Panhypopituitarism and bifid uvula / Journal of the ASEAN Federation of Endocrine Societies

@#A 20-year-old male was referred to the Endocrinology Clinic in view of abnormal thyroid function test result and poor development of secondary sexual characteristics. He was born out of non-consanguineous marriage and had a history of breech delivery at term. He had perinatal complications in the form of delayed cry and lower respiratory tract infection. Developmental delay was also present (delayed motor, speech and social milestones). His scholastic performance was below average and he reported being the shortest child in class from kindergarten.

Symptomatic oral squamous papilloma of the uvula – a rare incidental finding

@#Oral squamous papillomas are benign neoplasms of the oral cavity that occur commonly on the palate. Albeit benign and often asymptomatic, they may still cause concern due to their appearance, which may mimic other malignant oral pathologies. Human papillomavirus (HPV) is usually implicated in papilloma pathogenesis. We present a rare case of symptomatic oral squamous papilloma arising from the uvula and causing tongue and throat irritation. This benign lesion was excised with electrocautery.

Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population / Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population

Abstract Introduction: Bifid uvula is a frequently observed anomaly in the general population and can be regarded as a marker for submucous cleft palate. Objective: In this study aimed to determine the frequency of bifid uvula and submucous cleft palate and their relationship with oral clefts in a Brazilian population. Methods: We conducted a transversal, descriptive and quantitative study of 1206 children between August 2014 and December 2015. A clinical examination of the children was conducted by means of inspection of the oral cavity with the aid of a tongue depressor and directed light. After the clinical examination in children, parents answered a questionnaire with questions about basic demographic information and their family history of oral clefts in their first-degree relatives. After application of the questionnaires, the information collected was archived in a database and analyzed by the statistical program SPSS® version 19.0, by applying Chi-Square tests. Values with p < 0.05 were considered statistically significant. Results: Of the 1206 children included in this study, 608 (50.40%) were female and 598 (49.60%) were male (p = 0.773). The average age of children was 3.75 years (standard deviation ± 3.78 years). Of the 1206 children studied, 6 (0.5%) presented with bifid uvula. Submucosal cleft palate was not found in any child. When the family histories of children were examined for the presence of nonsyndromic cleft lip and/or cleft palate, no first degree relatives presented with the congenital anomaly. Conclusion: This study revealed that the incidence of bifid uvula and submucous cleft palate in this population was quite similar to previously reported incidence rates. Our study suggests an intensification of new reviews, with broader and diverse populations, seeking to associate the occurrence of bifid uvula, submucous cleft palate and oral clefts.

Resumo: Introdução: A úvula bífida é uma anomalia frequentemente observada na população em geral e pode ser considerada como um marcador de fissura palatina submucosa. Objetivo: Determinar a frequência de úvula bífida e fissura palatina submucosa e sua relação com fissura orais em uma população brasileira. Método: Realizamos um estudo transversal, descritivo e quantitativo de 1.206 crianças entre agosto de 2014 e dezembro de 2015. O exame clínico das crianças foi realizado por meio da inspeção da cavidade oral com auxílio de um abaixador de língua e luz direcionada. Após o exame clínico nas crianças, os pais responderam a um questionário com perguntas sobre informações demográficas básicas e antecedentes de fendas orais em familiares de primeiro grau. As informações coletadas foram arquivadas em um banco de dados e analisadas pelo programa estatístico SPSS® versão 19.0, aplicando testes de Qui-Quadrado. Os valores com p < 0,05 foram considerados estatisticamente significativos. Resultados: Das 1.206 crianças incluídas neste estudo, 608 (50,40%) eram do gênero feminino e 598 (49,60%) do masculino (p = 0,773). A idade média das crianças foi de 3,75 anos (desvio-padrão ± 3,78 anos). Das 1.206 crianças estudadas, seis (0,5%) apresentavam úvula bífida. A fissura palatina submucosa não foi encontrada em nenhuma criança. Quando as histórias familiares de crianças foram examinadas quanto à presença de fissura de lábio e/ou palato não sindrômica, nenhum parente de primeiro grau apresentava esta anomalia congênita. Conclusão: Este estudo revelou que a incidência de úvula bífida e fissura palatina submucosa nesta população é bastante semelhante às taxas de incidência previamente relatadas. Nosso estudo sugere uma intensificação de novas revisões, com populações mais amplas e diversas, buscando associar a ocorrência de úvula bífida, fissura palatina submucosa e fissura orais.

