Tension pneumocephalus: a life-threatening complication of septoplasty and septorhinoplasty.

UNLABELLED: PROBLEMS/ OBJECTIVES: Septoplasty and septorhinoplasty are two important surgical operations in otorhinolaryngology. Tension pneumocephalus is a rare, but potentially fatal, intracranial complication of these operations. METHODOLOGY: We present two cases of tension pneumocephalus following nasal surgery. Both patients had tension pneumocephalus, meningitis, and defects in the skull base. RESULTS: One patient underwent endoscopic repair of the defect, while the second case expired despite medical and neurosurgical management.

Endoscopic transnasal resection of sinonasal haemangiopericytoma involving anterior skull base: a case report and literature review.

Haemangiopericytoma is an uncommon vascular tumour of the sinonasal region with different clinical and pathological presentations. Given its origin from Zimmerman's pericytes around the capillaries, profuse bleeding during surgical manipulation is a characteristic sign. The open approach, with or without pre-operative embolisation, is therefore the usual technique for the resection of a large sinonasal haemangiopericytoma. We report on a case of haemangiopericytoma with massive unilateral involvement of the maxillary, anterior and posterior ethmoids, sphenoid, and frontal sinuses with extension to the ipsilateral orbit causing proptosis and diplopia. The tumour was completely removed endoscopically, and the dura exposed in the posterior part of the frontal recess was covered with a septal mucosal graft.

Anti-fibrotic effect of adipose-derived mesenchymal stem cell conditioned medium in muscle fibrosis.

OBJECTIVE: Recent investigations have demonstrated that the administration of MSC in mouse model of diseases provided beneficial effects. On the other hand, human adipose-derived MSC condition medium (ADSC-CM) is reported as containing beneficial secreted factors, but its role in muscle fibrosis has not been identified. The aim of this study was to investigate the inhibitory effects of MSC-CM in muscle fibrosis in vitro using the C2C12 murine muscle, myoblast cell line. MATERIALS AND METHODS: C2C12 cells were cultured overnight in 0.1% albumin-Dulbecco's Modifies Eagle's Medium (DMEM). The cells were then pre-incubated in ADSC-CM for 20 min, treated with 2.5-10 ng/mL human TGFß1 for 8-72 hours and analyzed using RT-qPCR, Western blot and immunofluorescent staining. RESULTS: Treatment with 20% ADSC-CM for 3 days suppressed αSMA protein expression in TGFß1 treated C2C12 cells. ADSC-CM stimulated the proliferation of C2C12 cells in a dose-dependent manner. Furthermore, TGFß1 induced Acta2/αSMA mRNA expression which was inhibited by ADSC-CM treatment for 8 hours. Decorin, one of the dermatan sulfate proteoglycans and an endogenous inhibitor of TGFß1, was expressed in ADSC-CM, but not in TGFß1 pre-incubated ADSC-CM. CONCLUSIONS: Our studies provide useful information for establishing anti-fibrotic mechanism(s) of ADSC-CM, thus facilitating potential application to prevent muscle fibrosis.

Correlation of autophagy type in podocytes with histopathological diagnosis of IgA nephropathy.

OBJECTIVE: IgA nephropathy (IgA-N) frequently leads to progressive renal failure, thus estimation of the degree of progression is important for patient management. Autophagy is a mechanism that facilitates clearance of waste products to preserve renal function. The aim of this study was to assess autophagy in podocytes in children with progressive IgA-N at initial diagnosis by electron microscopy and investigate the relationship between the types of autophagy and severity of the disease. METHODS: Renal biopsies from 16 children with established progressive IgA-N were examined by light and transmission electron microscopy with reference to autophagy types in the podocytes and histopathological diagnosis of IgA-N. RESULTS: Two autophagy types were found. Type I rarely transformed to autophagic vacuoles and did not dissolve, thus possibly impairing cell function. However, type II frequently transformed to autophagosomes and autophagic vacuoles thus facilitating protein and lipid clearance. Of the 16 children studied, 8 (50%) with type I autophagy at initial diagnosis showed focal proliferative glomerulosclerosis (GN) of mild type (3 cases, 37.5%), mild/moderate type (2 cases, 25%) and moderate type (3 cases, 37.5%). In contrast, the remaining 8 children with type II autophagy at initial diagnosis showed focal proliferative GN of mild type in 7 (87.5%) and mild/moderate type in 1 (12.5%) case. CONCLUSION: In IgA-N children, the occurrence of type I autophagy is correlated with histopathologically more progressive disease, possibly reflecting a tendency to a poorer prognosis.

