Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery.

INTRODUCTION: We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function. PATIENTS AND METHODS: Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor's semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek's operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller-Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients' pre- and post-operative complaints were evaluated. RESULTS: No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%-20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux. CONCLUSIONS: The laparoscopic Heller-Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

Rehospitalization, Treatment, and Resource Use After Inpatient Admission for Achalasia in the USA.

INTRODUCTION: Readmission for achalasia treatment is associated with significant morbidity and cost. Factors predictive of readmission would be useful in identifying patients at risk. METHODS: We performed a retrospective study using the Nationwide Readmission Database for the year 2016 and 2017. We collected data on hospital readmissions of 17,848 adults who were hospitalized for achalasia and discharged. The 30-day readmission rate as well as the primary cause, mortality rate, in-hospital adverse events, and total hospitalization charges were examined. A cox multivariate regression model was used to identify independent risk factors for 30-day readmission, including the surgical or endoscopic treatment used during the index admission. RESULTS: From 2016 to 2017, the 30-day readmission rate for index admission with achalasia was 15.2%. Of these 15.2%, 34% were readmitted with persistent symptoms of achalasia or treatment-related complications. Older age, higher comorbidity index, possessing private insurance, and those with either pneumatic balloon dilation or no endoscopic/surgical treatment showed higher odds of readmission on multivariate analysis. Those treated with laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) showed lower odds of readmission. There was no difference in rates of readmission between those undergoing POEM or LHM, but mortality rate for readmission was significantly higher for the LHM group. The in-hospital mortality rate and length of stay were significantly higher for readmissions (p < 0.01) than the index admissions. CONCLUSION: Three in 20 patients admitted with achalasia are likely to be readmitted within 30 days of their initial hospitalization, a number which can be higher in untreated patients and in those with multiple comorbidities. Rehospitalizations bear a higher mortality rate than the initial admission and present a burden to the healthcare system.

Effect of peroral endoscopic myotomy in geriatric patients: a propensity score matching study.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a safe and effective approach for achalasia. However, the safety, feasibility, perioperative and long-term efficacy in treating geriatric patients has not been well evaluated. METHODS: Data of 2367 patients diagnosed with achalasia and treated with POEM in the Endoscopy Center, Zhongshan Hospital, Fudan University from August 2010 to December 2017 were retrospectively reviewed. Last follow-up was in December 2018. Propensity score matching based on baseline characteristics was used to adjust for confounding. With a caliper of 0.01 in propensity scoring, 139 patients aged ≥ 65 years were matched at a 1:2 ratio with 275 patients aged < 65 years. Perioperative complications and long-term outcomes were compared between the two groups. RESULTS: After propensity score matching, the two groups had similar baseline clinical characteristics and distribution of propensity scores. The mean age was 70.22 years in geriatric patients and 42.02 in younger patients. Technical failure occurred in one geriatric and one non-geriatric patients (p = 0.485). The procedural time in geriatric patients was similar to younger patients [50 (interquartile range (IQR) 36-76) vs. 50 (IQR 36-70) min, p = 0.398]. There were also no significant differences in major perioperative adverse events (2.88% vs. 2.18%, p = 0.663) and hospitalization length (median 3 vs. 3 days, p = 0.488). During a median follow-up period of 41 months (IQR 26-60), mean decrease in Eckardt score and pressure of the LES were 6.63 and 11.9 mmHg in geriatric patients, which were similar to the change in non-geriatric patients (6.49 and 11.6 mmHg, p = 0.652 and 0.872, respectively). Clinical reflux occurred in 23.53% geriatric patients and 21.59% non-geriatric patients (p = 0.724). 5-year success rate of 92.94% was achieved in geriatric patients and 92.61% in younger patients (log-rank p = 0.737). CONCLUSIONS: POEM is a safe and reliable treatment in geriatric achalasia patients with confirmed short-term and long-term efficacy compared with those in non-geriatric patients.

Outcomes of pneumatic dilatation and Heller's myotomy for achalasia in England between 2005 and 2016.