Hiperplasia de la úvula: presentación de un caso clínico / Hyperplasia of the uvula: report of a clinical case

La hiperplasia de la úvula es una entidad poco frecuente. Puede tener diversas causas, tales como: surgir a partir de un proceso infeccioso; por reacciones alérgicas; angioedema hereditario (HANE) (14,16); inhalación de sustancias psicoactivas (7); traumatismos ocasionados por procedimientos como intubación o extubación endotraqueal, así como durante la aspiración de los líquidos de la cavidad oral en procedimientos quirúrgicos. (7,14,16) El alargamiento de la úvula, en algunos casos, se manifiesta asintomático. Este trabajo tiene como objetivo la descripción de esta entidad, la presentación de un caso clínico, y su manejo clínico-quirúrgico (AU)

The hyperplasia of the uvula is a rare entity, it can have diverse causes, such as: of an infectious process, allergic reactions, hereditary angioedema (HANE), (14 16) inhalation of psychoactive substances (7) traumatisms caused by procedures such as, intubation or endotracheal extubation, as well as during the aspiration of liquids from the oral cavity in surgical procedures (7,14,16). The lengthening of the uvula, in some cases, is asymptomatic. The aim of this work is the description of this entity, the presentation of a clinical case, and the clinical and surgical management (AU)

Quiste epidermoide de úvula palatina: presentación de un caso: revisión de la literatura / Epidermoid cyst of uvula: presentation of case: review of the literature

El quiste epidermoide es una entidad dermatológica frecuente, siendo muy rara su ubicación en la cavidad oral, con una mayor prevalencia a nivel de la cavidad oral. Es considerada de etiología congénita, aunque se presenta predominantemente en adulto jóvenes. Generalmente son masas bien circunscritas, decrecimiento lento y asintomáticos, aunque los ubicados en la cavidad oral y orofaringe pueden provocar trastornos fonatorios, deglutorios y respiratorios. El diagnóstico es clínico, siendo el diagnóstico diferencial con los quistes dermoides y teratoides solo posible con el estudio histopatológico. El tratamiento es quirúrgico y elpronóstico favorable sin recidivas. Se presenta un caso de quiste epidermoide localizado en la úvula palatina, en un varón de 6 meses de vida, tratado quirúrgicamente, con la excéresis del tumor por un abordaje trasoral

The epidermoid cyst is a frequent dermatological entity, being very rare its location in theoral cavity, with a higher prevalence at the level of the floor of the oral cavity. It is considered of congenitaletiology, although it occurs predominantly in young adults. They are generally well circumscribed, slowgrowing and asymptomatic masses, although those located in the oral cavity and oropharynx can causephonatory, swallowing and respiratory disorders. The diagnosis is clinical, being the differential diagnosiswith the dermoid and teratoid cysts only possible with the histopathological study. The treatment is surgicaland the prognosis is favorable without relapses. We present a case of epidermoid cyst located in uvula, in amale of 6 months of life, treated surgically, with the tumor excision by a transoral approach

Gastrointestinal Endoscopy-Assisted Minimally Invasive Surgery for Superficial Cancer of the Uvula

Previous studies reported that endoscopic resection is effective for the treatment of superficial pharyngeal cancers, as for digestive tract cancers. However, the optimal treatment for superficial cancer of the uvula has not been established because of the rarity of this condition. We present two male patients in their 70s with superficial cancer of the uvula, detected with upper gastrointestinal endoscopy. Both patients underwent surgical resection of the uvula under general anesthesia. The extent of the lesions was determined by means of gastrointestinal endoscopy by using magnifying observation with narrow-band imaging, enabling the performance of minimally invasive surgery. Endoscopic submucosal dissection was performed to achieve en bloc resection of the intramucosal carcinoma that had infiltrated the area adjacent to the uvula. Gastrointestinal endoscopists should carefully examine the laryngopharynx to avoid missing superficial cancers. Our minimally invasive treatment for superficial cancer of the uvula had favorable postoperative outcomes, and prevented postoperative loss of breathing, swallowing, and articulation functions.

