The etiologic role of intrauterine volvulus and intussusception in jejunoileal atresia

Purpose

Although intussusception has been reported as quite a rare cause of jejunoileal atresia (JIA), pediatric surgeons have noted the frequent presence of intussusception as well as volvulus at surgery. The aim of this study was to investigate the contribution of intrauterine intussusception and volvulus to the development of JIA.

Methods

In 48 newborns (24 boys and 24 girls) treated for JIA at our hospital between 1978 and 2004, the operative and pathologic findings were reviewed.

Results

Intussusception was responsible for gap and cord type atresia in 12 cases (25%). The cord showed an atrophic intestinal lumen in 2 cases. Volvulus was observed in 13 cases. Volvulus and intussusception were simultaneously noted in 1 case. This suggested that intussusception was the cause of the atresia, whereas volvulus was a secondary event. Neither intussusception nor volvulus was observed in high jejunal, apple peel, or multiple atresia.

Conclusions

Intrauterine volvulus and intussusception were commonly observed in single mid- and low JIA. Thus, intrauterine intussusception may be a common cause of gap and cord type JIA. Volvulus may not only cause JIA but also result from anatomic changes after the development of JIA in some cases.     

Renal angiomyolipoma in Japanese tuberous sclerosis patients

Purpose

Renal angiomyolipoma (AML) is a benign neoplasm that may grow massive in tuberous sclerosis (TS) patients. The aim of this study was to document the characteristics of renal AML in Japanese TS patients.

Methods

Medical records of 29 TS patients followed up at the authors’ center were reviewed for the presence, size, symptom, and treatment of renal AML.

Results

Twenty-four patients screened for renal AML were subdivided into 4 groups: group 0 (n = 8), no mass; group 1 (n = 5), AML less than 1 cm in diameter; group 2 (n = 4), AML 1 to 4 cm in diameter; group 3 (n = 7), AML greater than 4 cm in diameter. When present, AML always affected both kidneys and were multiple. All patients in groups 1 and 2 were symptom free, and the tumors seemed stable in size. All tumors in group 3 grew progressively causing various symptoms. Total or partial nephrectomy or transarterial embolization was performed in 5 patients with limited success.

Conclusions

AML in TS patients can be stable or aggressive. Pediatric surgeons aware of this problem should be involved in a follow-up program.     

Hepatolithiasis after hepatic portoenterostomy for biliary atresia

Background

Hepatolithiasis after hepatic portoenterostomy for biliary atresia has been paid little attention, with only 22 reported cases.

Patients and Methods

Fifteen patients underwent living-related liver transplantation for biliary atresia after hepatic portoenterostomy in our hospital between 1998 and 2004. The resected livers were examined for the existence and location of hepatolithiasis, composition of the calculi, and bacterial infection of bile. The relation between a history of cholangitis and the presence of hepatolithiasis was analyzed.

Results

Intrahepatic calculi were found in 8 (53%) of 15 patients. The calculi consisted of almost 100% calcium bilirubinate. Calculi were found in bile lakes in 8 patients. Bacteria were present in the bile in 8 (53%) of the 15 patients. Of the 8 patients, 7 (88%) had a history of ascending cholangitis.

Conclusions

Hepatolithiasis occurs after hepatic portoenterostomy for biliary atresia more frequently than previously thought. Bile stasis and possibly bile infection are the main causes of calculi formation.     

Simplified treatment of postoperative mediastinitis

Background

Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.

Methods

We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.

Results

All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.

Conclusions

In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.     

Prophylactic therapy with valganciclovir in high-risk (cytomegalovirus D+/R-) kidney transplant recipients: a single-center experience

Background

A prospective study was performed in kidney transplant patients at risk of developing cytomegalovirus (CMV) infection (CMV D⁺/R⁻). They were treated with valganciclovir (VGC) for 3 months as prophylactic therapy. The aim was to determine the safety and efficacy of prophylactic therapy with VGC.

Methods

Antigenemia and/or polymerase chain reaction CMV was routinely performed every 2 weeks up to month 3, monthly to month 6, and every other month until the end of the first year posttranplantation, as well as when clinically indicated.

Results

From July 2007 to April 2010, 366 renal transplantations were performed at our center, including 34 (9%) high-risk patients for CMV infection. The median age was 47 years; 19 were males and 15 females. Twelve (35%) patients developed CMV infections: 10 (34%) gastrointestinal disease and 3 viral syndromes. The timing of the clinical manifestations was 16% (3/12) between months 1 and 3, 75% (8/12) between months 4 and 6, and 8% (1/12) in month 9 posttransplantation.

