Obstructive sleep apnea affects the psychological and behavioural development of children-a case-control study.

This study aims to investigate the effects of obstructive sleep apnea on paediatric psychological and behavioural abnormalities. A total of 1086 paediatric patients with obstructive sleep apnea and 728 sample snoring controls were enrolled in the study. Patients with obstructive sleep apnea underwent bilateral tonsillectomy plus adenoidectomy or adenoidectomy alone. Repeated Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory were performed to assess the autism symptoms, anxiety level and depressive symptoms before and after surgery. The score of Autism Behaviour Checklist in preschool children with obstructive sleep apnea was higher than that in control. In school children with obstructive sleep apnea, the score of Spence Children's Anxiety Scale was also higher. School children with obstructive sleep apnea with depressive symptoms were significantly higher than that in control. The scores of Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory in the obstructive sleep apnea group after surgery were significantly lower than that before surgery. Our study showed that the score of Spence Children's Anxiety Scale and Children's Depression Inventory had a close correlation with the illness course and hypoxia duration. The Spence Children's Anxiety Scale and Children's Depression Inventory scores are also closely associated with the Autism Behaviour Checklist score. These results suggest that obstructive sleep apnea may have a significant impact on autism symptoms, anxiety levels and depressive symptoms in children. We found that the longer the duration of the obstructive sleep apnea course and hypoxia, the greater the impact on anxiety level and depressive symptoms. The suspected autism symptoms, anxiety level and depressive symptoms in children with obstructive sleep apnea were also significantly correlated. Thus, early detection and timely treatment may often reverse the psychological and behavioural abnormalities caused by obstructive sleep apnea.

Manejo de la hipoxia durante ventilación unipulmonar en un paciente con absceso mediastinal y mediastinitis para toracotomía abierta. Reporte de caso / Hypoxia Management during One-Lung Ventilation in a Patient with Mediastinal Abscess and Mediastinitis for Open Thoracotomy. Case Report

Introducción: la mayoría de los pacientes que se someten a cirugía torácica pueden ser clasificados en el grupo de alto riesgo para hipoxia, especialmente cuando se decide por una ventilación unipulmonar, debido al desequilibrio V/Q; por lo tanto, se han desa-rrollado nuevas estrategias ventilatorias y maniobras de rescate para hipoxia. Curso clínico: presentamos una paciente de 85 años de edad sin comorbilidades programada para toracotomía abierta y manejada con ventilación unipulmonar. Durante el mane-jo anestésico, se presenta hipoxia secundaria a desequilibrio V/Q y choque hipovolémi-co hemorrágico, con respuesta positiva a las maniobras de rescate para hipoxia. Con-clusión: es importante prevenir en la medida de lo posible la hipoxia en la ventilación unipulmonar, siguiendo las nuevas estrategias ventilatorias. Sin embargo, cuando se presenta una crisis, no debemos retrasar las maniobras de rescate de forma moderna. (AU)

Introduction: most of the patients undergoing thoracic surgery fit in the high risk group for hypoxia, especially when deciding to use one-lung ventilation due to the V/Q mis-match; therefore, new ventilation strategies and hypoxia rescue manoeuvres have been developed. Clinical course: we present an 85-year old female with no major co-morbidities scheduled for open thoracotomy and managed with one-lung ventilation. During the course of the anaesthetic management, hypoxia presents secondary to V/Q mismatch and haemorrhagic hypovolemic shock, with a positive response to hypoxia rescue manoeuvres. Conclusion: it is important to prevent as much as we can the hy-poxia in a one-lung ventilation following the new ventilation strategies. Although when facing a crisis, proper hypoxia management with a modern approach should not be de-layed. (AU)

Hypoxemia After Endobronchial Valve Deployment for Persistent Air Leak.

