Associations between the lower esophageal sphincter function and the level of physical activity.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a very frequent and multifactorial disease. It has been found that GERD is associated with obesity, smoking, esophagitis, diet and lifestyle. Physical activity is among the factors involved in the occurrence of GERD. OBJECTIVES: The aim of the study was to evaluate the associations between the different parameters of lower esophageal pressure (LES) and the level of everyday physical activity in patients with GERD. MATERIAL AND METHODS: The authors examined 100 consecutive patients who underwent manometry and pH-metry because of symptoms suggesting GERD. Physical activity was assessed by means of the International Physical Activity Questionnaire (IPAQ). In accordance with IPAQ categorical scoring, the authors divided the studied subjects into 3 groups according to their level of physical activity. The investigation comprised 59 men and 41 women, with the mean age 49 ± 14 years. RESULTS: The authors analyzed the relationships between the LES parameters (pressure, total LES length and HPZ length) and physical activity. The authors did not find any significant correlations between the studied parameters and the amount of physical activity. The authors also did not observe any association between the LES pressure and the level of physical activity. The subgroups distinguished on the basis of LESP did not differ as to the amount of everyday physical activity as well. CONCLUSIONS: Although most data indicates that intense exercise exacerbates GERD symptoms, the authors did not find any associations between LES parameters and physical activity. In view of the present results maintaining the recommended level of everyday physical activity does not interfere with the mechanisms of GERD.

Endocannabinoid type 1 receptor gene (CNR1) polymorphisms (rs806381, rs10485170, rs6454674, rs2023239) and cardiovascular risk factors in postmenopausal women.

INTRODUCTION: The risk of cardiovascular diseases (CVD) in women increases with menopausal stage. Obesity with metabolic disorders is the most important risk factor for CVD. The incidence of this phenotype of obesity increases in postmenopausal women. The endocannabinoid system plays an important role in regulation of several metabolic pathways. The aim of this work was to investigate whether genetic variations in the cannabinoid receptor gene (CNR1) can affect cardiovascular risk factors (e.g. fat distribution, obesity, fasting glucose, lipid profile, blood pressure, and free androgen and estrogen indexes) in postmenopausal women. METHODS: The rs806381, rs10485170, rs6454674, and rs2023239 polymorphisms of the CNR1 gene were genotyped in 384 randomly selected postmenopausal Polish women (aged 50-60) using the minisequencing technique. RESULTS: The rs806381, rs10485170, rs6454674, and rs2023239 polymorphisms were not significantly associated with anthropometric measures (waist circumference, carbohydrate and lipid metabolism, body mass index [BMI], total fat, glucose, insulin, fasting insulin resistance index [FIRI]). However, the rs2023239 polymorphism was associated with the free androgen index (p = 0.03). DISCUSSION: It seems that further genotyping of the endocannabinoid receptor gene cannot be used as a significant marker of predisposition to CVD in postmenopausal women, but it would be interesting to study this interrelation on a larger population of postmenopausal women.

Effect of moderate-intensity exercise on oxidative stress indices in metabolically healthy obese and metabolically unhealthy obese phenotypes in postmenopausal women: a pilot study.

OBJECTIVE: The aim of this work was to determine whether the level of oxidative stress induced by moderate-intensity exercise depends on obesity phenotypes: metabolically healthy but obese (MHO) and non-metabolically healthy obese (at-risk obesity; non-MHO). METHODS: We performed the study on 161 postmenopausal women aged 50 to 60 years. A metabolically healthy nonobese (MH-NO) group (n = 73), an MHO group (n = 27), and a non-MHO group (n = 61) exercised on a cycloergometer for 30 minutes at 50% of their peak oxygen consumption and were evaluated for oxidative status by determination of thiobarbituric acid-reactive substances (TBARS) and serum antioxidant activity (AS). RESULTS: No difference was found in AS between the MH-NO group and the MHO group. The AS of the non-MHO group was significantly lower than that of the MH-NO group (P < 0.05) and that of the MHO group (P = 0.011). The insulin resistance index homeostasis model assessment was the only biochemical parameter that correlated with AS. After exercise, a significant increase in the TBARS concentration in all tested groups of women was observed, but differences in the increment of TBARS level between groups were not found. CONCLUSIONS: Antioxidant status in obese postmenopausal women depends on obesity phenotypes and is higher for women with the MHO than those with the non-MHO phenotype. Independently of obesity phenotype, obese postmenopausal women exposed to moderate-intensity exercise seem to be at similar risk for oxidative stress compared with their nonobese counterparts. We suggest that homeostasis model assessment be taken into account when planning physical exercise for obese people.

