Lateral pharyngoplasty vs. traditional uvulopalatopharyngoplasty for patients with OSA: systematic review and meta-analysis.

OBJECTIVES: To compare the efficacy and success rates of lateral pharyngoplasty techniques (LP) vs. uvulopalatopharyngoplasty (UPPP) among adult patients surgically treated for obstructive sleep apnea. METHODS: A systematic literature review of the last 20 years' papers was conducted using PubMed/Medline, Embase, Web of Science, Scholar, and the Cochrane Library until April 2021. Only full-text English articles comparing LP and UPPP outcomes in adult patients with objective outcomes were included in the study. RESULTS: We included 9 articles for a total of 312 surgically treated patients with OSA. LP techniques for obstructive sleep apnea were used on 186 (60%) subjects, while 126 patients (40%) were treated with UPPP. Both surgical procedures resulted in significant improvements in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS) score, and lowest oxygen saturation (LOS) (p < 0.001 in all cases). Although better outcomes were reported with lateral pharyngoplasty, the differences were not significant compared to UPPP post-operative results (p > 0.05 in all cases). CONCLUSIONS: UPPP and LP are both effective surgical procedures in treating OSA in adults. Although not significant, LPs demonstrated improved post-operative outcomes. However, further evidence comparing the surgical effect on patients with OSA is needed to discriminate post-operative outcomes.

Vocal Cord Hemangioma: A Common Tumor in an Unusual Localization. A Case Report with Short Review of Literature.

Laryngeal adult-type hemangiomas are very rare lesions, more frequent in men, whose optimal treatment consists of microlaryngoscopical excision. We herein report a case of larynx cavernous hemangioma in a 64-year-old woman with hoarseness for about six months. Histologically, the tumor was composed of multiple vessels embedded in an edematous stroma.

A structural equation model to examine the clinical features of mild-to-moderate COVID-19: A multicenter Italian study.

The purpose of this study was to evaluate the clinical features of mild-to-moderate coronavirus disease 2019 (COVID-19) in a sample of Italian patients and to investigate the occurrence of smell and taste disorders. Infected individuals with suspected (clinical diagnosis) or laboratory-confirmed COVID-19 infection were recruited. Patients completed a survey-based questionnaire with the aim of assessing their epidemiological and clinical characteristics, general otorhinolaryngological symptoms, and smell and taste disorders. A total of 294 patients with mild-to-moderate COVID-19 completed the survey (147 females). The most prevalent general symptoms included fever, myalgia, cough, and headache. A total of 70.4% and 59.2% of patients reported smell and taste disorders, respectively. A significant association between the two above-mentioned disorders was found (rs: 0.412; P < .001). Smell disorders occurred before the other symptoms in 11.6% of patients and was not significantly associated with nasal obstruction or rhinorrhea. Interestingly, our statistical analysis did not show any significant difference, either for general symptoms or otorhinolaryngological features, between the clinical diagnosis group and the laboratory-confirmed diagnosis (polymerase chain reaction) group. The structural equation model confirmed significant standardized paths (P < .05) between general symptoms, comorbidities, and general otorhinolaryngological complaints in the absence of a significant correlation between these elements and smell and taste alterations. The prevalence of smell and taste disorders in mild-to-moderate Italian COVID-19 patients is significant both in suspected and laboratory-confirmed cases and reveals a strong correlation between these clinical signs regardless of the presence of general or otorhinolaryngological symptoms, such as nasal obstruction or rhinorrhea.

Olfactory function in patients with obstructive sleep apnea: a meta-analysis study.

