Vocal cord augmentation in a palliative setting for patients with lung cancer and mediastinal involvement.

Injection augmentation of the vocal cords is a recognized treatment modality in patients with glottal closure deficiency caused by paresis or paralysis of the vocal cord. The treatment can improve voice quality and also quality of life. It is preferable to minimize waiting time for the procedure for patients with lung cancer and mediastinal involvement, because the one-year mortality is above 40%, as argued in this review.

The Effect of Laser Thermal Ablation on Quality of Life: Improvements in Patients with Solid-Cystic Thyroid Nodules.

Background: Evidence of the efficacy of laser thermal ablation (LTA) in benign thyroid nodules is abundant. However, little is known about the effect on quality of life (QoL) of this treatment. Methods: Prospective cohort study investigating the effect of LTA before, three, and six months after LTA on QoL using the thyroid-specific patient-reported outcome (ThyPRO) measure. Patients receiving LTA (laser group [LG]) was compared with a well-characterized control group (CG) from the Danish civil registry. Results: The LG comprised 54 patients, with no age or sex differences compared with the CG (n = 739). Sixty-nine percent of the patients had a recurrent cystic thyroid nodule, 6% had a solid nodule, while the remaining 25% were of mixed character. The median nodule volume was 6.8 mL (interquartile range [IQR]: 4.0-11.1) before LTA, and 1.8 mL (IQR: 0.6-4.1) at 6 months post-LTA (p < 0.001), corresponding to a median reduction of 78%. All cystic fluid (median: 6 mL; IQR: 2.0-9.0) was aspirated before LTA. Median treatment time was 400 seconds (IQR: 300-600), applying a median energy of 823 J (IQR: 600-1200). At baseline and according to the ThyPRO scales, the LG differed significantly from the CG by having more goiter symptoms, hyperthyroid symptoms, tiredness, and cognitive complaints (p < 0.05 for all variables), but only the difference in the goiter symptom scale was of a clinically important magnitude. At three months, the LG experienced a large improvement in goiter symptoms (effect size [ES] = 1.05), a moderate improvement in cosmetic complaints (ES = 0.50), and a moderate improvement in the overall QoL (ES = 0.64). Only the improvements in the goiter symptom and the cosmetic complaint scales were clinically important. Six months after LTA, the anxiety scale showed further improvement of moderate size (ES = 0.52). At 6 months, the results above were maintained, and 79% of patients experienced a large and clinically important improvement in the goiter symptom scale and no clinically important differences were found between the LG and the CG. Conclusions: In this unblinded, prospective observational study, measures of disease-specific QoL were significantly improved compared with preprocedure levels, in patients with solid-cystic nodules.

The Impact of Post-Thyroidectomy Neck Stretching Exercises on Neck Discomfort, Pressure Symptoms, Voice and Quality of Life: A Randomized Controlled Trial.

BACKGROUND: Following surgery for benign nodular goiter, patients may experience neck and shoulder pain, neck pressure and tightness, choking sensation, altered voice function, and dysphagia leading to decreased short-term quality of life (QoL). This single-blinded randomized controlled trial investigated the effect of post-thyroidectomy rehabilitative neck stretching and movement exercises on these variables including QoL. METHODS: Patients undergoing thyroid lobectomy or total thyroidectomy were randomized to perform neck stretching and movement exercises three times daily in four weeks following surgery (intervention group) or conventional follow-up without exercises (control group). Outcome measures were scores in the following questionnaires: Disease-specific Thyroid-Related Patient-Reported Outcome (ThyPRO-39) involving symptoms of "sense of fullness in the neck," "pressure in the throat," and "discomfort swallowing" combined in the multi-item Goiter Symptom Scale, the Voice Handicap-Index-10 (VHI-10), neck and shoulder pain measurement by a numeric rating scale (NRS), and General measure of health (EQ-5D-5L). All scores were assessed prior to surgery and one, two, four weeks, and three months after surgery. Data were analyzed using a linear mixed model. RESULTS: Eighty-nine patients were included and randomized to the control (n = 45) or the intervention group (n = 44). At three months after surgery, both the control and the intervention group experienced large to moderate improvements in the Goiter symptom and Hyperthyroid symptom scale of the ThyPRO questionnaire (p < 0.004). No significant between-group differences were found in any of the other applied scales. CONCLUSIONS: This study confirms that patients experience profound improvements in QoL after surgery for benign nodular goiter. However, early post-thyroidectomy neck stretching and movement exercises did not result in further QoL improvement, reduction in pain or less impacted subjective voice function for patients primarily undergoing thyroid lobectomy. Trial Registration Number NCT04645056 ( https://clinicaltrials.gov ).

