Evaluation of radon exposure risk and lung cancer incidence/mortality in South-eastern Italy.

INTRODUCTION: Radon and its decay products may cause substantial health damage after long-term exposure. The aim of the study was to perform a spatial analysis of radon concentration in the Salento peninsula, province of Lecce (South-eastern Italy) in order to better characterize possible risk for human health, with specific focus on lung cancer. METHODS: Based on previous radon monitoring campaigns carried out in 2006 on behalf of the Local Health Authority (ASL Lecce) involving 419 schools and through the application of kriging estimation method, a radon risk map was obtained for the province of Lecce, in order to determine if areas with higher radon concentrations were overlapping with those characterized by the highest pulmonary cancer incidence and mortality rates. RESULTS: According to our data, areas at higher radon concentrations seem to overlap with those characterized by the highest pulmonary cancer mortality and incidence rates, thus indicating that human exposure to radon could possibly enhance other individual or environmental pro-carcinogenic risk factors (i.e. cigarette smoking, air pollution and other exposures). CONCLUSIONS: The radon risk should be further assessed in the evaluation of the causes resulting in higher mortality and incidence rates for pulmonary cancer in Salento area vs Italian average national data. For these reasons, ASL Lecce in cooperation with ARPA Puglia and CNR-IFC has included the monitoring of individual indoor radon concentrations in the protocol of PROTOS case-control Study, aimed at investigating the role of different personal and environmental risk factors for lung cancer in Salento.

The use of linear and angular measurements of maxillo-mandibular anteroposterior discrepancies.

OBJECTIVES: To extend the assessment of the clinical significance of the measurement of the anteroposterior discrepancy between maxilla and mandible on the bisector of the palatal plane to mandibular plane angle to a large group of randomly selected patients of both sexes, and to verify the correlation of this measurement to well established angular and linear assessments of anteroposterior discrepancy. DESIGN: Retrospective analysis of pre-treatment lateral cephalometric radiographs. SETTING AND SAMPLE POPULATION: The Laboratory of Functional Anatomy of the Stomatognathic Apparatus at Milan University, Italy. Three hundred and six orthodontic patients (165 males, 141 females) aged between 6 and 50 years. EXPERIMENTAL VARIABLE: ANB angle; corrected ANB* angle which compensates for the position of the maxilla and rotation of the mandible relative to the cranial base; Wits appraisal; MM-Wits: linear distance between the projections of A and B points on the bisector of the palatal plane to mandibular plane angle. RESULTS: The MM-Wits distance was significantly correlated to two angles (ANB and ANB*), as well as to the Wits appraisal. All the correlations performed did not show sex- or age-characteristic patterns. The correlation to the corrected ANB* was the best among the three, with a correlation coefficient of 0.915, MM-Wits (mm) = 1.497 x ANB* (degrees) -6.784. From the correlation, reference values for the new measurement have also been estimated, and found to be between -0.65 and -6.85 mm for skeletal Class I individuals. CONCLUSION: It is recommended that the diagnosis of orthodontic anomalies should be performed taking into consideration more than a single anteroposterior appraisal.

Simplified cephalometric lines for the estimation of muscular lines of action.

In the study of masticatory muscle performance, one of the biomechanical variables that can be estimated is the mechanical advantage of the masticatory muscles, namely, the ratio between the muscular moment arm and the bite force moment arm. In the present study, the position of the estimated line of action of the masseter muscle, drawn between gonion and orbitale (Go-Or) relative to dental (occlusal plane) and skeletal (Frankfort plane) references was analyzed in 431 pretreatment lateral cephalograms of orthodontic patients (195 males, 236 females) aged 6 to 50 years, and in the lateral tracings of the Bolton standards (6 to 18 years of age). The following measurements were evaluated: (1) skeletocutaneous class (soft tissue equivalent of Wits appraisal, linear distance in millimeters between the projections of points A' and B' on the occlusal plane); (2) angle between the Go-Or line and the perpendicular to the occlusal plane at the molar occlusal point; and (3) angle between the Go-Or line and the Frankfort plane. In the patients, the skeletocutaneous class ranged between--14.5 and 15.5 mm, without any sex- or age-related differences. The angle between the Go-Or line and the perpendicular to the occlusal plane was, on average, 39 degrees (range 15 to 53 degrees), and it decreased with advancing age; while the average angle between Go-Or and Frankfort plane was 42 degrees (range 30 to 54 degrees), and it increased in older patients. No effects of sex were found. The two angles were significantly correlated to each other, while no correlations were found with the sagittal jaw discrepancy. Similar results were obtained on the Bolton tracings. Overall, the present cephalometric analogue could be useful in biomechanical simulations.

