Assessment of Human Leukocyte Antigen Differences between Smokers with Reinke's Edema and Those with Laryngeal Cancer.

Introduction: The present study aimed to assess human leukocyte antigen (HLA) typing differences between smokers with Reinke's edema and those with laryngeal squamous cell carcinoma (SCC). Materials and Methods: The HLA class I, II alleles were examined in 76 unrelated Iranian patients using low-resolution polymerase chain reaction with the sequence-specific primer (PCR-SSP) method. Results: The frequency of the HLA-A*36 allele and HLA-B*35 was significantly higher in patients with SCC. The frequency of HLA-DRB1*01 alleles in Reinke's edema was significantly higher, as compared to that in others. In the volunteer group, HLA-DRB1*13 and HLA-DRB1*15 were significantly higher. Conclusions: As evidenced by the obtained results, HLA-A*36 was significantly higher in SCC, as compared to that in volunteers and Reinke's edema patients. It can be concluded that being positive for HLA-A*36 increases the chance of SCC by three times. This result should be further investigated in cohort studies conducted on larger samples. Furthermore, HLA-A*24 was significantly higher in the volunteer group, as compared to that in other groups. The HLADRB1*01 was remarkably higher in Reinke's edema, as compared to that in SCC.

Strain Elastosonography Measurement in Patients with Primary Muscle Tension Dysphonia Compared with Healthy Speakers: A Pilot Study.

OBJECTIVES: The purpose of this study was to investigate real-time elastosonography (RTE) to measure strain of the (para)laryngeal muscles in patients with primary muscle tension dysphonia (MTD) and healthy speakers. STUDY DESIGN: This is a cross-sectional study. METHODS: Ten patients with primary MTD (37.8 ± 10.53 years) and 10 healthy speakers (36.9 ± 9.8 years) participated. Participants were diagnosed as MTD patient or healthy via voice history, voice self-assessment, perceptual voice evaluation, laryngeal palpation, and videostroboscopy. Then, RTE was performed to extract strain index (SI) and strain ratio (SR) for all participants. The RTE was utilized for the suprahyoid, thyrohyoid, and the cricothyroid muscles, both in right and left sides during rest, /a/, and /i/ prolongations. To study the effect of group, task, and interactive effect on the SI and SR, two-way repeated-measures analysis of variance was performed. RESULTS: The effect of group on the SI was significant for the right cricothyroid (P ˂ 0.001). Significant effect of group on the SR obtained for the right suprahyoid, left thyrohyoid, and right cricothyroid (P < 0.05). Moreover, the only muscle whose SR was significantly affected by task was the left suprahyoid (P < 0.05). Compared to healthy speakers, the interactive effect was significantly lower in SI for the left cricothyroid, and higher in SR for both the right suprahyoid and left cricothyroid in patients (P < 0.05). CONCLUSIONS: The RTE can discriminate patients with primary MTD from healthy subjects in some laryngeal muscles, especially suprahyoid and cricothyroid. It may be regarded as a clinical instrument in the assessment of MTD in future. Further studies with bigger sample size are recommended.

Comparison of Laryngeal Palpatory Scale (LPS), With Surface Electromyographic Measures in Patients with Muscle Tension Dysphonia.

OBJECTIVES: The aim of this study was to examine the laryngeal palpatory scale (LPS) to ascertain possible correlation with neck surface electromyography (sEMG). METHODS: Two otolaryngologists and one certified speech-language pathologist assessed 21 participants (seven women and 14 men; with a mean age of 42.8 years; ranged: 21 to 70 years) with muscle tension dysphonia (MTD) diagnosed with the current version of the LPS rating system. Consequently, relationships between LPS and objective measures of sEMG were evaluated using Spearman's rank correlation coefficient (r). RESULTS: The results show that there was a low to moderate between correlations, (statistically positive and significant in 10 correlations among the examined items/states). CONCLUSIONS: In conclusion, low-moderate positive correlations between sEMG and LPS ratings were found with particular strength for LPS ratings of tightness and ratings made during dynamic tasks. Further investigations can provide useful evidence for researchers and clinicians to document treatment outcomes by using LPS and sEMG in patients with MTD and leading to the more standardized care and improved information about patient progress.

How Plastic and Endoscopic Assisted Surgery Can Help Foreign Body Removal?

