Rosai-Dorfman disease presenting multiple intracranial lesions with unique findings on magnetic resonance imaging. Case report

Rosai-Dorfman disease (RDD) is a rare idiopathic histoproliferative disease affecting the systemic lymph nodes. Although an extranodal lesion has also been recognized, central nervous system involvement is extremely rare. To the authors' knowledge, only 20 cases of intracranial lesions have been reported previously. Intracranial RDD is clinically and radiologically difficult to distinguish from meningioma, and histological examination is essential for a definitive diagnosis. The authors treated a large frontal lobe tumor associated with multiple meningeal nodules in a 67-year-old patient presenting with diplopia and headache. Radiological examination indicated that the mass was an inflammatory lesion rather than a meningioma. Microscopically the lesion consisted of mixed inflammatory infiltrate with marked emperipolesis, which is characteristic of RDD. A review of the literature and a discussion of the differential diagnosis of this rare lesion are also presented.

[Indication and outcome in emergent coronary artery bypass graft for acute coronary syndrome]

Among 462 cases receiving coronary artery bypass graft (CABG) during the period from November 1991 to January 1999, emergency operation was performed within 24 hours for 27 cases. Male-to-female ratio was 21:6, and age of patients ranged from 50 to 83 years (average age: 65.9 years). Intra aortic balloon pumping (IABP) was used from preoperative period for 25 cases, and PCPS was used for one case. Operation was performed under cardiac arrest in 25 cases and under ventricular fibrillation in 2. Average number of grafts was 2.4 +/- 1.0 and perioperative mortality was 25.9%. The results of emergency cases were extremely low compared with mortality of palliative operation of 3.4%, whereas mortality has been improved to 12.5% (2/16) in the last two years. These results suggest that it is important for the improvement of the outcome in emergency CABG to prevent aggravation of circulatory dynamics and to shift to operation under stable conditions.

An enzyme-linked immunosorbent assay using nuclear antigen for detection of feline herpesvirus 1 antibody

To detect antibody against feline herpesvirus 1 (FHV-1) in the sera of cats, the sensitivity and specificity of an enzyme-linked immunosorbent assay (ELISA) using nuclear antigen was investigated. The standardized optical density readings (ODs) of the ELISA obtained by the 1-step serum dilution (1:80) method were compared with the serum neutralization test (SNT) results, with a correlation of 0.993, and with the hemagglutination inhibition (HI) test results, with a correlation of 0.851. The ODs for the ELISA titers were obtained using the serial serum dilution method and were compared with the SNT results, with a correlation of 0.933, and with the HI test results, with a correlation of 0.987. In the experimental infection of 4 specific-pathogen-free cats, the results of different serologic tests (SNT and HI) and the ELISA using the serial serum dilution method revealed rapid production of antibodies after inoculation, whereas the ELISA using the one-step serum dilution method indicated that titers increased more slowly. These results indicate that with the present ELISA using nuclear antigen, there are fewer demands on time and labor, making the method convenient for monitoring FHV-1 infection.

[Endodermal cyst of the cerebellopontine angle cistern: case report]

We report a case of a 55-year-old man with endodermal cyst located in the cerebellopontine angle cistern. The patient presented with dizziness. Magnetic resonance imaging (MRI) revealed multilocular cystic lesion at the right cerebellopontine angle. T1-weighted image showed a mass with a low signal intensity, but higher intensity than CSF. Gd-DTPA T1-weighted image showed no enhancement in the mass. Diffusion-weighted image showed a mass with no signal lesion. After successful surgical removal, it was found to be an endodermal cyst. These cysts have usually been found in the spinal canal, and their intracranial occurrence is exceptional. The unusual location of the cyst and its histological features and radiological findings are discussed.