Evaluating the effect of tariff on wastage and return of blood products in Kerman province.

BACKGROUND: In Iran blood products had been available to health care centers on free order to reduce the wastage they were tariffed in 2016. Thus, health care centers must pay for the blood products and take back the payment from the insurance. The aim of this study was to examine the effects of the tariff on consumption, wastage and return rates of blood products in health care centers in Kerman province. MATERIALS AND METHODS: In this retrospective cross-sectional study, demand, delivery and return rates of blood products (fresh frozen plasma, red blood cell and platelet) were examined in 23 health care centers and hospitals before and after the tariff. RESULTS: After the tariff in 2016, the return of unused units of fresh frozen plasma and platelet to the blood transfusion organization was increased and the increase was not statistically significant, but a significant increase was observed in red blood cell return rate and return/delivery ratio. CONCLUSION: Fresh frozen plasma and platelet return rates increased after the tariff resulting in less wastage of unused products but were not statistically meaningful. Tariff was highly effective on the wastage and return of red blood cell therefore it can be considered as a sparing action in the management of red blood cell.

Two types of autophagy in the podocytes in renal biopsy specimens: ultrastructural study.

Two types of autophagy in the podocytes were found in renal biopsy specimens by electron microscopy. Type I autophagy (about 1 microm in diameter) was found in 10 out of the 100 cases with renal diseases, and showed a condensed ribosome area with a limiting membrane. The origin of limiting membrane appeared to be from degenerated mitochondria. During type I autophagy formation, the thickness of limiting membrane changed from 5-6 nm to about 8-10 nm thickness. Type I autophagy did not transform to autophagosomes and autophagic vacuoles. On the other hand, many cases (90 out of the 100 cases) showed type II autophagy. Type II autophagy (3-8 microm in diameter) showed that many ribosomes were aggregated, formed condensed ribosome area, which always included many aggregated lipid droplets at first. Next, during the formation of autophagosome, rough ER connected to condensed ribosome area, and partly formed limiting membranes from dilated ER membrane. Finally, the limiting membrane of autophagic vacuoles was completely formed, and this membrane changed from about 5-6 nm to 8-10 nm thickness. Ribosomes and lipid droplets were resolved in autophagic vacuoles. Thus, type II autophagy might play a significant role in clearance of proteins and lipids in comparison with type I autophagy. The occurrence of type I autophagy in the renal biopsy specimens was not clearly associated with age, sex or pathological diagnosis. However, cases with type I autophagy may show a tendency to poor prognosis.

Expression of nestin in rat and human glomerular podocytes.

Nestin is a neuroepithelial precursor cell marker expressed in a variety of human cell types during development. However, no information exists on the expression of nestin in mature glomeruli as well as during the glomerular development. Here, we examined nestin expression in rat and human glomerular tissues in quiescent states using RT-PCR and immunohistochemical methods. Nestin mRNA was detected in the rat glomeruli in parallel with its expression in developing rat brains. In the normal mature rat glomeruli, WT-1 positive cells expressed nestin. Co-expression of nestin and vimentin was observed in mature rat podocytes. Immunoelectron microscopy revealed nestin localization in the cell bodies and primary processes of podocytes. A similar expression pattern was observed for vimentin. In matured glomeruli, nestin was not expressed by mesangial and endothelial cells. In the newborn rat, early developing glomeruli (metanephric cap, metanephric vesicle, comma-shaped vesicle and S-shaped body phases) expressed nestin. In the capillary loop stage, Bowman's capsules also expressed nestin. Immunoelectron microscopy demonstrated that developing podocytes and endothelial cells in S-shaped phase glomeruli expressed nestin. Additionally, in immature glomeruli, the mesangial cells in capillary stage of glomerulus also expressed nexin. As in the rat, WT-1 positive cells in human glomeruli also expressed nestin and immunoelectron microscopy confirmed nestin expression in human glomerular podocytes. These results reveal that in normal condition nestin is expressed in several glomerular cell types at early stage of development and becomes confined to podocytes in mature glomeruli, thus implicating nestin in podocyte functions.