Endobronchial valves (EBVs) are a novel, minimally invasive bronchoscopic management technique for persistent air leaks that fail conservative therapy. Currently, 2 EBVs are available in the United States: the Spiration Valve System (Olympus, Redmond, WA) and the Zephyr Valve (Pulmonx, Redwood, CA). These valves are Food and Drug Administration-approved to reduce hyperinflation in emphysematous patients via bronchoscopic lung-volume reduction. However, more recently, the Spiration Valve has been granted a compassionate use exemption through the Food and Drug Administration for persistent postsurgical air leaks. Despite their popularity, these devices are not free from side effects. As an anesthesiologist, it is vital to be aware of the pathophysiology of this patient population so that safe and effective anesthetics may be provided during valve placement. Here, the use of EBVs is discussed in a patient who presented with a persistent air leak after a transthoracic needle aspiration that failed treatment due to persistent hypoxemia, warranting EBV removal.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis.

BACKGROUND: Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. METHODS: We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. RESULTS: The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). CONCLUSIONS: According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

[Efficacy Analysis of High-flow Nasal Oxygen Therapy in Patients 
Accepting Single-port Video-assisted Thoracoscopic Lobectomy].

BACKGROUND: Patients who underwent lobectomy resection are prone to hypoxemia, and the vast majority present with type I respiratory failure. Thus, improvement of hypoxemia is one of the most important factors to facilitate postoperative recovery of patients. In this study, the superiority-inferiority of different oxygen inhalation methods were compared with high-flow nasal oxygen therapy (HFNO), noninvasive mechanical ventilation (NIMV) and nasal oxygen breath (NOB) in patients with hypoxemia after single-port video-assisted thoracoscopic (VATS) lobectomy, and the clinical efficacy of HFNO in these patients was further investigated. METHODS: A total of 180 patients from the Second Affiliated Hospital of Soochow University in China with hypoxemia who accepting single-port VATS lobectomy from June 2021 to March 2022 were randomly divided into three groups (n=60), which were treated with HFNO, NIMV and NOB, respectively. The results of arterial blood gas analysis, patient's comfort score and incidence of complications were observed before, 1 h, 6 h-12 h and after use. Statistical analyses were conducted using statistical program for social sciences 25.0 (SPSS 25.0), and P<0.05 was considered as statistical significance. RESULTS: For patients with hypoxemia after accepting single-port VATS lobectomy, HFNO was no less effective than NIMV (P=0.333), and both of whom could fast increase patients' partial pressure of oxygen/fraction of inspiration O2 (PaO2/FiO2) compared to NOB (P<0.001). Besides, HFNO shows a great advantage in comfort degree and stay length (P<0.001, P=0.004), and incidence of complications were slightly lower than other groups (P=0.232). But it is worthy to note that HFNO is still slightly less effective than NIMV in patients with postoperative hypoxemia accompanied by elevated partial pressure of carbon dioxide (PaCO2). CONCLUSIONS: For patients with hypoxemia who accepting single-port VATS lobectomy, HFNO can be used as the first choice. However, for patients with postoperative hypoxemia accompanied by elevated PaCO2, NIMV is still recommended to improve oxygenation.

Prone Position in Treatment of Hypoxemia in Patients Who Underwent Type A Aortic Dissection Surgery.

BACKGROUND: Postoperative hypoxemia is a high-risk complication after acute type A aortic dissection (TAAD) surgery. Prone position (PP) is an effective treatment for acute respiratory failure, which may improve the gas exchange of the injured lung and the patient's survival. PP is reported to improve the respiratory condition after cardiac surgery. However, limited data exist on the effect of PP in patients who underwent acute TAAD surgery. METHODS: We retrospectively analyzed the clinical outcomes of seven patients with severe hypoxemia who underwent PP after acute TAAD surgery. The results of arterial blood gas, chest X-ray, and survival were collected. RESULTS: Seven patients (3 female, mean age 48.3±11.7 years) were recruited in this study. All patients received total arch replacement and frozen elephant trunk implantation procedure. The PaO2 at day 1 after PP was higher than before PP (126.3±49.3 vs. 77.8±15.5 mmHg). The oxygenation index rose sharply from 83.0 (80.0, 87.0) to 188.3±56.5 at day 3 after PP. There was no significant difference in heart rate between before and after PP procedure. Chest X-ray showed the diffuse shadow was significantly improved after PP. All patients responded well to PP, and all patients were discharged except for one patient, who died perioperatively due to multiple organ failure. CONCLUSIONS: PP is a safe and feasible option for severe hypoxemia patients after TAAD surgery.

