Head and neck MRI of Kimura disease

OBJECTIVES

The purpose of our study was to describe the MR appearance of Kimura disease and to interpret the differences in appearance from malignant parotid gland tumours.

METHODS

MR studies of seven patients with Kimura disease were reviewed. The MR studies included T(1) weighted, T(2) weighted, short tau inversion-recovery, diffusion-weighted (DW) and dynamic contrast-enhanced imaging.

RESULTS

Typical Kimura disease featured subcutaneous lesions, continuously infiltrated parotid lesions from the subcutaneous lesions with or without intraparotid lymphadenopathies, and reactive cervical lymphadenopathies. The subcutaneous lesions showed gradual upward enhancement on dynamic contrast-enhanced MR images. Reactive lymph nodes showed early enhancement on contrast-enhanced MR images and marked high intensity and low apparent diffusion coefficient values on DW images.

CONCLUSION

An indication for making the diagnosis of Kimura disease should be the subcutaneous tissue of the head and neck showing gradual upward enhancement on dynamic contrast-enhanced MRI and a lack of high intensity on DW images, associated with reactive lymph nodes.

Amplification of the MYC Gene in Osteosarcoma Secondary to Paget's Disease of Bone

Purpose. In a previous series of 25 human osteosarcoma samples studied for MYC gene amplification, we found amplification in two cases (8%), including one arising in association with Paget's disease (pagetic osteosarcoma). Based on this observation, we further investigated the prevalence of MYC gene amplification in pagetic osteosarcomas.Methods. MYC gene amplification was assessed by Southern blot analysis using frozen tissue samples in five cases of pagetic osteosarcoma and 53 cases of primary (non-pagetic) osteosarcoma. Amplification was considered present if the MYC copy number was six or greater.Results. Three out of five patients (60%) with pagetic osteosarcoma showed MYC gene amplification, whereas it was present in only 5/53 patients (9.4%) with primary osteosarcoma. The incidence of MYC amplification in pagetic osteosarcoma was thus significantly higher than that in primary osteosarcoma (p = 0.016).Discussion. The finding that MYC gene amplification may be more common in pagetic than primary osteosarcoma warrants further study and suggests pathogenetic differences between primary osteosarcomas and those arising in the setting of Paget's disease. Three of the four pagetic osteosarcomas from the present study were previously shown to be immunoreactive for p53, suggesting that p53 mutation may also be a frequent genetic lesion in these tumors.

Surgical treatment for skeletal metastases from soft tissue sarcomas: experience with 23 lesions in 20 patients

Purpose. This paper reports the procedures and the clinical results of a series of surgical treatments for skeletal metastases from soft tissue sarcomas.Subjects and methods. Surgical treatment of metastatic bony lesions from soft tissue sarcomas has been carried out over a 20 year period (1975-1996). Thirty-two patients developed skeletal metastases from soft tissue sarcomas, and 20 of these cases received surgical treatment. The 23 metastatic bony lesions in these 20 patients were treated using the following surgical approaches: wide resection with prosthetic replacement in five lesions, wide or marginal resection without reconstruction in four lesions, intramedullarly nailing with curettage and methylmethacrylate cementation in four lesions, marginal resection of vertebral body with replacement by a ceramic prosthesis in three lesions, laminectomy in three lesions, intramedullarly nailing in two lesions, and curettage in two lesions.Results. Relief of pain was achieved in 17 of the 20 patients. The ambulatory status of the patients with metastasis in the lower extremity or periacetabular region was significantly improved in nine of 10 cases. Seventeen patients died of disease, with a mean survival period of 17.9 months after surgery for metastasis.Discussion. Although surgical treatment for skeletal metastases from soft tissue sarcomas cannot save the life of the patient, it can be of value in improving their well-being and overall quality of life. In these cases, surgical intervention may be more frequently indicated than in tumors with an osteoblastic or mixed pattern.