Cadaveric Study on the Location of Pharyngeal Orifice of an Eustachian Tube in Relation to the Anatomical Landmarks.

Introduction: Eustachian tube is a communication between the nasopharynx and middle ear extending between the lateral wall of the nasopharynx to anterior wall of tympanic cavity.It maintains the equilibrium of air pressure on either side of the tympanic membrane for proper vibration of sound. The pharyngeal orifice of Eustachian tube is an important landmark for endoscopic surgeries and also for transnasal approach to infratemporal fossa. Materials and Methods: A total of 50 (25 right &25 left)sagittal section of head and neck specimens from adult formalin fixed cadavers from the department of anatomy, MVJ Medical college and Research Hospital, Banglore, India, were used for the study.The distance of pharyngeal orifice to posterior border of hard palate,C1 vertebra,posterior choana,tip of uvula, spehenoid sinus were measured with the digital Vernier caliper.The mean and standard deviation of these parameters were calculated. Conclusion: The knowledge of the relationship of Eustachian tube with anatomical landmarks would be useful to surgeons,otolaryngologists and radiologists.

Nuevas manifestaciones orales del síndrome branquio-óculo-facial: Caso clínico / New oral manifestations of Branchio-oculo-facial syndrome: Case report

El síndrome branquio-óculo-facial es una condición autosómica dominante con expresividad variable y que afecta particularmente las estructuras de la cara y cuello por un desarrollo inadecuado del primero y segundo arco branquial; presenta malformaciones de los ojos y oídos, con características faciales distintivas. Está asociado con alteraciones en el gen TFAP2A. Se presenta una paciente de 9 años con fenotipo de síndrome branquio-óculo-facial y la presencia de dos nuevas manifestaciones orales, la úvula bifida y la lengua con hendidura central parcial, no descritas hasta ahora en esta condición clínica.

The branchio-oculo-facial syndrome is a dominant autosomic condition with variable expressivity that affects particularly the facial and neck structures by an inadequate development of the first and second branchial arch. It is characterized by malformations of eyes and ears, with distinct facial characteristics. It is associated with alterations in TFAP2A gene. We present a patient with 9 years of age with phenotype of the branchio-oculo-facial syndrome and the presence of 2 new oral manifestations, the bifid uvula and the tongue with partial central cleft, not yet described in this clinical condition.

Auditory function after uvulopalatopharyngoplasty in adult patients with severe obstructive sleep apnea-hypopnea syndrome / 中国医师杂志

Objective To investigate the changes of uvulopalatopharyngoplasty on the auditory function in adult patients with severe obstructive sleep apnea-hypopnea syndrome (OSAHS).The possible mechanism of hypoxemia was analyzed,and hypercapnia might affect auditory function and the effect of operation to hearing was improved.Methods A total of 82 adult patients who were made a diagnosis by polysomnography (PSG) with severe OSAHS had been diagnosed by pure tone audiometry,tympa-nometry,auditory brainstem responses (ABR),and otoacoustic emissions (OAE) before and 6 months after surgical treatments.The control group included 43 non-snoring healthy people through the same line of the above test.Results (1)Among 82 patients who underwent uvulopalatopharyngoplasty,symptoms were resolved in 51 patients,significantly improved in 24 patients,and somewhat improved in7 patients at 6 months followed-up,yielding a total effective rate of 100％.(2)There were no significant differences in hearing threshold across 250 to 4 000 Hz on pure tone audiometry between OSAHS and control groups (P ＞ 0.05),although hearing thresholds at high frequencies showed significant differences (P ＜ 0.05).(3)The latencies of ABR waves Ⅰ and Ⅴ in the OSAHS group were significantly longer than control group (P ＜ 0.05).The interpeak lantency intervals of wave Ⅲ ～ Ⅴ in patients with OSAHS were longer than that in the control group (P ＜ 0.05).No significant difference was showed before and after surgery (P ＞ 0.05).(4)Distortion product otoacoustic emission (DPOAE) detection rate and amplitudes at all frequencies were poorer in OSAHS group before surgery compared with the control group (P ＜ 0.05),and significant changes were found after surgical treatments (P ＜ 0.05).Conclusions OSAHS can impair auditory function,probably from chronic hypoxia,which can be improved by surgical treatment in adult patients with severe OSAHS.