A three-dimensional computerized mesh diagram analysis and its application in soft tissue facial morphometry.

A modified computerized mesh diagram analysis that allows rapid and independent quantifications of soft tissue facial size and shape in the three-dimensional space is presented. Normal references are provided, and the application of the method is also exemplified by the analysis of two maxillofacial surgical patients. The Three-Dimensional Facial Morphometry method has been used for the collection of the x, y, z coordinates of 22 soft tissue landmarks in 50 men and 50 women (all healthy young white adults). The method detects the three-dimensional coordinates of retroreflective, wireless markers positioned on selected facial landmarks with two charge-coupled device cameras, working in the infrared field. The midpoint between the right and left tragus landmarks served as the origin of the coordinate axes, and the landmark coordinates were rotated, setting the intercantheal line horizontal on both the frontal and the horizontal planes, and the Camper's plane inclined at -7.5 degrees on the sagittal plane. A standardized mesh of equidistant horizontal (dimension: half the upper face width), vertical (half the vertical projection of upper face height), and anteroposterior (half the horizontal projection of upper face depth) lines was consequently constructed. The lattice was replicated on the entire face and comprised 84 parallelepipeds. Both male and female reference meshes had a harmonious and symmetric appearance, with gender differences in facial size but not in facial shape. The standard normal reference was superimposed on the patient's tracing, and the global (size plus shape) difference was then evaluated by the calculation of the relevant displacement vectors for each soft tissue landmark. A global difference factor was calculated as the sum of the modules of all the displacement vectors. Consequently, a size normalization was performed, and the shape difference (size-standardized) was then evaluated by the calculation of new relevant displacement vectors for each landmark, as well as a shape--global difference vectors.

Femoral asymmetry in healthy adults: elliptic Fourier analysis using computerized tomographic scout views.

Morphology (both size and shape) of paired structures differ in the left and right sides of body. Size and shape characteristics should be analyzed separately to supply information about the normal variations of human organs. In the present study, the within-subject size and shape asymmetries of normal human femur were analyzed from a mathematical standpoint. On the standardized frontal computerized tomographic scout views of both thighs of 14 healthy adults (7 women and 7 men aged 22-26 years), the outline of the femur was identified, and its size and shape were separately quantified. The left and right femur of each subject were compared, and size and shape asymmetry separately quantified on an intra-subject basis. Subjects were also grouped for sex, and mean values computed. Within-subject symmetry in femoral size and shape was high, with coefficients of superimposition ranging between 91% and 96.5%. In women, a slightly higher symmetry (up to 99.9%) was observed when the femoral outlines were standardize for size. Moreover, in the same group the asymmetry in the form of femoral outline seemed to be partly related to the asymmetry in femoral length. Conversely, no similar relations were found in men.

Functional anatomy of cavernous helicine arterioles in potent subjects.

PURPOSE: We investigated the morphological and functional features of cavernous helicine arterioles in male potent subjects. MATERIALS AND METHODS: Ten young men reporting normal rigid erections which were confirmed by polysomnographic recording underwent power Doppler sonography of the cavernous helicine arterioles during flaccidity, after intracavernous injection of alprostadil, and after subsequent genital and audiovisual sexual stimulation. RESULTS: During flaccidity the helicine arterioles were never detected by power Doppler imaging while they became evident in all cases after alprostadil injection. They usually originated from the cavernous artery forming an acute angle and showed 3 orders of ramifications. Systolic and diastolic flow was present. After genital and audiovisual sexual stimulation, and achievement of maximum rigidity, the helicine arterioles were still evident but with only 1 or 2 orders of distal ramifications. Only systolic flow was present. During penile tumescence the helicine arterioles disappeared in all cases. CONCLUSIONS: Using power Doppler sonography it is possible to investigate the functional anatomy of the cavernous helicine arterioles during the various phases of the erectile cycle. Our preliminary study suggests that the helicine arterioles are functionally inactive during penile flaccidity while they are activated during penile tumescence and continue to supply blood to the corpora also during maximum penile rigidity.

