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Quantification of the inflammatory reaction and collagen accumulation in an experimental model of open wounds in the rat. A methodological study.

An experimental model for studying the early healing of open wounds in the rat is described. With this model, exudate is easily collected, a standardized granulation tissue is achieved at different post-wounding time intervals and local treatment of the wounds is possible. The model involves the use of stainless steel rings with covers, fastened to the edges of two circular full-thickness open wounds, one on each side of the animal's back in the thoracic region. Blood flow and water content of the granulation tissue were determined acutely 3, 5, 7 and 10 days after wounding. The collagen accumulation in the granulation tissue was assessed by the amount of hydroxyproline, at the same time intervals. The amount of exudate which accumulated in the chamber was measured daily. Blood flow in the granulation tissue, as measured by radioactive microspheres, reached a maximum of 947 ml X min-1 X (100 g dry weight)-1 7 days after wounding. The water content, as assessed by freeze-drying, also reached its peak on the 7th day (5.5 ml X (g dry weight)-1). Changes in water content were found to be due to changes in interstitial fluid volume, as studied by 59Fe-labelled erythrocytes and 51Cr-EDTA. The amount of hydroxyproline in the granulation tissue increased from 22 micrograms X (mg dry weight)-1 on day 3 to 37 micrograms X (mg dry weight)-1 on day 10. Exudation increased to 28 microliters X h-1 X cm2-1 on day 4 and then declined. The results suggest that the inflammatory reaction, expressed as alterations in blood flow and water content, reaches a maximum on day 7 after wounding. The data also demonstrate a continuous increase in the collagen content of the granulation tissue during the 10-day period of observation. In addition, exudation was found to reach a peak on the 4th to 5th day, and then declined.

Animals↗

Differential uptake of gallium-67-labeled liposomes between tumors and inflammatory lesions in rats.

The differential gallium-67 (67Ga) accumulation in tumors and inflammatory lesions in rats after i.v. injection of liposome encapsulated 67Ga ([67Ga]liposomes) was studied. The 67Ga accumulation in the tumor was much greater than that in the granulation tissue regardless of the surface charge of liposomes; however, the difference between the two tissues was the greatest when using positive charged liposomes. Gallium-67 delivery to tumors by liposomes was greater than that to granulation tissue in all stages of growth. After i.v. injection, the accumulation of 67Ga in the tumor reached a maximum at 12 hr, whereas in the granulation tissue it was delayed to 24 hr postinjection. In the study of tissue distribution of 67Ga in rats bearing both tumor and granulation tissue, positively charged liposomes preferentially delivered 67Ga to the tumor than to the granulation tissue. These results suggest that [67Ga]liposomes are able to discriminate between the tumor and the inflammatory lesion.

Animals↗

[Experimental studies on augmentation of the mandibular region with proplast and lyophilized homogenous cartilage].

Proplast I, Proplast II and freeze-dried homogenous cartilage (1 x 2 x 5 mm) were implanted under and over the rabbit mandibular periosteum. Histological observations and contact microradiography (CMR) were performed to investigate the healing process in the surgical sites from 1 to 24 weeks after the operation. In addition, microangiography (MA) was carried out to investigate changes of vascularization in the groups in which Proplast implants were made. Results 1. Proplast implantation group 1) In the supraperiosteal placement group, CMR revealed no new bone formation around or inside the Proplast and no morphological changes of the host bone in contact with the Proplast. In the subperiosteal placement group, from the early postoperative stage, new bone formation occurred from the host bone beside the Proplast. New bone penetrated the Proplast from the new bone region and from the host bone in contact with the Proplast. In 6 months after the operation, Almost all Proplast pores were filled with new bone. From a comparatively early postoperative stage, resorption fossae appeared in the host bone surface. In addition, Haversian canals inside the host bone enlarged and the host bone cortex gradually grew thinner. No differences in new bone volume or host bone changes were noticed between the Proplast I and Proplast II groups. 2) In the supraperiosteal placement group, granulation tissue proliferation with slight round cell infiltration was observed around and inside the Proplast at an early stage. In 2 weeks after the operation, blood clots disappeared from the Proplast, in the center of which granulation tissue proliferated. Thereafter, granulation tissue was gradually transformed into fibrous tissue, although no new bone was observed in any region. Change almost never occurred in the host bone cortex, but slight swelling occurred in the periosteum in contact with the Proplast after 1 week. 3) In the subperiosteal placement group, swelling and slight round cell infiltration were observed in the periosteum covering the Proplast at an early postoperative stage. But, after 4 months, the periosteum had returned to normal condition. Beside and inside the Proplast, rapid granulation tissue proliferation and new bone formation were observed. New bone formation was observed beside the host bone, but not beside the periosteum. For a comparatively long time, resorbed fossae in the host bone surface and enlarged Haversian canals persisted. Host bone width gradually decreased.(ABSTRACT TRUNCATED AT 400 WORDS)