PURPOSE: This meta-analysis study was designed to analyze the olfactory function in obstructive sleep apnea patients (OSA). METHODS: A comprehensive review of the English language literature regarding OSA patients and olfactory function/dysfunction was performed. The papers assessing olfactory dysfunction with Sniffin' Sticks test were taken into consideration. RESULTS: A total of 420 OSA patients were judged eligible for the study. The average TDI score was found to be 24.3 ± 5.6. The olfactory identification (OD), the olfactory discrimination (OD), and the olfactory threshold (OT) average values were calculated resulting 9.9 ± 2.1, 9.8 ± 1.5, and 5.3 ± 2, respectively. There were 161 healthy control subjects in this meta-analysis. The average TDI of the control group was 30.7 ± 6.0 showing a statistical difference with the group of OSA patients (p = 0.03). A linear correlation between Apnea-Hypopnea Index (AHI) increase and TDI decrease (R2 = 0.1, p = 0.05) was detected. Finally, the average values of TDI of 151 patients classified as mild-moderate OSA and 159 patients considered as severe OSA were calculated. The difference between these two groups resulted not statistically significant (p = 0.3). CONCLUSION: The comparison between OSA patients and healthy subjects using Sniffin' Sticks test showed lower values of the various olfactory parameters. Although a linear correlation between AHI increase and olfactory dysfunction was observed, no statistical difference between mild-moderate and severe OSA patients in terms of the severity of olfactory dysfunction could be proved.

Voice-Related Quality of Life in Post-Laryngectomy Rehabilitation: Tracheoesophageal Fistula's Wellness.

(1) Introduction: Laryngeal cancer is one of the most common types of cancer affecting the upper aerodigestive tract. Despite ensuring good oncological outcome in many locoregionally advanced cases, total laryngectomy is associated with relevant physical and psychological sequelae. Treatment through tracheo-esophageal speech, if promising, can lead to very variable outcomes. Not all laryngectomee patients with vocal prosthesis benefit from the same level of rehabilitation mainly due to the development of prosthetic or fistula related problems. The relating sequelae in some cases are even more decisive in the patient quality of life, having a higher impact than communicational or verbal skills. (2) Material and Methods: A retrospective study was conducted on 63 patients initially enrolled with a history of total laryngectomy and voice rehabilitation, treated at the University Hospital of Catania from 1 January 2010 to 31 December 2018. Quality of life (QoL) evaluation through validated self-administrated questionnaires was performed. (3) Results: The Voice-Related Quality of Life questionnaire revealed significantly better outcomes in both socio-emotional and functional domains of the tracheoesophageal patient group compared to the esophageal group (p = 0.01; p = 0.01, respectively), whereas in the Voice Handicap Index assessment, statistically significant scores were not achieved (p = 0.33). (4) Discussion: The significant differences reported through the V-RQOL and Voice Handicap Index scales in the presence of fistula related problems and device lifetime reduction when compared to the oesophageal speech group have demonstrated, as supported by the literature, a crucial role in the rehabilitative prognosis. (5) Conclusions: The criteria of low resistance to airflow, optimal tracheoesophageal retention, prolonged device life, simple patient maintenance, and comfortable outpatient surgery are the reference standard for obtaining good QoL results, especially over time. Furthermore, the correct phenotyping of the patient based on the main outcomes achieved at clinical follow-up guarantees the primary objective of the identification of a better quality of life.

From Uncommon Infection to Multi-Cranial Palsy: Malignant External Otitis Insights.

PURPOSE: The progression of the otitic infectious process toward diseases of particular severity is often unpredictable, just as it is challenging to manage the patient over time, even after the apparent resolution of the disease. We aim to define a radiological reading key that allows us to correctly and promptly treat the disease, avoiding the possible severe complications. METHODS: We conducted a retrospective study of 13 cases of basal cranial osteomyelitis (SBO) due to malignant external otitis, by the ENT Department of the University of Catania. Through a standardized approach and following the latest guidelines, we have evaluated all patients performing a standardized and personalized radiological protocol according to the stage of the patient's pathology and modulating the treatment consequently. RESULTS: Clinical signs have been observed such as otorrhea (100%), otalgia in 13/13 patients (100%), granulations in external auditory canal (100%), preauricular cellulitis in 9/13 patients (69%) headache 6/13 cases (46%), dysphonia 4/13 cases (31%). HRCT of the temporal bone proved useful in identifying even minimal bone lesions in 13/13 (100%) while improving MRI in vascular and nervous involvement, although in 1/13 patient with nerve palsy clinical symptomatology preceded radiological evidence. The 99mTc 3-phase planar bone scintigraphy was positive for SBO in 9/13 cases (69%) during the initial phase and, in 100% of the cases in images delayed to 2-3 hours. Subsequent checks up to 1 year, using the Ga 67 scintigraphy, excluded the presence of recurrences in 100% of patients. CONCLUSION: The osteomyelitis of the base of the skull is a severe complication of malignant external otitis, often not always easily diagnosed. Recurrence can occur up to 1 year after stopping therapy. Imaging techniques such as Tc and MRI are relevant for the initial diagnostic approach and the staging of the pathology and its complications. Nuclear medicine imaging plays a fundamental role in the evaluation of related osteoblastic activity, especially in the remission phase of the disease.

