The impact of energy and protein intake on rehabilitation efficiency in convalescent patients.

BACKGROUND AND OBJECTIVES: It is well known that more than 40% of patients in the convalescent rehabilitation settings suffer from malnutrition, and that appropriate nutrition management can improve rehabilitation outcomes. METHODS AND STUDY DESIGN: In this study, we used a change in motor score of Functional Independent Measure (FIM-M) of convalescent rehabilitation to investigate whether daily energy intake could influence the rehabilitation outcomes. Of the 217 patients hospitalized in our convalescent rehabilitation ward (CRW) between September 2016 and February 2017, 162 met the eligibility criteria for this study. RESULTS: For a 25 kcal/ ideal body weight (IBW)/day cutoff point, 76 patients consumed more than 25 kcal/IBW/day of energy (H-E group), and 86 patients consumed up to 25 kcal/IBW/day of energy (L-E group). Patients in the L-E group had poorer nutritional status than those in the H-E group at CRW admission. Moreover, patients in the L-E group lost some body weight (BW) during hospitalization, whereas patients in the H-E group gained some BW. Furthermore, the FIM-M efficiency in the L-E group was significantly lower than that in the H-E group. CONCLUSIONS: We concluded that appropriate nutritional management given to rehabilitation patients for adequate energy intake to maintain or gain their BW could maximize the outcome of convalescent rehabilitation.

Discovery of Gut-Restricted Small-Molecule Inhibitors of Intestinal Sodium-Dependent Phosphate Transport Protein 2b (NaPi2b) for the Treatment of Hyperphosphatemia.

NaPi2b is primarily expressed in the small intestine, lungs, and testes and plays an important role in phosphate homeostasis. The inhibition of NaPi2b, responsible for intestinal phosphate absorption, is considered to reduce serum phosphate levels, making it a promising therapeutic approach for hyperphosphatemia. Using a novel phosphate uptake inhibitor 3 (IC50 = 87 nM), identified from an in-house compound collection in human NaPi2b-transfected cells as a prototype compound, we conducted its derivatization based on a Ro5-deviated strategy to develop orally administrable small-molecule NaPi2b inhibitors with nonsystemic exposure. Consequently, compound 15, a zwitterionic compound with a potent in vitro phosphate uptake inhibitory activity (IC50 = 64 nM) and a low membrane permeability (Pe < 0.025 × 10-6 cm/s), was developed. Compound 15 showed a low bioavailability (F = 0.1%) in rats and a reduction in phosphate absorption in the rat intestinal loop assay comparable to sevelamer hydrochloride, a clinically effective phosphate binder for treating hyperphosphatemia.

The novel potent TEAD inhibitor, K-975, inhibits YAP1/TAZ-TEAD protein-protein interactions and exerts an anti-tumor effect on malignant pleural mesothelioma.

The Hippo signaling pathway regulates cell fate and organ development. In the Hippo pathway, transcriptional enhanced associate domain (TEAD) which is a transcription factor is activated by forming a complex with yes-associated protein 1 (YAP1) or transcriptional coactivator with PDZ-binding motif (TAZ, also called WWTR1). Hyper-activation of YAP1/TAZ, leading to the activation of TEAD, has been reported in many cancers, including malignant pleural mesothelioma (MPM). Therefore, the YAP1/TAZ-TEAD complex is considered a novel therapeutic target for cancer treatment. However, few reports have described YAP1/TAZ-TEAD inhibitors, and their efficacy and selectivity are poor. In this study, we performed a high-throughput screening of a neurofibromin 2 (NF2)-deficient MPM cell line and a large tumor suppressor kinase 1/2 (LATS1/2)-deficient non-small-cell lung cancer cell line using a transcriptional reporter assay. After screening and optimization, K-975 was successfully identified as a potent inhibitor of YAP1/TAZ-TEAD signaling. X-ray crystallography revealed that K-975 was covalently bound to an internal cysteine residue located in the palmitate-binding pocket of TEAD. K-975 had a strong inhibitory effect against protein-protein interactions between YAP1/TAZ and TEAD in cell-free and cell-based assays. Furthermore, K-975 potently inhibited the proliferation of NF2-non-expressing MPM cell lines compared with NF2-expressing MPM cell lines. K-975 also suppressed tumor growth and provided significant survival benefit in MPM xenograft models. These findings indicate that K-975 is a strong and selective TEAD inhibitor with the potential to become an effective drug candidate for MPM therapy.