In this study we report a case with foreign body in the infratemporal fossa. The anatomic position of this region and the presence of important neurovascular structures make this region a sophisticated one. Commonly used open procedures can have morbidity of neurovascular system. To prevent probable complications like facial nerve injury in this case which was the most important factor for us, we decided to remove the foreign body under endoscopic guide.

A Novel Laryngeal Palpatory Scale (LPS) in Patients with Muscle Tension Dysphonia.

OBJECTIVES: Laryngeal palpation is a routine clinical method for evaluation of patients with muscle tension dysphonia (MTD). The aim of this study was to develop a new comprehensive valid and reliable "laryngeal palpatory scale" (LPS), based on psychometric criteria. METHODS: The scale items were selected based on an in-depth analysis of the literature and an expert focus group. Scale item generation and item reduction were followed by a psychometric assessment. Qualitative and quantitative content validity (the content validity ratio (CVR), content validity index (CVI)), the qualitative face validity, and the inter-rater reliability were determined. For this purpose, 531 patients were assessed and finally 55 patients with primary MTD (26 women, mean age: 40.8 years, SD: 12.5; 29 male, mean age: 41.6 years, SD: 11.8) participated in the study. A weighted kappa (k*) statistic was used to examine the inter-rater reliability for each single item. RESULTS: Based on the CVR, three items were omitted because they had a score of less than 0.62. The CVI for all remaining items was greater than 0.79 and the scale CVI was equal to 0.96. The final 45 items were a result of the study. The inter-rater reliability for each single item ranged from 0.41 to 1, indicating moderate to almost perfect agreement. CONCLUSIONS: The LPS is a reliable and valid instrument for assessing patients with MTD. However, future studies are needed to provide adequate data on sensitivity, specificity, concurrent validity, and cutoff scores.

Safe Use of Flammable Endotracheal Tubes During Anesthesia for Laryngeal Laser Surgery-Report of 1024 Cases and a Brief Literature Review.

INTRODUCTION: One of the major concerns in laryngeal laser surgery is the risk of airway fire. The introduction ofwrapped tubes and metal tubes has reduced the fire hazards. However, these tubes are expensive and do not provide convenient access to the surgical field. There are few laboratory studies addressing the resistance of polyvinylchloride tubes against ignition in the given circumstances. Nevertheless, its safety should be approved in clinical practices. MATERIALS AND METHODS: This retrospective studyevaluated the airway management on 1024 patients undergoing laryngeal laser surgery. The data collection included the information about the type of endotracheal tube (ETT), mode of ventilation, and airway hazards (e.g., tube ignition). RESULTS: Polyvinylchloride tubes and conventional positive pressure ventilation was applied for most of the patients (84.1%). The tube cuff was pierced with laser beam in 22 cases (2.5%). However, there was no case of ETT ignition or airway fire. CONCLUSION: Polyvinylchloride tubes can be safely used in this subset of surgeries pending meticulous attention to the safety recommendations.

The Effects of Size and Type of Vocal Fold Polyp on Some Acoustic Voice Parameters.

BACKGROUND: Vocal abuse and misuse would result in vocal fold polyp. Certain features define the extent of vocal folds polyp effects on voice acoustic parameters. The present study aimed to define the effects of polyp size on acoustic voice parameters, and compare these parameters in hemorrhagic and non-hemorrhagic polyps. METHODS: In the present retrospective study, 28 individuals with hemorrhagic or non-hemorrhagic polyps of the true vocal folds were recruited to investigate acoustic voice parameters of vowel/ æ/ computed by the Praat software. The data were analyzed using the SPSS software, version 17.0. According to the type and size of polyps, mean acoustic differences and correlations were analyzed by the statistical t test and Pearson correlation test, respectively; with significance level below 0.05. RESULTS: The results indicated that jitter and the harmonics-to-noise ratio had a significant positive and negative correlation with the polyp size (P=0.01), respectively. In addition, both mentioned parameters were significantly different between the two types of the investigated polyps. CONCLUSION: Both the type and size of polyps have effects on acoustic voice characteristics. In the present study, a novel method to measure polyp size was introduced. Further confirmation of this method as a tool to compare polyp sizes requires additional investigations.