Conclusion

Treatment with intravenous ganciclovir followed by oral VGC was successful in all patients. No opportunistic infections or allograft rejection were observed; only 1 patient developed thrombocytopenia as an adverse event to VGC.     

Decreased mortality but increased morbidity in neonates with jejunoileal atresia; a study of 114 cases over a 34-year period

Purpose

The aim of the study was to evaluate patient demographics, classification and location of the atresia, operative management, postoperative care, and outcome in 114 infants with jejunoileal atresia (JIA) over a period of more than 3 decades.

Methods

This was a retrospective case series in a tertiary care teaching hospital. Records of all patients with JIA treated at the authors' institution between 1971 and 2004 were examined.

Results

Sixty-two percent of atresia and stenosis was noted in the jejunum, 30% in the ileum, and 8% in both the jejunum and the ileum. Atresias and stenosis were classified as follows: 7% type 0, 16% type I, 21% type II, 24% type IIIa, 10% type IIIb, 22% type IV. Gastrointestinal anomalies were encountered in 24% of patients, genitourinary malformations in 9%, cystic fibrosis in 9%, neurologic anomalies in 6%, and congenital heart disease in 4%. Operative management included resection with primary anastomosis in 69% of all patients and temporary enterostomies in 26%. After operative management, 15% of children had resultant short bowel syndrome. Oral feeding was allowed on median day 7, and full energy expenditure via the enteric route was reached on median day 20. Forty-seven percent of infants required central venous line placement for total parenteral nutrition. Early postoperative complications occurred in 28% of patients with JIA and late postoperative complications in 17%. We observed a mortality rate of 11%.

Conclusions

This is one of the largest series of neonates with JIA described. Short bowel syndrome seems to be the biggest problem resulting in longer hospital stay, more feeding problems, and higher morbidity and mortality rates. Management of children with short bowel syndrome has improved because of the use of total parenteral nutrition, new operative techniques, and better intensive care. In the last 15 years, survival has increased at the cost of the surviving children as we noted a higher percentage of late complications.     

Percutaneous cholecysto-cholangiography in the diagnosis of obstructive jaundice in infants

Background

Once it is established that a jaundiced infant has an elevated direct bilirubin level, the principal diagnostic concern is the differentiation of hepatocellular from obstructive cholestasis, of disorders of physiology from disorders of anatomy, and of disease that is managed medically from disease that is managed surgically. Traditional tests such as ultrasonography, liver biopsy, and technotium 99m HIDA scan are often not sufficiently discriminating. General anesthesia is required for invasive imaging with endoscopic retrograde cholangio pancreatography (ERCP) or operative cholangiogram. The authors describe a facile alternative using percutaneous cholecystocholangiography (PCC) with intravenous sedation.

Methods

Nine cholestatic infants underwent PCC (age, 27 to 73 days; mean, 44 days) after ultrasoundscan, liver biopsy, and ^99mTcHIDA scan failed to provide a definitive diagnosis.

Results

In the 4 infants without complete biliary filling, we found biliary atresia (3) and biliary hypoplasia (1). The biliary tree was completely opacified in 5 infants with the following diagnosis: neonatal hepatitis (2), duplication of the gallbladder (1), choledochocele (1), total parenteral nutrition (TPN) cholestasis (1). There were no complications.

Conclusions

When the etiology of cholestasis remains elusive after traditional firstline tests, PCC has proven to be an accurate simple alternative in differentiating obstructive from hepatocellular causes of infantile cholestatic jaundice.     

Effects of intestinal electrical stimulation on postprandial small-bowel motility and transit in dogs

Background

Intestinal electrical stimulation (IES) with long pulses has been reported to inhibit motility as well as accelerate transit of continuous infusion. However, it is unknown whether there is a correlation between the IES-induced alterations in motility and transit and whether there is a difference in transit during IES between continuous infusion and bolus infusion.

Methods

The study was performed in 2 postprandial sessions (control and stimulation) in dogs with 2 pairs of serosal electrodes and 2 intestinal cannulas. Intestinal motility and transit with and without IES were measured by manometry and phenol red, respectively.

