联合门静脉胰腺癌切除术的安全性及疗效评价

目的对联合门静脉切除胰腺癌的可行性进行分析,为胰腺癌的治疗提供新途径。方法以行联合门静脉胰腺癌切除术的病变累及门静脉胰腺癌35例患者为观察组,20例同期行姑息旁路术的同类患者为对照1组,同期病灶未累及门静脉行标准根治手术的20例胰腺癌患者为对照2组,观察3组的手术效果及并发症情况。结果采用联合门静脉切除胰腺癌患者的手术后并发症发生率为25％,与对照2组的23．5％相比差异无统计学意义（P〉0．05）;对患者采用寿命表进行计算,观察组患者术后1、3、5年的生存率分别为78．5％,28．8％,9．58％,与对照2组的80．5％,30．9％以及10．23％的差异无统计学意义（均P〉0．05）,但显著高于对照1组的48．5％,11．5％,1．5％（均P〈0．05）。结论对于病变已累及门静脉的胰腺癌采用联合门静脉胰腺癌切除术,可有效提高胰腺癌手术切除率,有效延长患者寿命,改善患者预后。     

肝脏切除手术风险预测模型研究

目的建立肝脏切除术前风险预测模型。方法回顾性分析2012年6月至2013年9月我科连续性完成52例半肝切除的临床资料,采用Logistic回归分析模型明确术后肝功能不全发生的预测因素。结果术前吲哚菁绿15分钟滞留率(ICG R15)、残余肝脏体积/标准肝脏体积(RLV/SLV)、脾脏体积增大倍数(△SV/SSV)均为半肝切除术后肝功能不全发生的独立危险因素(P=0.001,P=0.003和P=0.002),风险系数R=3.545×(ICG R15)-5.743×(RLV/SLV)+8.982×(△SV/SSV)。结论相对较高的ICG15R和△SV/SSV,以及较低的RLV/SLV可能影响肝脏切除术后患者肝功能不全的发生。     

Survival and recurrences after hepatic resection or radiofrequency for hepatocellular carcinoma in cirrhotic patients: A multivariate analysis

Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. Radiofrequency ablation is a new emerging modality. The aim of this study was to compare two homogeneous groups of patients who underwent either surgical resection or laparoscopic radiofrequency, analyzing the factors predicting survival and intrahepatic recurrences with use of a multivariate analysis. From February 1997 to April 2003, 98 patients were enrolled in this prospective study. Inclusion criteria were a single nodule of less than 5 cm, Child A-B class of liver function, and no previous treatment: 40 patients were in the surgical group and 58 patients were in the radiofrequency group. The two groups were homogeneous as far as preoperative characteristics were concerned. Operative mortality was zero, and the rates of operative morbidity were similar. Actuarial survival at 4 years was not significantly different (61% after resection and 45% after radiofrequency). There was a significant higher incidence of intrahepatic recurrences after radiofrequency than after resection (53% versus 30%; P = 0.018). This was mainly due to local recurrences, whereas those appearing in other liver segments were similar in both groups. A multivariate analysis showed that the significant factors predictive of an intrahepatic recurrence were the level of α-fetoprotein, the etiology of cirrhosis, and the type of the treatment. On the other hand, multivariate analysis of the survival showed that only the level of α-fetoprotein was an independent predictor of survival. The results of our study showed a significant lower incidence of intrahepatic recurrences after resection compared with after radiofrequency. This seems not to significantly influence the overall survival, probably because of a prompt and effective treatment of the recurrences themselves. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

Hepatic artery vs. portal vein infusion of microbeads: a large animal pre‐clinical model evaluating the intrahepatic capacity for cell infusion and imaging