Expression of smooth muscle calponin in synovial sarcoma

Purpose. Histogenesis of synovial sarcoma remains controversial and reliable molecular markers for diagnosis are necessary. Expression of basic calponin, a smooth muscle differentiation-specific actin-binding protein, was studied in synovial sarcoma.Subjects and Methods. The basic calponin gene and the gene product were analyzed by reverse transcription PCR analysis (RT-PCR) and immunohistochemistry in 14 synovial sarcomas and a human synovial sarcoma cell line (HS-SY-II).Results and Discussion. Immunoreactivity for basic calponin was detected in the cytoplasm of 6 synovial sarcomas (43% positive). In the basic calponin-positive tumors and the HS-SY-II cells, expression for smooth muscle-specific genes, including basic calponin and SM22alpha , was detected by RT-PCR, suggesting a lineage relationship between synovial sarcoma cells and smooth muscle-like mesenchymal cells.Conclusions. A subset of synovial sarcomas expressing the basic calponin gene and the gene product were identified. The basic calponin may have potential utility as a novel molecular marker identifying certain synovial sarcomas.

Preparation of Silicon Carbide Nano-Particles Using a Pulsed Laser Deposition Method

We have developed a new pulsed laser deposition technique using two Nd:YAG laser beams for the nucleation of silicon carbide (SiC) crystalline nano-particles and single crystalline SiC thin films. Transmission electron microscopy and atomic force microscopy observation suggest that several nanometer size SiC particles can be prepared by the new pulsed laser deposition (PLD) method using two Nd:YAG laser beams (1064nm and 532nm). X ray photoelectron spectroscopy measurements suggest that the silicon/carbon composition ratio of the prepared SiC thin films can be controlled by laser fluence and wavelength.

The efficacy and safety of degarelix, a GnRH receptor antagonist: A multicenter, randomized, maintenance dose-finding phase II study with Japanese prostate cancer patients

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Background: Degarelix, a GnRH receptor antagonist inducing rapid, profound and sustained suppression of serum testosterone levels, without testosterone surge, was evaluated in a phase II dose finding study in Japan.

Methods: A total of 278 patients with adenocarcinoma of the prostate were randomized and 273 patients (any stage; median age, approx. 76 years; median testosterone, 4.46 ng/mL; median prostate-specific antigen (PSA) level, 22.8 ng/mL) received study treatment. Degarelix was administered subcutaneously at an initial dose of 240 mg followed by monthly maintenance doses of either 80 mg or 160 mg. The treatment continued for 12 months in the study.

Results: The primary endpoint was the proportion of patients with testosterone suppression to castrate level of ≤0.5 ng/mL during 12 months treatment. Both dose regimens of 80 mg and 160 mg kept 94.5% and 95.2% of patients on castrate level respectively throughout the treatment period. At 3 days of treatment, approximately 99% of the patients reached the castrate level without testosterone surge. The percentage change in serum PSA reduction exceeded 76% at 4 weeks. The overall tumor response rates (proportion of patients with complete and partial responses) were from 77.4% to 90.8% across the groups. Eighteen patients (6.6%) withdrew from the study due to adverse events. The most common adverse events were injection site reactions; other adverse events included pyrexia, weight increased, hypertension and hot flush. Degarelix appeared well tolerated.

Conclusions: With an initial dose of 240 mg followed by monthly maintenance doses of 80 mg or 160 mg, Degarelix resulted in a rapid profound and sustained testosterone suppression to castrate level and PSA reduction without testosterone surge for 12 months. Degarelix was well tolerated. The maintenance doses of 80 mg and 160 mg had similar efficacy and safety profiles. The study shows results similar to those from the degarelix pivotal phase III study (CS21). Assessment of risk-benefit would support the recommendation of the maintenance dose of 80 mg as a safe and effective monthly dose for the treatment of prostate cancer.

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In-Situ Observation of Stress in Cu/Pd Multilayers

Stress evolution was studied during growth of Cu/Pd multilayers using an in-situ, laserbased wafer curvature technique which allowed measurement of stress changes associated with sub-monolayer thickness increases. The apparent stress in the Cu layers changes during growth, from compressive, for thickness less than about 0.5 nm, to tensile for thicknesses above this. The stress behavior in the Pd layers depends on the thickness of the underlying Cu layer. Pd deposited on thick (2 nm) Cu layers is under an apparent compressive stress, while Pd deposited on thin (< 1 nm) Cu layers is initially under a tensile stress but changes to a compressive stress at about 0.5 nm. The overall compressive stress maxima observed in multilayers at a bilayer period of 2 nm is explained by this in-situ behavior. The stress behavior in this system is consistent with either island growth of Cu, or thickness dependent alloying behavior, or both.