[Prevalence and serotypes of verocytotoxin-producing Escherichia coli (VTEC) isolates from dairy cattle]

To clarify the source of infection and route of transmission of Verocytotoxin-producing Escherichia coli (VTEC) in humans, we collected fresh feces from healthy dairy cattle reared in Hokkaido, Fukushima, Kanagawa and Okinawa prefectures between June 1996 and March 1997, and attempted to isolate VTEC. The results are described below. 1) VTEC was isolated from 68 (27.1%) of 251 fecal samples tested. VTEC was isolated from 14 (28.0%) of 50 in Hokkaido, 13 (26.0%) of 50 in Fukushima, 20 (39.2%) of 51 in Kanagawa and 21 (21.0%) of 100 in Okinawa. There were no difference in the prevalence among the prefectures. 2) Toxin type and serotype of 85 isolates were determined. Thirty-three isolaties (38.8%) were classified into VT1 toxin and VT2 toxin, respectively, and 19 isolates (22.4%) were classified as the strain that produces both VT1 and VT2 toxins. The toxin types of these isolates were divided by serotypes. The VT1-producing isolates were the most frequent among O111:H-. The VT2-producing isolates included O2:H12, O2:H29, O2:H-, O82:H8, O82:HUT, O153:H19, O153:H42 and O153:H-. Among the isolates producing both VT1 and VT2 toxins, O153:H19 was relatively frequent. Based on findings that many bacterial strains coinciding with toxin types and serotypes of human-derived VTEC isolated from dairy cattle, it was suggested that dairy cattle are closely related to VTEC infection in human as a source of infection.

Heme oxygenase-1 expression in oral squamous cell carcinoma as involved in lymph node metastasis

Thirty-eight oral squamous cell carcinomas (SCCs) were semi-quantitatively analyzed by immunohistochemical staining, and the relation between heme oxygenase-1 (HO-1) expression and the clinical status were correlated. High immunostaining of HO-1 was detected in lymph node metastasis negative groups (P = 0.0018) and in well-differentiated SCCs (P = 0.0016). There were no significant correlations between heme oxygenase-1 expression and other factors, such as size of the tumor, staging, age and sex. These findings further support the proposition that high heme oxygenase-1 expression in oral SCCs can be useful in identifying patients at low risk of lymph node metastasis.

[Quantitative assessment of 201Tl-SPECT in tumors of bone and soft tissue]

201Tl-SPECT was performed to diagnose the malignancy of bone and soft tissue tumors by visual and quantitative assessment in 48 patients (17 malignant lesions and 31 benign lesions). SPECT images were obtained in the early phase (15 min after injection) and the delayed phase (240 min). By visual assessment a tumor was considered malignant if high accumulation was found in the tumor in the early phase and the accumulation was confirmed in the delayed phase. Tumors which did not meet these criteria were considered benign. For quantitative assessment, the ROI (region of interest) accumulation ratios of the tumor to the contralateral normal tissue in the early phase (ER) and in the delayed phase (DR), the ROI accumulation ratio of the delayed phase to the early phase of the tumor (Td/Te), and the ROI accumulation ratio of the delayed phase to the early phase of the contralateral normal tissue (Nd/Ne) were obtained. Sixteen patients with malignant tumors each had a high accumulation each but 12 of 31 benign lesions had no high accumulation on visual assessment. Furthermore, the accuracy was 85.4%, sensitivity 94.1%, and specificity 80.6%. Quantitative assessment was performed for 36 cases of high accumulation. The ER of malignant and benign lesions was 5.51 +/- 3.73 and 2.75 +/- 2.17, respectively, and the ER of malignant lesions was significantly higher than that of benign lesions. The DR did not demonstrate a significant difference. If the tumor having an ER greater than 3.9 was assumed to be malignant, the accuracy for differentiating malignant lesions from benign lesions was 85.4%. The Td/Te of benign lesions (0.97 +/- 0.28) was higher than that of malignant lesions (0.77 +/- 0.09). The Nd/Ne of normal tissue which contained muscles in both lesions were higher than 1.4. In conclusion, 201Tl-SPECT was very useful for the differential diagnosis of benign or malignant bone and soft tissue tumors. The ER was important for quantitative assessment, but a delayed image was necessary for visual assessment.