Energy requirements for patients in convalescent rehabilitation using motor scores as in the Functional Independent Measure.

BACKGROUND AND OBJECTIVES: Although appropriate nutrition management could improve rehabilitation outcomes, more than 40 % of patients in a convalescent rehabilitation ward (CRW) suffer from malnutrition. The study was undertaken to investigate whether adequate nutrition for each patient in a CRW could be estimated based on motor scores on the Functional Independence Measure (FIM-M). METHODS AND STUDY DESIGN: In 218 patients in our CRW, both basal energy expenditure (BEE) on admission and average energy intake (EI) for 2 weeks were calculated, and EI was divided by BEE to estimate the activity index (e-AI). The patients were classified according to FIM-M to investigate the relationship between the FIM-M and the e-AI. RESULTS: The e-AI tended to increase in proportion to the FIM-M. In the N group, where the increase-decrease rate for body weight was within 2%, the e-AI induced by a FIM-M greater than 60 was significantly higher than that induced by a FIM-M up to 60 (1.3 vs 1.1, p<0.01). Compared to the N group, altering the e-AI caused the same tendency of body weight change in patients with FIM-M greater than 60 and up to 60. CONCLUSIONS: The FIM-M could provide a criterial activity index for patients in a CRW when their energy requirement is appropriately estimated, considering the intensity of their physical activity.

Magnetic resonance imaging and thallium-201 scintigraphy for the diagnosis of localized pigmented villonodular synovitis arising from the elbow: A case report and review of the literature.

Pigmented villonodular synovitis (PVNS) arising from the elbow joint is extremely rare; only 24 cases have been reported. It is extremely difficult to differentiate PVNS from other soft tissue tumors on the basis of imaging findings alone. Therefore, a biopsy is required for definitive diagnosis. A 20-year-old female reported a mass on her right elbow. Physical examination revealed a tumor measuring 3.0x3.0 cm. Magnetic resonance imaging (MRI) revealed that the signal intensity of the tumor was isointense to muscle on T1-weighted images; however, it was hyper- or isointense to muscle on T2-weighted images. In images obtained by gadolinium-enhanced MRI, the margin of the tumor was well-contrasted. Thallium (Tl)-201 scintigrams revealed an abnormal accumulation in the area of the mass in the early and delayed phases. On the basis of clinical findings, imaging characteristics and incision biopsy results, localized PVNS was diagnosed and marginal excision was performed. We thus identified an extremely rare case of PVNS arising from the elbow joint. When interpreting Tl-201 images for the assessment of bone and soft tissue lesions, it is important to recognize PVNS as a condition that simulates malignant tumors. Furthermore, PVNS should be considered in the differential diagnosis when increased Tl-201 activity is closely related to the joint. MRI aids in the differentiation by demonstrating features of hemosiderin degradation products. These findings are likely to be extremely helpful in the differential diagnosis of bone and soft tissue tumors.

Effectiveness of sulforaphane as a radiosensitizer for murine osteosarcoma cells.

Sulforaphane (SFN), a naturally occurring member of the isothiocyanate family, is effective against various types of malignant tumor cells. We studied whether the combination of SFN and radiation would be more effective against osteosarcoma cells when compared to these treatments alone. LM8 murine osteosarcoma cells were cultured with various concentrations of SFN for 24 h and/or 2 Gy X-irradiation. The effects of individual and combination treatments on the number of cells, the cell cycle, cell proliferation-related factors and apoptosis were analyzed. The combination of SFN plus radiation had significantly greater antitumor effects than either treatment alone. Exposure to SFN increased the population of cells in the G2/M phase. Combination treatment resulted in a higher percentage of cells being in sub-G1 than did SFN alone. In addition, the combination of SFN and radiation effectively induced nuclear fragmentation and apoptotic bodies, as shown by DAPI staining. The combination of SFN and 2 Gy radiation increased the cleavage and activation of caspase-3 compared with SFN or radiation alone, as shown by western blotting. Although radiation alone increased the phosphorylation of ERK and Akt proteins, the combination of SFN and radiation induced suppression of ERK and Akt phosphorylation when compared with radiation alone. We found that SFN enhanced the radiosensitivity of LM8 murine osteosarcoma cells by inducing apoptosis through G2/M-phase arrest and by inhibiting ERK and Akt activation. These findings suggest that SFN can be used as a radiosensitizer for osteosarcomas.