INTRODUCTION: Achalasia is a disorder characterised by failed relaxation of the lower oesophageal sphincter. The aim of this study was to examine, at a national level, the long-term outcomes of achalasia therapies. METHODS: Hospital Episode Statistics include diagnostic and procedural data for all English National Health Service-funded hospital admissions. Subjects with a code for achalasia who had their initial treatment between January 2006 and December 2015 were grouped by treatment; pneumatic dilatation (PD) or surgical Heller's myotomy (HM). Procedural failure was defined as time to a further episode of the same therapy or a change to a different therapy. Up to three PDs were permitted without being considered a therapy failure. RESULTS: 6938 subjects were included; 3619 (52.2%) were men and median age at diagnosis was 59 (IQR 43-75) years. 4748 (68.4%) initially received PD and 2190 (31.6%) HM. The perforation rate following PD was 1.6%. Mortality at 30 days was 0.0% for HM and 1.9% for PD, and <8% after perforation following PD. Factors associated with increased mortality after PD included age quintile 66-77 (OR 4.55 (95% CI 2.00 to 10.38), p<0.001), >77 (9.78 (4.33 to 22.06), p<0.001); Charlson comorbidity score >4 (2.87 (2.08 to 3.95), p<0.001); previous HM (2.47 (1.33 to 4.62), p<0.001); and repeat PD 1-3 (1.58 (1.15 to 2.16), p=0.005), >3 (1.97 (1.21 to 3.19), p=0.006). Durability of up to 3 PD and HM over 10 years of follow-up was 86.2% and 81.9%, respectively (p<0.001). DISCUSSION: The efficacy of PD for achalasia appears to be greater than HM over 10 years. There was no mortality associated with HM, but 1.9% of subjects died within 30 days of PD. Mortality was associated with increasing age, comorbidity, previous HM and repeat PD.

Comportamiento de la acalasia en la provincia de Camagüey / Behavior of achalasia in Camagüey province

Fundamento: la acalasia es una enfermedad degenerativa, incurable, progresiva y poco frecuente. La acalasia primaria, idiopática o clásica trata de un trastorno de la motilidad esofágica, que combina una falta de peristaltismo del esófago (aperistalsis) con una relajación incompleta del esfínter esofágico inferior.Objetivo: describir el comportamiento de la acalasia en la provincia Camagüey.Métodos: se realizó un estudio descriptivo, de corte transversal y prospectivo. El universo de estudio se constituyó por 19 pacientes. Los datos se plasmaron en una ficha de recolección. La información se recopiló en una base de datos en Microsoft Excel 12.0. Los datos se procesaron con el sistema estadístico SPSS 11.0, se determinaron los porcentajes en el estudio. Para mejor comprensión la información se mostró en tablas.Resultados: prevalecieron los pacientes del sexo femenino, con un 68,4 porciento y las edades entre 60-69 años, con un 47,4 porciento. Todos los pacientes presentaron disfagia. Se halló un predominio de pacientes con acalasia clasificada como grado II, con un total de 11 pacientes que representa el 57,9 porciento.Conclusiones: hubo un predominio de pacientes del sexo femenino y con edades entre 60-69 años. Todos los pacientes refirieron disfagia y la acalasia moderada (grado II) fue la más frecuente(AU)

Background: achalasia is a degenerative incurable, progressive and infrequent disease. Primary, idiopathic, or classical achalasia treats an esophageal motility disorder, which combines a lack of esophageal peristalsis (aperistalsis) with incomplete relaxation of the lower esophageal sphincter.Objective: to describe the behavior of achalasia in Camagüey province.Methods: a descriptive, longitudinal, cross-sectional and prospective study was conducted. The universe of study was composed of 19 patients. The data were captured in a collection form. The information was compiled in a database in Microsoft Excel 12.0. Data were processed using the statistical system SPSS 11.0. The percentages were determined in the study. For a better understanding the information was shown in tables.Results: female patients prevailed, with 68,4 percent and ages between 60-69 years, with 47,4 percent. All patients had dysphagia. A predominance of patients with grade II-classified achalasia was found, with a total of 11 patients, representing 57,9 percent.Conclusions: there was a predominance of female patients aged 60-69 years. All patients reported dysphagia and moderate (grade II) achalasia was the most frequent(AU)

