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Waghray A, Jain A, Waghray N. Colorectal cancer screening in African Americans: practice patterns in the United States. Are we doing enough? Gastroenterol Rep (Oxf) 2016; 4:136-40. [PMID: 27071411 PMCID: PMC4863193 DOI: 10.1093/gastro/gow005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 02/10/2016] [Indexed: 01/20/2023] Open
Abstract
Background: Colorectal cancer (CRC) is a common form of malignancy and a leading cause of death in the United States. Screening decreases CRC incidence and mortality. African Americans are at an increased risk of developing CRC, and recommendations are to initiate screening at the age of 45. This study aims to assess the rate of screening for colorectal cancer in African Americans between the ages of 45–49. Methods: African Americans between the ages of 45–49 were identified in the Explorys national database. Patients who completed a colonoscopy, sigmoidoscopy or fecal occult blood test were identified and stratified by sex and insurance status. A P value < 0.05 was considered significant. Results: A total of 181 200 African Americans were identified as eligible for screening. Only 31 480 patients (17.4%) received at least one screening procedure for CRC. The majority of patients (66.7%) were screened via colonoscopy. African American females were more likely to complete a screening test (17.8% vs 16.7%; P < 0.01). The majority of patients (66.0%) who completed a screening test had private insurance. Conclusion: Race, gender and barriers to medical care contribute to disparities in CRC screening rates. Among African Americans, CRC screening remains suboptimal. Tailored public health initiatives, medical record alerts and improved communication between providers and patients are fundamental to addressing issues that impact poor adherence to CRC screening in African Americans.
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Affiliation(s)
- Abhijeet Waghray
- Department of Medicine, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA
| | - Alok Jain
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA
| | - Nisheet Waghray
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA
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Collazo TH, Jandorf L, Thelemaque L, Lee K, Itzkowitz SH. Screening Colonoscopy among Uninsured and Underinsured Urban Minorities. Gut Liver 2016; 9:502-8. [PMID: 25287165 PMCID: PMC4477994 DOI: 10.5009/gnl14039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background/Aims Uninsured individuals have lower rates of screening colonoscopy (SC), and little is known regarding the pathology results obtained when they undergo colonoscopies. Since 2004, we have participated in a program that offers SC to uninsured New Yorkers; herein, we report our findings. Methods Uninsured, average-risk patients who were at least 50 years of age underwent SC at our institution between April 2004 and June 2011. We analyzed polyp pathology, location, size, incidence of adenomas, and incidence of adenomas with advanced pathology (AAP) with respect to ethnicity, gender, and age. Results Out of 493 referrals, 222 patients completed the colonoscopies. Polyps were identified in 21.2% of all patients; 14% had adenomas, and 4.5% had AAP. The rates of adenomas among African-Americans, Hispanics, and Whites were 24.3%, 12.1%, and 11.6%, respectively, and the corresponding rates of AAP were 10.8%, 3.5%, and 2.3%. Differences in the polyp type, location, and AAP did not reach statistical significance with respect to ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared with younger patients (8.6% vs 2.6%, p=0.047). Conclusions Further efforts to fund screening colonoscopies for uninsured individuals will likely result in the identification of advanced lesions of the colon before they progress to colorectal cancer.
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Affiliation(s)
- Tyson H Collazo
- Departments of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lina Jandorf
- Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Linda Thelemaque
- Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kristen Lee
- Departments of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven H Itzkowitz
- Departments of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Colonoscopy Education Among African-American Males in the Primary Care Setting of Bronx County, New York. Gastroenterol Nurs 2015; 38:337-41. [PMID: 26422268 DOI: 10.1097/sga.0000000000000129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Healthcare disparities are prevalent throughout the United States of America, particularly among low socioeconomic communities and minority groups. As primary care providers in Bronx, New York, the authors have noted that African American males often decline colonoscopy screening measures more frequently than other minorities. Ironically, the same cohort of African American men has the highest incidence of colon cancer and less favorable outcomes from chemotherapy intervention. In hopes of making a segue into a more informed conversation with our patients, we have developed an informative fact sheet for patients and their families on the basis of evidence-based literature. The objective was to employ this fact sheet to educate patients about colorectal cancer screening in an understandable and clinically effective manner.