Alveolar Ridge Augmentation↗

Wound healing in the mitral valve.

BACKGROUND AND AIMS OF THE STUDY: Limited information is available on the healing of wounds in the mitral valve. In the present study, this process has been evaluated in young sheep. METHODS: Histologic, histochemical and transmission electron microscopic studies were made of the healing of wounds produced surgically under cardiopulmonary bypass, in the mitral valve (a 1 cm-long radially oriented incision at the free edge of the anterior leaflet) of young sheep (n = 11). RESULTS: All animals developed severe mitral regurgitation, as demonstrated by hemodynamic, ultrasound and ventriculographic studies. At four to five weeks, the edges of the incision were only partially covered by endothelium and had small deposits of fibrin. Two types of granulation tissue were associated with wound healing. The first covered the cut edge and consisted of myxoid tissue that extended from the valvular spongiosa and fibrosa; the second type consisted of spindle-shaped cells arranged parallel to the surface and surrounded by a slightly myxoid stroma. This granulation tissue resembled that caused by reactive fibrosis in regurgitant mitral valves. The connective tissue cells in granulation tissue developed increasing amounts of actin-like filaments as a function of time after operation. This differentiation resulted in the development of myofibroblasts. In contrast to the avascular nature of normal mitral leaflets, capillaries and arterioles first appeared in the middle portion of the leaflet at eight weeks, and at the proximal edges of the wounds at 12 weeks. CONCLUSION: The healing of mitral valvular wounds is a slow process that requires between eight and 12 weeks for the formation of a dense collagenous scar at the edges and complete restoration of the endothelial lining. Progression of healing is associated with the phenotypic modulation of connective tissue cells from fibroblasts to myofibroblasts and neovascularization of the leaflets.

Connective Tissue↗

Significance of vascular endothelial cell growth factor up-regulation mediated via a chymase-angiotensin-dependent pathway during angiogenesis in hamster sponge granulomas.

Chymase is a serine protease responsible for local production of angiotensin (Ang) II from its precursor Ang I in several species, including humans, dogs, and hamsters. We have previously reported that chymase facilitates angiogenesis in sponge granulation tissues via local production of Ang II. Herein, we report the significance of vascular endothelial growth factor (VEGF) up-regulation mediated by Ang II during angiogenesis in hamster sponge granulomas. Treatment of granulation tissues with an anti-VEGF neutralizing antibody or antisense oligomers against VEGF mRNA significantly reduced Ang II-induced angiogenesis, supporting a significant role for VEGF during angiogenesis. In cultured fibroblasts prepared from granulation tissues, VEGF mRNA was up-regulated in response to Ang II within 2 h and this enhanced expression was abolished in the presence of an Ang II type 1 receptor-selective antagonist, an inhibitor of nuclear factor-kappaB activation, or an activator protein-1 inhibitor. To study the significance of local production of Ang II by chymase, we examined the effects of chymostatin on in vivo angiogenesis. We found that chymostatin markedly inhibited both up-regulation of VEGF mRNA and angiogenesis in granulation tissues treated by compound 48/80 or basic fibroblast growth factor. Our results suggest that Ang II directly acts on fibroblasts in granulation tissue to up-regulate VEGF mRNA and thereby induce angiogenesis. Furthermore, a chymase-Ang II-VEGF pathway may operate in granulation tissue as the primary mediator of angiogenesis.

Angiotensin II↗

Development of peritoneal fibrosis occurs under the mesothelial cell layer.