Prominent Eustachian Valve and Atrial Septal Defect Presenting With Chronic Hypoxemia in a Teenager.

Prominent Eustachian valves, with obligate right-to-left shunts, have been reported as a cause of neonatal hypoxemia. This anomaly can present as an obstructive structure that inhibits antegrade flow through the tricuspid valve and furthermore contributes to right-to-left atrial shunting in the presence of a patent foramen ovale or atrial septal defect. This case highlights the evaluation and diagnostic workup for chronic hypoxemia in an adolescent female patient and considerations for percutaneous atrial septal defect closure.

Percutaneous Atrial Septal Defect Closure in Adult Ebstein's Anomaly with Exertional Hypoxemia.

In Ebstein's anomaly, percutaneous atrial septal defect (ASD) closure for the treatment of hypoxemia due to a right-to-left interatrial shunt remains controversial. We report the case of a 40-year-old woman with Ebstein's anomaly who developed cyanosis and shortness of breath on exercise. Her symptoms improved after percutaneous ASD closure and her clinical course has been good during follow-up. The balloon ASD occlusion test, combined with dobutamine stimulation before the procedure, is useful to confirm treatment indication. A prior electrophysiological evaluation is also important because Ebstein's anomaly is often complicated by atrioventricular recurrent tachycardia.

Therapeutic coil embolization of dominant shunt in hepatopulmonary syndrome enhances post-liver transplant respiratory recovery.

Coil embolization of the atypical enlarged pulmonary artery/arteriole with visible shunting may improve hypoxemia in patients with hepatopulmonary syndrome (HPS). When used selectively in cases with large shunts, either pre- or post-liver transplantation (LT), it can aid an early recovery and reduce morbidity. We present a case where a large intrapulmonary shunt was embolized preoperatively to improve hypoxemia associated with HPS and enhance post-operative recovery.

Hypoxic events during non-obstetric abdominal surgery in pregnant women.

OBJECTIVE: Every year 0.5-2% of women undergo non-obstetric surgery in pregnancy. Hypoxic events with short-term and long-term consequences are one of the most frequent complications in surgery. There is only limited data available regarding the impact of these events. This review aims to analyze the current literature on hypoxic events occurring in non-obstetric abdominal surgery in pregnant women, focused on maternal and fetal outcomes. MATERIALS AND METHODS: We performed a non-systematic review of the literature, through a PubMed search using the key words "hypoxemia", "non-obstetric surgery", "surgical procedures", "pregnancy", "pregnant women" and "outcome". RESULTS: There is little data available regarding maternal and fetal outcomes after hypoxic episodes during non-obstetric surgery in pregnancy. In these cases, conservative intrauterine resuscitation maneuvers or immediate delivery should be taken into account. Perimortem cesarean section can be lifesaving for both mother and fetus when maternal collapse is non responsive to resuscitation procedures. Inaccurate information regarding maternal and fetal outcomes is due to the lack of robust data and the heterogeneity of the causes underlying maternal respiratory complications during surgery. CONCLUSIONS: Non-obstetric surgery during pregnancy must be performed when indicated. An expert multidisciplinary team, composed of obstetricians, surgeons, and anesthesiologists need to be included, giving appropriate attention to the physiological changes of respiratory, cardiovascular, and gastrointestinal system that occur during pregnancy. The shortest operative time and peri-operative assistance should be ensured. Complications, such as hypoxic events in pregnant patients need adequate assistance. Multidisciplinary cooperation, continuous training and simulation for anesthesiology and resuscitative procedures can guarantee this.