Waist circumference and serum adiponectin levels in obese and non-obese postmenopausal women.

OBJECTIVES: A proposed missing link between obesity and metabolic disturbances is adiponectin, an adipocyte-derived peptide. Adiponectin is a potent antidiabetic hormone and seems to have a beneficial influence on lipid profile as well. The need to explain the complex physiological roles of this hormone prompted the authors to study the relationship between adiponectin level and obesity - related abnormalities in a homogenous population of postmenopausal women. STUDY DESIGN: The study involved 272 postmenopausal women aged 50-60 years. Invitations to participate in the study were sent to 4000 randomly chosen women from the Wroclaw city population fulfilling the age criterion. A telephone questionnaire was administered to the group of 1731 women who responded to the invitation and then subjects for the study were selected. Main outcome measures anthropometrical measurements of body fat tissue content and fat tissue distribution assessment were carried out in all the women. Moreover, serum concentrations of adiponectin, glucose, total cholesterol, HDL cholesterol, triglycerides and insulin were measured. RESULTS: The most frequent (76%) phenotype among the investigated women was obesity (BMI >25) with abnormal (=80cm) waist circumference (OAW), Obesity with normal (<80cm) waist (ONW) and normal weight with abnormal waist (NOAW) were observed in only 5% and 14% of the women, respectively. Non-obese women with normal waist (NONW) were noted in only 5% of the subjects. Serum adiponectin levels in both groups of non-obese women (NOAW and NONW) were significantly higher (p<0.05) than in the women with obesity or overweight and abnormal waist circumference (OAW group). Adiponectin levels in the women with obesity or overweight and normal waist (ONW) were also higher than in the OAW group; however, this difference was not statistically significant (p=0.05). In all the women, serum adiponectin level correlated negatively with BMI (r=-0.34, p=0.0001), total fat (r=-0.28, p=0.0001), android fat deposit (r=-0.23, p=0.0001), waist circumference (r=-0.33, p=0.0001), glucose (r=-0.27, p=0.0001), triglycerides (r=-0.34, p=0.0001), and FIRI (r=-0.34, p=0.0001) and positively with the gynoid/android fat deposit ratio (r=0.28, p=0.0001) and HDL cholesterol (r=0.36, p=0.0001). CONCLUSIONS: These results confirm that adiponectin could be a marker of the development of menopausal insulin resistance syndrome.

The vitamin D receptor gene BsmI polymorphism is not associated with anthropometric and biochemical parameters describing metabolic syndrome in postmenopausal women.

AIM: Vitamin D could have a direct effect on adipocyte differentiation and metabolism and might be involved in glucose regulation of insulin secretion. In recent years several polymorphisms in the gene encoding the vitamin D receptor (VDR), which are potent to alter the activity of VDR protein, have been described. The present study aimed to investigate the prevalence of the VDR BsmI polymorphism and its association with anthropometric and biochemical features of metabolic syndrome in postmenopausal women. MATERIALS AND METHODS: We studied 351 randomly selected healthy postmenopausal women, with mean age of 55.43 +/- 2.75 years and mean body mass index (BMI) of 27.5 +/- 4.78 kg/m2, to evaluate the frequency of BsmI polymorphism (by restriction fragment length polymorphism-polymerase chain reaction) in the VDR gene and to find out whether there is an association between this polymorphism and BMI, total fat volume and visceral fat (as determined by total body dual-energy X-ray absorptiometry), blood pressure, lipid profile (total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides) glucose and fasting insulin in the whole group, as well as subgroups of obese and non-obese women. RESULTS: The prevalence of BsmI genotypes in the study group was 51.0% Bb, 37.3% bb and 11.7% BB. Genotype distribution did not differ from that expected under Hardy-Weinberg equilibrium conditions (chi2 = 2.95, p = 0.22). Apart from LDL-C levels (F = 3.46, p = 0.032), there were no significant differences in anthropometric or metabolic parameters between genotypes. CONCLUSIONS: The BsmI polymorphism in the VDR gene does not seem to predispose to obesity and insulin resistance, but the BB genotype is connected with an unfavorable lipid profile.

beta(3)-adrenergic receptor polymorphism and metabolic syndrome in postmenopausal women.