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Characterization of the Hispanic or latino population in health research: a systematic review. J Immigr Minor Health 2015; 16:429-39. [PMID: 23315046 DOI: 10.1007/s10903-013-9773-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.
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Lathroum L, Ramos-Mercado F, Hernandez-Marrero J, Villafaña M, Cruz-Correa M. Ethnic and sex disparities in colorectal neoplasia among Hispanic patients undergoing screening colonoscopy. Clin Gastroenterol Hepatol 2012; 10:997-1001. [PMID: 22542749 PMCID: PMC3475984 DOI: 10.1016/j.cgh.2012.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/30/2012] [Accepted: 04/11/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) has a high prevalence among the US Hispanic population. In Puerto Rico, CRC is the third leading cause of cancer death in men and the second in women. There are limited published data on the prevalence of colorectal neoplasia (CRN) among the US Hispanic population. We determined the prevalence of CRN (colorectal adenomas and cancer) among asymptomatic, Hispanic subjects who were screened in Puerto Rico and evaluated risk factors associated with CRN. METHODS We performed a retrospective review of the medical, endoscopic, and pathology records of individuals who underwent first-time screening colonoscopies at an ambulatory gastroenterology practice from January 1, 2008, to December 1, 2009. The prevalence of CRN (overall and advanced), documented by colonoscopy and pathology reports, was calculated for the complete cohort and by sex. RESULTS Of the 745 Hispanic individuals who underwent screening colonoscopies during the study period, the prevalence for overall CRN was 25.1% and for advanced CRN (≥ 1 cm and/or with advanced histology) was 4.0%. The prevalence of CRN was higher for men than women (32.0% vs 20.6%; P = .001; odds ratio, 1.92; 95% confidence interval, 1.4-2.6). CRN was more frequently located in the proximal colon (67.7% proximal vs 32.3% distal). A family history of CRC was associated with advanced CRN (odds ratio, 2.73; 95% confidence interval, 1.10-6.79). CONCLUSIONS CRN was more common among Hispanic men than women and increased with age. CRNs among Hispanic individuals were predominantly located in the proximal colon. These findings indicate that there are ethnic and sex disparities in patterns of CRN that might be related to genomic admixture and have important implications for screening algorithms for Hispanic individuals.
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Affiliation(s)
| | | | | | | | - Marcia Cruz-Correa
- University of Puerto Rico Comprehensive Cancer Center,Department of Medicine, University of Puerto Rico School of Medicine,Department of Biochemistry, University of Puerto Rico School of Medicine
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Jilcott Pitts SB, Lea CS, May CL, Stowe C, Hamill DJ, Walker KT, Fitzgerald TL. "Fault-line of an earthquake": a qualitative examination of barriers and facilitators to colorectal cancer screening in rural, Eastern North Carolina. J Rural Health 2012; 29:78-87. [PMID: 23289658 DOI: 10.1111/j.1748-0361.2012.00424.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Colorectal cancer (CRC) is a leading cause of cancer mortality and disparately affects rural, low-income and minority individuals. Thus, to inform effective interventions and policies to increase screening rates and thus ameliorate CRC disparities, this study's purpose was to examine barriers and facilitators to CRC screening among low-income, rural eastern North Carolina residents. METHODS We conducted 4 focus group discussions in October and November 2011, among a convenience sample of eastern North Carolina residents (n = 45). The focus group discussion guide included open-ended questions about barriers and facilitators to CRC screening. Discussions were audio recorded and then transcribed verbatim. A codebook listing codes and operational definitions was developed by 2 research team members, who then iteratively and independently double-coded all transcripts. Nvivo (version 9, QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to manage data. Themes were extracted based upon depth and frequency of mention. FINDINGS Major barriers to CRC screening included the high cost of tests and follow-up care, fear of the test itself (colonoscopy), fear of cancer diagnosis, and fear of burdening family members. Violation (among men) and embarrassment (among women) were also barriers. Facilitators included doctor's recommendation, symptoms, support from family and friends, and the desire to live a long and healthy life. Intervention ideas included free tests with information and resources for follow-up care as needed. CONCLUSION Understanding barriers and facilitators to CRC screening can assist clinicians and public health practitioners in designing effective interventions to reduce CRC disparities.