Crosscultural Adaption and Validation of the Danish Voice Handicap Index-10.

BACKGROUND: The Voice Handicap Index 30 (VHI-30) is a much-used voice specific quality of life questionnaire. A shortened 10 item version has been developed by eliminating redundant items using item analyses. This is the first Danish translation of the VHI-10. OBJECTIVES: To evaluate the psychometric properties of the Danish VHI-10 questionnaire. STUDY DESIGN: Cross-sectional survey study. METHODS: A Danish translation of the VHI-10 was answered by 72 patients with voice disorders of different etiology (neurogenic, functional, and structural) and by a control group of 94 vocally healthy individuals. Thirty-two patients and 68 controls participated in a test-retest reliability analysis. The internal consistency, test-retest reliability, and clinical validity were assessed. RESULTS: Excellent internal consistency was found in the patient group with a Cronbach's α of >0.90. In the control group the internal consistency was good with a Cronbach's α of 0.88. Test-retest reliability was good with intra class correlation coefficient of 0.94 (95% confidence interval [95%CI]: 0.88-0.97) for patients and 0.82 (95%CI: 0.73-0.89) for the control group. This indicates a sufficient reliability of the questionnaire. The correlation between the Danish VHI-10 score and the patient's perception of the severity of the voice disorder was 0.75 (P < 0.001) indicating good clinical validity of the Danish VHI-10. CONCLUSION: The newly translated Danish VHI-10 was validated and performs similar to the original VHI-10. It showed good internal consistency, test-retest reliability, and clinical validity. The questionnaire is preferably for use in patients with moderate to severe voice complaints as its ability to distinguish mild voice changes from healthy voices is limited. However, the questionnaire is capable of assessing patients' perception of the severity of their voice disorder and is available for use in daily practice and in research projects.

The Impact of Post-thyroidectomy Paresis on Quality of Life in Patients with Nodular Thyroid Disease.

OBJECTIVE: To investigate the impact of postoperative paresis on disease-specific quality of life (DSQoL) after thyroidectomy in patients with benign nodular thyroid disease. STUDY DESIGN: Observational study. SETTING: University hospital. SUBJECTS AND METHODS: Patients were evaluated before and 3 weeks and 6 months after surgery in an individual prospective cohort study using videolaryngostroboscopy (VLS), voice range profile, voice handicap index (VHI), multidimensional voice program, maximum phonation time (MPT), and auditory perceptual evaluation. Changes in DSQoL were assessed by the Thyroid-specific Patient-Reported Outcome measure. Cohen's effect size was used to evaluate changes. RESULTS: Sixty-two patients were included, 55 of whom completed all examinations. Three weeks after surgery, a blinded VLS examination showed signs of paresis of either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve (RLN/EBSLN) in 13 patients (24%). A paresis corresponded to a 12 ± 28 point increase in VHI (P = .002) and was associated with a significant 4.3 ± 7.5 semitone decrease in the maximum fundamental frequency (P < .001) and a 5.3 ± 8.2 dB reduction in maximum intensity. Further, it was associated with a 4.5 ± 11.2 second reduction in MPT (P = .001) and an increase of 0.40 ± 1.19 in grade, 0.42 ± 1.41 in roughness, and 0.36 ± 1.11 in breathiness. Signs of postoperative RLN/EBSLN paresis correlated with an 11.0-point (P = .02) poorer improvement in goiter symptoms at both 3 weeks and 6 months after surgery. CONCLUSION: Signs of RLN/EBSLN paresis after thyroidectomy were associated with less pronounced improvement in goiter symptoms in patients with thyroid nodular disease. However, thyroidectomy was associated with an overall improved DSQoL by 6 months after surgery.

The Impact of Esophageal Compression on Goiter Symptoms before and after Thyroid Surgery.