OBJECTIVES: Some studies indicate that the Trp64Arg polymorphism in the gene encoding the beta(3)-adrenergic receptor (ADRB3) is associated with obesity, insulin resistance and earlier onset of type 2 diabetes mellitus. The aim of the present study was to evaluate the frequency of ADRB3 polymorphism and its association with metabolic syndrome in postmenopausal women. METHODS: We performed the study on 284 randomly chosen postmenopausal women, aged 50-60 years, who were then selected to the study. Measurements of anthropometric parameters and biochemical estimations such as lipid profile, glucose and insulin level in serum were carried out using commercial kits. ADRB3 genotyping was performed by polymerase chain reaction and mini-sequencing. RESULTS: The frequency of the Trp64/Arg64 genotype in the investigated population was 13%, and of the Trp64/Trp64 genotype, 85%. The Arg64/Arg64 genotype was present in only 2% of women. Metabolic syndrome was recognized in 22% of women bearing Trp64/Arg64 genotype and in 14% of women bearing Trp64/Trp64 genotype, without a statistically significant difference between the two groups (p > 0.05 in the chi(2) test). Women bearing the Trp64/Arg64 genotype had lower serum levels of high-density lipoprotein cholesterol (HDL-C) than Trp64/Trp64 genotype women (63.2 +/- 13.0 vs. 71.4 +/- 17.4 mg/dl). Both groups did not differ in any other investigated parameter. CONCLUSION: Trp64Arg polymorphism of the beta(3)-adrenergic receptor gene is not related to metabolic syndrome in postmenopausal Polish women; however, it seems to be associated with decreased HDL-C levels.

The relationship between gastroesophageal reflux disease and the level of physical activity.

PRINCIPLES: Data on associations between physical activity and gastroesophageal reflux disease (GERD) have been inconsistent. Although experimental and clinical studies prove that exercise increases gastroesophageal reflux, epidemiological observations on the relationship between GERD and everyday physical effort deliver contradictory results. Our aim was to examine the association between the level of everyday physical activity and parameters of the disease (pH-metry, symptoms) in patients diagnosed with GERD. METHODS: We assessed the level of physical activity in a survey of 100 consecutive GERD patients. All subjects had undergone 24-h pH monitoring in a tertiary setting and reported symptoms they experienced daily. Using the criteria of the short form of the International Physical Activity Questionnaire (7-day recall) we identified groups presenting with low (I), moderate (II) or high (III) levels of physical activity. The amount of physical activity was expressed as multiples of resting metabolic rate and minutes of performance during a week (METs-minute/week). For evaluation of relationships between everyday physical activity and pH-metric indices of GERD a multivariate regression analysis was performed. The parameters studied were adjusted for age, BMI, smoking and gender (as covariates). RESULTS: We did not observe any association between the amount of everyday physical activity (expressed as log base 10 METs-minute/week) and pH-metric parameters of GERD evaluated 5 cm and 15 cm above the lower oesophageal sphincter (LES). Furthermore, we analyzed relationships between investigated parameters and covariates: age, BMI, smoking and gender. We found significant correlations only between the number of reflux episodes 15 cm above LES and gender (beta -0.25; p <0.05) and between the number of reflux episodes 5 cm above LES and age (beta -0.24; p <0.05). The number of self-reported symptoms did not differ among the three groups of physical activity level. It reached 6 in groups I and II, and 7 in group III (p = 0.07). However we must note that we found a weak, positive correlation between the number of symptoms reported by patients and METs-minute/week (r = 0.21, p <0.05). CONCLUSIONS: In view of our results the level of everyday physical activity is not associated with symptoms of GERD. This observation should be confirmed in other populations with GERD diagnosed upon pH-metric criteria.

[Relationship of beta(3)-adrenergic receptor polymorphism with metabolic syndrome and oxidative stress parameters in postmenopausal women]. / Zwiazek polimorfizmu receptora beta(3)-adrenergicznego z wystepowaniem parametrów zespolu metabolicznego i stresu oksydacyjnego u kobiet po menopauzie.