Wang W, Liu S, Zheng W, Gao F, Hawthorne WJ, Yi S. Hepatic artery vs. portal vein infusion of microbeads: a large animal pre‐clinical model evaluating the intrahepatic capacity for cell infusion and imaging. Xenotransplantation 2010; 17: 207–214. © 2010 John Wiley & Sons A/S. Abstract: Background: Islet xeno‐transplantation via the portal vein has been proposed as an alternative of islet allo‐transplantation for treatment of type 1 diabetes. However, the precise hepatic capacity has not been addressed. Methods: We mimicked cell transplantation by infusion of dogs with alginate/poly‐1‐lysine/alginate (APA) microbeads via either the portal vein (PV) or hepatic artery (HA). The maximal adaptable capacity for infused microbeads was evaluated by examination of vasculature, microvasculature, hepatic hemodynamics, portal vein, and hepatic artery pressures and liver function in the microbead recipient dogs. Results: PV but not HA dogs demonstrated elevated portal pressure during the infusion procedure in a dose‐dependent manner. Four out of twelve PV dogs infused with 32 000 microbeads/kg developed acute liver infarction within 24 h after infusion with four of the remaining eight animals developing portal venous thrombosis within 24 h following infusion. All PV animals demonstrated abnormal alanine aminotransferase (ALT) values, and the extent and duration of increased ALT levels correlated with the increase in the number of microbeads infused. In contrast, HA animals infused with as many as 32 000 microbeads/kg had neither portal thrombosis nor abnormal liver function. Conclusions: The capacity for intrahepatic cell infusion is finite and the intrahepatic artery may have a less hemodynamic interference impact on transplantation of cells into the liver when a larger volume of cells is required to achieve curable outcomes in both allo‐ and xeno‐transplantation.     

Prognosis of hepatocellular carcinoma associated with Child class B and C cirrhosis in relation to treatment: a multivariate analysis of 411 patients at a single center

Background/Purpose: Given that the prognosis of patients with hepatocellular carcinoma (HCC) complicating severe cirrhosis remains uncertain, particularly with regard to various therapeutic strategies, we have evaluated the prognosis in a series of patients with homogeneous diagnostic and therapeutic histories. Methods: From 1990 to 1998, 411 consecutive HCC patients associated with Child class B and class C cirrhosis who did not have lymph node or distant metastasis were treated by partial hepatectomy (PH; n = 48), percutaneous ethanol injection (PEI; n = 105), transcatheter arterial chemoembolization (TACE; n = 189), chemotherapy, or supportive care (chemo/supportive; n = 69). Univariate survival curves were estimated. The Cox model, stratified by the treatment groups, was used for multivariate analysis. Results: As of January 1999, 305 patients (74.2%) had died. Overall median survival was 23.4 months. There were statistically significant differences between the survival times of patients receiving PH or PEI and TACE, as compared with those receiving chemo/supportive care. According to multivariate analysis, the independent predictive survival factors were: albumin level (≥3.0 g/dl), esophageal varices (i.e., absence), tumor size (≤3.0 cm), tumor number (solitary), and α-fetoprotein (AFP) level (<400 ng/ml). According to the total number of risk factors and the median survival, all patients were divided into four subgroups. For the score 0 group (no risk factor group), 3- and 5-year survival rates were 83.1% and 68.0% for PH, and 87.5% and 62.3% for PEI, respectively. In the score 1–2 group (one or two risk factors), survival rates at 3 and 5 years were 53.1% and 40.3% for PH, 54.8% and 33.2% for PEI, and 35.4% and 22.8% for TACE, respectively. For patients with a score of 3 or more, there were no differences among the treatment groups, excluding those with chemo/supportive care. Conclusions: These findings indicate that, in HCC patients with complicating Child B and C cirrhosis, PEI and PH should be considered first for subgroups of patients with scores (risk factors) of 0–2, as an acceptable survival rate was obtained in such patients. Therefore, the advantages and disadvantages of these therapies regarding tumor size and location should be counterbalanced. In patients with a score of 3 or more, TACE, when possible, could be a first choice because of its applicability and its adjuvant nature with respect to other therapies such as liver transplantation. Received: February 6, 2002 / Accepted: May 22, 2002 Offprint requests to: S. Ueno     

Impact of intraoperative blood pressure,blood pressure fluctuation,and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study