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Affiliation(s)
- Stephanie B Jilcott Pitts
- Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Thakkar K, Alsarraj A, Fong E, Holub JL, Gilger MA, El Serag HB. Prevalence of colorectal polyps in pediatric colonoscopy. Dig Dis Sci 2012; 57:1050-5. [PMID: 22147243 PMCID: PMC3878076 DOI: 10.1007/s10620-011-1972-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 11/08/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND The available data regarding the prevalence, types, and clinical determinants of colonic polyps in children is limited. AIMS We aimed to estimate the prevalence of colorectal polyps in a large cohort of children. METHODS We conducted a cross-sectional study to determine the presence, number, and location of colorectal polyps reported in all children (0-20 years) who underwent colonoscopy at 14 pediatric facilities between January 2000 and December 2007 recorded in Pediatric Endoscopy Database System Clinical Outcomes Research Initiative (PEDS-CORI). We compared procedures with and without polyps with respect to procedure indication, age, sex, and race. We also reviewed a sample of histopathologic reports from one participating center. RESULTS We analyzed 13,115 colonoscopy procedures performed in 11,637 patients. Colorectal polyps were reported in 810 procedures (6.1%; 95% CI: 5.7-6.5%) performed in 705 patients, and in 12% of patients with lower GI bleeding. Children with colorectal polyps were significantly younger (8.9 years vs. 11.9 years; p < 0.0001), male (58.3% vs. 49.0%; p < 0.001), non-white race (27.5% vs. 21.9%; p < 0.001), and had lower GI bleeding (54.4% vs. 26.6%; p < 0.001) as compared to children without polyps. In a sample of 122 patients with polyps from a single center, the histological types were solitary juvenile in 91 (70.5%), multiple juvenile in 20 (15.5%), adenoma in 14 (10.9%) and hyperplastic polyps in four patients (3.1%). CONCLUSIONS Colorectal polyps are detected in 6.1% overall and in 12.0% among those with lower gastrointestinal bleeding during pediatric colonoscopy. Approximately 26% are multiple juvenile or adenoma.