INTRODUCTION: Benign nodular goiter may be associated with swallowing difficulties, but insight into the associated pathophysiology is limited. The aim of this study was to investigate the effect of surgery on the degree of esophageal compression, and its correlation to swallowing difficulties. METHODS: Esophageal compression and deviation were evaluated blindly on magnetic resonance imaging (MRI) of the neck, prior to and 6 months after thyroid surgery for symptomatic benign goiter. Goiter symptoms and swallowing difficulties were measured by the Goiter Symptom Scale of the Thyroid-Specific Patient-Reported Outcome (ThyPRO) questionnaire. Cohen's d was used for evaluating effect sizes (ES). RESULTS: Sixty-four patients completed the study. Before surgery, median goiter volume was 57 (range 14-642) mL. The smallest cross-sectional area of the esophagus (SCAE) increased from a median of 95 (47-147) to 137 (72-286) mm2 (ES = 1.31, p < 0.001). Median esophagus width increased from 15 (range 10-21) to 17 (range 12-24) mm (ES = 0.94, p < 0.001) after surgery, while no statistically significant change was observed for the sagittal dimension (anterior-to-posterior), thus reflecting an increasingly ellipsoid esophageal shape. Median esophageal deviation decreased moderately after surgery from 4 (0-23) to 3 (0-10) mm (ES = 0.54, p = 0.005). The goiter symptom score improved considerably from (mean ± SD) 40 ± 21 to 10 ± 10 points (ES = 1.5, p < 0.001) after surgery, and the improvements were associated with improvements in SCAE (p = 0.03). CONCLUSIONS: In patients with goiter, thyroidectomy leads to substantial improvements in esophageal anatomy, as assessed by MRI, and this correlates with improved swallowing symptoms. This information is valuable in qualifying the dialogue with goiter patients, before deciding on the mode of therapy. Clinicaltrials.gov (NCT03072654).

Cross-cultural Adaption and Validation of the Danish Voice Handicap Index.

OBJECTIVES: We aimed to assess psychometric properties, including internal consistency, reliability, and clinical validity of the Danish version of the Voice Handicap Index (VHI). STUDY DESIGN: A cross-sectional survey study was carried out. METHODS: For validation, the existing nonvalidated Danish version of the VHI was used. Data from 208 patients with voice disorders of different etiology (neurogenic, functional, and structural) and a control group of 85 vocally healthy individuals were included. A test-retest reliability analysis of 42 patients and 45 control persons was performed. The internal consistency, test-retest reliability, and clinical validity of the questionnaire were assessed. RESULTS: Internal consistency was high with a Cronbach α >0.90 for both the patient and control group. Test-retest reliability measured as intraclass correlation coefficient was good with 0.93 (95% confidence interval [95% confidence interval]: 0.87-0.96) for patients and 0.78 (95% confidence interval: 0.63-0.87) for the control group which indicates sufficient reliability of the questionnaire. The Danish VHI has good clinical validity as it has a strong correlation between patient's perception of the severity of their voice disorder and the VHI score from the Spearman correlation of 0.69. CONCLUSION: The existing Danish version of the VHI has been thoroughly validated and found to be in line with the original VHI from Jacobsen et al. It showed good internal consistency, test-retest reliability, and clinical validity. It is suitable for use in daily practice and in research projects as it is able to assess patients' perception of their voice disorder severity.

The Impact of Goiter and Thyroid Surgery on Goiter Related Esophageal Dysfunction. A Systematic Review.