Epithelial Cyst of the Uvula with Unilateral Complete Cleft Lip and Palate

Efficacy of modified uvula palatopharyngeal plasty in the treatment of obstructive sleep apnea syndrome / 重庆医学

Objective To explore the efficacy of modified uvula palatopharyngeal plasty in the treatment of obstructive sleep ap-nea syndrome(OSAHS) .Methods 145 cases of OSAHS patients were treated from June 2006 to June 2010 in our hospital ,of which 54 were treated by traditional UPPP surgery ,and the remaining 91 cases were treated by h-UPPP surgery .Compared its effi-cacy by the preoperative and postoperative polysomnography map (PSG) analysis .Results In 145 cases of patients with OSAHS , the PSG monitoring indicators of 1 year after surgery were compared with preoperative ,and there were significant difference in the apnea total time(AI) ,the breathing hypopnea index(AHI) ,the lowest oxygen saturation(SaO2 )(P<0 .05) .The subjective symp-toms in postoperative recovery process of modified UPPP ,such as dry throat ,open nasal ,nasopharyngeal reflux symptoms were sig-nificantly reduced than that of traditional UPPP surgery .Conclusion h-UPPP surgery have a good effect .

Caso de intoxicación en Venezuela, por el uso de la planta de Estropajo o Tusa (Luffa cylíndrica ) / Case of intoxication by the use of the loofah sponge or tusa (Luffa cylindrica) in Venezuela

En algunas regiones del mundo, las plantas originan importantes problemas clínicos, causando gran morbilidad y mortalidad, principalmente después de la intoxicación no intencional. Este trabajo tiene como objetivo principal describir un caso clínico presentado en el Servicio de Toxicología Médica, Hospital “Doctor Leopoldo Manrique Terrero”, Caracas, Venezuela (2012), de una intoxicación con la planta de estropajo (Luffa  cylindrica), perteneciente a la familia de las Cucurbitáceas, usada inadecuadamente como instilación nasal. El análisis clínico otorrinolaringológico permitió evidenciar un cuadro agudo, grave con obstrucción de vías aéreas superiores, producido por el uso tópico de extracto de la planta de estropajo (Luffa  cylindrica), como medicamento nasal para tratar una sinusitis crónica. El paciente presentó 2 horas después de la instilación,  una disfonía,  con un intenso edema de úvula; se encontraba confundido, con cefalea, así como acentuada odinofagia y dificultad respiratoria. Tras la revisión de la literatura se permite plantear que se trata del primer caso referido o publicado de esta inusual intoxicación y daño de vías aéreas superiores ocasionado por esta planta. El paciente fue tratado con oxígeno (SOS), hidrocortisona y clorfeniramina recuperándose después de 48 h de tratamiento sintomático.

In some world regions, plants originate important clinical problems, causing significant morbidity and mortality, mainly after unintentional poisoning. This paper aims to describe a case seen at the Medical Toxicology Service, "Dr. Leopoldo Manrique Terrero " Hospital, Caracas, Venezuela (2012), which was a loofah plant poisoning (Luffa cylindrica), belonging to Cucurbitaceae family, used inappropriately as nasal instillation. The otorhinolaryngology clinical analysis demonstrated an acute, severe upper airway obstruction produced by the topical use of loofah (Luffa cylindrica) plant extract as nasal medication to treat chronic sinusitis. The patient developed 2 hours after instillation, a dysphonia, with intense uvula edema, confusion, headache and sore throat and accentuated respiratory distress. After literature review it is suggested that this is the first referred or published case in this unusual intoxication and upper airway damage caused by this plant. The patient was treated with oxygen (SOS), hydrocortisone and chlorpheniramine recovering after 48 h of symptomatic treatment.