Significance of electron-dense deposits in the mitochondrial matrix of erythroid precursors in aplastic anaemia and myelodysplastic syndrome

Recently the number of long-term survivors of aplastic anaemia has increased, with some of these cases evolving into myelodysplastic syndrome (MDS). Because it is difficult to discriminate between aplastic anaemia and hypoplastic MDS, it is unknown whether these patients have had MDS from the time of diagnosis of aplastic anaemia. Presence of ringed sideroblasts on an iron-stained bone marrow smear is a characteristic of some cases of MDS. Amorphous electron-dense deposits in the mitochondrial matrices of erythroid precursors observed with an electron microscope show ringed sideroblasts, and detection of this mitochondrial pathology is useful for confirming the presence of ringed sideroblasts because this mitochondrial pathology can be found not only in erythroblasts but also in reticulocytes, which is particularly useful in cases in which few erythroblasts are found. We found this mitochondrial pathology in two of nine children who had an initial diagnosis of aplastic anaemia and in three children with hypoplastic MDS. It is unknown at present whether the first two children had aplastic anaemia or hypoplastic MDS. Our results warrant further studies on more patients to confirm the significance of amorphous electron-dense deposits in the mitochondrial matrices of erythroid precursors.

Three-dimensional computed tomographic angiography of pulmonary vessels

OBJECTIVE

To assess the image quality of multiple threshold display (MTD) as a new technique for generating three-dimensional (3D) pulmonary computed tomographic (CT) angiographic images.

METHODS

We used MTD, a type of shaded surface display (SSD) offering the selection of multiple thresholds and transparencies, to reconstruct 3D-CT angiograms from enhanced helical CT data sets in 33 patients with lung disease. In MTD, eight thresholds of CT values are selected, and transparency is assigned to each. The selected voxels, ranging from -600 to 1,000 Hounsfield Units, were divided into eight classes, and transparency ranging from 0 to 100% was assigned to each. The CT scanner employed was a Toshiba Xvigor. MTD and SSD images were generated by using an Xtension with a Sun SPARC station 20, and they were compared by two radiologists.

RESULTS

The image quality of MTD images was superior to that of SSD images (p < 0.01), because the MTD images demonstrated clearly both the major and small vessels.

CONCLUSION

MTD is a useful technique for 3D pulmonary CT angiography.

Effect of nitric oxide synthase inhibitor on cochlear dysfunction induced by transient local anoxia

To evaluate whether nitric oxide (NO) plays a role in the mechanism of generation of cochlear dysfunction induced by anoxia and reperfusion, the effects of a nitric oxide synthase (NOS) inhibitor, N-nitro-L-arginine, were examined using 71 albino guinea pigs. Transient cochlear anoxia of different duration (15, 30 or 60 min) was induced by pressing the labyrinthine artery and compound action potential (CAP) was measured before and 4 h after anoxia. N-nitro-L-arginine (1-30 mg/kg) administered intraperitoneally 1 h before the onset of anoxia alleviated the cochlear dysfunction when the anoxic period was 15 or 30 min. No beneficial effect was observed, however, in the 60-min anoxia. These results indicate that NO contributes to the generation of anoxia-induced cochlear dysfunction and that NOS inhibitor has a protective effect on the cochlear injury induced by anoxia of moderate duration.

[Evaluation of 99mTc-MAG3 (mercaptoacetyltriglycine) renography for pediatric patients]

It is difficult to evaluate renal function with 99mTc-MAG3 renography in both adult and pediatric patients. We examined 109 pediatric patients with various renal diseases using 99mTc-MAG3 renography. Tenal diseases were classified as follows: 9 vesicoureteral reflux, 4 ureteropelvic junctional stenosis, 3 double pelvis, 23 hydronephrosis, 4 glomerulonephritis, 4 nephrotic syndrome, 24 hemolytic uremic syndrome, 10 others; and 24 patients without abnormal findings on other examinations. After hydration and sedation, 100-200 MBq of 99mTe-MAG3 was injected intravenously. All patients were placed in the supine position, and dynamic data acquisition at 12 sec/frame x 100 frames was performed from the back. The renograms were prepared with the ROIs (regions of interest) set to include the entire kidney. Tmax and T1/2 of renograms were measured for 26 kidneys with no abnormal findings. The correlations between Tmax or T1/2 and age (days after birth) were determined by a linear or logarithmic function. The logarithmic function (Y = 7.49 - 0.56 logeX, r2 = 0.134) yielded a higher correlation than did the linear function (Y = 5.16 - 0.00194X, r2 = 0.089) between Tmax and age. For T1/2 and age (days after birth), the linear function (Y = 8.07 - 0.00451X, r2 = 0.222) yielded a higher correlation than the logarithmic function (Y = 11.9 - 0.986 logeX, r2 = 0.192). Our findings suggest that prolonged Tmax is normalized more rapidly than T1/2 after birth in infants. A delayed excretion phase is not suggestive of renal dysfunction, but is characteristic of renograms in pediatric patients. Abnormality was detected in all patients with hydronephrosis using 99mTc-MAG3 renography. On the other hand, a quantitative study was required because renography detected no abnormality for some of patients with disorders of renal parenchyma.