Genital plus audiovisual sexual stimulation following intracavernous vasoactive injection versus re-dosing for erectile dysfunction--results of a prospective study.

PURPOSE: We assessed whether re-dosing of a vasoactive agent or the combination of a vasoactive injection and genital plus audiovisual sexual stimulation caused the greatest erectile effect to determine which of the 2 procedures would be better for dynamic penile color Doppler sonography in patients with erectile dysfunction. MATERIALS AND METHODS: A total of 20 consecutive patients with erectile dysfunction underwent 2 sessions under real-time RigiScan* recording of penile erection. Session 1 consisted of adaptation in 10 minutes, intracavernous injection of 10 micrograms. alprostadil in 10 minutes and re-dosing of 10 micrograms. alprostadil in 10 minutes. Session 2 consisted of adaptation in 10 minutes, injection of 10 micrograms. alprostadil in 10 minutes and genital plus audiovisual sexual stimulation in 10 minutes. The total duration of each session was 30 minutes. The order of the 2 sessions was randomly assigned with a week interval between each session. RESULTS: Re-dosing and genital plus audiovisual sexual stimulation caused a significant increase in erectile response compared to the result seen after the first injection (re-dosing p < 0.05, injection plus stimulation p < 0.01). However, erectile response after the genital stimulation session was significantly greater than that after re-dosing (p < 0.01). An erection comparable to the greatest spontaneous erection reported by the patient was much more frequently achieved after genital stimulation than after the re-dosing session (p < 0.01). CONCLUSIONS: The combination of injection and stimulation caused a significantly greater erectile response than re-dosing. We suggest that the former should always be used during color Doppler sonography to optimize the accuracy of the test. Re-dosing is suggested when an incomplete erectile response occurs after the injection plus stimulation phase.

Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial.

PURPOSE: This study was aimed at assessing prospectively the effect of postoperative intracavernous injections of alprostadil on the recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 30 potent patients with clinically localized prostate cancer (clinical stage B1 or B2, Gleason sum 7 or greater, prostatic specific antigen less than 20 ng./ml.) underwent nerve-sparing radical retropubic prostatectomy and was subsequently randomized to alprostadil injections 3 times per week for 12 weeks (group 1, 15 patients) or observation without any erectogenic treatment (group 2, 15 patients). Patients were assessed at the 6-month followup by sexual history, physical examination, color Doppler sonography of the cavernous arteries and polisomnographic recording of nocturnal erections. RESULTS: In group 1, 12 patients (80%) completed the entire treatment schedule and were evaluated at the long-term followup. Eight patients in this group (67%) reported the recovery of spontaneous erection sufficient for satisfactory sexual intercourse, compared with 3 patients (20%) in group 2. The difference between the 2 groups was statistically significant (p <0.01). In group 1, all but 1 patient reporting normal postoperative erections also showed normal erections at nocturnal testing, whereas color Doppler sonography demonstrated normal penile hemodynamics in all of them. In these patients, failures were the result of cavernous veno-occlusive dysfunction (2 cases, 17%) and cavernous nerve injury (2 cases, 17%). In group 2, patients with normal erections showed both normal nocturnal testing and penile hemodynamics, whereas failures were the result of cavernous veno-occlusive dysfunction (8 cases, 53%), cavernous arterial insufficiency (2 cases, 13%) or cavernous nerve injury (3 cases, 20%). Complications in patients treated with alprostadil injections accounted for 2 cases (13%) of a penile nodule and 1 further case (6%) of prolonged penile erection. Complications were not seen in group 2 patients. CONCLUSIONS: Early postoperative administration of alprostadil injections significantly increases the recovery rate of spontaneous erections after nerve-sparing radical retropubic prostatectomy. It is our belief that programmed vasoactive injections improve cavernous oxygenation, thereby limiting the development of hypoxia-induced tissue damage. The potential complications related to the use of intracavernous injections must be clearly explained to patients.

A size-standardized analysis of soft tissue facial profile during growth.