Verbal performance of total laryngectomized patients rehabilitated with esophageal speech and tracheoesophageal speech: impacts on patient quality of life.

INTRODUCTION: Total laryngectomy has important psychophysical and social consequences for patients' quality of life because of the functional changes resulting from the removal of the larynx. Voice deprivation is perhaps the most relevant limiting factor in social relationships, increasing feelings of solitude and tending to drive individuals into social isolation. Multiple voice rehabilitation methods after total laryngectomy are available. This study aimed to determine the acoustic quality of the rehabilitated voice achieved with esophageal speech (ES) and tracheoesophageal speech (TES), and acoustic quality impacts on patients' perceptions of their quality of life. MATERIALS AND METHODS: The patient inclusion criterion was the completion of a speech rehabilitation course with ES or TES at least 6 months after total laryngectomy. The voice acoustic analysis was carried out automatically by using the Multidimensional Voice Program. The following parameters were extracted: fundamental frequency (F0), Jitter% (Jitt), Shimmer% (Shim), and noise-to-harmonic ratio (NHR). Subjective voice evaluation was performed by using the following questionnaires: Voice Handicap Index (VHI), Voice-related Quality of Life (V-RQOL), and Voice Performance Questionnaire (VPQ). RESULTS: The acoustic analysis showed a difference between ES and TES patients on all acoustic parameters; this difference was significant for F0 (133.09±2.4 and 119±3.3, respectively; p<0.001), NHR (0.43±0.21 and 0.31±0.14, respectively; p=0.02), and maximum phonation time (2.02±038 s and 10.64±0.28 s, respectively; p=0.01. Regarding patient-related outcomes, TES correlated with better total scores compared with ES; however, the differences in the total scores on the VHI (p=0.09), V-RQOL (p=0.39), and VPQ (p=0.52) were not statistically significant. CONCLUSION: The rehabilitation of laryngectomized patients must be addressed by a multidisciplinary team that considers the personalities, personal needs, and relational conditions of individual patients in order to determine and apply the phonatory rehabilitation method most suitable for achieving a better quality of life.

Influence of cigarette smoking on allergic rhinitis: a comparative study on smokers and non-smokers.

It has been described that exposure to tobacco smoke causes worsening of allergic rhinitis symptoms. Otherwise, some studies have demonstrated a negative association between cigarette smoke and allergic rhinitis (AR). Given this inconsistency, this study evaluated the quality of life and immuno-inflammatory parameters in current smokers and nonsmokers suffering from AR. A comparative cross-sectional study was conducted in patients who presented symptoms of AR. Patients were categorized into two groups: current smokers and non-smokers based on salivary cotinine measurements. Primary outcomes were the levels of immuno-inflammatory biomarkers (IgE, IL-4, IL-5, IL-13, IL-17, and IL-33) in serum and nasal lavage and the quality of life assessed by the Mini Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ). Secondary outcomes included salivary cotinine levels, and pulmonary function parameters, such as forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), and FEV1/FVC ratio. Twenty-two patients per group were included in the analysis, with no significant difference regarding demographic characteristics. Statistically significant higher values in salivary cotinine levels (p<0.001) and lower lung function FEV1 (p=0.044) and FEV1/FVC (p=0.047) were found in smokers than in nonsmokers. Only serum IL-33 was significantly different in the 2 groups (p<0.001): smokers had higher values compared to non-smokers. There were no significant differences in MiniRQLQ parameters. Although cigarette smoking was not associated with more severe symptoms, smoking could be associated with increased risk of developing airway remodeling and decreased lung function in AR patients, thus appropriate treatment should be prescribed if smoke avoidance is unfeasible.

Oral health in children with sleep-disordered breathing: a cross-sectional study.