Pre-treatment Eckardt score is a simple factor for predicting one-year peroral endoscopic myotomy failure in patients with achalasia.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a novel treatment for achalasia with excellent outcomes. But the predictor for treatment failure is not well defined. This study was aimed to prospectively investigate the factors for predicting failed POEM. METHODS: From June 2011 to May 2015, a total of 115 achalasia patients treated by POEM were included for the retrospective cohort study from Nanfang Hospital and the First People's Hospital of Yunnan Province. Patients were followed up with Eckardt score, high-resolution manometry and endoscope. POEM failure was defined as primary failure (Eckardt score failed to decrease to 3 or below) and recurrences (decrease of Eckardt score to 3 or below, then rise to more than 3) during one-year follow-up. Univariate and multivariate Cox regression analyses were performed to assess the predictive factor. For the associated factor, receiver operating characteristic curve (ROC) was utilized to determine the cutoff value of the predicting factor. RESULTS: The failure rate of POEM after 1 year was 7.0% (8/115), including 5 primary failure cases and 3 recurrences. Multivariate analysis showed higher pre-treatment Eckardt score was the single independent factor associated with POEM failure [9.5 (6-12) vs. 7 (2-12), odds ratio (OR) 2.24, 95 confidence interval (95% CI) 1.39-3.93, p = 0.001]. The cutoff value (Eckardt score ≥9) had 87.5 sensitivity (95% CI 47.3-99.7%) and 73.8% specificity (95% CI 64.4-81.9%) for predicting failed POEM. CONCLUSIONS: Pre-treatment Eckardt score could be a predictive factor for failed POEM. Eckardt score ≥9 was associated with high sensitivity and specificity for predicting POEM failure.

Outcomes of esophagectomy for esophageal achalasia in the United States.

BACKGROUND: While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. METHODS: This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000-2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2. RESULTS: Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006). CONCLUSION: This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

Tratamiento quirúrgico de la acalasia esofágica: experiencia en 328 pacientes / Surgical treatment of achalasia: experience in 328 patients

Background: Patients with achalasia may require surgical treatment. Aim: To assess postoperative evolution, complications and mortality after surgical treatment of achalasia. Material and Methods: Analysis of 328 patients aged 13 to 80 years (51 percent females) with achalasia, operated in a period of 40 years. Open surgery was used in 165 patients and a laparoscopic modality (starting in 1994) in 163. Results: Patients subjected to open or laparoscopic surgery had similar demographic and manometric features. Mucosal injury during myotomy occurred in 20 (12 percent) and 10 (6 percent) of patients subjected to open or laparoscopic surgery, respectively (p < 0.05). Four patients operated using a laparoscopic approach had to be converted to open surgery. Two patients operated using an open approach had a postoperative leak. One patient had an abscess and one a hemoperitoneum. Conclusions: The surgical approach of choice for achalasia is laparoscopic, with a low incidence of complications.

Objetivos: Evaluar la evolución postoperatoria inmediata y morbimortalidad en 328 pacientes con acalasia sometidos a tratamiento quirúrgico en un período de 40 años. Material y Método: Se analizan 328 pacientes con acalasia, sometidos a abordaje laparotómico en 165 pacientes y laparoscópico en 163 pacientes, evaluando la morbilidad y mortalidad postoperatoria exclusivamente. Se aplicó el mismo protocolo quirúrgico en ambos grupos, variando sólo en la vía de acceso abdominal. Resultados: Ambos grupos son enteramente comparables tanto en edad, distribución por género, síntomas, duración de síntomas y estudio manométrico. Hubo significativamente más apertura de la mucosa esofágica durante cirugía laparoscópica comparada con la vía laparotómica. Hubo 2 pacientes con filtración postoperatoria con cirugía laparotómica y 1 hemoperitoneo después de abordaje laparoscópico. No hubo mortalidad operatoria. Conclusión: El abordaje laparoscópico es la técnica de elección en la actualidad en pacientes con acalasia, con una muy baja morbilidad.

Clinical factors associated with death before discharge and overall survival time in dogs with generalized megaesophagus.