Electron microscopic studies on the occurrence of activated neutrophils in peripheral blood of children with acute leukemias.

Peripheral blood (PB) cells are examined to assess cellular maturity and the degree of bone marrow abnormality in children with acute leukemias. During the ultrastructural assessments of PB cells in these children, we noted a frequent occurrence of activated neutrophils. This phenomenon had not been reported previously. We here report for the first time the identification of activated neutrophils in PB of children with acute leukemias. To examine the impact of activated neutrophils, we compared two groups of children including 18 with acute lymphoblastic leukemia (ALL) and 7 with acute myelogenous leukemia (AML) by an ultrastructural leukocyte count method. Many cases (50%) showed more than 30% activated neutrophils per total neutrophil count in PB. Activated neutrophils were elongated or amoeboid-shaped cells ranging from 13-18 microns in greater diameter with a decreased number of granules in the cytoplasm. A significantly higher rate of activated neutrophils was observed in ALL as compared with AML (median: 42.97% vs. 10.64%). Non-leukemic hospitalized (n =3) and healthy (n = 3) control cases showed a median rate of 3.32% activated neutrophils in PB. These findings reveal that a significantly high rate of activated neutrophils occurs in PB of children with ALL which may be exploited in the diagnostic assessment of children with acute leukemias.

Reduplicated basal lamina of the peritubular capillaries in renal biopsy specimens.

Reduplicated basal lamina of the peritubular capillaries (PTC) is usually found in kidney allografts in association with chronic transplant nephropathy and sometimes in native renal biopsies. In order to assess the incidence of this phenomenon in native renal biopsy specimens, we have carried out a retrospective review of the diagnostic ultrastructural pathology records of 80 consecutive renal biopsies excluding renal allografts and children with clinical signs of heavy proteinuria. Reduplicated basal lamina of the PTC was found in 19 out of the 80 cases (23.8%) with renal diseases. It was frequently seen in lupus nephritis, IgA nephropathy, and membranoproliferative glomerulonephropathy, being the subtypes of mesangial proliferative lesions. In a few cases it was also found in anti-neutrophil cytoplasmic autoantibody (ANCA) associated glomerulonephritis and benign nephrosclerosis renal biopsies. Reduplicated basal lamina of the PTC was strongly associated with glomerular and peritubular inflammation, and tubular necrosis. Peritubular interstitial edema, slight to moderately increased collagen fibrils, many spiraled collagen fibrils (indicative of degeneration), and collagen fibrils drawing from basal lamina were found around the reduplicated basal lamina of the PTC but not in normal basal lamina. These results indicate that in native renal biopsy specimens, reduplication of the basal lamina of the PTC is associated with endothelial cell injury and capillary permeability abnormality.

Synthesis of endothelin-1 in rat uterus during pregnancy.

Endothelin is a potent vasoconstrictive peptide first isolated from the supernatant of cultured porcine aortic endothelial cells. The purpose of this study was to determine the source of endothelin-1 (ET-1) production in rat uterus during pregnancy and to clarify its role in normal pregnancy. ET-1, as recognized by immunohistochemistry, was weakly expressed only in endometrial glandular cells in nonpregnant rats but was intensely expressed in both glandular and myometrial cells in the early postpartum period. In situ hybridization confirmed the localization of prepro-ET-1 mRNA in the cytoplasm of endometrial glandular and myometrial cells but not in stromal cells or in smooth muscle cells of blood vessels. Northern blot analysis detected prepro-ET-1 mRNA in myometrial tissue from pregnant but not nonpregnant rats. In particular, the expression of prepro-ET-1 mRNA was strongest in the early postpartum period compared with the various stages of pregnancy. These results indicate that, in addition to endothelial cells and endometrial glandular cells, myometrial cells also produce ET-1 and its production significantly increases in the early postpartum period. Therefore, ET-1 may play a pivotal role in controlling bleeding from the placental bed through myometrial contraction.

Mucin carbohydrate antigens (T, Tn, and sialyl-Tn) in human ovarian carcinomas: relationship with histopathology and prognosis.