Subjective and Objective Assessment of Quality of Life for Coblation-Assisted Operation in Patients with Severe OSAHS / 天津医药

Objective To evaluate the subjective and objective improvement of quality of life in patients with low-temperature plasma-assisted modified uvulopalatopharyngoplasty (H-UPPP) combined with lymphoidectomy in radix lin-guae and coblation-channeling of the tongue(CCT) treating for severe obstructive sleep apnea hypopnea syndrome (OSAHS) , and compare the surgical efficacy with that of H-UPPP. Methods A total of 81patients with severe OSAHS were divided in-to treatment group (n=42) and control group (n=39). Treatment group underwent the low-temperature plasma-assisted H-UPPP combining lymphoidectomy in radix linguae and CCT,and control group underwent H-UPPP treatment. The apnea hy-popnea index (AHI), the lowest saturation of arterial oxygen (LSaO2) and Quebec sleep questionnaire (QSQ) and Epworth sleepiness scale (ESS) before operation and 6-month after operation were recorded and compared between two groups. Re-sults All of detection indicators were significantly improved after operation in treatment group (P＜0.01). The total surgical efficacy was significantly higher in treatment group than that of control group (83.3%vs 12.8%,χ2=40.225,P＜0.01). The to-tal improvement rate of five dimensions in QSQ such as daytime sleepiness symptoms (76.2%vs 25.6%), signs during the day (71.4%vs 10.2%) and night (54.8%vs 5.1%), emotion (54.8%vs 2.5%), ability of social intercourse (50.0%vs 2.5%) and the total score (57.1%vs 7.7%) after operation were significantly higher in treatment group than those of control group. The se-vere indexes of ESS decreased to 23.8% after operation in treatment group than those of control group (51.3%). Conclu-sion Low-temperature plasma-assisted H-UPPP combined with lymphoidectomy in radix linguae and CCT is effective in patients with severe OSAHS, which can also improve the quality of life postoperatively.

Larsen Syndrome: A Case Report.

Larsen syndrome was first described in 1950 by Larsen, Schottstaedt and Bost. This rare inherited disorder is characterized by congenital dislocation of multiple joints along with other anomalies of heart, face, hands and bones. Awareness of this condition and assosciated complications helps in better follow up and management of these patients.

Tuberculosis of nose and palate with vanishing uvula.

During the past two decades, tuberculosis - both pulmonary and extrapulmonary - has re-emerged as a major health problem worldwide. Nasal tuberculosis - either primary or secondary to pulmonary tuberculosis or facial lupus - is rare, but it should be considered in the differential diagnosis of nasal granulomas. We describe a case of tuberculosis in an adult male who presented with palatal perforation with vanishing uvula and arch deformity of the palate. The diagnosis was based on histopathology and patient's successful response to antituberculous drug treatment.

The treatment of obstructive sleep apnea patient using extended uvulopalatal flap: a case report

The uvulopalatal flap (UPF) technique is a modification of uvulopalatopharyngoplasty (UPPP) for the surgical treatment of obstructive sleep apnea. In the UPF technique, an uvulopalatal flap is fabricated and sutured to the residual mucosa of the soft palate to expand the antero-posterior dimensions of the oropharyngeal inlet. In the extended uvulopalatal flap (EUPF) technique, an incision at the tonsillar fossa is added to the classical UPF technique followed by the removal of mucosa and submucosal adipose tissue for additional expansion of the lateral dimension. The EUPF technique is more conservative and reversible than UPPP. Therefore, complications, such as velopharyngeal insufficiency, dysphagia, dryness, nasopharyngeal stenosis and postoperative pain, are reduced. In the following case report, the patient was diagnosed with obstructive sleep apnea and treated with the EUPF technique. The patient's total respiratory disturbance events per hour (RDI) was decreased to 15.4, the O2 saturation during the sleep was increased, and the excessive daytime sleepiness had disappeared after the surgery without complications. The authors report this case with a review of the relevant literature.

Prevalência da fissura de úvula em familiares de fissurados lábio-palatinos / Cleft uvula prevalence in relatives of cleft lip and palate individuals

O objetivo deste estudo foi verificar se a prevalência da fissura de úvula (FU) é maior em familiares de portadores de fissura labiopalatina em relação à população em geral. Esta pesquisa foi realizada com um grupo de estudo composto por 136 familiares de pacientes fissurados e com um grupo controle formado por 287 indivíduos sem história familiar de qualquer deformidade craniofacial. A metodologia consistiu em inspeção da cavidade oral por 2 examinadores, com luz direcionada ao palato posterior e auxílio de abaixador de língua e jatos de ar para elicitar o reflexo do vômito e definir e extensão da FU, segundo a classificação de Meskin. Os resultados mostraram que a prevalência da FU no grupo de estudo foi 2,9:100, sendo todas classificadas como parciais 25% de extensão, e no grupo controle 2,4:100, sendo que prevaleceu a parcial 25%. Concluiu-se que a FU não prevalece em familiares de portadores de fissuras labiopalatinas; não há correlação com o gênero e a fissura de úvula parcial 25% foi a mais incidente.