Preoperative Venovenous Extracorporal Membrane Oxygenation for Transposition of Great Arteries With Severe Pulmonary Hypertension in a Newborn.

Severe persistent pulmonary hypertension in a newborn combined with transposition of great arteries increases the risk of early death before the arterial switch operation. We report the case of a newborn with transposition of great arteries and ventricular septal defect associated with severe pulmonary hypertension. Profound hypoxemia, despite successful balloon atrial septostomy and conventional supportive measures with mechanical ventilation, inhaled nitric oxide, and inotropes, led to the use of venovenous extracorporeal membrane oxygenation to rapidly stabilize the child preoperatively. Different from most reported cases on this scenario, we intentionally opted for a venovenous mode of support despite the presence of circulatory compromise.

Arteriovenous fistula creation for hypoxia after single ventricle palliation: A single-institution experience and literature review.

BACKGROUND: Hypoxia is a common and sometimes severe morbidity of single ventricle congenital heart disease (CHD). Creation of an arteriovenous fistula (AVF) is occasionally performed for patients after superior or total cavopulmonary connection (SCPC or TCPC) in an attempt to improve oxygen saturations. Despite previous reports, AVF creation is a rare palliation with inadequately defined benefits and risks. We sought to determine changes in peripheral oxygen saturation (SpO2 ) and risk of adverse event after AVF creation in children with single ventricle CHD at our institution. METHODS: We conducted a retrospective chart review of patients with a history of single ventricle palliation and history of surgical AVF creation who were seen at our tertiary care center from 1996 to 2017. RESULTS: A total of seven patients were included in our study. SpO2 for the overall cohort did not significantly increase after AVF creation (pre-AVF 79.1 ± 6.9%, post-AVF 82.7 ± 6.0% [P = .23]). SpO2 trended up for large shunts (>5 mm) (pre-AVF 75.0 ± 7.6%, post-AVF 84.0 ± 5.3% [P = .25]). SpO2 did not improve for small shunts (≤5 mm) (pre-AVF 82.3 ± 6.5%, post-AVF 81.0 ± 8.5% [P = .50]). The 12-month overall and transplant-free survival were 85.7% and 71.4%, respectively. Freedom from AVF-related complication (cephalic edema, thrombotic occlusion) was 51.4% at 12 months. CONCLUSION: Palliative AVF creation for patients with single ventricle CHD and hypoxia does not universally improve SpO2 and is prone to early complications. Despite a lack of durable benefit and known risks, AVF creation remains a reasonable palliation for a subset of patients after SCPC who are not candidates for TCPC, or potentially as a bridge to heart transplantation.

Expiratory Central Airway Collapse in Adults: Anesthetic Implications (Part 1).

Expiratory central airway collapse (ECAC) is a general term that incorporates tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). TBM and EDAC are progressive, degenerative disorders of the tracheobronchial tree, causing airway collapse. Induction of general anesthesia can trigger intraoperative airway collapse in patients with these conditions. This crisis presents as the sudden inability to ventilate, which can lead to life-threatening hypoxemia and hypercapnia. This article reviews the definition, pathophysiology, diagnosis, and anesthetic implications of ECAC.

Improvement in Nocturnal Hypoxemia in Obese Patients with Obstructive Sleep Apnea after Bariatric Surgery: a Meta-Analysis.