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Affiliation(s)
- Kalpesh Thakkar
- The Section of Pediatric Gastroenterology, Hepatology and Nutrition at Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Abeer Alsarraj
- The Sections of Gastroenterology and Health Services Research at The Houston Veterans Affairs Medical Center and the Department of Medicine at Baylor College of Medicine, Houston, TX
| | | | - Jennifer L. Holub
- Department of Gastroenterology, Oregon Health & Science University, Portland, OR
| | - Mark A. Gilger
- The Section of Pediatric Gastroenterology, Hepatology and Nutrition at Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Hashem B. El Serag
- The Sections of Gastroenterology and Health Services Research at The Houston Veterans Affairs Medical Center and the Department of Medicine at Baylor College of Medicine, Houston, TX
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Adler A, Aminalai A, Aschenbeck J, Drossel R, Mayr M, Scheel M, Schröder A, Yenerim T, Wiedenmann B, Gauger U, Roll S, Rösch T. Latest generation, wide-angle, high-definition colonoscopes increase adenoma detection rate. Clin Gastroenterol Hepatol 2012; 10:155-9. [PMID: 22056301 DOI: 10.1016/j.cgh.2011.10.026] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 10/05/2011] [Accepted: 10/20/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Improvements to endoscopy imaging technologies might improve detection rates of colorectal cancer and patient outcomes. We compared the accuracy of the latest generation of endoscopes with older generation models in detection of colorectal adenomas. METHODS We compared data from 2 prospective screening colonoscopy studies (the Berlin Colonoscopy Project 6); each study lasted approximately 6 months and included the same 6 colonoscopists, who worked in private practice. Participants in group 1 (n = 1256) were all examined by using the latest generation of wide-angle, high-definition colonoscopes that were manufactured by the same company. Individuals in group 2 (n = 1400) were examined by endoscopists who used routine equipment (a mixture of endoscopes from different companies; none of those used to examine group 1). The adenoma detection rate was calculated on the basis of the number of all adenomas/number of all patients. RESULTS There were no differences in patient parameters or withdrawal time between groups (8.0 vs 8.2 minutes). The adenoma detection rate was significantly higher in group 1 (0.33) than in group 2 (0.27; P = .01); a greater number of patients with least 1 adenoma were identified in group 1 (22.1%) than in group 2 (18.2%; P = .01). A higher percentage of high-grade dysplastic adenomas were detected in group 1 (1.19%) than in group 2 (0.57%), but this difference was not statistically significant (P = .06). CONCLUSIONS The latest generation of wide-angle, high-definition colonoscopes improves rates of adenoma detection by 22%, compared with mixed, older technology endoscopes used in routine private practice. These findings might affect definitions of quality control parameters for colonoscopy screening for colorectal cancer.
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Affiliation(s)
- Andreas Adler
- Central Interdisciplinary Endoscopy Unit, Department of Gastroenterology, Charité University Medical Hospitals, Berlin, Germany
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Erim T, Rivas JM, Velis E, Castro F. Role of high definition colonoscopy in colorectal adenomatous polyp detection. World J Gastroenterol 2011; 17:4001-4006. [PMID: 22046088 PMCID: PMC3199558 DOI: 10.3748/wjg.v17.i35.4001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 03/11/2011] [Accepted: 03/18/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the rates of polyp detection in a mixed risk population using standard definition (SDC) vs high definition colonoscopes (HDC). METHODS This was a retrospective cohort comparative study of 3 colonoscopists who each consecutively performed 150 SDC (307, 200 pixel) and 150 HDC (792, 576 pixels) in a community teaching hospital. RESULTS A total of 900 colonoscopies were evaluated (mean age 56, 46.8% men), 450 with each resolution. Polyps of any type were detected in 46.0% of patients using SDC and 43.3% with HDC (P = 0.42). There was no significant difference between the overall number of polyps, HDC (397) and SDC (410), detected among all patients examined, (P = 0.73). One or more adenomatous polyps were detected in 24.2% of patients with HDC and 24.9% of patients with SDC colonoscopy (P = 0.82). There was no significant difference between HDC (M = 0.41) and SDC (M = 0.42) regarding adenomatous polyp (P = 0.88) or advanced adenoma (P = 0.56) detection rate among all patients examined. CONCLUSION HDC did not improve yield of adenomatous polyp, advanced adenoma or overall polyp detection in a population of individuals with mixed risk for colorectal cancer.