AimPostoperative delirium (PD) is a frequent complication of hip fracture surgery, but its pathophysiology remains poorly understood. We investigated the impact of a single episode of intraoperative hyper/hypotension, blood pressure (BP) fluctuation (ΔMAP), and pulse pressure (PP) on hyper/hypoactive PD in elderly patients undergoing surgery for hip fracture. We also assessed the effect of PD on clinical outcomes.MethodsThis was a prospective 1-year follow-up study of patients over 60 years of age with a primary diagnosis of acute low-energy hip fracture. Perioperative delirium was assessed using the Confusion Assessment Method (CAM); the development of PD and the type, hyperactive or hypoactive PD, were recorded. Cognitive assessment was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ). The lowest and highest BP values were extracted from the patients’ anaesthesia charts. Postoperative complications, reinterventions and 1-month mortality were recorded.ResultsPD occurred in 148 (53%) patients during the first postoperative week, with 75% of the cases diagnosed as hypoactive PD. Patients developing PD of any type were older, had a lower body mass index, higher SPMSQ and Charlson scores, more severe systemic diseases, a lower lowest intraoperative BP, a higher ΔMAP, a lower PP, and a higher postoperative pain score. They also took more drugs and received more blood transfusion intraoperatively. Multivariate logistic regression analyses showed that a higher MAP min had a protective effect on the occurrence of any type of PD, as well as hypoactive and hyperactive. PD had negative effect on outcomes.ConclusionOur results provide evidence of an association between maximal hypotension, the lowest intraoperative mean blood pressure (MAP), ΔMAP, PP, and PD. A progressive decrease in MAP during surgery was associated with the increased odds of developing either type of PD.     

A method of measuring quantitative hepatic function and hemodynamics in cirrhosis: The changes following distal splenorenal shunt

Quantiative measurement is required to define the severity of chronic liver disease and the effects of therapy on its complications. This paper presents a method of such assessment based on measurement of hepatocyte function, liver volume, functional liver blood flow, portal perfusion and cardiac output. Data are presented on 54 patients evaluated prior to, and one year after DSRS for variceal bleeding. Preoperative testing showed that alcoholics (n=24) had significantly (p<0.05) larger liver and smaller spleen volumes than nonalcoholic cirrhotics (n=22) and patients with portal vein thrombosis (n=8), but that the other parameters were not significantly different by etiologies. At one year after DSRS: all groups showed a significant (p<0.01) reduction of 41 per cent in spleen size: liver volume was significantly (p<0.05) reduced in cirrhotics: there was a significantly (p<0.01) greater loss of portal perfusion in alcoholic cirrhosis: liver blood flow showd a significant (p<0.05) rise in alcoholics when compared to nonalcoholics and portal vein thrombosis patients: cardiac output ros in alcoholic cirrhosis: hepatocyte function was not significantly different in any group. This study shows that in patients all doing well clinically one year after DSRS, there are markedly different hemodynamic responses. Further studies on cirrhosis aimed at improving therapy for its complications should include some objective, quentitative assessment, first to define the study population, and second to measure the effect of the therapy.     

The effects of intraoperative glucose infusion on portal blood insulin concentration and hepatic mitochondrial redox state during surgery: Comparison of short-term and continuous infusions

(Received for publication on Dec. 14, 1998; accepted on Sept. 17, 1999)     