Human Papillomavirus (HPV) Genotype Distribution in Patients with Recurrent Respiratory Papillomatosis (RRP) in Iran

Background: Currently, recurrent respiratory papillomatosis (RRP), common laryngeal warts in the upper airway systems of children and adults are on the increase. Human papillomaviruses (HPVs) are suspected as causative agents. This study concerned HPV incidence and genotype distribution in Iranian RRP patients. Methods: Specimens were collected from RRP patients referred to hospitals affiliated with Iran University of Medical Sciences, Tehran, Iran, from Dec 2014 to Feb 2016 in a cross sectional study. After DNA extraction with an QIAamp® DNA FFPE Tissue Kit, conventional PCR was performed and products were sequenced. INNO-LiPA HPV Genotyping Extra assays as another method for genotyping were conducted. CLC Main Workbench 5 and MEGA6 software as well as SPSS v.20 were used for further analysis. Results: Of the total of 12 patients, 6 (50%) were male. Total mean age (y) ± SD was 9.8±6.3. All RRP patients suffered from HPV infection, with HPV-6 found in 75% (9/12) and HPV-11 in 16.7% (2/12) and one co-infection by both HPV-6 and 11. Statistically, there were no correlations between demographic variables and HPV infection. Conclusion: The major cause of RRP is HPV genotypes 6 and 11 increasing the risk of a requirement for medical interventions. Broader studies are needed to clarify the major risk factors in RRP patients.

Chondroradionecrosis of the Larynx in a Patient with Laryngeal: A Case Report.

INTRODUCTION: Actinomycosis of the larynx has been rarely reported in the literature and usually occurs in patients with a history of laryngeal carcinoma and radiation therapy. However, its co-existence with chondroradionecrosis due to radiotherapy is even rarer. The most common site of infection is the cervicofacial region, especially in the submandibular area. CASE REPORT: Here we report a 63-year-old male with a history of chemoradiotherapy because of laryngeal cancer 1 year earlier who presented with laryngeal actinomycosis. After prolonged penicillin-based treatment, the patient underwent thyroid cartilage defect reconstructive surgery because of a laryngocutaneous fistula due to chondroradionecrosis. The diagnosis, work-up, and management of the case are discussed, as well as a review of the literature. CONCLUSION: Although actinomycotic infection of the larynx is rare, it should be considered in the differential diagnosis of laryngeal complaints, especially in immunocompromised patients.

Effects of transcutaneous electrical stimulation on vocal folds adduction.

According to most previous studies, inducing movements in internal laryngeal muscles by transcutaneous electrical stimulation (TES) was impossible. However, the movements have been reported after using needle electrodes inserted into the internal superior laryngeal nerve (ISLN). Herein, we aimed to apply an innovative TES protocol to cause movements in vocal folds. A short duration and high frequency electrical current was applied by two surface electrodes just above the entrance of ISLN to larynx. The subjects were 32 normal participants (mean age = 23.87; SD = 3.43). During TES application, the vocal folds' movements were examined by flexible videonasolaryngoscopy. Statistical paired t test was used to analyze the differences of vocal folds opening angle, in degrees, during rest and TES periods. Furthermore, the movements were judged by seven experienced speech pathologists via a 9-point rate scale from -1 (any abduction) to 8 (complete adduction). The mean vocal folds adduction increased by 35.68° (t = 9.35, p > 0.001) due to TES application. The mean qualitative scores assigned by raters to each subject were between 6 and 7 points, which indicate an acceptable adduction in vocal folds through TES. Unlike previous studies, the applied TES protocol in this research induced significant vocal fold movements. This might be attributed to our different stimulation parameters, which were designed to penetrate deeply and stimulate ISLN specifically. It is worth noting that we introduced a novel TES protocol, which should be confirmed and then examined as a complementary therapy for neurologic voice disorders in future studies.

Tapia's Syndrome after Corrective Jaw Surgery under General Anesthesia: A Case Report.

INTRODUCTION: Tapia's syndrome is a rare complication of recurrent laryngeal and hypoglossal nerve paralysis due to anesthetic airway mismanagement or malpositioning of the patient's head during surgery. CASE REPORT: Here we present a case of Tapia's syndrome in a 22-year-old male after corrective jaw surgery under general anesthesia, with a long period of recovery, related to airway management procedures and/or overstretching of the neck during positioning for surgery. CONCLUSION: Although it is a rare condition, every surgeon should be aware of Tapia's syndrome in order to consider the correct positioning of the head and endotracheal tube during surgery and avoid this complication.