This study was carried out in order to find out which part of the peritoneal wall reacts toward silica and produces peritoneal fibrosis. Colloidal silica was injected into the peritoneal cavity of rats to induce chemical peritonitis and frozen sections of the peritoneal wall were stained with specific antibodies toward type I and III collagens and fibronectin. A massive proliferation of granulation tissue was observed between the submesothelial and muscular layers within 48 hr visualized by prominent fibronectin staining. Type III collagen formed lamellar-like structures in the newly formed granulation tissue. The connective tissue reaction was extended into the underlying muscular tissue. Three weeks after silica injection the reactive granulation tissue exceeded the original peritoneum three- to fourfold in thickness. At this stage it contained extended fibrillar structures oriented perpendicular to the surface or muscular layers of the peritoneum. Type I collagen antibody was bound to the superficial cell layer in the control samples and in the early peritonitis whereas the entire granulation tissue was evenly stained at 3 weeks. Type III collagen antibody was bound to the surface layer of the peritoneum, granulation tissue, and perimysial connective tissue throughout the healing period. The results indicate that the peritoneal fibrotic process occurs under the thin peritoneal lining cell layer and on the surface of the muscle layer.

Animals↗

The dipeptide Lys-Pro restores the diminished wound healing following treatment with anti-T-helper cell monoclonal antibody.

To determine the role of T-cell subsets in wound healing, we studied the granulation tissue proliferation after depletion of CD4 or CD8 positive cells. Granulation tissue proliferation in CD8-diminished AB mice was significantly higher than in the control group as a result of depleted suppressor cell activity. The CD4-depleted mice produced granulation tissue in less than 30% of the control group. To investigate the role of dipeptidylpeptidase IV on CD4 positive cells in wound healing we used Lys-[Z(NO2)]-Pro, a chemically modified dipeptide which may result by degradation of polypeptides by this peptidase. It was possible to restore the diminished capability of granulation tissue proliferation in CD4-depleted mice by a single treatment with the dipeptide Lys-[Z(NO2)]-Pro. Our results suggest that: (i) the CD4 positive T-helper subset regulates wound healing, and (ii) products of degradation by dipeptidylpeptidase IV may bypass T-helper cell function.

Animals↗

Transient functional expression of alphaVbeta 3 on vascular cells during wound repair.

During early granulation tissue formation of wound repair, new capillaries invade the fibrin clot, a process that undoubtedly requires an interaction of vascular cells with the wound provisional matrix composed mainly of fibrin, fibronectin, and vitronectin. Integrin alphaVbeta3 is the vascular cell receptor for these wound-associated adhesive proteins. Therefore, we investigated the expression of this receptor on new capillaries of healing full-thickness cutaneous porcine wounds. During granulation tissue formation, alphaVbeta3 was expressed specifically on capillary sprouts invading the central fibrin clot whereas the closely related integrin alphaVbeta5 failed to localize to these cells. Cyclic peptides or antibody antagonists of alphaVbeta3 specifically inhibited granulation tissue formation in a transient manner during the period of invasive angiogenesis. Immunolocalization studies revealed that alphaVbeta3 became aggregated and lost from sprouting vessels after treatment with a peptide antagonist. In contrast, beta 1 integrins were not modulated by this treatment. Once granulation tissue filled the wound and invasive angiogenesis terminated, the alphaVbeta3 showed little or no expression in the granulation tissue microvasculature. These data demonstrate that integrin alphaVbeta3 plays a fundamental, but transient, role during invasive angiogenesis and granulation tissue formation in a healing wound.

Analysis of Variance↗

Myofibroblasts from diverse pathologic settings are heterogeneous in their content of actin isoforms and intermediate filament proteins.

We examined by immunofluorescence the distribution of vimentin, desmin, alpha-smooth muscle actin and alpha-sarcomeric actin in normal human soft tissues and in pathologic tissues containing myofibroblasts, including normally healing granulation tissue, hypertrophic scar, and fibromatosis. The pattern of actin isoforms was also documented biochemically by two-dimensional gel electrophoresis. Fibroblastic and/or myofibroblastic cells in each setting always expressed vimentin and never alpha-sarcomeric actin. Moreover, these cells showed an heterogeneous cytoskeletal composition which defined four phenotypes: (a) cells expressing only vimentin; (b) cells expressing vimentin, alpha-smooth muscle actin and desmin; (c) cells expressing vimentin and alpha-smooth muscle actin; and (d) cells expressing vimentin and desmin. Given this, two groups of lesions are distinguished: the first contains only vimentin cells and consists of normally healing granulation tissue, eschars and normally healed scars; the second contains vimentin cells admixed with variable proportions of vimentin, alpha-smooth muscle actin and desmin, vimentin and alpha-smooth muscle actin, and vimentin and desmin cells and consists of hypertrophic scars and fibromatoses. Immunogold electron microscopy showed that alpha-smooth muscle actin was present in a proportion of cells with ultrastructural features of myofibroblasts. Our findings suggest that contrary to myofibroblasts of normally healing granulation tissue and normally healed scars, myofibroblasts of pathologic conditions characterized by chronic retraction express always immunochemical features indicative of smooth muscle differentiation.