Sleep-disordered breathing (SDB) is associated with a wide range of oral manifestations, including adeno-tonsillar hypertrophy, narrow dentoalveolar width, increased overjet, reduced overbite, and malocclusion. There are no studies about the relationship between SDB and poor oral health in the pediatric population. The aim of this study was to investigate oral health status and oral health-related quality of life (OHRQoL) in children at risk of SDB (SDB+), compared with a control group, not at risk for SDB (SDB). The current cross-sectional study recruited consecutive children, aged between 8 and 17 years, from a university-based dental clinic. Caregivers completed the Pediatric Sleep Questionnaire (PSQ) to stratify risk of SDB. Both children and caregivers completed the Child Oral Health Impact Profile (COHIP) to measure the OHRQoL. A dental exam was conducted to evaluate dental caries, periodontal status, oropharyngeal characteristics, and dental occlusion. DMFS (decay-missing-filled for permanent teeth), dmfs (for primary teeth), PPD (pocket probing depth), parent COHIP score, child COHIP score, and BOP (bleeding on probing) were compared between children SDB+ and SDB-. In this study, 122 children were enrolled and divided into two equal subgroups (61 each). There was a significant association between SDB and all six outcomes (all p < 0.05) with higher values in SDB+ children. SDB+ was associated with a poorer OHRQoL, and a greater COHIP score for both parents and children. In conclusion, the current study suggests that the impact of SDB on oral health and OHRQoL in children is relevant and far-reaching. Therefore, it is necessary to closely monitor the oral health of SDB+ children, and, if appropriate, to use gentle non-pharmacological treatments able to reduce nasal congestion.

Rhinogenic Contact Point Headache: Surgical Treatment Versus Medical Treatment.

Rhinogenic contact point headache (RCPH) is a headache syndrome secondary to mucosal contact points in the sinonasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sinonasal polyps, or masses. It may result from pressure on the nasal mucosa due to anatomic variations among which the septal deviation, septal spur, and concha bullosa, are the most commonly observed. In recent years, RCPH has remained a subject of controversy regarding both its pathogenesis and treatment. This study aimed to investigate the effect of surgical and medical treatment of pain relief in patients with RCPH, evaluating the intensity, duration, and frequency of headaches, and the impact of different treatments on quality of life. Ninety-four patients with headache, no symptoms or signs of acute and chronic sinonasal inflammation and who present with intranasal mucosal contact points positive to the lidocaine test were randomized into 2 equal groups and given medical or surgical treatment. The authors used visual analog scale, number of hours, and days with pain to characterize the headache and Migraine Disability Assessment score (MIDAS) to assess the migraine disability score before and 3 to 6 months after treatment. After treatment the severity, duration, and frequency of the headache decreased significantly (P < 0.001, P < 0.001, and P = 0.031, respectively) as well as the MIDAS in the surgical group compared with medical group. Our results suggest that surgical removal of mucosal contact points is more effective than local medical treatment improving the therapeutic outcomes in patients with contact point headache.

Relationship between sleeping difficulties and airway symptoms severity with the health-related quality of life in patients with GERD.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a chronic disease highly associated with several pulmonary disease and sleep disorders leading to a negative impact on the quality of life. Aim of this study was to investigate the correlation between these disorders and the health-related quality of life. METHODS: Patients were recruited from the Department of Medical Sciences, Surgical and Advanced Technologies, GF Ingrassia, University of Catania, from October 2015 to May 2016. Enrolled patients were classified by different symptomology severity presentation according to the Reflux, Airway and Sleep Questionnaire (RASQ). General data, modified GERD impact scores and the 36-Item Short Form (SF-36) questionnaire scores of these patients were analyzed. RESULTS: A total of 173 patients were included into the study. Patients with moderate severity of airway symptoms had a significant lower SF-36 scores than those with mild severity. Patients with advanced sleeping difficulties severity owned the lowest scores among all cases. The impact to the daily activity of each affected individuals had a positive association with the severity of airway and sleeping disorders. CONCLUSIONS: The severity of these reflux-related disorders is well correlated with a significant negative impact on the normal daily activity. The cases with advanced severity of sleeping difficulties had the worst well-being.

Post laryngectomy speech rehabilitation outcome in elderly patients.