Vapor Phase Epitaxy of GaN Using Gallium Tri-Chloride and Ammonia

GaN films with good crystalline quality are grown on sapphire by atmospheric pressure vapor phase epitaxy using gallium tri-chloride (GaCl3) and ammonia (NH3). Epitaxial growth is carried out over temperature and V/III-ratio ranges of 800–1000°C and 100–1000, respectively. Typical growth rate obtained is in the range of 5–20 μm/hr. The films grown below 925°C typically show three dimensional (island) growth, while above that temperature, continuous films are obtained. Films grown at 975°C with a V/III ratio > 300 exhibit a smooth surface. XRD analysis shows that the films are single crystal with hexagonal polytype. Strong band-edge photoluminescence is observed with a FWHM of 60 meV at room temperature and 25 meV at 77K. The results indicate that this simple growth technique is effective for growing high quality bulk GaN, which can be used as a substrate for subsequent epitaxy. In order to further improve the surface morphology, a preliminary experiment on GaN growth on a thin GaN buffer layer prepared by gas source MBE is also presented.

Hydrogen sensing properties of protective-layer-coated single-walled carbon nanotubes with palladium nanoparticle decoration

Protective-layer-coated single-walled carbon nanotubes (SWNTs) with palladium nanoparticle decoration (Pd-SiO(2)-SWNTs) were fabricated and their sensing properties for hydrogen (H(2)) were investigated. SWNTs were coated with a 3-4 nm thick SiO(2) layer by pulsed laser deposition and subsequently decorated with Pd nanoparticles by electron beam evaporation. Even though the SWNTs were completely surrounded by a protective layer, Pd-SiO(2)-SWNTs responded to H(2) down to a concentration of 1 part per million. Compared with the Pd nanoparticle-decorated SWNTs without a protective layer (Pd-SWNTs), Pd-SiO(2)-SWNTs exhibited highly stable sensor responses with variations of less than 20%; Pd-SWNTs showed a variation of 80%. The density of the Pd-SWNTs significantly decreased after the sensing test, while that of the Pd-SiO(2)-SWNTs with the netlike structure remained unchanged. The hydrogen sensing mechanism of the Pd-SiO(2)-SWNTs was attributed to the chemical gating effect on the SWNTs due to dipole layer formation by hydrogen atoms trapped at the Pd-SiO(2) interface. Moreover, the relationship between H(2) concentration and sensor response can be described by the Langmuir isotherm for dissociative adsorption.

Inhibiting microbial adhesion to denture base acrylic resin by titanium dioxide coating

Mechanical cleaning of dentures is effective in preventing infections such as aspiration pneumonia and denture stomatitis. For denture wearers with a physical handicap and the elderly, however, mechanical cleaning can present problems. The aim of this study was to investigate the effect of coating denture base acrylic resin with titanium dioxide (TiO(2)) in the inhibition of oral microbial adhesion. We prepared uniformly sized acrylic resin plates (10 mm x 10 mm x 0.5 mm), which were divided into two groups (a non-coated group and a TiO(2)-coated group). The plates were immersed in cultured Streptococcus sanguinis or Candida albicans and incubated for 24 h. After incubation, each plate was washed to remove loosely adherent microorganisms, and then incubated for a further 24 h. Adenosine triphosphate (ATP) content of the microorganisms was evaluated using a reagent containing benzalkonium, which extracts intra-cellular ATP. In addition, to determine biofilm formation, we also observed each plate by scanning electron microscopy (SEM). We found that the ATP content of both S. sanguinis and C. albicans was reduced by the TiO(2) coating (P = 0.000). Observation by SEM confirmed that the TiO(2) coating inhibited biofilm formation. The results indicate that a TiO(2) coating on a denture base acrylic resin inhibits adhesion of S. sanguinis and C. albicans.

Long-term changes in airway-wall thickness on computed tomography in asthmatic patients

BACKGROUND

Effects of long-term treatment with inhaled corticosteroids (ICSs) on airway-wall thickness in patients with asthma remain unknown.

OBJECTIVES

To determine whether airway-wall thickness consistently decreases after long-term ICS treatment, and to analyze factors contributing to long-term airway-wall changes in asthmatics.