Actins↗

Concepts of granulomatous inflammation.

Table 8 lists the patterns of the five discrete tissue reaction patterns of granulomatous inflammation and relates them to the predominant microscopic tissue reaction as well as to the dominant cell type present in the infiltrate. The possibility of a sixth group, granulation tissue, was also considered for this classification schema. The term "granulation tissue" was used by Virchow to define granulomatous inflammation. He probably used this term in a broader context than our present definition of granulation tissue (ie, fibrocapillary proliferation). Using the more narrow and perhaps more precise definition, we think that granulation tissue does not constitute a form of granulomatous inflammation.

Dermatitis↗

The bone marrow-derived endothelial progenitor cell response is impaired in delayed wound healing from ischemia.

OBJECTIVE: Vasculogenesis relies on the recruitment of bone marrow-derived endothelial progenitor cells (BMD EPCs) and is stimulated by tissue-level ischemia. We hypothesized that the BMD EPC response is impaired in ischemic wounds and studied the relationship between BMD EPCs and wound healing. METHODS: We used transgenic Tie-2/LacZ mice, which carry the beta-galactosidase (beta-gal) reporter gene under Tie-2 promoter control. Wild-type mice were lethally irradiated and reconstituted with Tie-2/LacZ bone marrow. Four weeks later, the mice underwent unilateral femoral artery ligation/excision and bilateral wounding of the hindlimbs. Ischemia was confirmed and monitored with laser Doppler imaging. A subset of mice received incisional vs excisional nonischemic bilateral hindlimb wounds, without femoral ligation. Excisional wound closure was measured by using daily digital imaging and software-assisted calculation of surface area. RESULTS: Ischemia resulted in significantly delayed wound healing and differentially affected the number of BMD EPCs recruited to wound granulation tissue and muscle underlying the wounds. At 3 days postwounding, the granulation tissue of the wound base contained significantly fewer numbers of BMD EPCs in ischemic wounds compared with the nonischemic wounds (P < .05). In contrast, significantly more BMD EPCs were present in the muscle underlying the ischemic wounds at this same time point compared with the muscle under the nonischemic wounds (P < .05). In ischemic wounds, eventual wound closure significantly correlated with a delayed rise in BMD EPCs within the wound granulation tissue (Kendall's correlation, -.811, P = .0005) and was significantly associated with a gradual recovery of hindlimb perfusion (P < .0001). By 7 days postwounding, BMD EPCs were incorporated into the neovessels in the granulation tissue. At 14 days and 75 days, BMD EPCs were rarely observed within the wounds. CONCLUSIONS: Granulation tissue of excisional ischemic wounds showed significantly less BMD EPCs 3 days postwounding, in association with significantly delayed wound closure. However, the number of BMD EPCs were increased in ischemic hindlimb skeletal muscle, consistent with the notion that ischemia is a powerful signal for vasculogenesis. To our knowledge, this is the first report identifying a deficit in BMD EPCs in the granulation tissue of ischemic skin wounds and reporting the key role for these cells in both ischemic and nonischemic wound healing.

Animals↗

Pathological studies on esophageal varices treated with injection sclerotherapy.

Injection sclerotherapy is one of the most effective treatments for esophageal varices. To investigate the fate of esophageal varices embolized with a sclerosant (ethanolamine oleate), we have examined at autopsy the esophageal wall of 14 patients with esophageal varices. When the sclerosant was injected into the varices, at first thrombi formed. After two weeks, granulation tissue appeared and the thrombi were gradually replaced. The granulation tissues were organized slowly after 3 months and in the organized granulation tissue, microscopic recanalization of vessels were seen in 8 out of 9 cases. There was no recurrence of the original varices and de novo varices occurred in one patient. These observations indicate that the varices embolized with ethanolamine oleate become organized in three months after the treatment, and accordingly the esophageal varices are cured. It became also clear that recurrence of the original varices did not occur after the organization.