Features of hindfoot 3D kinetics in flat foot in ankle-joint maximal dorsiflexion and plantarflexion.

BACKGROUND: It is difficult to evaluate the kinematics of flat foot from 2D images, and no definitive methods have so far been established to diagnose flat foot. This study evaluated hindfoot kinetics through the progression of posterior tibial tendon dysfunction (PTTD) in patients with stages II and III PTTD flat foot compared with those in normal patients under dorsiflexion and plantarflexion conditions using 3D computed tomography (CT) reconstruction images. MATERIALS: CT images were taken of 26 normal and 32 flat feet in neutral, plantarflexion, and dorsiflexion positions of the ankle joint, from which 3D virtual models were made of each hindfoot bone. The 3D bone motion of these models was calculated using volume merge methods in three major planes. RESULTS: Tibiotalar-joint motion in ankle-joint plantarflexion became less plantarflexed (normal -41.2°, stage II -33.5°, stage III -25.3°) and less adducted (normal -13.9°, stage II -10.7°, stage III -5.6°) as the stage progressed. Talocalcaneal-joint motion in stage III became more plantarflexed (normal -0.8°, stage II -3.0°, stage III -8.7°) and more adducted (normal -0.3°, stage II -4.7°, stage III -10.3°) as the stage progressed. Talonavicular-joint motion in stage III became more plantarflexed (normal -7.2°, stage II -7.6°, stage III -14.9°) and more adducted (normal 1.0°, stage II -7.3°, stage III -17.9°) as the stage progressed. CONCLUSIONS: Tibiotalar-joint plantarflexion decreased and talocalcaneal and talonavicular-joint adduction increased in the maximal ankle-joint plantarflexion in stage II in comparison with normal cases. Tibiotalar-joint plantarflexion and adduction were decreased and of the talocalcaneal and talonavicular joints increased in stage III in comparison with stage II cases.

Distribution and metabolism of selenohomolanthionine labeled with a stable isotope.

The distribution and metabolism of selenohomolanthionine (4,4'-selenobis[2-aminobutanoic acid], SeHLan), a newly identified selenoamino acid in selenized Japanese pungent radish, were evaluated by administering 77Se-labeled SeHLan at a dose of 25 µg/kg body weight in rats. Exogenous 77Se of SeHLan was preferably distributed to the kidneys and remained in the intact form for up to 6 h after dosing. The accumulation in the kidneys is one of the specific characteristics of SeHLan, differing from other selenoamino acids, such as selenomethionine and Se-methylselenocysteine, which preferably accumulate in the pancreas. The intact form of SeHLan was detected in the serum and kidney supernatant but not in the urine, suggesting that the amount of exogenous Se that was distributed to the kidneys was within metabolic capacity. Indeed, the exogenous Se was converted into two urinary metabolites, Se-methylseleno-N-acetyl-galactosamine and trimethylselenonium. Exogenous Se was also detected in several selenoproteins, including selenoprotein P and extracellular glutathione peroxidase. SeHLan is expected to be a potential supplemental source of Se because its distribution differs from that of selenomethionine and Se-methylselenocysteine.

Comparison of selenohomolanthionine and selenomethionine in terms of selenium distribution and toxicity in rats by bolus administration.

The distribution and metabolism of selenohomolanthionine (4,4'-selenobis[2-aminobutanoic acid], SeHLan), a newly identified selenoamino acid in selenized Japanese pungent radish, were compared with those of selenomethionine (SeMet) in rats. Either selenoamino acid was injected intravenously at a bolus dose of 1.0 mg Se/kg body weight. SeMet was preferably accumulated in the pancreas, increasing the serum amylase level, an index of pancreatic damage. SeHLan was preferably accumulated in the kidneys, raising the serum creatinine level, an index of kidney damage. On the other hand, the levels of two major urinary selenometabolites, i.e., Se-methylseleno-N-acetyl-galactosamine and trimethylselenonium, were comparable between SeHLan- and SeMet-administered rats, suggesting that there may be no differences in the efficiency of metabolism of these two selenoamino acids to the urinary selenometabolites despite the difference in distribution. SeHLan is expected to be a potential supplemental source of Se without inducing the onset of pancreatic damage. The specific toxicity of SeHLan to the kidneys may be avoided if its dose is lower than the one used in the present study.