METHODS

A retrospective analysis of long-term changes in airway-wall thickness using computed tomography was performed in 14 patients with asthma. Wall area corrected by body surface area (WA/BSA) was examined at baseline, 12 weeks after the commencement of ICSs (second measurement), and at least 2 years (mean +/- SEM. 4.2 +/- 0.5) after the second measurement (third measurement). Mean +/- SEM changes in WA/BSA from the second to the third measurements were analyzed.

RESULTS

The mean change in WA/BSA was not significant between the second and the third measurements (-0.27 +/- 0.59 mm2/m2/y). Overall, the changes were significantly associated with disease duration but not with other clinical indices. When the 14 patients were divided into 2 groups using a cutoff value of 0.32 mm2/m2/y for the mean change in WA/BSA, for the 5 patients whose WA/BSA exceeded this cutoff, daily ICS doses were not reduced and both forced expiratory volume in the first second (FEV1) and forced vital capacity decreased significantly. For the remaining 9 patients, daily ICS doses were reduced and long-term FEV1 values did not change.

CONCLUSIONS

Despite long-term treatment with ICSs, airway-wall thickness did not consistently decrease. One possible mechanism underlying poor response to long-term treatment may be long-standing asthma.

Recovery of cerebrovascular reserves after stenting for symptomatic carotid artery stenosis

Although a decrease in cerebrovascular reserves (CVR) is known to enhance the risk of stroke, changes in this parameter after carotid artery stenting (CAS) have rarely been investigated. The present study is the first to compare CVR recoveries after applying CAS to patients with symptomatic carotid artery disease. CAS was performed for 31 consecutive patients with symptomatic carotid artery disease. They underwent acetazolamide-challenged single photon emission computed tomography (SPECT) before and after CAS to obtain data on resting stage cerebral blood flow (CBF(rest) values) in various regions of interest (ROIs) defined by a three-dimensional stereotactic ROI template. CVR values on ipsilateral and contralateral hemispheric sides were then calculated based on the CBF(rest) data. The 31 patients were dichotomized into unilateral (n=22) and bilateral (n=9) lesion groups, and no significant between-group differences were observed in CBF(rest) before and after CAS. In the unilateral group, there were no differences in CVR values before and after CAS. In the bilateral group, however, the CVR values significantly increased in nearly all the investigated ROIs on the contralateral side. Also, the hemispheric CVR values on both sides significantly increased after CAS in the bilateral group, while no such increase was observed in the unilateral group. CAS in patients with symptomatic bilateral carotid artery disease has the potential utility for their haemodynamic improvement even on the contralateral hemispheric side.

Age-related changes in elastic properties and moisture content of lower labial mucosa

The purpose of this study was to clarify age-related changes in the elastic properties and moisture content of the lower labial mucosa. Elastic properties and moisture content were also compared between the lower labial mucosa and skin. A total of 85 adults aged 20-82 took part in the study. Elastic properties (distensibility and elasticity) and moisture content of lower labial mucosa and skin were determined in each participant. Measurements for the oral mucosa were taken at the midline of the lower labial mucosa; for the skin, they were taken at the midpoint of the right anterior surface of the forearm. Pearson's correlation coefficient and the Mann-Whitney U test were used for the statistical analysis. A stepwise multiple linear regression analysis was also performed, with age as the dependent variable and sex, distensibility, elasticity and moisture content of the lower labial mucosa as independent variables. A negative correlation was found between age and distensibility of the lower labial mucosa. No correlation was observed between age and elasticity of the lower labial mucosa. A negative correlation was observed between age and moisture content of the lower labial mucosa. A significant difference was observed in moisture content between the 20- to 39-year-old group and the over 40-year-old group. Stepwise analysis identified distensibility and moisture content of the lower labial mucosa as predictive factors of age. The results indicate that distensibility and moisture content of the lower labial mucosa decrease with age. Moisture content in the over 40-year-old group, in particular, was lower than in the 20- to -30-year-old group.