INTRODUCTION: Some studies indicate, that the Trp(64)/Arg(64) polymorphism of beta(3)-adrenergic receptor (ADRB3) is associated with obesity, insulin resistance and earlier onset of type 2 diabetes mellitus. The aim of our study was evaluation of frequency of this ADRB3 polymorphism and his association with metabolic syndrome parameters and oxidative stress in postmenopausal women. MATERIAL AND METHODS: We performed the study among 94 women, aged 50-60, selected randomly from Wroclaw city population. Estimation of anthropometric parameters, densitometry (total body fat, android and gynoid deposits--using DPX(+) Lunar, USA device) and biochemical estimations such as lipid profile, glucose, insulin, estradiol and FSH serum level (using commercial kits) were carried out. Oxidative stress was estimated by measurement of thiobarbituric-reactive substances (TBARS) serum concentration, using Yagi method, on spectrofluorimeter Perkin-Elmer LS55. Blood for analysis was collected before, direct after and 6 h after the 30-minutes physical test using cycloergometer. ADRB3 genotyping was performed by PCR and mini-sequencing using ABI 310 sequencer (Applied Biosystems). RESULTS: The frequency of Trp(64)/Arg(64) genotype in investigated population was 15.8%. The Arg(64)/Arg(64) genotype had only one woman. Women bearing Trp(64)/Arg(64) genotype showed higher mean serum level of triglycerides and lower serum level of HDL-cholesterol in comparison to women bearing Trp(64)/Trp(64) genotype, however without statistical significance (p > 0.05) (respectively, means +/- SD for triglycerides: 140.3 +/- 64.1 vs. 113.9 +/- 56.2 mg/dl; and for HDL-cholesterol: 60.9 +/- 11.9 vs. 67.0 +/- 16.9 mg/dl). Both groups did not differ in any other investigated anthropometric nor biochemical parameter. CONCLUSIONS: 1. The Trp(64)/Arg(64) polymorphism of beta(3)-adrenergic receptor could be associated with lipid profile disorders observed in metabolic syndrome in postmenopausal women, however it should be explained basing on the study with more included subjects. 2. The Trp(64)/Arg(64 )polymorphism of beta(3)-adrenergic receptor has no influence on oxidative stress intensification after standardized physical effort in postmenopausal women.

Post-exercise oxidative stress and obesity in postmenopausal women: the role of beta3-adrenergic receptor polymorphism.

AIM: Some studies indicate that the Trp64Arg polymorphism in the gene encoding the beta3-adrenergic receptor (ADRB3) is associated with obesity, insulin resistance and earlier onset of type 2 diabetes mellitus. The aim of the present study was to evaluate the frequency of this polymorphism and its relationship with obesity and oxidative stress in postmenopausal women. MATERIAL AND METHODS: We performed the study on 200 women, aged 50-60 years. Estimation of anthropometric parameters and total body fat, android and gynoid fat deposits was carried out using dual-energy X-ray absorptiometry. Oxidative stress was estimated by measurement of thiobarbituric acid-reactive substances (TBARS) in serum. Blood for analysis was collected before, directly after and 6 h after a 30-min physical test on a cycle ergometer. ADRB3 genotyping was performed by polymerase chain reaction. RESULTS: The frequency of Trp64/Arg64 genotype in the investigated population was 12%, and of Trp64/Trp64 was 87%. The Arg64/Arg64 genotype was present in only 1% of women. Women bearing the Trp64/Arg64 genotype did not differ in any measured anthropometric parameters from women bearing the Trp64/Trp64 genotype. Moreover, genotype had no influence on oxidative stress parameters. Likewise, in both groups, mean plasma level of TBARS was increased significantly (p < 0.05) directly after the endurance test and remained elevated 6 h after the test. CONCLUSIONS: The Trp64Arg polymorphism of ADRB3 seems to not be related to obesity in postmenopausal women. Moreover, the Trp64Arg polymorphism has no influence on oxidative stress intensification after standardized physical effort in postmenopausal women.

Sex steroids concentrations in relation to bone mineral density in men with coronary atherosclerosis.