The aim of our work has been to evaluate the different options of tracheoesophageal voice rehabilitation in over 70-year-old patients, who had undergone laryngectomy, assessing advantages and drawbacks of this method of vocal recovery. A retrospective study has been carried out. This has included 40 subjects, all aged more than 70 years old, who have been referred to tracheoesophageal voice rehabilitation. It has been realized a phonatory fistula between trachea and esophagus with prosthesis positioning by means of a primary puncture in 18 cases and it has been realized a secondary puncture in 22 cases. The results gathered in these patients were compared with data obtained from a group made of 39 patients, less than 70 years of age that therefore represented our control group. In primary tracheoesophageal puncture (TEP), the short-term success was 67 %, while in the 22 cases who underwent secondary TEP, the short-term success was 64 %. After 2 years from TEP, the long-term success was 82.5 %. In the control group, the short-term success was 65 % in primary TEP and 73 % in secondary TEP. After 2 years from TEP, the long-term success was 77 %. The evaluation of the results has shown the absence of a statistically significant difference both as regards complications incidence, during and after surgery (p > 0.9) and as regards overall success ratio of prosthesis implants between the two groups (p > 0.7). The possibilities of tracheoesophageal recovery of elderly patients do not show dissimilarities in comparison with the results in younger subjects.

ADAM-9 expression in intestinal-type adenocarcinoma of the sinonasal tract.

Malignant tumors of the paranasal fossae and sinuses represent 0.2% to 0.8% of all malignant tumors in the body and 3% to 6% of other head and neck tumors. It is possible to distinguish 4 different histologic types of sinonasal malignant tumors: squamous carcinoma, adenocarcinoma, adenoid cystic carcinoma, and sinonasal undifferentiated carcinoma. According to the WHO classification, there are 2 main types of adenocarcinomas: intestinal-type (ITAC) and nonintestinal type. ITACs are generally connected with professional exposure to wood and leather dust. The metalloproteinase 9 (ADAM-9) is a type 1 transmembrane protein that has been associated with cancer development and metastases. Our case of poorly differentiated sinonasal ITAC showed moderate to strong cytoplasmic positivity for ADAM-9 in association with moderate membrane staining for c-erbB-2 oncoprotein. In our opinion, the expression of these proteins could explain the tumoral growth and together they could represent the most interesting targets when designing any tumor treatment scheme.

Prospective study evaluating olfactometric and rhinomanometric outcomes in postmenopausal women on 1 mg 17beta-estradiol and 2 mg drospirenone HT.

OBJECTIVE: To evaluate the effects of drospirenone on the olfactory sensitivity in postmenopausal women treated with hormone therapy (HT). DESIGN: Forty-seven naturally postmenopausal women participated in the prospective study. The women underwent continuous combined HT containing 1 mg 17beta-estradiol and 2 mg drospirenone (DRSP). Airflow resistance values and olfactometric thresholds were measured by using rhinomanomety and olfactometry, respectively, performed at baseline and in the third and sixth cycle of HT. RESULTS: Rhinomanometric values were better during 17beta-estradiol/DRSP HT with respect to those observed at baseline (P < 0.001). Olfactometric threshold data indicated a higher sensitivity during both the third (P < 0.05), and sixth cycles of 17beta-estradiol/DRSP HT (P < 0.001) than at baseline. CONCLUSIONS: Our study confirmed that the nasal airflow resistance and olfactory thresholds to odors may depend on steroid hormones. We believe that estrogens could influence neuronal plasticity and the neuronal conduction time in the olfactory system. The antimineralocorticoid activity of DRSP may produce a decrease in nasal edema, inducing a better interaction between odorous substances with receptors.

Characteristics of nasal epithelial cells in naturally postmenopausal women receiving hormone therapy with 1 mg 17beta-estradiol and 2 mg drospirenone: a prospective study.

OBJECTIVE: To investigate the effects of drospirenone on nasal respiratory epithelium in postmenopausal women who are treated with hormone therapy (HT). DESIGN: Thirty-five naturally postmenopausal women participated in the prospective study. Women received continuous-combined HT containing 1 mg 17beta-estradiol and 2 mg drospirenone. Cytological changes of nasal middle and inferior turbinate respiratory epithelium were evaluated by using the maturation index, performed at baseline and on the sixth cycle of HT. RESULTS: Hematoxylin-eosin staining for the maturation index of the epithelial nasal cells of women reached better trophic aspects during 17beta-estradiol/drospirenone intake with respect to those observed at baseline (P < 0.001). The smears during HT emphasized the superficial and the intermediate types of cells, with a ratio index greater than 2. The parabasal cell content was less than 20%, and the karyopyknotic index showed degenerative changes in superficial and intermediate cells. CONCLUSIONS: Our study confirmed that the nasal respiratory epithelium is an ovarian steroid target. Drospirenone acts on nasal cells similarly to other progestogens.