Vocal Function Exercises for Muscle Tension Dysphonia: Auditory-Perceptual Evaluation and Self-Assessment Rating.

OBJECTIVE: Muscle tension dysphonia (MTD) is a functional dysphonia, which appears with an excessive tension in the intrinsic and extrinsic laryngeal musculatures. MTD can affect voice quality and quality of life. The purpose of the present study was to assess the effectiveness of vocal function exercises (VFEs) on perceptual and self-assessment ratings in a group of 15 subjects with MTD. METHODS: The study comprised 15 subjects with MTD (8 men and 7 women, mean age 39.8 years, standard deviation 10.6, age range 24-62 years). All participants were native Persian speakers who underwent a 6-week course of VFEs. The Voice Handicap Index (VHI) (the self-assessment scale) and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale (perceptual rating of voice quality) were used to compare pre- and post-VFEs. RESULTS: GRBAS data of patients before and after VFEs were compared using Wilcoxon signed-rank test, and VHI data of patients pre- and post-VFEs were compared using Student paired t test. These perceptual parameters showed a statistically significant improvement in subjects with MTD after voice therapy (significant at P < 0.05 (*) and P < 0.004 (**)). Also results indicated statistically noticeable reduction in the mean VHI scores across subjects with MTD (significant at P < 0.05 (*) and P < 0.004 (**)). CONCLUSIONS: Significant improvement after therapy for participants has been observed by the aid of auditory-perceptual ratings of voice quality (with the GRBAS scale) and the patient's self-assessment ratings measurements (with the VHI). As a result, the data provide evidence regarding the efficacy of VFEs in the treatment of patients with MTD.

Validity and Reliability of Surface Electromyography in the Assessment of Primary Muscle Tension Dysphonia.

OBJECTIVE: The study aims to evaluate the reliability and the discriminative validity of surface electromyography (sEMG) in the assessment of patients with primary muscle tension dysphonia (MTD). STUDY DESIGN: The study design is cross-sectional. METHODS: Fifteen patients with primary MTD (mean age: 34.07 ± 10.99 years) and 15 healthy volunteers (mean age: 34.53 ± 10.63 years) were included. All participants underwent evaluation of sEMG to record the electrical activity of the thyrohyoid and cricothyroid muscles. The outcome measures were the root mean square (RMS), activity peak, duration, and time to the peak activity, which were obtained during /a/ and /i/ prolongation for test-retest reliability. RESULTS: The test-retest reliability was good to excellent for the RMS and peak activity measures (intraclass correlation coefficient [agreement] [ICCagreement] = 0.49-0.98). The reliability for the activity duration was poor to excellent (ICCagreement = 0.19-0.9). Poor test-retest reliability was found for the time to peak measure (ICCagreement = 0.15-0.37). The standard error of measurement for all sEMG measures was between 0.41 and 2.05. The smallest detectable change (SDC) was calculated between 1.13 and 5.66. The highest SDC values were obtained for the peak and the lowest SDCs were documented for the duration (5.66 and 1.13, respectively). All sEMG measures were not able to discriminate between the MTD patients and healthy subjects (P > 0.05). CONCLUSIONS: The sEMG is a reliable tool to measure the RMS, the peak activity, and the activity duration in primary MTD. However, it is not able to discriminate the patients with primary MTD from healthy subjects.

Objective Voice Analysis of Pediatric Cochlear Implant Recipients and Comparison With Hearing Aids Users and Hearing Controls.