Background: Patients with goiter referred for thyroidectomy report swallowing difficulties. This might be associated with esophageal compression and deviation as this is present in a significant number of patients. Studies on how goiter and subsequently its treatment affect the esophagus are sparse and point in various directions. Our aim was to investigate, through a systematic review, the impact of goiter and thyroidectomy on esophageal anatomy, esophageal physiology, and subjective swallowing dysfunction. Methods: The search period covered 1 January 1975 to 1 July 2018, using the scientific databases PubMed and EMBASE. Inclusion criteria were adult patients with goiter who were either observed or underwent thyroidectomy. Search terms were variations of the terms for goiter, esophagus, swallowing, and dysphagia. From an initial 3,040 titles, 55 full text evaluations led to the final inclusion of 27 papers. Seventeen papers investigated, prospectively, the impact of thyroidectomy on the esophagus, while five observational and five retrospective studies were also included. Results: Esophageal anatomy impairment: Esophageal deviation occurred in 14% and esophageal compression in 8-27% of goiter patients. The prevalence increased with goiter size and with the extent of substernal extension. The smallest cross-sectional area of the esophagus increased by median 34% after thyroidectomy. Esophageal physiology changes: Goiter patients had increased esophageal transit time, positively correlated with goiter size, but unrelated to esophageal motility disturbances. Decrease in the upper esophageal sphincter pressure occurred early after surgery, and normalized within 6 months. Swallowing related patient-reported outcomes: Evaluated by validated questionnaires, swallowing symptoms worsened in the early period after thyroidectomy, but improved after 6 months, as compared to baseline. Conclusions: Thyroidectomy relieved patients with goiter from dysphagia, within 6 months of surgery probably via increase in the cross-sectional area of the esophagus. Attention to the impact by goiter on the esophagus is needed, and balanced and individualized information about the potential benefits and risks of thyroid surgery is crucial in the management of patients with goiter.

[Syncope due to giant goitre].

We present a case report of a 70-year-old male patient with a giant goitre. The patient experienced recurrent episodes of syncope/fainting, when he turned his head towards to the right, and he experienced discomfort when lying on his back. A CT scan showed compression of the right carotid artery and carotid sinus from a thyroid mass. After a mass of 1,473 g of thyroid tissue had been removed by a right thyroid lobectomy, the patient experienced no further episodes of syncope. It is well known, that giant goitres can bring a wide range of symptoms including compression of arteries, veins, nerves and related structures on the neck and in the thorax.

The impact of surgery on quality of life, esophageal motility, and tracheal anatomy and airflow in patients with benign nodular goiter.

Surgery - is it any good for goiter? In patients with goiter the benefits of thyroid surgery have previously rarely been investigated, as only few alternatives existed. However, the increasing evidence of the advantages with non-surgical substitutes with lower costs and preferable risk profiles prompted us to investi-gate the evidence base for thyroid surgery thoroughly. This thesis consists of three published studies investigating the impact of thyroidectomy on: 1) changes in disease-specific quality of life, 2) swallowing symptoms and esophageal motility, and 3) tracheal anatomy and airflow, in a cohort of patients with benign nodular goiter.

Changes in Swallowing Symptoms and Esophageal Motility After Thyroid Surgery: A Prospective Cohort Study.

INTRODUCTION: Swallowing difficulties, the pathophysiology behind which is incompletely understood, have been reported in 47-83% of goiter patients referred for thyroidectomy. We aimed at examining the influence of thyroid surgery on swallowing symptoms and esophageal motility. METHODS: Thirty-three patients with benign nodular goiter undergoing thyroid surgery were included. All completed high-resolution esophageal manometry examinations and the goiter symptom scale score, assessed by the thyroid-specific patient-reported outcome measure. The evaluations were performed before and 6 months after surgery. RESULTS: Before surgery, the goiter symptom score was median 39 points (range 2-61), which improved to median five points (range 1-52) after surgery (p < 0.001). The motility parameters were within the limits of normal swallowing physiology, both before and after surgery. Only the upper esophageal sphincter (UES) pressure increased significantly from 70.6 ± 27.7 to 87.7 ± 43.2 mmHg after surgery (p = 0.04). Using regression analyses, there was no significant correlation between change in goiter symptoms and weight of the removed goiter, motility parameters, or motility disturbances. However, patients undergoing total thyroidectomy experienced a larger reduction in pressure in the area of the UES and former thyroid gland after surgery in comparison with patients undergoing less extensive surgery. CONCLUSIONS: Goiter symptoms improved significantly after thyroidectomy, but without correlation to esophageal motility disturbances. This information is essential when interpreting dysphagia in patients with nodular goiter, and when balancing patients' expectations to surgical goiter therapy. REGISTRATION NUMBER: NCT03100357 ( www.clinicaltrials.org ).

The compensatory enlargement of the remaining thyroid lobe following hemithyroidectomy is small and without impact on symptom relief.