OBJECTIVE: To conduct a meta-analysis examining the effects of bariatric surgery on nocturnal hypoxemia in obese patients with obstructive sleep apnea (OSA). METHODS: PubMed, EMBASE, Cochrane Library, and Web of Science were searched (the last search date was June 10, 2018) to identify relevant clinical studies. The mean arterial oxygen saturation (MeanSaO2), nadir oxygen saturation (NadirSaO2), apnea hypopnea index (AHI), and body mass index (BMI) data during the perioperative period were extracted and analyzed using a random effects model. Then, we performed subgroup and sensitivity analyses and calculated the publication bias to assess the between-study heterogeneity. RESULTS: In total, 15 studies with 636 patients were included; 13 were prospective observational trials, 1 was a randomized controlled trial (RCT), and 1 was a retrospective trial. After surgery, the MeanSaO2 and NadirSaO2 increased by 1.36 [95% CI (0.72, 2.00)] and 1.08 [95% CI (0.68, 1.49)], respectively, and the AHI and BMI decreased by 1.11 [95% CI (0.82, 1.40)] and 1.97 [95% CI (1.67, 2.27)], respectively. However, the heterogeneity across all trials was high; we identified some of the sources of that heterogeneity through subsequent subgroup and sensitivity analyses. CONCLUSIONS: Bariatric surgery is effective at improving nocturnal hypoxemia in obese patients with OSA; it also reduces body weight and the number of apnea events. More randomized controlled and comparative trials are necessary in the future to confirm our findings and to explore the potential underlying mechanisms.

Nocturnal Hypoxemia, But Not Sleep Apnea, Is Associated With a Poor Prognosis in Patients With Pulmonary Arterial Hypertension.

BACKGROUND: Sleep apnea (SA) can cause repeated nocturnal arterial oxygen desaturation and result in acute increase in pulmonary arterial pressure (PAP). The presence of SA is associated with a poor prognosis in patients with chronic left-sided heart failure, but little is known for patients with pulmonary arterial hypertension (PAH). Methods and Results: We enrolled 151 patients with PAH (44±16 years old, male/female=37/114). They were all in the Nice Classification group 1 (idiopathic PAH/associated PAH=52/48%, mean PAP of 46±16 mmHg). They underwent right-heart catheterization and a sleep study with simplified polysomnography. Averaged percutaneous oxygen saturation (SpO2) during sleep was measured and an apnea-hypopnea index >5 was defined as SA. SA was noted in 58 patients (obstructive SA/central SA: 29/29). Over an average follow-up of 1,170±763 days, 32 patients died. By Kaplan-Meier analysis, there was no significant difference in deaths of patients with and without SA (χ2=2.82, P=0.093). On the other hand, the mortality in patients with lower averaged SpO2 was significantly higher than in those with higher averaged SpO2 (χ2=14.7, P<0.001) and that was the only independent variable related to death in multivariate Cox proportional hazards analysis. CONCLUSIONS: SA in patients with PAH was not associated with worse prognosis, unlike left ventricular heart failure, but nocturnal hypoxemia was related to poor prognosis.

Toll-like receptors 2, 4 and 9 and hypoxia markers HIF-1alpha and CAIX in pancreatic intraepithelial neoplasia.

Pancreatic cancer arises from precursor lesions called pancreatic intraepithelial neoplasia (PanIN) characterized by inflammatory microenvironment. In pancreatic cancer, strong innate immunity and hypoxia responses are typical. Occurrence and relationship of these responses in human PanINs is unknown. We have studied the expression of toll-like receptors (TLR) TLR2, TLR4 and TLR9, and hypoxia markers HIF-1alpha and Carbonic anhydrase IX (CAIX) in normal and inflamed pancreatic ducts, in PanINs and in cancers. The samples of 69 surgically resected pancreatic ductal adenocarcinoma patients were stained using immunohistochemistry. We found TLR2, TLR9, HIF-1alpha and CAIX to be prominently expressed in pancreatic intraepithelial neoplasia. Expression of TLR2 showed a linear increase from PanIN1 to PanIN3, while the highest TLR4 expression was detected in inflamed ducts, and TLR9 expression in PanIN1 lesions. Within the PanIN1-group, nuclear HIF-1alpha correlated with membranous and cytoplasmic TLR2 expression (ρ = 0.982 and 0.815; p < 0.001 and p = 0.025, respectively), and in the PanIN2-group nuclear HIF-1alpha correlated with nuclear TLR9 expression 0.636, p = 0.026). Our findings show that the expression of TLRs 2, 4 and 9, and hypoxia markers HIF-1alpha and CAIX is abnormal in pancreatic intraepithelial neoplasia suggesting that both the innate immunity activation and hypoxia response are involved in early pancreatic carcinogenesis. However, these processes might be independent.