BACKGROUND: Although suspected, relationships between sex steroids and bone mineral density (BMD) are not fully defined in male population. According to recent data there may also exist an association between low BMD and atherosclerosis. OBJECTIVE: Our aim was to investigate relationships between serum sex steroids and BMD, and between BMD and atherosclerosis in men with coronary artery disease (CAD). SUBJECTS AND METHODS: We recruited for the study 55 men aged 40-60 years with angiographically confirmed CAD and 30 healthy, age-matched controls. In each of the examined subjects serum levels of total testosterone (T), estradiol (E(2)), estrone and DHEA-S, as well as femoral neck, lumbar spine and total skeleton BMD were measured. RESULTS: We found that the prevalence of osteopenia/osteoporosis recognized on spine and/or femoral BMD (T-score below -1.0) did not differ between men with CAD and healthy controls (respectively 47% versus 47%; p=0.8 in chi(2) Yates test). The mean BMD value at different regions did not differ between both groups either. Hormonal status of men with CAD and normal BMD was similar to men with CAD and osteopenia/osteoporosis except for the level of testosterone. After adjustment for age and BMI, men with lower BMD had lower testosterone and lower T/E(2) ratio than men with normal BMD (geometric means for testosterone were respectively: 16.1+/-8.3 versus 16.2+/-4.2; p<0.05 in ANCOVA with BMI and age as covariates; for T/E(2) ratio it was: 202.1+/-94.7 versus 222.8+/-83.9; p=0.05). However, we did not find any correlation between sex hormones concentrations and bone mineral density. There was a relationship between the advance of atherosclerosis (ranged by number of stenotic arteries) and BMD: men with the most advanced form of the disease (three-vessels) had the lowest femoral neck BMD. The groups did not differ in lumbar spine BMD. CONCLUSIONS: Our data suggest that in middle-aged men with CAD: (1) lower serum testosterone and lower T/E(2) ratio are associated with lower BMD; (2) advance of coronary atherosclerosis is inversely related to femoral neck BMD, however this relationship is weak and requires further investigation.

[Thyroid function in organic lesions of the hypothalamo-pituitary area]. / Funkcja tarczycy u osób ze zmianami organicznymi okolicy podwzgórzowo-przysadkowej.

The aim of our work was the retrospective evaluation of thyroid function in patients with organic lesions of hypothalamo-pituitary system. In the group of 57 examined patients (31 females and 26 males), 43 were affected by pituitary adenomas, in the other patients organic lesions were caused by other tumors of central nervous system (2), tuberculosis (3) developmental or vascular disorders (5), nonspecific inflammation (1). Pituitary tumors (predominantly macroadenomas) were the cause of acromegaly in 14 cases, Cushing's disease in 9 and hyperprolactinaemia in 5. Next 14 subjects, were affected by nonsecreting pituitary tumors with a visual-field defects or different level of hypopituitarism and diabetes insipidus hypothalamo-hypophyseal. In 6 persons clinical manifestations of hypothyroidism with a low level of free thyroxin and normal TSH were observed. Surgical cure with transsphenoidal or transcranial operation was performed in 54 patients. Next 23 of the patients had lowered thyroxine level as a consequence of surgery. Considering the whole 57 person group with organic lesions of the hypothalamo-pituitary system, 29 patients (50.8%) were affected by secondary or tertiary hypothyroidism as a result of sellar and parasellar area illness or their surgical treatment. We didn't observe any correlation between TSH and FT4 in the patients with normal or low plasma FT4 levels. (1) secondary or tertiary hypothyroidism is a common consequence of organic lesions of the sellar and parasellar area or is due by their surgical treatment; (2) laboratory examination of thyroid function in these patients can not be evaluated only by TSH assessment, but also by thyroid hormone plasma level estimation because of the disturbances in thyroid an hypothalamo-pituitary system feedback.

Serum adiponectin concentration and cardiovascular risk factors in climacteric women.