A genetic approach to visualization of multisynaptic neural pathways using plant lectin transgene

The wiring patterns among various types of neurons via specific synaptic connections are the basis of functional logic employed by the brain for information processing. This study introduces a powerful method of analyzing the neuronal connectivity patterns by delivering a tracer selectively to specific types of neurons while simultaneously transsynaptically labeling their target neurons. We developed a novel genetic approach introducing cDNA for a plant lectin, wheat germ agglutinin (WGA), as a transgene under the control of specific promoter elements. Using this method, we demonstrate three examples of visualization of specific transsynaptic neural pathways: the mouse cerebellar efferent pathways, the mouse olfactory pathways, and the Drosophila visual pathways. This strategy should greatly facilitate studies on the anatomical and functional organization of the developing and mature nervous system.

The effect of mannitol upon cochlear dysfunction induced by transient local anoxia

Transient local anoxia of the cochlea was induced by pressing the labyrinthine artery, and compound action potential (CAP) or endocochlear potential (EP) was measured before and after transient local anoxia ranging from 5 to 60 min using 106 albino guinea pigs. The complete interruption of the cochlear blood flow by this procedure and its full restoration after releasing the pressure on the artery was confirmed by a laser-Doppler flowmeter. The anoxia of less than 10 min induced no post-anoxic cochlear dysfunction, whereas the anoxia of a longer duration induced an irreversible dysfunction of the cochlea. It was evident that the post-anoxic recovery of the CAP threshold was worse as the anoxia period was prolonged, and CAP was almost completely abolished after 60-min anoxia. In animals which were administered mannitol intravenously just after the restoration of the cochlear blood circulation, the recovery of the CAP threshold was significantly better than that in the control animals, when the animals were subjected to local anoxia of 15- to 30-min duration. No beneficial effect, however, was observed in the 60-min anoxia group. In conclusion, local anoxia of 10 min or longer caused cochlear dysfunction, which was partially but significantly alleviated by mannitol.

Combination therapy of fasudil hydrochloride and ozagrel sodium for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

Fasudil hydrochloride is a new type of intracellular calcium antagonist, different from the calcium entry blockers that are commonly employed for clinical use. Since September 1995, the combination of fasudil hydrochloride and ozagrel sodium, an inhibitor of thromboxane A2 synthesis, has been used to treat 60 patients at risk of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The effectiveness of this combination therapy was investigated by comparison with the outcome of 57 patients previously treated with only ozagrel sodium. The combination therapy was significantly more effective (p < 0.01) in reducing the incidence of low density areas on computed tomography scans, and reduced, but not significantly, the occurrence of symptomatic vasospasm. The combination therapy of fasudil hydrochloride and ozagrel sodium has superior effectiveness over only ozagrel sodium in treating patients at risk of vasospasm after aneurysmal subarachnoid hemorrhage.

A novel Drosophila paired-like homeobox gene related to Caenorhabditis elegans unc-4 is expressed in subsets of postmitotic neurons and epidermal cells

We have isolated a novel Drosophila paired-like homeobox gene, DPHD-1. The homeodomain of DPHD-1 showed 85% amino-acid identity with that of the C. elegans Unc-4 protein. Whole-mount in situ hybridization of embryos and third-instar larvae revealed that the DPHD-1 mRNA is specifically localized in subsets of postmitotic neurons in the central nervous system (CNS) and in the developing epidermis with a segmentally repeated pattern. Double staining with a posterior compartment marker, an anti-Engrailed antibody, showed that DPHD-1 expressing neurons in the CNS were present in the posterior compartment, whereas DPHD-1 expression in the epidermis was restricted to the anterior compartment in each segment. This temporal and spatial expression pattern suggests that DPHD-1 may play a role in determining the distinct cell types in each segment.