胸腔镜下肺段切除术后护理特殊性分析及护理方案改进

目的分析胸腔镜下肺段切除术后护理的特殊性并改进护理方案。 方法选择2015年9月1日—2016年8月31日,在厦门大学附属成功医院胸外科行胸腔镜下单操作孔单肺叶切除或单肺段切除术的60例患者,将肺叶切除术后的护理方案定义为常规护理,将肺段切除术后改进的护理方案定义为特殊护理,根据手术方法和护理方案将患者分为三组。①肺叶切除常规护理组(n＝18);②肺段切除常规护理组(n＝21);③肺段切除特殊护理组(n＝21)。特殊护理措施是指在常规护理方案的基础上,强化术后呼吸道护理、延长拔胸管时间、术后不适指数评估与充分止痛。比较三组患者术后胸腔引流量、并发症发生率、不适指数、住院天数等指标的差异。 结果三组患者的平均年龄、性别构成、手术时间、术中出血量、术后胸腔引流量比较,差异均无明显统计学差异(P>0.05)。肺段切除常规护理组术后第1、5天的不适指数显著高于肺叶切除常规护理组和肺段切除特殊护理组,差异均有统计学意义(P≤0.01);但三组间术后第3天的不适指数比较差异无统计学意义(P>0.05)。肺段切除常规护理组的术后住院时间显著高于肺叶切除常规护理组和肺段切除特殊护理组,差异均有统计学意义(P<0.05)。 结论因手术术式的不同,胸腔镜下肺段切除术后护理与肺叶切除术相比有其特殊性,通过改进的护理方案,可减少术后并发症、减轻术后不适和缩短住院时间。     

High-field intraoperative MRI in glioma surgery: A prospective study with volumetric analysis of extent of resection and functional outcome

Background

High-field intraoperative MRI (IoMRI) is a useful tool to improve the extent of glioma resection (EOR).

Skin hydration measurement and the prediction of the early development of pressure ulcers among at risk adults: A systematic review

This systematic review aimed to examine skin hydration and determine if this biophysical parameter can predict pressure ulcer development in at risk adults. A literature search was conducted in March 2022, using PubMed, CINAHL, SCOPUS, Cochrane, and EMBASE databases. A total of 1727 records were returned, with 9 studies satisfying the inclusion criteria. Data were extracted using a pre-designed extraction tool and a narrative synthesis of the data was undertaken. The methodological quality of the included articles was assessed using the evidence-based librarianship checklist. Included studies were published between 1997 and 2021, with most using a prospective cohort design (88.9%, n = 8). The mean sample size was 74 participants (SD = 38.6; median 71). All studies measured skin hydration objectively, with 55.6% (n = 5) using the Corneometer® CM825 and 33.3% (n = 3) of studies reported a statistically significant association between skin hydration and pressure ulcer development. The mean evidence-based librarianship percentage was 66.6% (SD: 20.7%), however, only 33.3% (n = 3) of studies scored ≥75%, indicating validity. The quality of included studies, methodology variation, and reported results has reduced the homogeneity of outcomes. This review highlights the requirement for future research evidence to ascertain the role of skin hydration in pressure ulcer development.     

The effect of intraoperative isometric measurement on the outcome of anterior cruciate ligament reconstruction: A clinical analysis

The concept of isometry is based on the measurement of displacement between potential femoral and tibial anterior cruciate ligament (ACL) graft attachment sites while the knee is taken through a range of motion. To evaluate the clinical benefit of intraoperative isometry measurements in ACL reconstruction, we prospectively compared 59 patients (58% acute) in whom isometry was tested (group I) with 35 patients (77% acute) in whom isometry was not tested (group II). All patients underwent arthroscopically assisted ACL reconstruction using autogenous bone-patella tendon-bone graft and interference screw fixation, and were followed-up for a minimum of 24 months (mean, 30 months). With 88% follow-up, no significant differences were found in objective testing, which included the pivot shift test, the Lachman test, KT-1000 arthrometer measurements, and range of motion. A significant difference was found between the two groups when Lysholm scores (P = .04) and Tegner Scores (P = .02) were compared, with group II having higher scores. In addition, one of 15 visual analog scales, “gives way,” showed a significant difference between the two groups (P = .01). On a scale of 1 to 10 with 1 being “no giving way” and 10 being “very frequent giving way”, group I had an average of 1.68 and group II had an average of 0.58. These differences were related to the greater percentage of chronic cases in group I. Analysis of only those patients with acute injuries from each group showed no significant differences in any objective or subjective measurement. Group I had an overall failure rate of 13%, and group II had a failure rate of 6.7% (χ² = .848). These results indicate that, in the hands of a surgeon experienced in ACL reconstruction, intraoperative assessment of isometry has little effect on the clinical outcome.     