A novel MEK1/2 inhibitor induces G1/S cell cycle arrest in human fibrosarcoma cells.

Blockade of the ERK pathway has antitumor effects against malignant tumor cells. In this study, we investigated the antitumor activity of JTP-70902, a novel specific MEK inhibitor, against human fibrosarcoma cells in which the ERK pathway is constitutively activated. JTP-70902 was synthesized at Japan Tabacco. Human fibrosarcoma HT1080 cells were cultured. JTP-70902 was added at various concentrations. The number of viable cells was counted employing a trypan blue dye exclusion test. Unsynchronized cells were exposed to JTP-70902 for 24 h. The nuclei were stained with propidium iodide. The DNA content was measured using a FACSCalibur flow cytometer. Protein extraction and Western blot analysis were performed. (1) A dose-dependent inhibition of cell growth was observed at concentrations of 10 nM or more. Forty-eight hours after the treatment, the growth of HT1080 cells was completely inhibited by 200 nM JTP-70902. (2) FACS analysis revealed that a 24-h exposure to JTP-70902 increased the population of G1/S phase cells in a dose-dependent manner. (3) The phosphorylation of ERK was inhibited by JTP-70902. Furthermore, after the treatment with JTP-70902, p21WAF1/CIP1 and p27KIP1 protein expression increased and the phosphorylation of RB was reduced. Our results showed that JTP-70902 inhibits cell growth and induces cell cycle arrest in human Ras mutant fibrosarcoma cells. These results indicate that JTP-70902 might be an attractive compound for molecular-targeting chemotherapy for malignant soft tissue tumors with the activation of the Ras-MEK-ERK pathway.

The clinical usefulness of preoperative dynamic MRI to select decompression levels for cervical spondylotic myelopathy.

The study subjects included 54 patients with cervical spondylotic myelopathy who underwent a selective laminoplasty. The patients were divided into three groups according to the number of decompressed levels: two levels, three levels and four or five levels. The number of cord compressions at every intervertebral level was determined in the flexion, neutral, and extension position using a dynamic magnetic resonance imaging (MRI) scan in consideration of both static and dynamic compressions. For each group, the clinical outcomes were evaluated. Moreover, the patients were divided into two groups according to their age. Then, the appearance ratios of cord compression between the neutral and extension position were compared at each intervertebral level. The clinical outcomes were satisfactory. There were no statistical differences among the three groups, except for the age and operation time. The position of the neck influenced the number of cord compressions. The appearance ratios of cord compression, which were especially prominent at C2/3, C3/4 and C4/5, showed high scores in the aged. The preoperative dynamic MRI scan was clinically useful. In the aged, attention should be given to C2/3, C3/4 and C4/5.

In vivo three-dimensional analysis of hindfoot kinematics.

BACKGROUND: Knowledge of normal bone motion of the foot is important for understanding the gait as well as for various pathologies; however, the pattern of 3D motion is not completely understood. The aim of this study was to quantify the in vivo motion of the tibiotalar joint, talocalcaneal joint, and talonavicular joint in normal adult feet using a noninvasive (e.g., nonsurgical) measurement technique. MATERIALS AND METHODS: CT images were taken of both feet of ten normal young adults (six males, four females) in neutral, plantarflexion, and dorsiflexion positions of the ankle joint, from which 3D virtual models were made of each mid-hind foot bones. The 3D bone motion of these models was calculated using volume merge methods in three major planes. These data were used to analyze the relationship between the motion of the ankle joint and each other joint. RESULTS: Tibiotalar rotation was observed in dorsiflexion, abduction, and eversion during maximal dorsiflexion of the ankle joint. Talocalcaneal and talonavicular rotation was very small because the ankle joint motion was limited to the sagittal plane. Tibiotalar rotation was also observed in plantarflexion and adduction during maximal plantarflexion of the ankle joint, and talocalcaneal rotation was very small. Talonavicular rotation was observed in plantarflexion and inversion. The motion of the x-axis and the z-axis of tibiotalar joint, and the x-axis and the y-axis of the talonavicular and talocalcaneal joint were associated with the ankle motion. CONCLUSION: Bone motion could be easily and accurately calculated using volume merge methods more effectively than it could with other methods. CLINICAL RELEVANCE: The data elucidates the baseline segmental motion for comparison with symptomatic subjects which could help us to better understand pathokinematics of various foot and ankle pathologies.