Model-based surgical planning and simulation of cranial base surgery

Plastic skull models of seven individual patients were fabricated by stereolithography from three-dimensional data based on computed tomography bone images. Skull models were utilized for neurosurgical planning and simulation in the seven patients with cranial base lesions that were difficult to remove. Surgical approaches and areas of craniotomy were evaluated using the fabricated skull models. In preoperative simulations, hand-made models of the tumors, major vessels and nerves were placed in the skull models. Step-by-step simulation of surgical procedures was performed using actual surgical tools. The advantages of using skull models to plan and simulate cranial base surgery include a better understanding of anatomic relationships, preoperative evaluation of the proposed procedure, increased understanding by the patient and family, and improved educational experiences for residents and other medical staff. The disadvantages of using skull models include the time and cost of making the models. The skull models provide a more realistic tool that is easier to handle than computer-graphic images. Surgical simulation using models facilitates difficult cranial base surgery and may help reduce surgical complications.

Blood blisterlike aneurysms of the internal carotid artery

OBJECT

An aneurysm arising from the anterior wall of the internal carotid artery (ICA) is a poorly understood entity. A small hemispherical bulge from the anterior wall of the ICA, which is called a "blood blisterlike aneurysm" (BBA), may be confused with a tiny berry aneurysm although the clinical features are distinctly different. This paper summarizes the clinical course of patients with this lesion to clarify the nature of the BBA.

METHODS

Six patients with BBAs who presented with subarachnoid hemorrhage (SAH) are described. In all patients, the initial angiogram obtained soon after SAH showed only a small bulge from the anterior wall of the ICA. In three of the six patients this bulge had progressed to a saccular appearance within a few weeks. The wall of the lesion was so thin and fragile that the aneurysm ruptured at the base during clipping or within a few hours after clipping in two patients.

CONCLUSIONS

From the authors' experience, as well as a review of the literature, which includes an autopsy study of similar cases, it is inferred that these lesions are focal wall defects covered only with thin fibrous tissue and that they are therefore not true aneurysms. Direct clipping often causes laceration of the lesion, whereas complete wrapping or clipping after wrapping is effective, but may fail to prevent growth of the aneurysm. Endovascular occlusion of the cervical ICA with or without bypass surgery, which is less risky than direct surgery, is another option.

Localization of 5-HT2A receptor in rat cerebral cortex and olfactory system revealed by immunohistochemistry using two antibodies raised in rabbit and chicken

Serotonin 2A receptor (5-HT2A receptor) is widely distributed in the central nervous system, and has been suggested to be involved in a variety of behavioral conditions and neuropsychiatric disorders. Two polyclonal antibodies were raised against the N-terminus peptide of rat 5-HT2A receptor in chickens (5-HT2A-N) and a glutathione S-transferase fusion protein that contained the C-terminus of the mouse 5-HT2A receptor in rabbits (5-HT2A-C). Affinity-purified 5-HT2A-N and -C antibodies reacted strongly with a single band of 77-78 kDa in postsynaptic density proteins prepared from the rat cortex. The distribution pattern of immunoreactive structures in the rat brain was virtually the same for the two antibodies. The highest levels of immunoreactivity were observed in the olfactory bulb, neocortex, claustrum, piriform cortex, mamillary bodies, pontine nuclei, red nucleus and cranial motor nuclei. In the olfactory bulb, mitral cells were intensely labeled. In the neocortex, many immunoreactive neurons were found in layers II-VI. In layer IV of the neocortex, strong neuropil labeling was observed. In a double-labeling study using chicken 5-HT2A-N and rabbit anti-glial fibrillary acidic protein (GFAP) antibody, a considerable number of GFAP positive cells also showed 5-HT2A immunoreactivity. By using an immunoelectron microscopic technique, 5-HT2A receptor immunoreaction was shown to be localized just beneath the postsynaptic membrane thickening of asymmetric synapses.

Magnetic resonance imaging of the shoulder in abduction

To simulate the painful arm position in subacromial impingement syndrome, magnetic resonance imaging of the shoulder was done with the arms at the sides and at 80 degrees abduction in two groups of patients. Group A had 20 shoulders in 20 patients with subacromial impingement syndrome and Group B had 19 shoulders in 19 patients without impingement syndrome. When arm position was changed from adduction to abduction, an increase in signal intensity of the rotator cuff tendon was seen more often in Group A (45%) than in Group B (26%). Group A shoulders showed encroachment of the acromion or the acromioclavicular joint to the rotator cuff in 25% of the shoulders with the arms at the sides, and in 75% with the arms in abduction. Similar findings were observed in only 14% and 21% of Group B shoulders in the respective arm positions. Abduction of the arms seemed to cause encroachment of the overlying structure, especially of the acromioclavicular joint, to the rotator cuff in patients with subacromial impingement syndrome, even if there were no such findings in the images with the arms at the sides.