Prospective study on the cytological aspects of the nasal respiratory epithelium in premenopausal women taking 30 mcg ethinylestradiol and 3 mg drospirenone oral contraceptive.

BACKGROUND: This study was conducted to determine the effects of the monophasic oral contraceptive (OC) containing 30 mcg ethinylestradiol (EE) and 3 mg drospirenone (DRSP) on the nasal respiratory epithelium in premenopausal women. STUDY DESIGN: Fifty premenopausal women participated in the prospective study. Baseline endovaginal ultrasound examination and blood test to measure serum progesterone to confirm an ovulatory cycle were performed. The cytologic changes on the nasal respiratory epithelium were evaluated with the maturation index, performed during the follicular, periovular and luteal phases of the menstrual cycle, and on the sixth cycle of pill intake. RESULTS: The maturation indexes of the nasal smears were higher during both the follicular and periovular phases than during the luteal phase of the menstrual cycle (p<.05). Women on the OC pill had similar changes in the nasal epithelium as those seen during the follicular phase (p NS), and less than the periovular phase (p<.05) and higher than the luteal phase (p<.05). The maturation index of the nasal respiratory epithelium seems to depend on the variation of the ovarian steroids during the menstrual cycle and on the iatrogenic effects of oral contraception. CONCLUSIONS: DRSP+EE seems to provoke cytological changes that are different from previously shown gestodene plus EE.

Oxidative stress, nitric oxide, endothelial dysfunction and tinnitus.

To assess whether pathogenic endothelial dysfunction is involved in acute idiopathic tinnitus we enrolled 44 patients and 25 healthy volunteers. In blood from the internal jugular vein and brachial vein we determined malonaldehyde, 4-hydroxynonenal, myeloperoxidase, glutathione peroxidase, nitric oxide, L-arginine and L-ornitine, thrombomodulin (TM) and von Willebrand factor (vWF) activity during tinnitus and asymptomatic period. Higher plasma concentrations of oxidative markers and L-arginine, and lower nitric oxide and L-ornitine levels were observed in jugular blood of patients with tinnitus, there being a significant difference between brachial and jugular veins. TM and vWF activity were significantly higher in patients' jugular blood than in brachial blood. Our results suggest oxidant, TM, vWF activity production are increased and nitric oxide production reduced in brain circulation reflux blood of patients with acute tinnitus. These conditions are able to cause a general cerebro-vascular endothelial dysfunction, which in turn induce a dysfunction of microcirculation in the inner ear.

Olfactometric and rhinomanometric outcomes in post-menopausal women treated with hormone therapy: a prospective study.

BACKGROUND: The aim of this prospective study was to evaluate the effects of hormone therapy (HT) on olfactory sensitivity in post-menopausal women. METHODS: Forty-six naturally post-menopausal women underwent rhinomanometric and olfactometric measurements to compare nasal airflow resistance values and olfactometric thresholds during the eighth month of HT treatment with baseline levels prior to starting HT. Eighteen women used an oral HT regimen, and twenty-eight women used transdermal patch HT. RESULTS: Rhinomanometric values during HT were statistically differ from those at baseline (P < 0.001). Olfactometric threshold data indicated a higher sensitivity during the HT treatment than at baseline (P < 0.001). Finally, no statistically significant difference was observed among women using oral or patch HT administration on rhinomanometric and olfactometric values. CONCLUSIONS: Our study demonstrates that 8 months of treatment with estrogen and progestogens in HT preparations has an effect on nasal airflow resistance and the olfactory thresholds to odours. We believe that estrogens could influence neuronal plasticity, and the neuronal conduction time into the olfactory system. Our findings confirm that gonadal steroids such as estrogen have an influence on non-genital targets; this relationship might have a beneficial impact on sensorineural communication and emotional behaviour.