Results

IES significantly decreased intestinal motility and increased transit time. There was a significant correlation between motility index and transit during IES.

Conclusions

IES inhibits both intestinal bolus motility and transit. There is correlation between motility and transit during IES.     

Terlipressin as Rescue Therapy in Catecholamine-Resistant Hypotension in Solid Organ Donors: A Case Report

Objective

The objective of this study was to report the effects of Terlipressin treatment in 2 potential organ donors with intractable, catecholamine-resistant hypotension.

Design and Setting

This study was based on case reports in the intensive care unit of a general hospital.

Patients

Patients included 2 adult patients with cerebral death and catecholamine-resistant hypotension.

Interventions

A low dose of Terlipressin (3.5 μg/kg) by intravenous bolus was added to the standard treatment.

Measurement and Results

In both cases, Terlipressin induced a rapid improvement in arterial pressure with a consequent increase in urine output and the appearance of diabetes insipidus. In 1 patient it allowed for the withdrawal of norepinephrine infusion. No related adverse effects were detected in either patient. Organ removal was not possible in the second case due to lack of family consent.

Conclusions

Terlipressin might be considered as a rescue therapy for potential organ donors with intractable, catecholamine-resistant hypotension. In spite of the positive results obtained here and by other authors in the treatment of septic shock, its judicious use is recommended, and an optimal administration schedule must still be elucidated.     

Role of Socioeconomic Conditions on Outcome in Kidney Transplant Recipients

Introduction

While deaths with a functioning graft have occurred more frequently in recent years, other nonimmunologic factors may have an important role in late allograft loss. These variables include socioeconomic and cultural status as risk factors for posttransplantation noncompliance with therapy. We examined the effect of socioeconomic and cultural status on graft and patient survival in a population of kidney transplant recipients.

Patients and Methods

This retrospective study included 223 kidney transplantations performed between September 2000 and December 2006.

Results

A significant improvement in graft and recipient survival was observed with increased educational achievement level. Subjects with a high school diploma or college degree demonstrated significantly better outcome. Recipients who had attended intermediate or technical schools were also significantly more likely to have a better outcome than the lowest educational group. Using the lowest socioeconomic class as a reference, a proportional hazard model demonstrated statistically significant benefit for better outcome in patients with skilled occupations.

Conclusions

Results of the present study showed a significant difference in kidney transplantation outcome between different socioeconomic and educational classes. These results could help physicians to educate patients with end-stage renal disease to better understand long-term recovery after transplantation.     

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

Purpose

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

Methods

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

Results

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

Conclusions

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.     

Cholangitis as a late complication in long-term survivors after surgery for biliary atresia

Background/purpose

A retrospective review was performed to assess the utility of diagnostic imaging (DI), efficacy of treatment, and outcome of late cholangitis in long-term survivors after surgery for biliary atresia.

Methods

Sixty-one patients surviving without liver transplantation (LTx) for more than 20 years were divided into 2 groups depending on whether cholangitis developed after age 20. Clinical factors including the type of obstruction, the age at the initial operation, and the early complication with cholangitis were compared between the 2 groups. DI such as computed tomography scan and magnetic resonance imaging, clinical courses after treatment of cholangitis, and current status of the patients were also evaluated.

Results

Thirteen patients had cholangitis after age 20. There was no statistical difference in the clinical factors studied between the 2 groups. Abnormal DI findings including dilatation of intrahepatic bile ducts and hepatic fibrosis were seen in 10 patients with late cholangitis. One patient died, and 2 ultimately underwent LTx. The remaining 10 patients including 4 with normal or near-normal liver function have survived without LTx.

Conclusions

Although the majority of the patients had potential predisposing factors for cholangitis such as dilatation of intrahepatic bile ducts, a few patients unexpectedly had cholangitis without such abnormal findings after an excellent, long-term postoperative course.     

Augmentation mentoplasty with osteocartilaginous nasal graft

Objective

Augmentation mentoplasty is a common procedure, applied especially in conjunction with rhinoplasty. Although various materials have been used, autogenous nasal hump tissue has not been studied in a big series of patients. The main objective of this study was to evaluate the use of autogenous nasal hump in chin augmentation.

Study Design

Case series with chart review.

Setting

University hospital.