OBJECTIVES: Phonation is influenced by hearing as a feedback mechanism. The purpose of the present study was to compare selected acoustic parameters in children using cochlear implants (CIs), those using hearing aids (HA), and their normal-hearing (NH) peers. METHODS: The participants were 15 children using CI (mean age: 72 months), 15 children using HA (mean age: 74 months), and 15 NH children (mean age: 77 months). The vowel /a/ was produced to measure perturbation and mean fundamental frequency. The six Persian vowels in /CbVCd/ were obtained to extract vowel duration. Data were analyzed by one-way analysis of variance. RESULTS: Results revealed a statistically significant difference between the NH group and the HA group regarding fundamental frequency (F2,51 = 3.443, P < 0.05), jitter local (F2,51 = 1.629, P < 0.05), jitter local absolute (F2,51 = 6.519, P < 0.001), jitter rap (F2,51 = 7.151, P < 0.001), jitter ppq5 (F2,51 = 5.894, P < 0.001), shimmer local (%) (F2,51 = 8.070, P < 0.001), shimmer local (dB) (F2,51 = 3.884, P < 0.05), shimmer apq3 (F2,51 = 4.926, P < 0.05), shimmer apq5 (F2,51 = 8.442, P < 0.001), and harmonic-to-noise ratio (F2,51 = 4.117, P < 0.001). The mean values of the duration of all six vowels were significantly greater in children with CI and HA than in NH children (P < 0.001). CONCLUSION: It seems that after 8 months of using CI, auditory control of voice production would be enabled. Furthermore, children with hearing impairment potentially regard vowel sound duration as a distinguishing feature, whereas in NH speakers, the duration has the least effect in vowel identification.

Role of the Internal Superior Laryngeal Nerve in the Motor Responses of Vocal Cords and the Related Voice Acoustic Changes.

BACKGROUND: Repeated efforts by researchers to impose voice changes by laryngeal surface electrical stimulation (SES) have come to no avail. This present pre-experimental study employed a novel method for SES application so as to evoke the motor potential of the internal superior laryngeal nerve (ISLN) and create voice changes. METHODS: Thirty-two normal individuals (22 females and 10 males) participated in this study. The subjects were selected from the students of Iran University of Medical Sciences in 2014. Two monopolar active electrodes were placed on the thyrohyoid space at the location of the ISLN entrance to the larynx and 1 dispersive electrode was positioned on the back of the neck. A current with special programmed parameters was applied to stimulate the ISLN via the active electrodes and simultaneously the resultant acoustic changes were evaluated. All the means of the acoustic parameters during SES and rest periods were compared using the paired t-test. RESULTS: The findings indicated significant changes (P=0.00) in most of the acoustic parameters during SES presentation compared to them at rest. The mean of fundamental frequency standard deviation (SD F0) at rest was 1.54 (SD=0.55) versus 4.15 (SD=3.00) for the SES period. The other investigated parameters comprised fundamental frequency (F0), minimum F0, jitter, shimmer, harmonic-to-noise ratio (HNR), mean intensity, and minimum intensity. CONCLUSION: These findings demonstrated significant changes in most of the important acoustic features, suggesting that the stimulation of the ISLN via SES could induce motor changes in the vocal folds. The clinical applicability of the method utilized in the current study in patients with vocal fold paralysis requires further research.

Autologous Cricoid Cartilage as a Graft for Airway Reconstruction in an Emergent Technique - A Case Report.

INTRODUCTION: Laryngotracheal stenosis can be caused after traumatic injuries to the neck from the subglottic larynx to the trachea. Patients with laryngotracheal stenosis often need a tracheotomy and occasionally may become tracheotomy dependent. Different procedures have been described for the management of these lesions. Management options include techniques of endoscopic dilation, laser resection, laryngo-fissure, and an innovative array of plastic reconstructions with or without the use of stents. CASE REPORT: This paper presents airway reconstruction in a young patient with severe subglottic stenosis due to a blunt trauma to the neck, who was treated using particles of an autologous fractured cricoid cartilage as the source for airway augmentation. An incision was made in the anterior midline of the cricoid lamina and deepened through the scar tissue to the posterior cricoid lamina. Then two lateral incisions (right & left) were made in the cricoid lamina and fractured cartilage particles and the scar tissue were removed via these two lateral incisions. The mucosal lining at the right and left of the midline incision, after debulking, were sutured to a lateral position. Thereafter three cartilage particles were used to reconstruct the anterior cricoid lamina and augment the lumen. CONCLUSION: It is worth to mention that an autologus cartilage graft can be used for certain cases with traumatic airway stenosis. Further follow up and more patients are needed to approve this method of reconstructive surgery in emergent situations.

Extracellular matrix protein 1 gene (ECM1) mutations in nine Iranian families with lipoid proteinosis.