Adult↗

In vitro and in vivo analysis of macroporous biodegradable poly(D,L-lactide-co-glycolide) scaffolds containing bioactive glass.

Recent studies have demonstrated the angiogenic potential of 45S5 Bioglass. However, it is not known whether the angiogenic properties of Bioglass remain when the bioactive glass particles are incorporated into polymer composites. The objectives of the current study were to investigate the angiogenic properties of 45S5 Bioglass particles incorporated into biodegradable polymer composites. In vitro studies demonstrated that fibroblasts cultured on discs consisting of specific quantities of Bioglass particles mixed into poly(D,L-lactide-co-glycolide) secreted significantly increased quantities of vascular endothelial growth factor. The optimal quantity of Bioglass particles determined from the in vitro experiments was incorporated into three-dimensional macroporous poly(D,L-lactide-co-glycolide) foam scaffolds. The foam scaffolds were fabricated using either compression molding or thermally induced phase separation processes. The foams were implanted subcutaneously into mice for periods of up to 6 weeks. Histological assessment was used to determine the area of granulation tissue around the foams, and the number of blood vessels within the granulation tissue was counted. The presence of Bioglass particles in the foams produced a sustained increase in the area of granulation tissue surrounding the foams. The number of blood vessels surrounding the neat foams was reduced after 2 weeks of implantation; however, compression-molded foams containing Bioglass after 4 and 6 weeks of implantation had significantly more blood vessels surrounding the foams compared with foams containing no Bioglass at the same time points. These results indicate that composite polymer foam scaffolds containing Bioglass particles retain granulation tissue and blood vessels surrounding the implanted foams. The use of this polymer composite for tissue engineering scaffolds might provide a novel approach for ensuring adequate vascular supply to the implanted device.

Angiogenesis Inducing Agents↗

Lack of antigen-specific tissue remodeling in mice deficient in the macrophage galactose-type calcium-type lectin 1/CD301a.

Macrophage galactose-type C-type lectins (MGLs), which were recently named CD301, have 2 homologues in mice: MGL1 and MGL2. MGLs are expressed on macrophages and immature dendritic cells. The persistent presence of granulation tissue induced by a protein antigen was observed in wild-type mice but not in mice lacking an endogenous, macrophage-specific, galactose-type calcium-type lectin 1 (MGL1) in an air pouch model. The anti-MGL1 antibody suppressed the granulation tissue formation in wild-type mice. A large number of cells, present only in the pouch of MGL1-deficient mice, were not myeloid or lymphoid lineage cells and the number significantly declined after administration of interleukin 1 alpha (IL-1alpha) into the pouch of MGL1-deficient mice. Furthermore, granulation tissue was restored by this treatment and the cells obtained from the pouch of MGL1-deficient mice were incorporated into the granulation tissue when injected with IL-1alpha. Taken together, MGL1 expressed on a specific subpopulation of macrophages that secrete IL-1alpha was proposed to regulate specific cellular interactions crucial to granulation tissue formation.

Air↗

Fibronectin filaments and actin microfilaments are organized into a fibronexus in Dupuytren's diseased tissue.

The fibronexus is a close transmembrane association between fibronectin filaments and actin microfilaments. It has been found at the surfaces of fibroblasts in tissue culture, as well as within contracting granulation tissue. This specialized connection has been proposed to play an important role in the adhesive properties of fibroblasts. The purpose of this study is to determine whether the fibronexus is present in other contracting tissues besides granulation tissue, specifically in Dupuytren's diseased tissue. Dupuytren's disease is a pathologic condition in which the palmar aponeurosis becomes shortened leading to irreversible flexion of the digits. Shortening of the aponeurosis is believed to be an active cellular process. Extracellular filaments and actin microfilaments form close transmembrane associations at the surfaces of actin-rich fibroblasts in Dupuytren's disease. Extracellular filaments extend from the cell surface into the surrounding tissue connecting fibroblasts with collagen fibrils and adjacent cells. In this study we have used immunoelectron microscopy to demonstrate that the extracellular filaments that participate in these close transmembrane associations contain fibronectin. High voltage electron microscopy has been used to examine the three-dimensional relationships between the cytoskeleton and fibronectin filaments in Dupuytren's diseased tissue. We propose that the fibronexus is a dominant adhesive structure at the surface of fibroblasts in Dupuytren's diseased tissue. The fibronexus, by mediating cell-to-cell and cell-to-matrix attachments, may serve to transmit contractile forces generated by actin microfilaments in these cells throughout the diseased tissue.