Effectiveness, safety, and Economic Comparison of Two Inhaled Epoprostentol Products (Flolan and Veletri) in Cardiothoracic Surgery Patients.

BACKGROUND: No previous studies exist examining two inhaled epoprosternol formulations (Flolan compared with Veletri) in a homogenous cardiothoracic surgery patient population. OBJECTIVE: To compare the impact of inhaled Flolan and inhaled Veletri on the effectiveness, safety, or cost in cardiothoracic surgery patients. MATERIALS AND METHODS: This was a retrospective, noninferiority study comparing inhaled Flolan and inhaled Veletri in cardiothoracic surgery patients. Participants included were ≥18 years old, admitted to the cardiothoracic intensive care unit, and received inhaled Flolan or inhaled Veletri therapy for ≥1 hour. RESULTS: A total of 244 patients were included in the primary outcome analysis (122 patients per group). The primary outcome, change in the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio 1 hour after administration of inhaled Flolan or inhaled Veletri, did not cross the lower limit of the noninferiority margin (95% CI = -14.8 to 65.4). Significant differences in secondary outcomes included duration of mechanical ventilation (4.4 vs 2.6 days; P < 0.01), number of tracheostomies (24 vs 9; P = 0.01), number of patients initiated on dialysis (25 vs 12; P = 0.02), and cost per median duration of therapy ($257 vs $183; P = 0.02) in the inhaled Flolan and inhaled Veletri groups, with the average duration of therapy being 1.6 and 1.3 days, respectively. CONCLUSIONS AND RELEVANCE: Inhaled Veletri was demonstrated to be non-inferior to inhaled Flolan when comparing change in PaO2/FiO2 ratio 1 hour post -therapy initiation,and inhaled Veletri was an acceptable alternative to inhaled Flolan in a cardiothoracic surgery patient population.

Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno-Arterial Extracorporeal Membrane Oxygenation-A Case for Atrial Septostomy.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical circulatory support for patients with advanced cardiogenic shock, facilitating myocardial recovery and limiting multi-organ failure. In patients with severely limited left ventricular ejection, peripheral VA-ECMO can further increase left ventricular and left atrial pressures (LAP). Failure to decompress the left heart under these circumstances can result in pulmonary edema and upper body hypoxemia, that is, myocardial and cerebral ischemia. Atrial septostomy can decrease LAP in these situations. However, the effects of atrial septostomy on upper body oxygenation remain unknown. After IRB approval, we identified 9 out of 242 adult VA-ECMO patients between January 2011 and June 2016 who also underwent atrial septostomy for refractory pulmonary edema/upper body hypoxemia. We analyzed LAP/pulmonary capillary wedge pressure (PCWP), right atrial pressures (RAPs), Pa O2 /Fi O2 ratios (blood samples from right radial artery), intrathoracic volume status, and resolution of pulmonary edema before and up to 48 h after septostomy. There were no procedure-related complications. Thirty-day survival was 44%. LAP/PCWP decreased by approximately 40% immediately following septostomy and remained so for at least 24 h. Pa O2 /Fi O2 ratios significantly increased from 0.49 (0.38-2.12) before to 5.35 (3.01-7.69) immediately after septostomy and continued so for 24 h, 6.6 (4.49-10.93). Radiographic measurements also indicated a significant improvement in thoracic intravascular volume status after atrial septostomy. Atrial septostomy reduces LAP and improves upper body oxygenation and intrathoracic vascular volume status in patients developing severe refractory pulmonary edema while undergoing peripheral VA-ECMO. Atrial septostomy therefore appears safe and suitable to reduce the risk of upper body ischemia under these circumstances.