不同压力负压闭式引流术对足踝部碾轧伤疗效分析

目的探讨高、中、低三种负压闭式引流（vacuum sealing drainage,VSD）术对足踝部碾轧伤治疗效果,并为足踝部碾轧伤治疗提供合适的VSD负压值。方法2008年10月-2010年3月,应用VSD高（-40．1—-60kPa）、中（-20．1--40kPa）、低（-16．6--20kPa）三种压力对足踝部碾轧伤进行治疗,观察不同负压梯度下患者的体温、引流量、局部微循环等变化。术后1个月和6个月分别进行Maryland足功能评分．并对评分结果进行统计学分析。结果本组27例术后随访6～12个月,完整随访24例,随访率78％：VSD三种压力治疗组在术后1个月差异无显著性（P〉0．01）,但术后6个月统计学分析差异有显著性（P〈0．01）。结论VSD技术是治疗足踝部碾轧伤的一种可靠、实用的方法,高（-40．1—-60kPa）负压力治疗组较其他两组可获得更好的足功能恢复。     

High body mass index is a strong predictor of intraoperative acquired pressure injury in spinal surgery patients when prophylactic film dressings are applied: A retrospective analysis prior to the BOSS Trial

We reported the efficacy of soft silicone multilayered foam dressings in preventing intraoperatively acquired pressure injuries (IAPIs) in the prone position using a Relton‐Hall frame (BOSS trial). The aim of this study was to clarify the incidence and extract the risk factors for IAPIs in cases in which polyurethane film dressing was used against IAPIs before the BOSS trial period. This study conducted as a retrospective dual‐center cohort study between August 2014 and Jun 2015 using the medical records in the operating room. The incidence of IAPIs that developed within 24 hours after surgery was 7.1% (7/99). The multivariate logistic regression analysis revealed that body mass index (BMI) (P = .0016, odds ratio [OR]: 1.22, 95% confidence interval (CI) 1.08‐1.4) and length of surgery (P < .0001, OR 2.47, 95% CI 1.86‐3.51) were independently associated with the development of IAPIs. Since high BMI was not extracted in BOSS trial, we conclude that the application of soft silicone multilayer foam dressings is important for preventing the development of IAPIs in patients with high BMI values.     

A comparison of long‐term outcomes of portal versus systemic venous drainage in pancreatic transplantation: a systematic review and meta‐analysis

Pancreas transplantation venous effluent can be drained via the portal vein or the systemic circulation; however, no recommendation exists for the ideal technique. A systematic review of the literature from 1989 through 2014 using PubMed, CINHAL, and Cochrane Library for portal versus systemic venous drainage was undertaken. Only studies on humans and published in English were considered. Measures of glycemic control and total cholesterol were synthesized for meta‐analysis utilizing random‐effects models. Of 166 articles retrieved, 15 articles were included for meta‐analysis. Patient and graft survival were comparable in a large database study as well as in the only randomized control study. No differences in complications were seen when exocrine drainage was enteric for the systemic venous group. Fasting insulin (?34.13 pmol/mL, p < 0.001) was significantly lower within the portal drained group; however, fasting blood glucose levels (?3.4 mg/dL, p = 0.32) and hemoglobin A1C levels (mean difference 0.124%, p = 0.25) were comparable. Total cholesterol levels (?3.62 mg/dL, p = 0.447), as well as other measures of lipids, showed no difference. Based on this systematic review and meta‐analysis, there is no evidence of differences in outcomes or metabolic control in patients undergoing pancreatic transplant with portal venous drainage compared to the systemic venous drainage.     

The urethral pressure profile under stress: A comparison of profiles on coughing and straining

In terms of urethral pressure measurements the distinction between stress-incontinent and continent women is perhaps best made by examining the urethral response to stress. Profiles may be performed during the repeated intraabdominal pressure rises due to coughing, or the sustained effect of straining; the relationship between the two has not previously been defined. This comparative study involves 120 patients with a variety of urinary symptoms in whom stress profiles were performed both on coughing and on straining. Parameters of the cough profile were found to be more repeatable than those of the strain profile. and also related more closely to the severity of incontinence. Calculation of pressure transmission ratios from cough profiles also proved more useful. since they allow the acute and sustained components of the urethral response to stress to be readily distinguished.     