OBJECTIVE: To investigate the association of 6 clinical features with outcome of dogs with generalized megaesophagus. DESIGN: Retrospective cohort study. ANIMALS: 71 client-owned dogs with radiographic evidence of generalized esophageal dilation. PROCEDURES: Medical records were reviewed for data on signalment, age at onset of clinical signs, body weight, evidence of undernutrition, and the administration of drugs to treat or prevent esophagitis. Radiographs were reviewed for evidence of aspiration pneumonia (AP) and to calculate the relative esophageal diameter. Details of outcome were collected from the medical records and by contacting owners and referring veterinarians. The association of 6 factors with death before discharge and overall survival time was assessed. RESULTS: Overall median survival time was 90 days. Nineteen (26.7%) patients died before discharge from the hospital. Radiographic evidence of AP was both positively associated with death before discharge and negatively associated with overall survival time. An age at onset of clinical signs of >13 months was negatively associated with overall survival time. No evidence of an association of the degree of esophageal dilation or the use of drugs to prevent or treat esophagitis with death before discharge or overall survival time was found. CONCLUSIONS AND CLINICAL RELEVANCE: Radiographic evidence of AP and the age at onset of clinical signs were the only variables found to be significantly associated with survival time in this study, and this should be considered when advising on prognosis in dogs with megaesophagus.

Long-term outcome and risk of oesophageal cancer after surgery for achalasia.

BACKGROUND: Few studies have reported very long-term results after surgery for oesophageal achalasia. The aim of the present study was to assess long-term subjective outcomes after cardiomyotomy and partial fundoplication, focusing specifically on the risk of oesophageal cancer. METHODS: Clinical and demographic information from 228 consecutive patients who had surgery between 1980 and 1992 was extracted from hospital files. Survival status and dates of death were obtained from census offices. Causes of death were obtained from public registries and compared with those of the general population. Symptoms were assessed by means of a questionnaire and endoscopy results were scrutinized. RESULTS: Among 226 patients who could be traced, 182 of 184 survivors were contacted and the cause of death established for 41 of 42 patients. At a median follow-up of 18.3 years, almost 90 per cent of patients were satisfied with the treatment. Four had developed squamous cell oesophageal carcinoma 2, 8, 13 and 18 years after surgery, one of whom was still alive. The standardized mortality ratio for oesophageal carcinoma was significantly higher than expected in men. CONCLUSION: Cardiomyotomy and partial fundoplication is an excellent long-term treatment for achalasia. Men with achalasia have an increased risk of developing oesophageal cancer.

Life expectancy, complications, and causes of death in patients with achalasia: results of a 33-year follow-up investigation.

BACKGROUND: Patients with achalasia require repeated invasive therapies and may experience multiple complications. The objectives of this study were to determine the incidence of such complications, causes of death, and life expectancy in 253 patients. METHODS: Patients consisted of two groups: group A comprised 177 patients with newly diagnosed achalasia; group B consisted of 76 patients in whom the diagnosis had been established in external institutions. All patients regularly underwent structured interviews and were reinvestigated if changes in health status occurred. Survival rates were determined by Kaplan-Meier estimates and were compared with those of an average German population. Causes of death were determined from hospital records, information supplied by private physicians, and from death certificates. RESULTS: Complete follow-up was obtained in 98.9% (group A) and in 100% (group B) of all patients. The observation period for group A ranged from 2 to 33 years and for group B from 2 to 26 years (disease duration: 4-68 years). The most frequent complications were reflux esophagitis (group A: 6.2%, group B: 19.7%) and megaesophagus (group A: 6.2%, group B: 21.0%). Thirty-six patients had died during follow-up. Five of these deaths were related to achalasia. In group A, the estimated 20-year survival rates in patients with achalasia [76% (95% confidence interval (CI): 66-85%)] did not significantly differ from those in controls 80% (95% CI: 71-89%). In group B, 25-year survival rates were also similar in patients [87% (95% CI: 78-97%)] and controls [86% (95% CI: 76-97%)]. CONCLUSION: Patients with achalasia experience a significant number of complications. Causes of death and life expectancy, however, do not differ from those of the average population.

Treatment of achalasia: lessons learned with Chagas' disease.

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

Laparoscopic Heller myotomy for achalasia: a review of the controversies.

