary completion
- May 2026 (estimated)
- Study completion
- Jun 2026 (estimated)
- First posted
- 31 May 2024 (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.
In patients with high levels of fear and anxiety, it is recommended to perform dental procedures under sedation or general anesthesia depending on the nature of the procedure. In dental treatment under anesthesia, it is important that the procedure is comfortable and well tolerated by the patient. In addition, patient comfort is important in all dental procedures to prevent the development of avoidance behavior.
During dental procedures performed under anesthesia, the oral cavity is completely within the scope of the surgical or procedure field. In this respect, sedation and general anesthesia in dental procedures and operations have specific risks and challenges.Since there is a risk of respiratory depression, hypoxia and hypercarbia during deep sedation, non-invasive ventilation support provided to patients with airway devices would be beneficial. In the research clinics where the study will be conducted, deep sedation with non-invasive mechanical ventilation support using a nasal CPAP (Continuous Positive Airway Pressure) mask or nasal airway is applied during the extraction of impacted molars. Thus, many dental procedures are routinely performed under deep sedation without the need for general anesthesia. There are very limited data in the literature on the use of a nasal CPAP mask during sedation for different procedures in patients with obstructive sleep apnea or obesity. However, no study comparing ventilation support during deep sedation with nasal CPAP mask and nasal airway has been found in the literature.
The aim of this study is to compare the non-invasive ventilation support provided with 2 different airway devices during the procedure in terms of intraoperative and postoperative related complications, ventilation parameters, patient and surgeon satisfaction.
The hypothesis of the study is that two different ventilation support methods during deep sedation may be superior to each other in terms of anesthesia quality, postoperative complications related to airway devices, patient and surgeon satisfaction.
In the study, a total of 60 patients (Group airway, n;30, Group Mask, n;30) from 2 centers are planned to be included in the study by performing power analysis with a statistical power of the trial >0.8.
The permutation method will be applied within the scope of the restricted randomization method to determine the group of patients to be included.
Detailed description
In the study to be conducted in two dental faculties, it is planned to use a total of 60 patient data, 30 patients with nasal CPAP mask and 30 patients with nasal airway. In the centers where the study will be conducted, deep sedation during dental procedures with ventilatory support via nasal airway and nasal CPAP mask, which will be compared in the study, is applied in routine practice. In this context, anxiolysis with 2 mg IV midazolam is administered to the patients before they are taken to the operating room on the day of the procedure. Patients are administered 1.5 mg/kg propofol and 0.5 mcg/kg fentanyl intravenously for sedation induction. Non-invasive ventilation support is then applied with a nasal airway or nasal CPAP mask and ventilation parameters are screened. Sevoflurane at 1 MAC (minimum alveolar concentration) level is administered inhalationally for sedation maintenance and the level of sedation is evaluated using the Ramsey sedation scale. Surgical dental extraction procedures between 20-60 minutes will be included in the study. For postoperative analgesia, paracetamol 1 g and dexketoprofen trometamol 50 mg are administered intravenously. The data planned to be collected within the scope of the study are blood pressure, heart rate, peripheral oxygen saturation (number of desaturation episodes), respiratory rate, ventilation parameters (Tidal volume (TV); set and actual, minute volume , end tidal CO2-EtCO2, and Peak pressure (Peak P). The total dose of agents used for sedation will also be recorded. During the post-operative follow-up period, the presence of nausea-vomiting, nasal pain, dryness in the nasal mucosa, epistaxis, sore throat, and dryness in the throat will be evaluated. Patient and surgeon satisfaction scores will be recorded.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Group Airway | – | Device: Non-invasive ventilation support equipmentGroup to receive non-invasive ventilation support via nasal airway during dental extraction under deep sedation. |
| Group Mask | – | Device: Non-invasive ventilation support equipmentGroup to receive non-invasive ventilation support via nasal CPAP mask during dental extraction under deep sedation |
Who may qualify
- Ages
- 18 to 60 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult
- Study population
- It is planned to investigate patients with a diagnosis of impacted molars, who have an indication for dental extraction, and who are scheduled for dental extraction under sedation.