According to previous studies, hemithyroidectomy results in growth of the remaining thyroid lobe by up to 30% in first 12 months after surgery. However, this estimate is based on imprecise methods, high inter- and intra-observer variability, and lack of blinding of the measurements. Furthermore, it is unknown whether enlargement of the remaining hemi-thyroid interferes with the improvement in symptoms after surgery for goiter. We aimed to assess the impact of postoperative thyroid growth on goiter symptom relief following hemithyroidectomy in patients with benign nodular goiter. Outcomes were measured before and 6 months after hemithyroidectomy in 44 patients. Thyroid volumes were determined by two independent and blinded observers using magnetic resonance imaging (MRI). Inter- and intra-observer variability was visualized by Bland-Altman plots. Goiter symptoms were assessed by the Thyroid-Specific Patient-Reported-Outcome Questionnaire (ThyPRO) on a scale from 0 to 100 points. After hemithyroidectomy, the remaining thyroid lobe was 13.7 ± 6.4 mL, and enlarged by a mean of 1.8 mL over 6 months [95% confidence interval (CI) (1.6; 2.1), p < 0.001], corresponding to an increase of 17% [95% CI (12; 22)]. The Goiter Symptom score improved by 27 points [95% CI (21; 34), p < 0.0001] from median 39 points (range 2-86) at baseline, and was unaffected by the compensatory thyroid growth. Six months after hemithyroidectomy, using blinded MRI evaluations, we demonstrated a small but significant postoperative growth of the remaining hemi-thyroid, which did not significantly affect the considerable improvement in goiter symptoms.

Test-Retest Reliability of the Dual-Microphone Voice Range Profile.

OBJECTIVES: The voice range profile (VRP) measures vocal intensity and fundamental frequency. Phonosurgical and logopedic treatment outcome studies using the VRP report voice improvements of 3-6 semitones (ST) in ST range and 4-7 decibels (dB) in sound pressure level range after treatment. These small improvements stress the importance of reliable measurements. The aim was to evaluate the test-retest reliability of the dual-microphone computerized VRP on participants with healthy voices. STUDY DESIGN: This is a prospective test-retest reliability study. METHODS: Dual-microphone VRPs were repeated twice on healthy participants (n = 37) with an interval of 6-37 days. Voice frequency and intensity (minimum, maximum, and ranges) were assessed in combination with the area of the VRP. RESULTS: Correlations between VRP parameters were high (r > 0.60). However, in the retest, a statistically significant increase in voice frequency range (1.4 ST [95% confidence interval {CI}: 0.8-2.1 ST], P < 0.001), intensity ranges (2.2 dB [95% CI: 1.0-3.4 dB], P < 0.001), maximum frequency (1.0 ST [95% CI: 0.5-1.6 ST], P < 0.001), maximum intensity (1.4 dB [95% CI: 0.5-2.3 dB], P = 0.002), and area inside the VRP (148 cells [95% CI: 87-210 cells], P < 0.001) was observed. CONCLUSION: The intra-examiner variation of the dual-microphone VRP is well below the differences seen after surgical or logopedic intervention, even when measuring in non-sound-treated rooms. There is a need for studies regarding inter-examiner reliability with a longer interval between test and retest before the assessment is fully reliable for clinical application.

Thyroidectomy Improves Tracheal Anatomy and Airflow in Patients with Nodular Goiter: A Prospective Cohort Study.

OBJECTIVE: A large goiter may cause compression of the trachea. The aim of this study was to investigate the impact of thyroidectomy on tracheal anatomy and airflow and to correlate this with changes in health-related quality of life (HRQoL) in patients with benign nodular goiter. METHODS: Magnetic resonance images of the neck and respiratory flow-volume curves, including both inspiration and expiration, were performed prior to and 6 months following surgery. HRQoL was measured by selected scales from the thyroid-specific patient-reported outcome (ThyPRO). Cohen's effect size (ES) was calculated as mean change divided by standard deviation at baseline. ES of 0.2-0.5 were defined as small, 0.5-0.8 as moderate, and values >0.8 as large. RESULTS: Sixty-five patients completed all examinations. Median goiter volume was 58 mL (range, 14-642 mL) before surgery with surgical removal of a median of 43 g (range, 8-607 g). Six months after surgery, tracheal narrowing and deviation were diminished by a median of 26% (ES = 0.67, p < 0.001) and 33% (ES = 0.61, p < 0.001), respectively. Correspondingly, each 10% decrease in goiter volume resulted in 1.0% less tracheal narrowing (p < 0.001). Concomitantly, a small improvement was seen in forced inspiratory flow at 50% of forced vital capacity (ES = 0.32, p < 0.001). A reduction in tracheal narrowing was associated with improvements in the Impaired Daily Life scale (0.33 points per 1% decrease in tracheal narrowing, p = 0.03) of the ThyPRO questionnaire. CONCLUSIONS: In patients with symptomatic benign nodular goiter, thyroidectomy resulted in substantial improvements in tracheal anatomy and improvements in inspiratory flow, which were followed by gains in HRQoL. This information is pertinent when counseling patients before choice of treatment.

Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study.

BACKGROUND: Using the thoroughly validated Thyroid-Related Quality-of-Life Patient-Reported Outcome (ThyPRO) questionnaire, the purpose of this study was to investigate changes in disease-specific quality of life (QOL) after surgical treatment in patients with benign nontoxic multinodular goiters. METHOD: Patients with goiters scheduled for thyroid surgery (n = 106) and individuals from the general population (n = 739) were studied. The ThyPRO data before, 3 months, and 6 months after surgery were compared with normative scores from the general population using a linear mixed model and t tests. RESULTS: Before surgery, patients with goiters experienced poorer scores on all scales compared to the general population. After surgery, moderate to large improvements were seen in goiter symptoms, tiredness, anxiety, and overall QOL. After surgery, all scales returned to values equal to the general population. The degree of anxiety was, in fact, lower than in the general population. CONCLUSION: Thyroid surgery leads to significant benefit among patients with benign nontoxic goiters by restoring QOL equal to that in the general population.

Respiratory Manifestations of Hypothyroidism: A Systematic Review.

BACKGROUND: Hypothyroidism has been associated with increased pulmonary morbidity and overall mortality. A systematic review was conducted to identify the prevalence and underlying mechanisms of respiratory problems among patients with thyroid insufficiency. METHODS: PubMed and EMBASE databases were searched for relevant literature from January 1950 through January 2015 with the following study eligibility criteria: English-language publications; adult subclinical or overt hypothyroid patients; intervention, observational, or retrospective studies; and respiratory manifestations. The Preferred Reporting Items for Systematic reviews and Meta-Analyses statement was followed, and Cochrane's risk of bias tool was used. RESULTS: A total of 1699 papers were screened by two independent authors for relevant titles. Of 109 relevant abstracts, 28 papers underwent full-text analyses, of which 22 were included in the review. Possible mechanisms explaining respiratory problems at multiple physiological levels were identified, such as the ventilator control system, diaphragmatic muscle function, pulmonary gas exchange, goiter caused upper airway obstruction, decreased capacity for energy transduction, and reduced glycolytic activity. Obstructive sleep apnea syndrome was found among 30% of newly diagnosed patients with overt hypothyroidism, and demonstrated reversibility following treatment. The evidence for or against a direct effect on pulmonary function was ambiguous. However, each of the above-mentioned areas was only dealt with in a limited number of studies. Therefore, it is not possible to draw any strong conclusions on any of these themes. Moreover, most studies were hampered by considerable risk of bias due for example to small numbers of patients, lack of control groups, randomization and blinding, and differences in body mass index, sex, and age between subjects and controls. CONCLUSION: Mechanistic data linking hypothyroidism and respiratory function are at best limited. This area of research is therefore open for retesting hypotheses, using appropriate study designs and methods.

[Diagnostic challenges during cranial osteonecrosis elucidation]. / Diagnostiske udfordringer under udredning af kranial osteonekrose.

This is a case report of an 81-year-old male with severe headaches caused by osteonecrotic lesions in the frontotemporal part of the skull. Initially, metastatic lesions were suspected but other causes had to be identified because of chronic inflammation evidence in all biopsies. In the diagnostic process a discussion of missed malignancy, morbus Paget and steroid induced avascular necrosis are presented.

[Satisfactory professional benefit from simulation-based training in acute medical conditions]. / Godt fagligt udbytte af simulationstræning i behandling af den akutte patient.

Simulation-based training in acute medical conditions is mandatory for Danish interns. A new concept for improving the effect of this training has been evaluated at our Center for Medical Simulation. By introducing an exercise in prioritizing patients as a supplement to simulation-based training we have gained a higher degree of self-reported learning compared to observing other participants and participating in the debriefing.