Subjects and Methods

The osteocartilaginous mentoplasty procedure was performed in 124 patients along with rhinoplasty in a series of 218 patients who had undergone combined rhinoplasty and mentoplasty with various techniques. The median follow-up was 58 months (range, 12-120 months) over a 10-year period. The procedure commenced under general anesthesia for all patients with large humps and poor chin projection. During the rhinoplasty procedure, the osteocartilaginous nasal hump was removed, tailored to achieve an anatomic mental form, and inserted into the mental pocket through a submental or an intraoral incision.

Results

Infection was detected in five patients, two of whom required graft removal. All other patients recovered normally along an almost painless process, without displacements or any other complaints.

Conclusion

Nasal hump in reduction rhinoplasty is a useful alternative for augmentation mentoplasty on patients with large humps and poor chin projection. It also avoids all the disadvantages of alloplastic materials and eases integration compared with other alternatives in selected cases.     

Cloacal exstrophy: morbidity associated with abnormalities of the gastrointestinal tract and spine

Background/purpose

The aim of this study was to review the management of the gastrointestinal tract in cloacal exstrophy and to assess the effect of spinal dysraphism on nutritional outcome.

Methods

Twenty-two patients with cloacal exstrophy were reviewed retrospectively. Gastrointestinal and spinal anomalies were documented. The need for nutritional supplementation was recorded. Weights at 1 and 5 years of age were used to assess growth in childhood.

Results

Ten patients were treated initially with ileostomy, 7 with colostomy, and 3 without stoma. Two patients died before surgical reconstruction. Total parenteral nutrition (TPN) was utilized in 8 infants for a median of 10 days (range, 5 to 200). Three patients had complications with colostomies requiring conversion to ileostomy. Patients with an ileostomy required more nutritional supplementation compared with patients with a colostomy (50% v 28%). High-output stoma losses were more common in patients with an ileostomy (40% v 14%). Fourteen patients (67%) with spinal dysraphism had a higher incidence of failure to thrive in the first year of life (69% v 26%) and multiple episodes of enteritis (40% v 25%). Two neonates with duodenal atresia and small bowel deletion died within the first month of life. One patient with short bowel syndrome died of TPN-associated liver disease at 6 months of age. There were no other deaths.

Conclusions

The gastrointestinal tract contributes significantly to the morbidity and mortality in cloacal exstrophy. Nutritional supplementation is more frequently required in patients with an ileostomy. Stoma complications were higher in those with a colostomy. Morbidity is high in patients with spinal dysraphism.     

Incidence and risk factors of non-fatal injuries in Chinese children aged 0-6 years: A case-control study

Aim

To identify the incidence and related risk factors of injuries in pre-school children aged 0-6 years in China.

Methods

Children with non-fatal injuries (n = 122) were matched to healthy controls by sex, age, community of residency and history of injury. Conditional multiple logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

Results

The overall incidence of injuries was 3.3%. After adjustment for all selected variables, the risk factors for childhood injuries included father's occupation as a self-employed person (OR: 5.7, 95% CI: 1.8-18.5), child's active temperament type (OR: 2.8, 95% CI: 1.5-5.3), inappropriate storage of medicines (OR: 3.1, 95% CI: 1.3-6.9) and inappropriate placement of heating equipments (OR: 2.1, 95% CI: 1.0-4.4). The protective factors included children's acquirements of safety education from their teachers at school (OR: 0.03, 95% CI: 0.01-0.2), and from their parents (OR: 0.08, 95% CI: 0.02-0.3).

Conclusions

Interventions targeting the risk factors specifically may help prevent and reduce the occurrence of injuries in young children.     

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl

Study Objective

To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose.

Design

Randomized, double-blinded study.

Setting

Labor suite of a tertiary care hospital.

Patients

60 ASA physical status 1 and 2, laboring, nulliparous women.

Interventions

All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 μg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 μg/mL at 10 mL/hr (epinephrine group).

Measurements

Time to re-dose, pain scores, and side effects were recorded.

Main Results

The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04).

Conclusions

The administration of 0.625 mg/mL bupivacaine with epinephrine 5 μg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.     

Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations

Aims

The aim of this study was to evaluate the frequency and risk factors of postoperative anastomotic stricture, and the efficacy and complications of esophageal bougie dilatations for symptomatic anastomotic stricture in a population of children with esophageal atresia.

Patients and Methods

The medical records of 62 children operated on for esophageal atresia type III (Ladd and Gross) over a 5-year period were retrospectively reviewed.