Interferon-α increases monocyte migration via platelet-monocyte interaction in murine intestinal microvessels

The aim of this study was to investigate the effect of interferon (IFN)-α on recruitment of platelets and monocytes within the murine small intestinal venular endothelium. Monocytes were isolated from bone marrow of C57B6 mice. Platelets were collected from murine blood. Rolling and adhesion to submucosal microvessels in the small intestine were examined under an intravital fluorescence microscope after injection of fluorescein-labelled monocytes or platelets. In some mice, IFN-α (5×10(5) U/kg) was administered intraperitoneally. After treatment with an antibody against P-selectin, changes in monocyte and platelet migration were also investigated. Changes in monocyte migration under the condition of thrombocytopenia were also investigated. Platelets and monocytes interacted with murine intestinal microvessels, although only few platelets and monocytes showed migration behaviour. Intraperitoneal injection of IFN-α enhanced the migration of both platelets and monocytes in the intestinal microvessels. Pretreatment with anti-P-selectin attenuated the increase in migration of platelets and monocytes induced by administration of IFN-α. Thrombocytopenia decreased the rolling ratio of monocytes, suggesting that the effect of IFN-α on migration was P-selectin-dependent, derived from both the endothelium of microvessels and platelets. The results of this study suggest that IFN-α acts as a potent proinflammatory agent via its stimulatory effect on the endothelium-platelet-monocyte interaction in intestinal microvessels by a P-selectin-dependent mechanism.

Adverse effects of trichothiodystrophy DNA repair and transcription gene disorder on human fetal development

The effects of DNA repair and transcription gene abnormalities in human pre-natal life have never been studied. Trichothiodystrophy (TTD) is a rare (affected frequency of 10(-6)) recessive disorder caused by mutations in genes involved in nucleotide excision repair (NER) pathway and in transcription. Based on our novel clinical observations, we conducted a genetic epidemiologic study to investigate gestational outcomes associated with TTD. We compared pregnancies resulting in TTD-affected offspring (n = 24) with respect to abnormalities during their antenatal and neonatal periods to pregnancies resulting in their unaffected siblings (n = 18), accounting for correlation, and to population reference values. Significantly higher incidence of several severe gestational complications was noted in TTD-affected pregnancies. Small for gestational age (SGA) <10th percentile [Relative risk (RR ) = 9.3, 95% CI = 1.4-60.5, p = 0.02], SGA <3rd percentile (RR = 7.2, 95% CI = 1.1-48.1, p = 0.04), and neonatal intensive care unit (NICU) hospitalization (RR = 6.4, 95% CI = 1.4-29.5, p = 0.02) occurred more frequently among TTD-affected neonates compared with their unaffected siblings. Compared with reference values from general obstetrical population, pregnancies that resulted in TTD-affected infants were significantly more likely to be complicated by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (RR = 35.7, 95% CI = 7.6-92.5, p = 0.0002), elevated mid-trimester maternal serum human chorionic gonadotropin (hCG) levels (RR = 14.3, 95% CI = 7.0-16.6, p < 0.0001), SGA <3rd percentile (RR = 13.9, 95% CI = 7.4-21.1, p < 0.0001), pre-term delivery (<32 weeks) (RR = 12.0, 95% CI = 4.9-21.6, p < 0.0001), pre-eclampsia (RR = 4.0, 95% CI = 1.6-7.4, p = 0.006), and decreased fetal movement (RR = 3.3, 95% CI = 1.6-5.2, p = 0.0018). Abnormal placental development is an underlying mechanism that may explain the constellation of observed complications in our study. Thus, we hypothesize that TTD DNA repair and transcription genes play an important role in normal human placental development.

Significant expression of interleukin 15 in rat experimental severe acute pancreatitis

PURPOSE

In severe acute pancreatitis (SAP), multiple organ dysfunction syndrome is a contributor to high mortality. We recently demonstrated that the serum interleukin (IL)-15 level is a predictor of the complications and mortality in clinical SAP. The aim was to investigate the role of IL-15 in experimental SAP.

MATERIALS AND METHODS

SAP was induced by retrograde injection of 3 and 20% sodium deoxycholate (DCA) into biliopancreatic ducts in rats (DCA pancreatitis). Expressions of IL-15 were evaluated by Western blotting and immunohistochemical staining. Recombinant IL-15 protein was administered intraperitoneally, and the effects were investigated.