Transepiphyseal reconstruction of the anterior cruciate ligament in skeletally immature athletes: an MRI evaluation for epiphyseal narrowing.

Reconstructive surgery for anterior cruciate ligament (ACL) injury in skeletally immature athletes presents various clinical problems, because the reconstructive route penetrating both the femoral and tibial physes might cause their growth arrest. Anatomical changes in the physes after ACL reconstruction have not yet been clarified using MRI. Intra-articular ACL reconstructions using femoral and tibial bone tunnels were performed in 10 skeletally immature athletes, who sustained midsubstance ACL tears. The physes of the surgically reconstructed knee and the contralateral knee were compared using MRI obtained 6 months postoperatively. Plain radiography was used to determine the extent of ossification in the tunnel walls. In all patients, MR imaging showed narrowing of the growth plates in the reconstructed knee in comparison with that in the contralateral knee. Radiographic analyses showed corticalization around the drill holes in all cases. Although ACL reconstruction caused narrowing or the early closure of the open physes in adolescents, the patients did not experience limb-length discrepancies and angular deformities.

Selenium metabolism in rats with long-term ingestion of Se-methylselenocysteine using enriched stable isotopes.

Se-methylselenocysteine (MeSeCys) is not only a selenium (Se) supplement but also a more promising precursor of an anti-tumor drug containing Se than selenomethionine, which is currently used as Se supplement. In this study, the metabolism of MeSeCys labeled with an Se isotope, 82Se, in rats depleted of endogenous natural abundance isotopes with another Se isotope, 78Se, was traced for 21 days when MeSeCys was continuously and perorally ingested at a supplemental dose. The tracer experiment was performed with our improved method that utilized an inductively coupled plasma-deuterium reaction-mass spectrometer. The substitution of endogenous Se with a single isotope, 78Se, facilitated the detection of exogenous labeled Se. Exogenous Se in the form of MeSeCys preferably accumulated and/or assimilated in the liver, kidneys and testes with long-term ingestion of MeSeCys and was utilized for the synthesis of selenoproteins, i.e., extracellular and cellular glutathione peroxidases and selenoprotein P. Meanwhile, intact MeSeCys was not excreted into urine although trimethylselenonium was detected in addition to selenosugar. The results suggest that MeSeCys was transformed into selenide via methylselenol by beta-lyase. Consequently, it is surmised that MeSeCys is a precursor of methylselenol under long-term ingestion.

Risk factors for hip fracture in Japanese elderly women with osteoporosis: applicability of biochemical markers in bone turnover.

AIM: The purpose of this study was to investigate risk factors for hip fracture in 169 Japanese elderly women. METHODS: Patients were divided into three groups: 53 patients had osteoporosis with hip fractures (FX-G), 59 patients had osteoporosis without hip fractures (NFX-G) and 57 patients had low back pain with neither osteoporosis nor hip fracture (NOP-G). Bone mineral density (BMD) of lumbar spine, bone-specific alkaline phosphatase (BAP) and deoxypyridinoline (DPD) were compared among the three groups. RESULTS: The mean BMD of FX-G and NFX-G was lower than that of NOP-G, but there was no significant difference between FX-G and NFX-G. Although the mean BAP of FX-G was similar to that of NOP-G, both were lower than NFX-G (P < 0.05). However, the mean DPD of FX-G was higher than the other groups (P < 0.05, vs NFX-G, P < 0.001, vs NOP-G). The percentage of patients who showed BAP levels less than 35 IU/L and DPD levels of 7.5 nmoL/mmol-Cr or more, was highest in FX-G (72.7%). This percentage was lower for NFX-G (30.9%) and NOP-G (16.4%). The odds ratio of hip fracture occurring was 5.77 (95% confidence interval, 2.25-14.66). CONCLUSION: Bone turnover consisting of increase in bone resorption and decrease in bone formation apart from BMD of lumbar spine resulted in a higher incidence of hip fracture for Japanese elderly women with osteoporosis.

Preferential organ distribution of methylselenol source Se-methylselenocysteine relative to methylseleninic acid.