A method for the quantitative and qualitative analysis of the facial soft tissue profile has been developed and applied to analyze the age differences in lateral cephalograms for the annual Bolton standards from ages 1 to 18 years. To standardize for different facial sizes, profiles were traced in polar coordinates without modifications of facial shape. Most of the soft tissue landmarks showed progressive modifications from birth to 18 years of age. Soft tissue nasion and lower lip had a steep change between 2 and 3 years of life, pronasale between 3 and 5 years of life, A', upper lip, and stomion between 4 and 5 years of life. Hereafter, all these landmarks but N' had several minor modifications progressing toward the adult value. Soft tissue nasion did not modify significantly after 2 years of age. Conversely, changes in the relative positions of B' and Pg' were more scattered in the analyzed period. Age-related size differences were more linear than shape modifications, with gradual increments from 1 to 18 years of age. The method allowed a simple and rapid quantitative evaluation of soft tissue profiles during facial growth. An approximate evaluation of the soft tissue thickness at nose, lips, and chin was also possible. No particular mathematical knowledge was required at any step of the analysis. Results were in good agreement with the well-known patterns of normal growth and development, thus confirming the practical possibilities of the method.

Statistical evaluation of Monson's sphere in healthy permanent dentitions in man.

The three-dimensional curvature of the mandibular dental arch was studied in 20 men and 20 women with sound dentitions and free from temporomandibular joint problems. The x, y, z coordinates of cusp tips of all but the third molars were obtained with a three-dimensional digitizer, and used to derive a spherical model of the curvature of the occlusal surfaces. From the best interpolating sphere the radii of the left and right curves of Spee (quasi-sagittal plane) and of the canine and molar curves of Wilson (frontal plane) were computed. The occlusal curvature of the mandibular arch was not significantly influenced by gender, even if, on average, all the computed variables were larger in men than women. The radii of the overall sphere, right and left curves of Spee, and curve of Wilson in the molar area were about 105 mm in men, and about 100 mm in women. A relatively large intrasample variability in arch curvature was found. The mean sphere radius in men was very close to the classical value of 4 in, confirming Monson's observations, but the relatively large intrasample variability prevented any definitive determination of a sexual dimorphism in the three- dimensional characteristics of occlusal curvature.

Asymmetry of normal mandibular condylar shape.

Morphological studies of the facial skeleton in human beings are usually made from radiographs (frontal and lateral projections and orthopantomographs). The conventional linear and angular measurements provide quantitative information only about size, and fail to define the shape and form of the skeletal features and their variations. Mathematical methods such as the Fourier series allow a correct quantitative analysis of the shape and its variations. The outlines of the mandibular condyles in the orthopantomographs of 20 men and 20 women (mean age 29 years) were traced and digitized. All subjects had a good dentition, no temporomandibular joint problems, and were referred to a dental surgery for periodontal problems. A Fourier analysis of the outlines was performed. Fourier coefficients and reconstructed outlines were compared to analyze the condylar symmetry of shape on an intra- and intersubject basis. A significant condylar asymmetry for shape as distinct from size was found on an intrasubject basis, i.e. the left and right condyles of a single individual had a different shape with a large interindividual variability. Conversely, the mean condyle shape of the male and female groups was symmetric.

Open-close movements in the human temporomandibular joint: does a pure rotation around the intercondylar hinge axis exist?

Mandibular movements near the maximum intercuspal position were analysed for the location of the mean instantaneous centre of curvature of the interincisal point path. Measurements were performed using a kinesiograph in 28 healthy young adults with sound dentitions and free from temporomandibular joint disorders. The subjects performed habitual open-close cycles at different speeds; opening movements starting from the centric relation occlusion were also analysed. In none of the 28 subjects was the interincisal point path derived from pure rotation movements performed around the intercondylar axis, not even in the first millimetres of motion. Translation and rotation were always combined, and the position of the centre of curvature changed during the motion, showing different characteristics in the open and close movements; these patterns were also dependent upon motion speed. The results show that the hinge axis theory cannot explain the mandibular movements because a pure rotation did not occur around the intercondylar axis.

AMS 700 CX inflatable penile implants for Peyronie's disease: functional results, morbidity and patient-partner satisfaction.