OBJECTIVE: Adiponectin plays a significant role in the modulation of glucose tolerance and insulin sensitivity. We attempted to evaluate the relationship between adiponectin level and parameters of the menopausal metabolic syndrome: body mass index, waist-to-hip ratio, lipid profile and insulin resistance indices. SUBJECTS AND METHODS: Thirty-two women and ten men aged 40-63 years were included. The percentage of body fat and of abdominal fat deposits were measured with dual-energy X-ray absorptiometry. Serum adiponectin, tumour necrosis factor-a (TNFalpha) and leptin were measured with commercially available radioimmunoassay kits. To exclude the influence of nutritional factors on adiponectin secretion, diet content was analysed in the preceding three days. RESULTS: Postmenopausal non-obese women had a non-significantly lower level of adiponectin compared with premenopausal women of corresponding body mass. Serum adiponectin level was significantly lower in postmenopausal obese women than in non-obese women (p = 0.0023). Men with similar age and body mass to the women had the lowest level of adiponectin (p = 0.06). Three months of estrogen replacement therapy in women with surgical menopause did not significantly change the serum level of adiponectin. We found a negative correlation of adiponectin with leptin, insulin resistance index and total cholesterol, and a positive correlation with high-density lipoprotein cholesterol. Adiponectin level was negatively correlated with free testosterone, but we did not find such a relationship with estradiol. There was no correlation of adiponectin level with TNFalpha; however, serum TNFalpha correlated positively with leptin. The dietary analysis showed no differences between the diets of obese and non-obese women over the preceding three days. Moreover, mean diastolic and systolic blood pressures were noted to be significantly lower in premenopausal women than in postmenopausal non-obese women (p = 0.05). CONCLUSIONS: Our results suggest that adiponectin could be a marker of risk for developing menopausal metabolic syndrome. Moreover, it is possible that sex steroids have an influence on adiponectin secretion.

Plasma adiponectin concentration in relation to severity of coronary atherosclerosis and cardiovascular risk factors in middle-aged men.

UNLABELLED: Adiponectin, an adipocyte-derived protein, seems to be a link between obesity, insulin resistance, and atherosclerosis. The present study investigated the association between adiponectin and coronary artery disease in middle-aged men. MATERIAL AND METHODS: We examined 48 men (aged 40-60) with angiographically confirmed coronary atherosclerosis and 19 healthy men, matched by age, as a control group. Concentrations of glucose and lipids were estimated with enzymatic methods. Plasma level of adiponectin, total and free testosterone, estradiol, estrone, DHEA-S, and insulin were estimated with RIA commercial kits. RESULTS: Men with coronary atherosclerosis had lower plasma adiponectin level than controls (16.2+/-9.2 vs 20.5+/-6.7 microg/mL; p<0.05). However, after including BMI and waist as covariate data in ANCOVA, the difference in adiponectin levels between men with CAD and controls lost statistical significance (respectively for BMI and waist: p=0.4 and p=0.7). Moreover, although not significant, adiponectin levels decreased as a function of the number of significantly narrowed coronary arteries. In a priori comparison the lowest adiponectin plasma concentration was in men with three-vessel coronary artery disease (14.3+/-9.8 microg/mL) and the high-est in controls (20.5+/-6.8 microg/mL; p=0.09). Adiponectin plasma level correlated negatively (p<0.05) with BMI, waist, percentage of total fat, fasting-insulin-resistance index (FIRI), total cholesterol and triglycerides, and positively with quantitative insulin sensitivity check index (QUICKI), HDL cholesterol, total testosterone, and total testosterone/estradiol ratio. CONCLUSIONS: Our data suggest that low plasma adiponectin level is connected with insulin resistance syndrome and atherogenic lipid profile. It seems that adiponectin plays a role in pathogenesis of coronary atherosclerosis, especially in obese and insulin-resistant subjects.

[Autoimmune multiglandular syndrome type I--a case study]. / Wielogruczolowa niedoczynnosc wewnatrzwydzielnicza typu 1--opis przypadku.

We have described a case of a rare autoimmune disease, called autoimmune polyglandular syndrome type I (APS type I), in a 44-year-old woman. APS type I is an autosomal recessively inherited disorder, connected with mutations in AIRE (autoimmune regulator) gene. Subsequently, autoantibodies directed towards tissue-specific enzymes are produced, which causes destruction of multiple tissues and organs, first of all--endocrine glands. In the described woman, primary hypoparathyroidism occurred in childhood. Addison disease, chronic candidiasis of the nails and vitiligo developed in adolescence. Before she was 30, a premature ovarian failure, and axilla and pubis alopecia occurred. The last recognized disorders were cholelithiasis and candidiasis of oesophagus. The late diagnosis resulted in numerous complications of the disease and the patient's life quality impairment.