[Clinical usefulness of scatter and attenuation correction for brain single photon emission computed tomography (SPECT) in pediatrics]

This investigation was undertaken to study clinical usefulness of scatter and attenuation correction (SAC) of brain SPECT in infants to compare the standard reconstruction (STD). The brain SPECT was performed in 31 patients with 19 epilepsy, 5 cerebro-vascular disease, 2 brain tumor, 3 meningitis, 1 hydrocephalus and psychosis (mean age 5.0 +/- 4.9 years old). Many patients was necessary to be injected sedatives for restraining body motion after Technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) was injected at the convulsion or rest. Brain SPECT data were acquired with triple detector gamma camera (GCA-9300 Toshiba Japan). These data were reconstructed by filtered backprojection after the raw data were corrected by triple energy windows method of scatter correction and Chang filtered method of attenuation correction. The same data was reconstructed by filtered backprojection without these corrections. Both SAC and STD SPECT images were analyzed by the visual interpretation. The uptake ratio of cerebral basal nuclei was calculated by the counts of the thalamus or lenticular nuclei divided by the cortex. All images of SAC method were excellent than that of STD method. The thalamic uptake ratio in SAC method was higher than that of STD method (1.22 +/- 0.09 > 0.87 +/- 0.22 p < 0.01). The lenticular nuclear uptake ratio in SAC method was higher than that of STD method (1.26 +/- 0.15 > 1.02 +/- 0.16 p < 0.01). Transmission scan is the most suitable method of absorption correction. But the transmission scan is not adequate for examination of children, because this scan needs a lot of time and the infants are exposed by the line source radioisotope. It was concluded that these scatter and absorption corrections were most suitable method for brain SPECT in pediatrics.

Plain CT findings of brain death confirmed by hollow skull sign in brain perfusion SPECT

Computed tomographic (CT) findings of 13 patients manifesting brain death were reviewed. This diagnosis was confirmed by the so-called "hollow skull" pattern observed in brain perfusion single photon emission computed tomography (SPECT), which was performed between 4 hours before and 3 days after the CT scans, and by subsequent corporal death. The brain perfusion SPECT was performed with the intravenous administration of technetium (Tc)-99m-hexamethylpropyleneamine oxime (HMPAO) or iodine (I)-123-N-isopropyl-p-iodoamphetamine (IMP). CT scans showed diffuse cerebral edema and the loss of gray-white matter differentiation in all the cases, and transtentorial herniation in 12 patients. These CT findings were considered predictive of brain death.

[Histological findings in aneurysm treated with IDC: scanning electron microscopical study]

We reported the scanning electron microscopic findings of an aneurysm embolized with interlocking detachable coils (IDC). A 78-year-old man was referred to our hospital because of left hemiparesis and dysphagia. CT scan showed multiple lacunar infarction in the bilateral corona radiata. Angiography demonstrated a small incidental aneurysm of the right internal carotid artery (IC-PC junction). The left hemiparesis gradually improved and 2 weeks after admission the aneurysm was treated with IDC. Three coils were placed in the aneurysm and post-operative angiography demonstrated complete embolization. Dysphagia caused by the pseudobulbar pulse did not improve and, 4 weeks after endovascular surgery, the patient died of aspiration pneumonia. An autopsy was performed and the scanning electron microscopical findings of the aneurysm showed development of endothelial cells on the coil surface. Many clinical reports supported the usefulness of Guglielmi detachable coils (GDC) and several experimental reports demonstrated the intimal proliferation in aneurysms embolized with coils. However, pathological changes of the aneurysms treated with coils have been reported in only four clinical cases. There was no evidence of endothelialization in any of these cases. To our knowledge, our case is the first report describing the endothelial proliferation over the coils. It is necessary to accumulate histopathological data and long-term follow-up in humans treated with coils.