This study was designed to clarify the functional results, morbidity and the patient-partner satisfaction observed with, the American Medical System 700 CX three-piece inflatable prosthesis in the treatment of impotence associated with Peyronie's disease. Thirty-three patients were treated and additional plaque surgery was performed in 13 cases (40%). Within 10 days of surgery, four patients (12%) developed a wound infection which was treated conservatively and one patient (3%) experienced glandular ischemia. At the 6-week follow-up, complete penile straightening was achieved in 23 patients (70%), while penile rigidity was considered optimal by all patients. On the contrary, the penis was considered short by 10 patients (30%). Five diabetic patients (15%) complained of severe scrotal and penile pain during full activation of the implant and in one of these patients (3%) the implant had to be removed. Due to spontaneous erections occurring after implant activation one patient (3%) required replacement of the reservoir from the Retzius space into the peritoneum. At the long-term follow-up (mean +/- SE: 17 +/- 2.2 months), 23 patients were evaluated and all found to be engaging in intercourse with the prosthesis. However, five patients (21%) and three of the 13 partners (25%) assessed were not yet completely satisfied. The American Medical System CX700 inflatable penile prosthesis obtains complete penile straightening in 70% and rigidity in 100% of impotent patients with Peyronie's disease. Patients should be fully informed about possible surgical morbidity and actual post-operative penile length.

The effect of intracorporeal injection plus genital and audiovisual sexual stimulation versus second injection on penile color Doppler sonography parameters.

PURPOSE: We assessed whether genital and audiovisual sexual stimulation following 1 or 2 intracorporeal injections caused the greatest changes in penile hemodynamics as recorded by color Doppler sonography. MATERIALS AND METHODS: A total of 50 impotent patients underwent multiphasic color Doppler sonography of the cavernous arteries before and after intracorporeal injection (phase 1), subsequent genital and audiovisual sexual stimulation (phase 2), a second injection (phase 3) and repeat genital and audiovisual sexual stimulation (phase 4). Peak systolic velocity, end diastolic velocity, resistance index and erectile response were studied. RESULTS: Penile erection after injection 1 was upgraded in 41 patients (82%) by genital and audiovisual sexual stimulation. Further upgrading due to injection 2 with stimulation was noted in 11 patients (22%). Among the patients who completed the 4 phases of the test the maximal peak systolic velocity was noted after 1 and 2 injections in 20 (59%) and 14 (41%), respectively. The resistive index was always increased by genital and audiovisual sexual stimulation compared to post-injection values. The maximal resistive index occurred after initial and repeat genital and audiovisual sexual stimulation in 15 (48%) and 16 (52%) patients, respectively. After injection 1 with genital and audiovisual sexual stimulation, impotence was diagnosed as nonvasculogenic in 14 patients (28%), arteriogenic in 9 (18%), venogenic in 17 (34%) or mixed arteriovenogenic in 10 (20%). After injection 2 with stimulation these results were noted in 18 (36%), 9 (18%), 13 (26%) and 10 (20%) patients, respectively. Thus, there were 4 false-positive cases (8%) of venogenic impotence. CONCLUSIONS: To study cavernous artery inflow and veno-occlusive function, color Doppler sonography should be performed after injection plus genital and audiovisual sexual stimulation. When the erectile response does not equal the maximal physiological erection reported by the patient, a second injection with stimulation should be given.

Fourier analysis of human soft tissue facial shape: sex differences in normal adults.

Sexual dimorphism in human facial form involves both size and shape variations of the soft tissue structures. These variations are conventionally appreciated using linear and angular measurements, as well as ratios, taken from photographs or radiographs. Unfortunately this metric approach provides adequate quantitative information about size only, eluding the problems of shape definition. Mathematical methods such as the Fourier series allow a correct quantitative analysis of shape and of its changes. A method for the reconstruction of outlines starting from selected landmarks and for their Fourier analysis has been developed, and applied to analyse sex differences in shape of the soft tissue facial contour in a group of healthy young adults. When standardised for size, no sex differences were found between both cosine and sine coefficients of the Fourier series expansion. This shape similarity was largely overwhelmed by the very evident size differences and it could be measured only using the proper mathematical methods.

A computerized non-invasive method for the assessment of human facial volume.