It has been proposed that Se-methylselenocysteine (MeSeCys) and methylseleninic acid (MSA(IV)) are efficiently transformed through the beta-lyase and reduction reactions, respectively, into methylselenol, the assumed biologically active selenometabolite responsive for the anti-carcinogenicity and anti-oxidant actions of selenium. The bioavailability and distribution of the two selenium sources in major organs/tissues were compared under exactly identical conditions. Namely, labeled selenium sources (76)Se-MeSeCys and (77)Se-MSA(IV), at a single oral dose of 10 microg Se/kg body weight each, were administered simultaneously to rats that had been depleted of natural abundance selenium with a single isotope (78)Se. The same dose of (82)Se-selenite was also administered as a reference selenium source. The distributions of the three labeled selenium isotopes were determined 3 h after the administration in 13 organs/tissues/blood. MeSeCys was taken up more efficiently by most organs, especially the pancreas and duodenum, than MSA(IV) and selenite, the latter two sources being taken up similarly to each other except for in the kidney, liver, and spleen, where the three labeled isotopes were detected at comparable concentrations. The labeled selenium in the liver supernatant was speciated by HPLC inductively coupled argon plasma-mass spectrometry (ICP-MS), and it was suggested that MeSeCys was delivered in its intact form to organs, and then transformed into methylselenol. In addition to the known properties of that MeSeCys is chemically more stable than MSA(IV) and is a naturally occurring edible product, and that MeSeCys produces methylselenol much more efficiently than a homologous selenoamino acid selenomethionine, the present study revealed that MeSeCys is more efficiently distributed than MSA(IV) in its intact form, and then produces methylselenol, suggesting that MeSeCys is the best methylselenol source in most organs/tissues.

Radiological grading of cervical destructive spondyloarthropathy in long-term hemodialysis patients.

On the basis of the radiological findings of dialysis patients, we made a radiological grading and analyzed the progression of destructive spondyloarthropathy (DSA) using this grading system. In this system, the radiological features of the vertebral endplates and intervertebral disc spaces were divided into 4 grades (grade 0 to grade III). Grades II and III were defined as DSA. In this study, out of the 787 dialysis patients (447 men and 340 women, mean age: 60.0 years) examined, 133 patients (16.9%) were diagnosed with DSA. During 7 years follow-up, 108 dialysis patients were examined to investigate the clinical characteristics of DSA. Fifteen of 90 non-DSA cases progressed to DSA. Six of 18 DSA cases showed grade progression. The duration required for progression of each grade was analyzed. A new classification of DSA, namely, degenerative DSA and classical DSA, was applied in this study. The degenerative DSA showed faster grade progression than the classical DSA. Therefore, great attention should be paid in the radiological follow-up of elderly patients with grade I who start dialysis at an old age.

Clinical study of a modified Brooks technique for atlanto-axial subluxation using polyethylene tape.

Forty-four patients, 15 males and 29 females (3-71 years old; mean age, 52.9), were treated for the control of cervical instability with a modified Brooks operation using Tekmilon tape (an ultrahigh molecular weight polyethylene tape) instead of metal wires. Forty of the patients had rheumatoid arthritis (RA) with atlanto-axial subluxation (AAS), three patients had os odontoideum, and one patient had a cervical spine injury. The mean follow-up period was 8 years and 4 months. These patients were divided into three groups: 30 years or less, 31 to 60 years, and over 60 years. Atlanto-dental interval (ADI), inclination angle of atlanto-axial vertebrae (A-A angle), and bone fusion were examined on plain radiographs. The proportion of patients with reduced neck pain (Ranawat's grade 0 or grade 1) increased from 42.5% to 97.9% at the time of postoperative evaluation. Surgical complications, such as dural tear, lamina fracture, and spinal cord injury did not occur in any cases. Thirty-nine patients (88.6%) achieved bone union. ADI in the maximum flexed position improved from 10.3 to 2.5 mm. There was no statistical difference between ADI in males and females. ADI did not change in any age group both before and after surgery. A-A angle also improved from 9.4 to 24.4 degrees. The polyethylene tapes, used for internal fixation, caused no neurologic complications during sublaminar wiring and produced no MR artifacts. This modified Brooks technique using Tekmilon tape was proved to be a simple and safe treatment of AAS.