Key inclusion criteria (5 listed)
- Volunteer adult patients aged 18-60 years
- Patients scheduled for impacted tooth extraction
- Cases with surgical time ≥20 minutes and ≤60 minutes
- American Society of Anaesthesiologists (ASA) physical status I and II patients
- Patients with BMI≤30
Key exclusion criteria (8 listed)
- Patients under 18 years old-over 60 years old
- Surgeries with a procedure time over 1 hour or less than 20 minutes
- American Society of Anaesthesiologists (ASA) physical status III and higher patients
- Presence of conditions such as mental retardation that impair the patient's ability to make decisions about himself/herself
- Patients with respiratory system diseases such as asthma, chronic obstructive pulmonary disease (COPD) or airway hyperreactivity
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 |
|---|---|---|
| Non-invasive ventilation support equipmentNon-invasive ventilation support is provided by nasal airway and nasal CPAP mask to avoid respiratory complications such as hypoxia, desaturation, hypercarbia, respiratory depression etc. during extraction of impacted molars under deep sedation. | Device | Group Airway, Group Mask |
Primary outcome
Non-invasive blood pressure
Time frame: Intraoperative period and for 4 hours after surgery
It is planned to record non-invasive blood pressure values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Changes in blood pressure above 20% from baseline will be recorded additionally.
ECG
Time frame: Intraoperative period and for 4 hours after surgery
It is planned to record heart rate values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Changes in heart rate greater than 20% of baseline will be recorded additionally.
Peripheral oxygen saturation
Time frame: Intraoperative period and for 4 hours after surgery
It is planned to record peripheral oxygen saturation values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Hypoxia (SpO2<90%) will be recorded additionally.
Respiratory rate
Time frame: Intraoperative period and for 4 hours after surgery
It is planned to record respiratory rate values of the patients at regular intervals during the operation, recovery unit and inpatient ward follow-up. Respiratory depression will be recorded additionally.
Number of interruptions for an anesthesia-related reason
Time frame: Intraoperative period
Number of episodes during deep sedation when the procedure has to be interrupted due to desaturation or patient movement will be recorded
Tidal volume
Time frame: Intraoperative period
During non-invasive ventilatory support, set and actual tidal volume values will be recorded at regular intervals during the operation.
Peak pressure
Time frame: Intraoperative period
During non-invasive ventilatory support, peak pressure values will be recorded at regular intervals during the operation.
End tidal carbon dioxide level (EtCO2)
Time frame: Intraoperative period
During non-invasive ventilatory support, end tidal carbon dioxide values will be recorded at regular intervals during the operation.
Minute ventilation
Time frame: Intraoperative period
During non-invasive ventilatory support, minute ventilation values will be recorded.
4 secondary outcomes
Postoperative complications related non-invasive ventilation support devices and sedation
Time frame: During the next 3 hours after the end of the operation
Patient and surgeon satisfaction
Time frame: Perioperative period
Total dose of medications used for sedation during the procedure
Time frame: Intraoperative period
Recovery duration from anesthesia
Time frame: From the end of the operation until discharge to the ward
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 20 Mar 2026.
- Background: PubMed 27022303Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016 Mar 10;8:35-50. doi: 10.2147/CCIDE.S63626. eCollection 2016.
- Background: PubMed 37406462Cukierman DS, Perez M, Guerra-Londono JJ, Carlson R, Hagan K, Ghebremichael S, Hagberg C, Ge PS, Raju GS, Rhim A, Cata JP. Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial. J Clin Anesth. 2023 Oct;89:111196. doi: 10.1016/j.jclinane.2023.111196. Epub 2023 Jul 3.
- Background: PubMed 31313720Bai Y, Xu Z, Chandrashekar M, St Jacques PJ, Liang Y, Jiang Y, Kla K. Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial. Eur J Anaesthesiol. 2019 Sep;36(9):633-640. doi: 10.1097/EJA.0000000000001052.
- 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.
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 Deep Sedation and Non-invasive Ventilation Support, run by Gözde Nur Erkan at 2 sites in Turkey (Türkiye).
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 5 inclusion and 8 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: looking for participants now, as of the sponsor's last update on 20 Mar 2026. 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 Turkey (Türkiye). 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?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Gözde Nur Erkan, Asst. Prof. (+905054334692, dr.gozdenur@gmail.com), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Non-invasive blood pressure (time frame: Intraoperative period and for 4 hours after surgery). The study lists 9 primary outcomes in all. 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 NCT06436638, which also lists 3 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 20 Mar 2026.