The three-dimensional coordinates of 22 standardized soft-tissue facial landmarks were used in the definition of a three-dimensional model of the adult human face. The model allows the estimation of the volume of the face in toto and of its parts (upper, middle and lower thirds, nose). Landmark coordinates were collected in 80 healthy young adults (40 men and 40 women selected according to criteria of dentofacial normality) by infrared photogrammetry by an automated instrument, and facial volumes calculated. Sample variability was larger in women than in men; the nose and the upper third of face had the largest variability regardless of gender. On average, all volumes computed in men were significantly larger than the corresponding values computed in women. Also the lower-to-middle third face ratio was significantly higher in men than in women. The sexual dimorphism in human facial volume did not involve the different parts of the face to the same extent: a large part of male facial volume preponderance was explained by the lower third of face. The proposed facial model could adequately represent the human face in all those research and clinical fields where noninvasive surface measurements could be employed alone or in support of conventional radiographic data.

Is there a role for transrectal microwave hyperthermia in the treatment of benign prostatic hyperplasia? A critical review of a six-year experience.

We critically reviewed our 6-year experience with transrectal microwave hyperthermia of the prostate for benign prostatic hyperplasia (BPH) in 320 patients either at high surgical risk or refusing surgery. Transrectal prostatic hyperthermia was given in five to ten 60-minute sessions with an intraprostatic temperature ranging from 42 degrees to 43.5 degrees C. Although an amelioration of symptoms and urodynamic measures was seen initially in most patients, only residual urine volume showed a statistically and clinically significant improvement at the long-term follow-up. According to maximum flow nomograms, bladder outlet obstruction was not resolved by the treatment. We conclude that although the transrectal hyperthermia proved to be a safe procedure, it did not cure BPH in the long term. Considering the results seen with newer nonsurgical procedures such as prostatic stents and prostatic lasers, we believe that transrectal hyperthermia should not be recommended to symptomatic BPH patients.

Three-dimensional reconstruction of the Meissner corpuscle of man, after silver impregnation and immunofluorescence with PGP 9.5 antibodies using confocal scanning laser microscopy.

The 3-dimensional organisation of the neural component of the human Meissner corpuscle was studied after silver impregnation and following immunofluorescence for protein gene product 9.5 (PGP 9.5) by confocal scanning laser microscopy. The morphology of the Meissner corpuscle was found to show consistent differences depending on the labelling method used. After silver impregnation by the Winkelmann technique the branches of the afferent nerve fibres of the corpuscle showed both thin regions and varicose elements, the latter probably corresponding to the portions rich in mitochondria observed by transmission electron microscopy. The bulkier elements were never more than 5-6 microns in diameter. After immunolabelling for PGP 9.5 the nerve fibre branches in the corpuscle always presented flattened and discoidal expansions with a diameter of up to 30 microns. On the basis of what is known as to the mechanism of action of silver impregnations it is considered that the black precipitate preferentially labels the parts of neurons that are rich in neurofilaments. In any case the precipitate is deposited throughout the neuronal cytoplasm except in the mitochondria and the nucleus. Accordingly, in the varicosities of the Meissner corpuscles that are rich in mitochondria, there is little space for the formation of the precipitate. The use of antiserum against PGP 9.5, which labels the larger proteinaceous component of the axoplasm, demonstrates the complete architecture of the neural component of the Meissner corpuscle, and visualises the discoidal and flattened expansions which are absent in the impregnated corpuscles. It is concluded that immunostaining provides images of the corpuscles, and of peripheral neural structures that are in general closer to reality.

Improved minimally-invasive assessment of penile haemodynamics: the combination of colour Doppler sonography and injection-stimulation test.

The aim of this study was to assess the diagnostic value of erotically enhanced penile colour Doppler sonography as a minimally invasive tool to evaluate penile haemodynamics. Colour Doppler sonography was used to study the cavernosal arteries of 135 consecutive impotent patients after intracavernous injection of a vasoactive mixture (injection phase) and after subsequent genital and audiovisual sexual stimulation (stimulation phase). The erectile response was upgraded after the adjunct of genital and audiovisual stimulation in 36% of patients. Colour Doppler assessment performed after the stimulation phase identified 16% of patients as arteriogenic despite normal erections, and 7% of patients falsely diagnosed as venogenic after the injection phase. When colour Doppler sonography and the injection-stimulation test are performed together as a single diagnostic procedure the overall diagnostic accuracy is significantly enhanced.