Altered glycosylation of mucins leading to the expression of T, Tn, and sialyl-Tn antigens has been shown in ovarian carcinoma, but its relationship with prognosis is still unclear. We investigated immunohistochemically the expression of these antigens in 38 (17 serous and 21 mucinous) ovarian carcinomas to assess their potential prognostic value as compared with stage of disease, histopathology of tumors, and survival time of patients. Eight benign ovarian tumors (four serous and four mucinous), and four normal ovarian tissues also were studied. Of the 38 carcinomas, 25 (66%) expressed T, 27 (71%) expressed Tn, and 33 (87%) expressed sialyl-Tn antigens. Most cases (83%) expressed two or all of the three types of antigens simultaneously. Normal ovarian epithelia showed no staining for these antigens, and benign ovarian tumors were either negative or occasionally expressed weak staining in less than 25% of epithelial cell areas. Statistical analyses showed strong associations between Tn and sialyl-Tn antigen expressions and disease stage as well as histological grade. In 19 ovarian carcinoma patients with available survival data, the overall survival times of patients with high Tn or sialyl-Tn antigen expression were significantly worse than those of the patients with negative and low expression (P < .05 and P < .01). In multivariate stepwise regression analysis, disease stage (P = .000) and Tn antigen expression (P = .02) were found to be significant independent parameters associated with the overall survival time. These findings suggest that, with exception of T antigen expression, the expression of Tn and sialyl-Tn antigens in ovarian carcinomas may provide additional prognostic information on patient outcome.

Aerogenous spread of primary lung adenocarcinoma induces ultrastructural remodeling of the alveolar capillary endothelium.

To determine whether pulmonary alveolar capillaries manifest ultrastructural remodeling at areas of neoplastic invasion of primary lung adenocarcinomas, we examined 17 well-differentiated adenocarcinomas of lung (2 bronchioloalveolar and 15 papillary adenocarcinomas) by electron microscopy. The expression of vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) was demonstrated by immunohistochemical stainings. VEGF messenger RNA (mRNA) isoforms were detected by reverse-transcription polymerase chain reaction (RT-PCR) in alveolar walls microdissected from normal and tumor-associated tissues. Cytoplasm of neoplastic cells expressed VEGF protein in all patients. Endothelial cell nuclei of alveolar capillaries showed positive reaction for PCNA. Alveolar capillary lumina were distended like venules, and some intercellular junctions remained open. The cytoplasm of the capillary endothelial cells was enlarged and developed numerous organelles such as Weibel-Palade bodies and vesiculovacuolar organelles, in contrast to marked attenuation in their normal counterpart. Capillary sprouting occurred from proper alveolar capillaries in 2 patients. Cytoplasmic segments became extremely attenuated and developed diaphragm-like fenestrae in 65% of the patients. A relatively higher expression of diffusable isoforms of VEGF mRNA was seen in the tumor-bearing alveolar walls than in normal walls. Expression of KDR (one of the VEGF receptors) mRNA in tumor exceeded that in normal tissues. These results suggest that diffusable isoforms of VEGF mRNA released from the neoplastic cells are deeply involved in the induction of growth activity of alveolar capillary endothelial cells as much as in the characterization of tumor-associated microvessels in primary lung adenocarcinomas.

Tissue polypeptide antigen expression in human prostate tumors.

Thirty-seven specimens of benign and malignant prostatic tumors were studied for the localization of tissue polypeptide antigen (TPA) by an avidin-biotin-peroxidase complex technique. In addition, 23 metastases of prostatic carcinoma in other organs and 12 nonepithelial tumors of prostate also were studied. All benign and malignant tumors of epithelial origin, including their metastasis, stained positively. Nonepithelial tumors were uniformly negative. In the metastatic lesions, small foci of tumor cells and even single tumor cells could be identified by TPA staining. Immunohistochemical localization of TPA appeared to be a useful tool for assessing the micrometastases of prostatic carcinoma in other organs, especially lymph nodes, or elucidating the epithelial origin of an otherwise undifferentiated prostatic cancer.

Prognostic value of proliferative activity of ovarian carcinoma as revealed by PCNA and AgNOR analyses.