BACKGROUND & OBJECTIVES: Lipoid proteinosis (LP) is an autosomal recessive disease. Clinical characteristics of this disease are hoarse voice, scarring of the skin, brain calcifications, and eyelid papules (moniliform blepharosis). Mutations in the ECM1 gene on 1q21.2 are responsible for this disease. This study was conducted to investigate the mutation spectrum of ECM1 gene in nine Iranian families having at least one LP patient diagnosed clinically. METHODS: The entire ECM1 gene was screened using PCR and direct sequencing in nine Iranian families with 12 suspected LP patients who were referred to the clinic, along with their parents and siblings. Thirty healthy individuals were included as controls. RESULTS: In only one patient a homozygous G>A transition at nucleotide c.806 in exon 7 was detected. A G>A substitution at nucleotide 1243 in exon 8 that changes glycine (GGT) to serine (AGT) was observed in most of our patients. Furthermore, in one patient there was a change in the sequence of intron 8, the A>T transition in nucleotide 4307. In addition, in two cases (one patient and one healthy mother with affected child) there was a C (4249) deletion in intron 8. INTERPRETATION & CONCLUSIONS: Our results indicate that although mutation in ECM1gene is responsible for lipoid proteinosis, it is likely that this is not the only gene causing this disease and probably other genes may be involved in the pathogenesis of the LP disease.

Inflammatory Myofibroblastic Tumor of the Larynx:A Case Report.

INTRODUCTION: Inflammatory myofibroblastic pseudotumors are initially described in the lung and various extrapulmonary sites such as the orbits, palatine tonsils, ears, gingiva, pterygomaxillary space, and periodontal tissues. These tumors rarely involve the larynx and predilection to the glottis occurs in an indolent manner. CASE REPORT: This case describes a laryngeal myofibroblastic tumor in a 46-year-old woman who presented with an aggressive tumor that extended to the floor of the mouth and the base of the tongue. Extended supraglottic laryngectomy was undertaken for the patient. The diagnosis was spindle cell proliferation with dense lymphoplasma cell infiltration compatible with inflammatory myofibroblastic tumor (Inflammatory pseudotumor or plasma cell granuloma). Definitive diagnosis was achieved with immunohistochemical (IHC) staining. CONCLUSION: We believe that further IHC studies are required to define the true nature of these tumors especially for those that behave in an aggressive pattern.

Prevalence of Voice Disorders and Associated Risk Factors in Teachers and Nonteachers in Iran.

OBJECTIVES: Teachers are at increased risk for development of voice disorders. Because there is no published study on Iranian teachers, the aim of this study was to compare the prevalence of voice disorders among teachers and nonteachers in Iran and define the causing risk factors. METHODS: In the present study, 104 teachers and 41 nonteacher participants, whose jobs did not involve vocal effort, completed a questionnaire regarding to vocal complaint and four relevant risk factors. RESULTS: According to our gained data, 54.6% of teachers experienced vocal complaints during their work, although this value was 21.1% for the nonteacher group (P < 0.001). Moreover, investigating the prevalence of voice disorders during other periods of life was performed. Analyzing the questionnaire data indicated a significant higher vocal load risk factor for teachers (70.77%; standard deviation [SD], 29.48), in comparison with their nonteacher counterparts (27.44%; SD, 37.83; P < 0.001). In addition, our study revealed the significance of vocal load, as well as physical and environmental risk factors in the development of voice disorders in teachers with voice complaints. CONCLUSIONS: Present findings indicated a higher epidemiology of voice problems among teachers in comparison with nonteacher individuals and introduced vocal load as the most important risk factor in development of voice disorder in Iranian teachers. Accordingly, it is recommended to pay special attention to negative effects of vocal load, although environmental and physical factors are also of importance.

Occult Laryngeal Foreign Body Mimicking Normal Thyroid Cartilage.

INTRODUCTION: Foreign body aspiration is common especially in children. The absence of history of choking does not rule out the diagnosis. Diagnosis required high index of suspicion. CASE PRESENTATION: Undiagnosed foreign body aspiration mostly occurs in bronchial airway rather than larynx and can cause severe complications. In this article, we report a silent laryngeal foreign body aspiration to show that careful history taking and accurate evaluation of radiography are important factors for diagnosis. CONCLUSIONS: The single most significant factor leading to detect of tracheobronchial foreign body aspiration is a high index of suspicion; this case highlights the possibility of a foreign body in the airway in patients who presents with a recent onset of chronic respiratory complaints.