The goal of this study was to verify if the prevalence of cleft uvula is higher in families of cleft palate individuals than in the general population. The study group was composed of 136 relatives of cleft individuals and the control group was composed of 287 individuals without family history of cleft palate. The methodology consisted of oral examination by two examiners, with depression of the tongue to elicit the vomit reflex and air jets to define the cleft extension according to Meskin’s classification. The results showed that the study group presented a 2,9:100 prevalence of cleft uvula being all classified as partial 25% of extension and the control group showed a prevalence of 2,4:100, with higher occurrence of partial 25% of extension. In conclusion, the cleft uvula does not prevail in relatives of cleft palate individuals in relation to the general population, there is no sex correlation and the cleft uvula classified as partial 25% of extension has higher incidence.

Musculus Uvulae Shortening for the Treatment of Snoring

BACKGROUND AND OBJECTIVES: We investigated the effectiveness of shortening the uvula muscle for the treatment of snoring. This new and simple procedure was developed to promote the elevation of the uvula position using a minimally invasive technique. SUBJECTS AND METHODS: Fifteen habitual snorers were included in this study. In order to find the exact anatomical position of the uvula muscle, we first dissected the soft palate of a cadaver to better understand the exact anatomical location and structure of the uvula muscle. With this result, we developed a new surgical technique for treating snoring. The results of our surgery were evaluated by both the patient and bed partner before surgery, at 30 days, and 90 days after surgery respectively using the visual analogue scale (VAS). RESULTS: Post-operative physical examinations showed superiorly displaced uvula position. The lower half of the soft palate and uvula were also anteriorly flexed. Those findings remained unaltered beyond the 90th post-operative day. The patient and bed partner snoring symptoms assessed by VAS were significantly improved compared to the pre-treatment values (p<0.05). CONCLUSION: The uvula muscle shortening is an effective and simple method for the treatment of snoring.

The Modified Uvulopalatopharyngoplasty(UPPP)to Prevent the Complications and Destroy of UPPP / 医学研究杂志

Objective To improre typieal proeedure of UPPP,increase clinical effects and deerease complioations caused by the operation.Methods Twenty eight patients with obstructive sleep apnea syndrome who had been confirmed by PSG in our hospital from 2003 to 2005 were involved in this study.1)improving stripping method:the fat and tonsil were removed by electric knife.2)improving molding method:the muscle of uvula was maitained,but the fat was removed;mucous and the tissue under it were double-layer sutured.3) the data before and 6 months after UPPP were analyzed by questionnaire and polysomnography(PSG)detection.Result No fissuration occurred.The distance between soft palate and posterior wall was 3?0.6 before operation and it was 6?0.8 6 months after operation.The effect is 100% based on the questionnaire investigation and PSG detection.Conclusions 1)Hemostasis of electric knife was reliable;2)Double-layer suture of mucous and the tissue under it can avoid hemorrhage and insure molding of pharyngeal cavity;3)The results of the uvula preservation can improve the effect of the UPPP by increasing the nasopharyngeal and oropharyngeal cavity,and avoiding velopalatal insufficiency.

Modified uvulopalatopharyngoplasty for treatment of obstructive sleep apnea hypopnea syndrome / 中国耳鼻咽喉头颈外科

OBJECTIVE To investigate the therapeutic effect of modified uvulopaoatopharyngoplasty(UPPP)on obstructive sleep apnea hypopnea syndrome(OSAHS).METHODS Sixty eight cases of OSAHS were treated with modified UPPP.During operations,the uvula was preserved,the fat tissues of space veli palatine were dissected,palatoplasty and pharyngoplasty were performed.All the patients were followed up for over 6 months.Polysomnography(PSG)was monitored again one year after operation.RESULTS The symptoms of dyspnea,snoring,sleepiness were disappeared or improved obviously after 6 months.The effective rate was 95.6% at one year after operation.CONCLUSION The modified UPPP not only extends the oropharyngeal cavity,but also avoids postoperative complications and improve the effectiveness of UPPP.