Proliferative activity of a malignant tumor is known to reflect its biologic aggressiveness. Proliferating cell nuclear antigen (PCNA) is a marker of cellular proliferation, and silver-stained nucleolar organizer regions (AgNORs) have been shown to correlate with ploidy and proliferative activity of cells depending on the method of assessment; the mean number of AgNORs per nucleus reflects ploidy, whereas the mean percentage of nuclei with five or more AgNORs per nucleus indicates proliferative activity. In ovarian carcinoma, the prognostic value of these markers has not been well defined. We studied PCNA expression and the AgNOR count in 43 ovarian carcinomas (25 serous, 13 mucinous, and 5 clear cell types) to assess their potential prognostic significance compared with the stage of disease and histopathologic features of the tumors. Eight benign (four serous and four mucinous) and six normal ovarian tissues were also evaluated. A standard colloidal silver staining and an immunohistochemical method were used. The mean percentage of PCNA positivity (PCNA index), the mean number of AgNORs per nucleus (mAgNOR), and the mean percentage of nuclei with more than five AgNORs per nucleus (pAgNOR) for each lesion were determined. In univariable analysis, PCNA indexes and mAgNOR and pAgNOR values were significantly higher in benign ovarian tumors compared with normal ovarian tissues and in adenocarcinomas compared with benign ovarian tumors. In multivariable analysis, PCNA indexes were significantly associated with histologic grade (P=.003), whereas associations of mAgNOR and pAgNOR values were highly significant with both histologic grade and disease stage (P=.0001). Histologic grade, but not subtype, was also associated with disease stage at a significant level (P=.008). Our findings indicate that differences in biologic behavior of ovarian carcinomas may, in part, be defined by differences in their ploidy and proliferative activity, and that whereas PCNA expression is of limited value, assessment of AgNORs holds promise in providing valuable prognostic information on the biologic behavior of the tumors.

Immunohistochemical localization of CA 125 antigen in formalin-fixed paraffin sections of ovarian tumors with the use of Pronase.

The OC 125 monoclonal antibody was used to localize CA 125 antigen in routine paraffin sections of ovarian tumors with the use of a modified avidin-biotin-peroxidase complex (ABC) technic. Pretreatment of the paraffin sections with Pronase allowed subsequent detection of CA 125 antigen. OC 125 stained 4 (80%) of 5 benign and borderline serous ovarian tumors, 12 (86%) of 14 serous adenocarcinomas, and 3 (23%) of 13 benign and malignant mucinous ovarian tumors. The pattern of distribution of CA 125 antigen was mostly at the intraluminal and peripheral cell surfaces, while intracytoplasmic staining also was seen. Overall, CA 125 antigen detectability rate in paraffin sections was found to be compatible with those reported in frozen sections. The method allows retrospective immunohistochemical examination of a large number of cases with ovarian tumors.

Immunohistochemical and ultrastructural localization of T antigen in ovarian tumors.

Thomsen-Friedenreich (T) antigen, the immediate precursor antigen of the human blood group MN system, has been found in many carcinomas, but it is suppressed in normal tissues and nonmalignant diseases. Using a monoclonal antibody specific for the T epitope and an indirect immunoperoxidase technique at light and electron microscopic levels, the authors studied the expression of T antigen and its potential diagnostic value in ovarian tumors. Among 30 serous and mucinous ovarian cystadenocarcinomas, 20 (67%) were positive and 10 (33%) were negative for T antigen. In carcinomas, positive rates increased in parallel with the tumor grade and were 37%, 75% and 80% for grade 1, 2, and 3 tumors, respectively. Of the nine patients with metastasis, seven (78%) had positive and two had negative reactions in their primary and metastatic tumors. T antigen staining was observed at the intraluminal cell surfaces and peripheral cell membranes. The ultrastructural localization of T antigen revealed electron-dense reaction products at the cell surface and microvillous surfaces. Of the ten benign ovarian tumors, three (30%) were weakly positive and seven (70%) were negative for T antigen. These findings indicate a positive correlation between the presence of immunoreactive T antigen and conventional unfavorable prognostic indicators in ovarian carcinoma. The surface location of T antigen suggests that it may have a functional role at the cell membrane and the membrane may be involved in secretion (shedding) of T antigen. Detection of T antigen may be a useful marker of prognosis in ovarian carcinoma.

Interphase cytogenetic and AgNOR analyses of hydatidiform moles.