Actin Cytoskeleton↗

Time-related changes in computed tomographic appearance and pathologic findings after radiofrequency ablation of the rabbit lung: preliminary experimental study.

PURPOSE: To evaluate correlations between computed tomographic (CT) appearance and pathologic findings after radiofrequency (RF) ablation of lungs and to determine whether CT appearance could predict the extent of the effective therapeutic area. MATERIALS AND METHODS: The lungs of 14 rabbits were subjected to RF ablation and CT scans were obtained immediately and at various intervals thereafter. Four rabbits were killed immediately after the initial CT imaging (n = 4). The remaining 10 rabbits were killed after additional CT scans at intervals of 3 days (n = 2), 1 week (n = 4), 2 weeks (n = 2), and 3 weeks (n = 2) after RF ablation. Pathologic findings were correlated with CT appearance. RESULTS: Immediately after RF ablation, a restricted area of central dense opacity enclosed by an extensive area of ground-glass opacity was noted in the ablated region on CT images. Pathologically, the former corresponded to destructive tissue and the latter corresponded to tissue with some degree of injury. After 1 week, the entire ablated region appeared as a well-demarcated homogeneous dense opacity on CT that corresponded to necrotic tissue and its surrounding rim of granulation tissue on histopathologic examination, indicating that the enclosing extensive area of ground-glass opacity on the initial CT scan represented an ongoing necrosis. Within 2-3 weeks, the ablated region gradually contracted on the CT images, representing a tissue repairing process in which the granulation tissue was encroaching on the inner necrotic tissue. CONCLUSION: Ground-glass opacity of the ablated region on CT immediately after RF ablation represents an ongoing necrosis.

Animals↗

Stimulation of wound healing by epidermal growth factor. A dose-dependent effect.

This work was undertaken to study the effects of various doses of locally applied epidermal growth factor (EGF) on developing granulation tissue in rats. Cylindrical hollow sponge implants were used as an inductive matrix for the growth of granulation tissue. In the test groups, the implants were injected daily with a solution containing 0.2, 1, or 5 micrograms of EGF in 0.1% albumin while the implants of the control group were treated correspondingly with the carrier solution only. Analyses of granulation tissue in the sponge cylinders were carried out 7 days after implantation. A stimulatory, dose-dependent effect of EGF on granulation tissue formation was observed: cellularity increased, as evidenced by the elevated amounts of nucleic acids, and accumulation of collagen and glycosaminoglycans was enhanced.

Animals↗

Sucrose has no beneficial effects on wound healing in rats.

OBJECTIVE: To evaluate the effects of sucrose treatment on the formation of granulation tissue in a standard wound model. DESIGN: Animal study. SETTING: University hospital, Finland. ANIMALS: 32 male Sprague-Dawley rats divided into 4 groups. INTERVENTIONS: Implantation of viscose cellulose sponge subcutaneously, and daily injection of three concentrations of sucrose (0.01, 0.1 or 1 M) or vehicle for 7 days. MAIN OUTCOME MEASURES: The amount of granulation tissue measured by chemical analysis and histology. The amount and distribution of types I and III collagen assayed by immunofluorescence. RESULTS: None of the three concentrations altered the amounts of DNA, RNA, hydroxyproline, nitrogen, hexosamines, and uronic acids in granulation tissue. Neither improvement nor deterioration was seen in the growth of granulation tissue in histological specimens. The amount and distribution of types I and III collagen was similar in controls and sucrose-treated rats. Type III collagen was most abundant near newly-formed vessels. Neither sucrose nor fructose was found in wound fluid while the concentration of glucose was significantly lower in all test groups than in controls. CONCLUSIONS: Sucrose solution had neither beneficial nor deleterious effects on the amount of developing granulation tissue in an experimental wound model. The amount and distribution of types I and III collagens were also not altered by sucrose treatment.

Animals↗