Pelvic hemodynamics before and after aortoiliac vascular reconstruction: The significance of penile blood pressure

The relationship between penile pressure and hypogastric arterial insufficiency, as well as the changes in the penile brachial pressure index and male sexual function after aortoiliac vascular reconstruction, were investigated in 47 patients with arteriosclerosis obliterans and in 6 patients with Buerger’s disease. When the penile brachial pressure index was greater than 0.7, a value compatible with normal sexual function, there was enough arterial circulation to keep at least one hypogastric artery patent. In cases where there was insufficiency of both hypogastric arteries the index increased significantly after the inflow was restored, even if it was unilateral, following arterial reconstruction. Reconstruction of the blood flow to the femoral artery tended to increase the index even without restoration of hypogastric flow, especially when the inferior mesenteric artery was occluded. In cases of high aortic occlusion, restoration of blood to the femoral artery alone led to a greatly significant increase in the index. These facts indicate that branches of the femoral artery and the inferior mesenteric artery play an important role in the collateral circulation of pelvic hemodynamics when the hypogastric artery is occluded. A part of this work was presented at the 27th Congress of the Japanese College of Angiology held in Kofu, Japan on October 30th, 1986     

The relationship between pressure injury complication and mortality risk of older patients in follow‐up: A systematic review and meta‐analysis

Pressure injuries (PIs) have now become a common complication of the elderly patients. Some studies have observed that pressure injuries may increase mortality, but this area of evidence has not been evaluated and summarised. The aim of this study was to compare the mortality of patients with pressure injuries and those without pressure injuries. A meta‐analysis of observational studies was performed. PubMed, Cochrane Library, Embase, and Web of Science were searched up to April 2019. Studies about mortality among the elderly patients with and without pressure injuries were included. Methodological quality was assessed by the Newcastle‐Ottawa Scale (NOS). The fixed effect or random effect model was determined by the test of heterogeneity. The subgroup analysis was performed based on the pressure injuries stages, the region, and the type of study design. The meta‐regression analysis was performed to investigate the relationship between the mortality and patients' enrolled year, average age, the incidence of pressure injuries, and gender ratio. The sensitivity analysis was used to explore the impact of an individual study by excluding one at a time. The hazard ratio (HR) and 95% confidence intervals (CIs) in terms of the comparison of two groups were extracted for meta‐analysis. A survival curve between two groups by individual patient‐level was drew. Eight studies with 5523 elderly patients were included in the analysis. Follow‐up periods for the included studies ranged from about 0.5 to 3 years. The elderly patients who complicated with pressure injuries had a higher risk of death. The pooled HR was 1.78 (95% CI 1.46‐2.16). A funnel plot showed no publication bias. Further subgroup analysis showed that HR values for the patient stage 3 to 4 pressure injuries (HR:2.41; 95% CI:1.08‐5.37) were higher than stage 1‐4 and 2‐4 pressure injuries (HR: 1.66; 95% CI: 1.35‐2.05; HR: 1.74; 95% CI: 1.16‐2.60). The meta‐regression analysis found that patients' enrolled year, average age, the incidence of pressure injuries, and gender ratio were not the sources of heterogeneity. Sensitivity analyses showed that the outcomes of the study did not change after removing the Onder's article. The survival curve at the individual patient‐level also indicated that patients complicated with pressure injuries significantly increased the risk of death (HR: 1.958; 95% CI: 1.79‐2.14) in elderly patients. Our meta‐analysis indicated that patients complicated with pressure injuries are estimated to have a two times higher risk on mortality compared with patients without pressure injuries during the 3 years follow‐up period. Particular attention should be given to the elderly patients who are at higher risk for mortality.