AIM: To determine the potential value of interphase cytogenetic and argyrophilic nucleolar organiser region (AgNOR) analyses in the diagnosis and classification of hydatidiform moles. METHODS: Serial tissue sections from 37 hydatidiform moles, histologically classified as 11 complete and 15 partial, and from 11 hydropic abortuses were examined by in situ hybridisation using digoxigenin labelled probes specific for chromosomes 1, X, and Y, and a one step silver staining method. The percentages of diploid and triploid nuclei, and the mean number of AgNORs for each tissue were determined. RESULTS: Interphase cytogenetics showed that eight of the 11 cases (73%) each of complete mole and hydropic abortus had diploid pattern and the three remaining cases (27%) of each group were triploid. Two of the triploid complete moles and one of the triploid hydropic abortuses were revised to partial moles and one remaining triploid complete mole was revised to hydropic abortus. Of the 15 partial moles, nine (60%) were triploid, and six (40%) were diploid. These diploid cases were revised to three complete moles and three hydropic abortuses. There was a significant difference (p < 0.0001) between the mean (SD) AgNOR count in partial mole (5.11 (0.91)) versus hydropic abortus (3.79 (0.90)) and complete mole (3.39 (0.97)). The total of 15 triploid cases showed a high mean AgNOR count of 5.24 (0.73). Also, after reclassification, eight of the nine partial moles (89%) had a mean AgNOR count of > or = 5. The results of analyses by the two methods were closely correlated. CONCLUSIONS: Interphasecytogeneticanalysis using chromosome specific probes and AgNOR count provides a valuable approach for ploidy analysis in histological sections of hydatidiform moles and helps to resolve difficult cases.

Direct immunofluorescence for ABH blood group isoantigens: use of FITC-conjugated lectins.

A direct immunofluorescence method was used to detect A, B, or H blood group isoantigens in deparaffinized tissue sections of 30 bladder tumors of various grades and stages. The results were compared with those of the specific red cell adherence test performed on the replicate sections. The two methods showed identical results for isoantigens A, B, and H. Direct immunofluoresence method appeared to be less time-consuming, more simple to perform, and reproducible with less subjectivity in the interpretation of the results.

Further studies on specificity of red cell adherence test: nonmalignant bladder lesions.

Specific red cell adherence test for blood group antigens was utilized in 32 nonmalignant bladder lesions, none of which was associated with bladder cancer, to determine the specificity of this test. All of the 14 lesions of cystitis cystica, cystitis glandularis, and chronic cystitis retained their antigens. Of the 18 lesions of squamous metaplasia, 13 (72%) were antigen positive. Testing for blood group antigens showed an overall 84 per cent specific rate in 27 of the 32 nonmalignant bladder lesions.

Apoptosis mediates decrease in cellularity during the regression of Arthus reaction in cornea.

BACKGROUND/AIMS: The Arthus type allergic reaction is characterised by inflammatory cell infiltration and marked neovascularisation in the cornea. During the healing stages, inflammatory cells and newly formed microvessels gradually disappear. The aim was to establish whether apoptosis affected the regression of inflammatory cells and newly formed microvessels, in order to define more clearly the cellular mechanisms involved in the pathobiology of corneal diseases. METHODS: Albino male rabbits were injected subcutaneously with 5 mg/ml bovine serum albumin (BSA) incorporated in Freund's complete adjuvant twice weekly. Under the anaesthesia, 30 microl of a 0.5 mg/ml BSA solution was injected into the central corneal stroma to induce an Arthus type allergic reaction. The injured corneas were collected at various time points ranging from 3 to 20 days. Apoptotic cells were identified by both light microscopy using in situ TdT-dUTP nick end labelling (TUNEL) method and electron microscopy. RESULTS: With increasing time after induction of the Arthus reaction, marked neovascularisation and infiltrated inflammatory cells such as polymorphonuclear cells (PMNs) and plasma cells were observed in the cornea. Thereafter, the inflammatory cells and newly formed microvessels gradually disappeared. Coincidently, the numbers of microvessel endothelial cells and infiltrated inflammatory cells undergoing apoptosis were increased. Apoptotic bodies were taken up by macrophages, PMNs, as well as myofibroblasts derived presumably from transformation of migrated keratocytes. CONCLUSIONS: These data demonstrate that regression of the cellular infiltrates and microvessel endothelial cells associated with the Arthus reaction in the cornea occurs via apoptosis. This finding adds insights into the cellular mechanisms regulating the pathobiology of corneal diseases.