Achalasia is a rare primary motility disorder of the esophagus with a United States prevalence of less than 0.001%. Laparoscopic modified Heller myotomy has become the standard of care for palliation of this incurable but benign disease. The role of a fundoplication with the myotomy continues to be controversial. This report summarizes the current laparoscopic management of achalasia with a review of the medical literature on the outcome of combining a fundoplication with a laparoscopic myotomy. The optimal length of myotomy as suggested in the literature is also summarized. To complete the goal, peer-reviewed publications were identified in PubMed by search terms achalasia, myotomy, fundoplication, Nissen, Dor, and Toupet.

[Features of Chagas' disease patients with emphasis on digestive form, in a tertiary hospital of Ribeirão Preto, SP]. / O perfil dos portadores de doença de Chagas, com ênfase na forma digestiva, em hospital terciário de Ribeirão Preto, SP.

In order to characterize the demographic and clinical profile of patients with digestive manifestations of Chagas' disease, the medical records were reviewed of patients (n = 377) currently attended at Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto with positive serologic reaction for Chagas' disease and admitted from January 2002 to March 2003. Median age was 67 years and 210 (56%) were women. Megaesophagus and/or megacolon were present in 135 patients, 59% of these had cardiopathy. For 49% of patients with digestive disease, at least two medical prescriptions of medicines for the treatment of cardiovascular diseases were found. In 66 patients, chronic comorbidities were detected. The population with digestive manifestation of Chagas' disease referred to HCFMRP is mostly geriatric, with an elevated frequency of cardiopathy, which may indicate a high risk for surgical approach to the treatment of chagasic megaesophagus and megacolon.

O perfil dos portadores de doença de Chagas, com ênfase na forma digestiva, em hospital terciário de Ribeirão Preto, SP / Features of Chagas' disease patients with emphasis on digestive form, in a tertiary hospital of Ribeirão Preto, SP

Para caracterizar o perfil clínico e demográfico dos portadores da forma digestiva da doença de Chagas atualmente atendidos no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, foram revistos 377 prontuários de pacientes com resultado positivo para reação sorológica para a doença de Chagas atendidos entre janeiro de 2002 a março de 2003. A idade mediana dos pacientes era de 67 anos e 210 (56 por cento) eram mulheres. Megaesôfago e/ou megacólon chagásicos estavam presentes em 135 pacientes, dos quais, 59 por cento apresentavam cardiopatia. Para 49 por cento dos pacientes com doença digestiva, havia prescrição de pelo menos dois medicamentos para tratamento de doença cardiovascular. Em 66 pacientes, foram detectadas comorbidades crônicas. A população de portadores da forma digestiva da doença de Chagas do HCFMRP é majoritariamente geriátrica e apresenta freqüência elevada de doenças cardiovasculares, o que sugere risco elevado das modalidades de tratamento cirúrgico do megaesôfago e megacólon.

Percutaneous endoscopic gastrostomy in Trinidad and Tobago

Percutaneous endoscopic gastrostomy tube placement is rapidly becoming the preferred method of gastrostomy tube placement. We describe our experience with this procedure in nine patients. The main complications were minor and due to local infection. This report demonstrates the simplicity and safety of this technique

Percutaneous endoscopic gastrostomy in Trinidad and Tobago.

Percutaneous endoscopic gastrostomy tube placement is rapidly becoming the preferred method of gastrostomy tube placement. We describe our experience with this procedure in nine patients. The main complications were minor and due to local infection. This report demonstrates the simplicity and safety of this technique.

Expandable metal stents in achalasia--is there a role?

OBJECTIVE: Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our community's experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates. METHODS: Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II. RESULTS: One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for > or =6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each. CONCLUSIONS: Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.

Spontaneous laryngeal paralysis in four white-coated German shepherd dogs.

Four cases of spontaneous laryngeal paralysis in juvenile white-coated German shepherd dogs are described. The presenting signs were typical for laryngeal paralysis, with stridor present in all four cases. Laryngoscopy revealed bilateral laryngeal paralysis in three cases, and unilateral paralysis in one. Concurrent megaoesophagus was also identified in one dog. All dogs underwent surgical treatment for laryngeal paralysis. Euthanasia was performed in one case due to intractable regurgitation and aspiration pneumonia. A possible association with white coat colour is discussed.