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Dhar S, Michel R, Kanna B. Improving Visit Cycle Time Using Patient Flow Analysis in a High–Volume Inner–City Hospital–Based Ambulatory Clinic Serving Minority New Yorkers. J Healthc Qual 2011; 33:23-8. [DOI: 10.1111/j.1945-1474.2010.00111.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kanna B, Narang TK, Atwal T, Paul D, Azeez S. Ethnic disparity in mortality after diagnosis of colorectal cancer among inner city minority New Yorkers. Cancer 2009; 115:5550-5. [DOI: 10.1002/cncr.24614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Percac-Lima S, Grant RW, Green AR, Ashburner JM, Gamba G, Oo S, Richter JM, Atlas SJ. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med 2009; 24:211-7. [PMID: 19067085 PMCID: PMC2628981 DOI: 10.1007/s11606-008-0864-x] [Citation(s) in RCA: 268] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Minority racial/ethnic groups have low colorectal cancer (CRC) screening rates. OBJECTIVE To evaluate a culturally tailored intervention to increase CRC screening, primarily using colonoscopy, among low income and non-English speaking patients. DESIGN Randomized controlled trial conducted from January to October of 2007. SETTING Single, urban community health center serving a low-income, ethnically diverse population. PATIENTS A total of 1,223 patients 52-79 years of age overdue for CRC screening, randomized to intervention (n = 409) vs. usual care control (n = 814) groups. INTERVENTION Intervention patients received an introductory letter with educational material followed by phone or in-person contact by a language-concordant "navigator." Navigators (n = 5) were community health workers trained to identify and address patient-reported barriers to CRC screening. Individually tailored interventions included patient education, procedure scheduling, translation and explanation of bowel preparation, and help with transportation and insurance coverage. Rates of colorectal cancer screening were assessed for intervention and usual care control patients. RESULTS Over a 9-month period, intervention patients were more likely to undergo CRC screening than control patients (27% vs. 12% for any CRC screening, p < 0.001; 21% vs. 10% for colonoscopy completion, p < 0.001). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 in the control group (p = 0.04). LIMITATIONS Patients were from one health center. Some patients may have obtained CRC screening outside our system. CONCLUSIONS A culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates for low income, ethnically and linguistically diverse patients. ClinicalTrials.gov registration number: NCT00476970.
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Affiliation(s)
- Sanja Percac-Lima
- Chelsea HealthCare Center, Massachusetts General Hospital, Chelsea, MA 02150, USA.
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Adler A, Aschenbeck J, Yenerim T, Mayr M, Aminalai A, Drossel R, Schröder A, Scheel M, Wiedenmann B, Rösch T. Narrow-band versus white-light high definition television endoscopic imaging for screening colonoscopy: a prospective randomized trial. Gastroenterology 2009; 136:410-6.e1; quiz 715. [PMID: 19014944 DOI: 10.1053/j.gastro.2008.10.022] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 09/01/2008] [Accepted: 10/09/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Narrow-band imaging (NBI) has been implemented in gastrointestinal endoscopy to improve the contrast of endoluminal pathologic structures, one of the aims being to increase colonic adenoma detection. Previous studies from referral centers have yielded variable and conflicting results with regard to improvement in adenoma detection rates by using NBI. The present large randomized trial was designed to finally settle this issue. METHODS In a prospective study performed exclusively in a multicenter private practice setting involving 6 examiners with substantial lifetime experience (>10,000 colonoscopies), 1256 patients (men:women, 47%:53%; mean age, 64.4 y) were randomized to HDTV screening colonoscopy with either NBI or white-light imaging on instrument withdrawal. The primary outcome measure was the adenoma detection rate (ie, number of adenomas/total number of patients). RESULTS There was no difference between the 2 groups in terms of the general adenoma detection rate (0.32 vs 0.34), the total number of adenomas (200 vs 216), or in detection in subgroups of adenomas. This was despite a minimal, but significantly longer, withdrawal time in the NBI group (8.5 vs 7.9 min; P < .05). Only hyperplastic polyps were found more frequently in the NBI group (P = .03). CONCLUSIONS This large randomized trial in a homogeneous private practice screening setting could not show any objective advantage of the NBI technique over white-light high definition television imaging in terms of improved adenoma detection rate. Contrast enhancement therefore likely will not contribute to a reduction in adenoma miss rates among experienced colonoscopists.
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Affiliation(s)
- Andreas Adler
- Central Interdisciplinary Endoscopy Unit, Charité Medical University Hospitals, Campus Virchow, Berlin, Germany
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