RESULTS

Western blotting revealed the expressions of IL-15 in the pancreas, liver, lung and intestine in 3% DCA pancreatitis. Immunohistochemical staining showed the expression of IL-15 in the cytoplasm of each organ. In 3% DCA pancreatitis, administration of recombinant IL-15 protein attenuated the elevation of serum alanine aminotransferase (ALT) levels and improved the morphological change of the lung 18 h after the induction of SAP. Moreover, in 20% DCA pancreatitis, IL-15 improved the elevation of serum amylase and ALT levels 6 h after the induction.

CONCLUSIONS

These results suggest that IL-15 is related to organ dysfunction during SAP, and that IL-15 functions as a protective factor against the organ injuries.

The compact electron cyclotron resonance ion source KeiGM for the carbon ion therapy facility at Gunma University

A high-energy carbon-ion radiotherapy facility is under construction at Gunma University Heavy Ion Medical Centre (GHMC). Its design was based on a study of the heavy ion radiotherapy at the National Institute of Radiological Sciences (NIRS) in order to reduce the size and construction cost of the facility. A compact electron cyclotron resonance ion source (ECRIS) for Gunma University, called KeiGM, was installed in 2008. It is almost a copy of the prototype ECRIS Kei2 which was developed by NIRS; meanwhile this prototype produced over 1 e mA of C(4+) using C(2)H(2) gas (660 W and 40 kV). The beam intensity of C(4+) was 600 e microA with CH(4) gas (250 W and 30 kV). The beam intensity satisfies the required value of 300 e microA.

Oral environmental factors affecting number of microbes in saliva of complete denture wearers

The purpose of this study was to clarify which oral environmental factors affected number of microbes in saliva in an edentulous environment. We enrolled 68 edentulous subjects in the study. Numbers of total anaerobic bacteria and Candida species in saliva were determined. Age, sex, un-stimulated salivary flow rate, pH and viscosity of saliva, histatin level in saliva, tongue coating status, tongue pressure, denture plaque status, material of denture base, duration of edentulism, frequency of self oral health care and number of cigarettes per day were also investigated as oral environmental factors. Correlation between number of total anaerobic bacteria or Candida species and each oral environmental factor was determined with the Spearman rank correlation coefficient. Stepwise logistic regression analysis was used to identify which factors were significantly associated with level of total anaerobic bacteria and Candida species. Correlation and stepwise logistic regression analyses revealed associations between un-stimulated salivary flow rate, tongue coating status, denture plaque status or frequency of self oral health care and number of total anaerobic bacteria. The correlation analysis showed a significant correlation between age and number of total anaerobic bacteria. Stepwise logistic analysis revealed associations between pH of saliva or viscosity of saliva and level of anaerobic bacteria; it also revealed associations between histatin level in saliva or un-stimulated salivary flow rate and level of Candida species. We conclude that salivary flow rate, in particular, affects number of salivary microbes in an edentulous environment.

Degeneration of patellar cartilage in patients with recurrent patellar dislocation following conservative treatment: evaluation with delayed gadolinium-enhanced magnetic resonance imaging of cartilage

OBJECTIVE

To examine the characteristics of cartilage degeneration in patients with recurrent patellar dislocation (RPD) following conservative treatment using delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC).

DESIGN

This study evaluated three groups of knees: group I, 35 knees from both knees of patients with bilateral RPD and dislocated side knees of patients with unilateral RPD; group II, 15 non-dislocated side knees of patients with unilateral RPD; and group III, 20 knees from both knees of healthy volunteers. Differences in post-contrast T1 [T1(Gd)] of cartilage at both medial and lateral facets between groups I, II and III were analyzed. For group I, possible relationships were evaluated between T1(Gd) of cartilage and patient age, length of time between the initial dislocation and MRI and the total number of dislocations between the initial dislocation and MRI for both medial and lateral facets.

RESULTS

The mean T1(Gd) of cartilage at medial facets for groups I, II and III were 411+/-46ms, 465+/-38ms and 490+/-29ms, respectively; there were significant differences between these means (P<0.05). The mean T1(Gd) of cartilage at lateral facets for groups I, II and III were 426+/-53ms, 466+/-45ms and 510+/-36ms, respectively; there were also significant differences between these means (P<0.05). Significant correlations were observed between T1(Gd) of cartilage for both medial and lateral facets and length of time between the initial dislocation and MRI (P<0.05). No other correlations were significant.

CONCLUSION

dGEMRIC may be a useful method to monitor glycosaminoglycan concentration in patients with RPD following conservative treatment.