Results

Anastomotic stricture developed in 23 (37%) of patients. Anastomotic tension during primary repair of esophageal atresia was associated with subsequent stricture formation (P < .05). Patients required esophageal dilation at a mean age of 149 days (range, 30-600 days). Stricture resolution occurred after a mean of 3.2 dilatations per patient (range, 1-7). Dilation was successful in 87% of patients. Three patients continued to present mild (n = 1) to severe (n = 2) dysphagia, mainly related to esophageal dysmotility. No complications were observed during or after the dilatation sessions.

Conclusions

Anastomotic stricture, secondary to the surgical treatment of esophageal atresia, remains a frequent complication in patients with esophageal atresia. Esophageal dilation with Savary-Gilliard bougies is a safe and effective procedure in the management of strictures.     

Management of the primary tumor in patients with metastatic pancreatic neuroendocrine tumor: a contemporary single-institution review

Background

Pancreatic nonfunctioning neuroendocrine tumors (PNFNETs) are an uncommon malignancy and often present with metastatic disease. There is a lack of information on the management of the primary tumor in patients who present with unresectable synchronous hepatic metastases.

Methods

A retrospective review (2001-2008) of PNFNETs was conducted. Patients were divided into 3 groups: PNFNET without evidence of hepatic metastasis (group A), PNFNET with metastatic disease involving less than 50% of the liver (group B), and PNFNET with metastatic disease involving more than 50% of the liver (group C). Clinical data and outcomes were analyzed.

Results

Thirty-five patients with PNFNET were identified (group A = 15, group B = 11, group C = 9). Resection of the pancreatic tumor was performed in 26 patients. With a mean follow-up period of 30 months, death from disease progression occurred in 1 patient in group A, none in group B, and in 7 in group C.

Conclusions

In selected patients, resection of the primary pancreatic tumor even in the setting of unresectable but limited hepatic metastases may be indicated.     

Active surveillance of small renal masses: progression patterns of early stage kidney cancer

Background

Most early stage kidney cancers are renal cell carcinomas (RCCs), and most are diagnosed incidentally by imaging as small renal masses (SRMs). Indirect evidence suggests that most small RCCs grow slowly and rarely metastasize.

Objective

To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology.

Design, setting, and participants

A multicenter prospective phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and/or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression.

Intervention

Patients underwent serial imaging and needle core biopsies.

Measurements

We measured rates of change in tumor diameter (growth measured by imaging) and progression to ≥4 cm, doubling of tumor volume, or metastasis with histology on biopsy.

Results and limitations

Local progression occurred in 25 patients (12%), plus 2 progressed with metastases (1.1%). Of the 178 subjects with 209 SRMs, 127 with 151 SRMs had > 12 mo of follow-up with two or more images, with a mean follow-up of 28 mo. Their tumor diameters increased by an average of 0.13 cm/yr. Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate. Limitations included no central review of imaging and pathology and a short follow-up.

Conclusions

This is the first SRM active surveillance study to correlate growth with histology prospectively. In the first 2 yr, the rate of local progression to higher stage is low, and metastases are rare. SRMs appear to grow very slowly, even if biopsy proven to be RCC. Many patients with SRMs can therefore be initially managed conservatively with serial imaging, avoiding the morbidity of surgical or ablative treatment.     

Outcomes of circulatory arrest procedures for the treatment of thoracic aortic disease at a veterans facility

Background

The outcomes of thoracic aortic surgery involving hypothermic circulatory arrest at a US Department of Veterans Affairs medical center were evaluated.

Methods

Using the Veterans Affairs Continuous Improvement in Cardiac Surgery Program, all thoracic aortic operations performed with hypothermic circulatory arrest between December 1999 and December 2009 were identified (n = 24). Operative mortality and morbidity were evaluated, and survival was assessed by using the Kaplan-Meier method.

Results

Aortic dissection was the underlying disease in 10 patients (42%). Full or hemiarch aortic repair was performed in 16 patients (67%); of these operations, 3 (13%) involved elephant trunk repair. There was 1 operative death (4%). Four patients (17%) had strokes (all but 1 fully recovered), and 1 (4%) had renal failure. The survival rate was 90% at 1 year and 67% at 3 years.

Conclusions

Despite the magnitude and risk of thoracic aortic surgery involving hypothermic circulatory arrest, good outcomes can be achieved when such surgery is performed at an experienced Veterans Affairs center.