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PubMed1992

Care of maxillofacial injuries: survey of plastic surgeons.

The purpose of this survey was to evaluate the current trends in the care of facial trauma. Data were obtained through the responses of a survey mailed to all those members and candidates listed in the 1989 American Society of Plastic and Reconstructive Surgeons Directory. A total of 2777 questionnaires were sent, with 1113 (40 percent) returned by means of a self-addressed envelope. Demographic results show that over 70 percent of the treating plastic surgeons fall within the age range 30 to 50 years. Although significant advances have occurred, treatment goals have remained unchanged. These center around the principles of accurate reduction and precise stabilization of fracture segments. The results of this survey reveal that a number of acceptable techniques were employed in the surgical repair of mandibular and zygomatic complex fractures. In the care of Le Fort III fractures, 59 percent of the respondents preferred the use of miniplates and screws for stabilization. Only 26.8 percent believed that facial fracture repair should be performed within the initial 24 hours. With frontal sinus fractures, the vast majority of plastic surgeons (82.1 percent) obtained a neurosurgical consultation. When the posterior wall was involved, 45.6 percent favored removal of the sinus mucosa, 29.7 percent obliterated the frontal sinus with a variety of autogenous materials, while 20.5 percent preferred cranialization. In summary, this survey shows a wide variation in the practice of facial fracture management within the plastic surgical community.

Adult↗
PubMed1995

The business acumen of Canadian plastic surgeons.

We as plastic surgeons are engrossed and consumed by our quest to optimize patient care. In so doing, we are often distracted by that aspect of our practice which has direct bearing on patient care yet for which we are the least prepared--the business aspect. The entire population of Canadian plastic surgeons was surveyed in an effort to establish real and perceived needs of this group with respect to the business management of their practices. The survey elicited demographic information, information on business educational background, interest, and current commitment in acquiring business knowledge, and a final category of questions dealing with how well these surgeons function as business managers. Of the 315 plastic surgeons surveyed, 122 (39 percent) responded, which, in and of itself, indicates an interest in this aspect of their practices. Twelve respondents were excluded from the study for various reasons. Eighty of the 110 remaining respondents (72 percent) used a hospital-integrated facility for both emergency and elective outpatient procedures. Eighty-four of the 110 respondents (76 percent) indicated that 10 percent of their hours per week of inpatient booked operating time was canceled. Ninety-three percent of respondents felt that a business course to familiarize surgeons with common business situations and areas of personal finance would be beneficial. Few were previously educated in business, and similarly, few had great ongoing interest in business, although the majority of respondents used publications specifically dealing with financial matters (provided by the Canadian Medical Association). Twenty-three percent of respondents saw themselves in a growing role as businesspeople; 24 percent felt this dual role was enjoyable, while 29 percent felt this role was forced on them. A total of 21 percent of respondents did not see themselves as businesspeople at all. The six basic functions of a manager (planning, acquiring, organizing, actuating, controlling, and evaluating) were all made use of by these practicing surgeons, although the evaluating and controlling functions seemed to predominate managerial time. These surgeons do recognize, for the most part, that a surgical practice is a form of business enterprise as well as a professional endeavor. Patient care, which is of paramount importance, is affected by the business aspect of our practices. The Canadian plastic surgeons surveyed have expressed the lack of business education and training as a problem. In the present medical environment, we need to be more responsible and efficient in our business practices through education and training in this aspect of our practices.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1997

Does double gloving protect surgical staff from skin contamination during plastic surgery?

In a randomized study, the effectiveness of double gloving in maintaining an intact barrier between the patient and the hands of the surgical staff during plastic surgery operations was tested. For 2 months, the surgical staff of a plastic surgery unit randomly wore single or double gloves during all elective surgical procedures. At the end of the operations, the gloves were tested by the water filling test. A total of 1092 gloves were examined. Twelve accidental injuries were noticed during the operations, and 67 unnoticed perforations occurred. The data suggest that the risk of perforation and exposure increases with the length and complexity of the procedures. It was concluded that double gloving is effective in plastic surgery, inasmuch as the barrier protection was maintained by the inner glove in two of three cases in which the outer glove was perforated inadvertently. Plastic surgeons must balance the improved security of double gloving with the possible discomfort or reduced sensitivity.

Gloves, Surgical↗
PubMed1997

Anxiety disorders in plastic surgery.

Surgery is a stressful event, with the potential for profound disturbance to the patient's psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patient's reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patient's psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.

Adult↗
PubMed1998

Competitive forces and academic plastic surgery.

Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.

Academic Medical Centers↗
PubMed2000

Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery.

Several previous studies have shown that breast implant patients demonstrate a number of differences compared with the general population. However, studies have not compared patients with breast implants with women receiving other types of plastic surgery, of interest because this latter group has been proposed as a comparison group for assessing the long-term health effects experienced by breast implant patients. Questionnaire data obtained from 7447 breast implant patients and 2203 patients with other types plastic surgery were collected during the course of a retrospective cohort study, to determine whether implant patients demonstrate different characteristics compared with a more restricted group of patients. In contrast to previous investigations that compared implant patients with the general population, distinctive differences with respect to family income, number of pregnancies, alcohol consumption, cigarette smoking, or histories of previous gynecologic operations or operations for benign breast disease were not found. However, implant patients were significantly more likely than other plastic surgery patients to be white, have low levels of education, have early ages at first birth, be thin, and be screened frequently for breast disease. Furthermore, implant patients reported somewhat greater use of exogenous hormones and familial histories of rheumatoid arthritis. These results support the notion that other plastic surgery patients are a more appropriate comparison group than women in the general population for studies of the health effects of breast implants; however, there continue to be distinctive characteristics possessed by breast implant patients, which need to be taken into account in an assessment of what disease effects can be uniquely attributed to silicone breast implants.

Adult↗
PubMed2001

General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications.

The popularity of elective office-based plastic surgery has increased significantly over the past two decades. The continuing demand for improved aesthetic results has stimulated the development of ever more complex plastic surgical techniques. These techniques may require extended periods of operative time spent under anesthesia. Patients have come to expect an almost perfect anesthetic and surgical experience, with safety and comfort being their foremost concerns. Because of increasingly complex and lengthy operations, the authors believe that intravenous sedation, used for many years in their plastic surgery practice, is now suboptimal for most longer and complex surgical procedures. In their experience, under most circumstances, general anesthesia provides the optimal anesthetic experience for the patient, anesthesiologist, and surgeon. The authors present a consecutive 18-year study of general anesthesia in more than 23,000 procedures in an accredited, office-based plastic surgical facility that offers a very safe and uniformly pleasant anesthesia experience for patients. There were no intraoperative or postoperative deaths and no significant complications. The authors' experience differs from the common perception that general anesthesia is too risky for aesthetic surgery procedures.

Ambulatory Surgical Procedures↗
PubMed2001

The thersites complex in plastic surgical patients.

Body dysmorphic disorder describes the preoccupation with an imagined defect of appearance. A subgroup of patients suffer from the so-called Thersites complex, in which a minimal physical deformity causes excessive psychological disturbances and distress. Patients with body dysmorphic disorder tend primarily to visit a plastic surgeon for relief with distinct plans for surgical correction of their "deformity." Psychotherapy is generally refused or ineffective. The plastic surgeon should be familiar with this mental disorder and recognize these patients during consultation. Most of these patients should be excluded from surgery; however, patients of the Thersites complex category might be candidates for plastic surgical correction after careful selection. Only the experienced plastic surgeon should make the decision to operate in this situation. A successful treatment can relieve the patient from his or her distress and improve the quality of life substantially. A surgical result that is not accepted by the patient can end in a tragedy for either the patient or the doctor.

Adolescent↗
PubMed2002

The prevention of emesis in plastic surgery: a randomized, prospective study.

Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission, and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview, chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13 percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk, prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases. Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the subjective experience for our patients.

Analgesics, Opioid↗
PubMed1986

Immunologic and biologic evaluation of insulin degradation following prolonged storage in plastic syringes.

Insulin potency during storage in plastic disposable syringes for short periods of time is a concern of diabetics as well as syringe manufacturers. Previous studies have indicated that leaching of organic materials from rubber gaskets may have cytotoxic effects. The purpose of this study was to evaluate the immunologic and radioreceptor degradation of insulin storage in commercial plastic syringes. Insulin syringes were filled with insulin and stored at 4 degrees C for 2 weeks. Immunologic potency was assessed by radioimmunoassay while biologic potency was evaluated by binding to hepatic insulin receptors. Recoverable insulin was measured on days 1, 3, 7, and 14 and compared with highly purified porcine insulin. Insulin content of samples stored in all three plastic syringes showed no statistically significant (p less than 0.05) loss of immunologic or biologic potency for 2 weeks compared with stock controls. Lente insulin gave more variability in storage in the radioimmunoassay, possibly due to settling, and was less effective in displacing labeled insulin in the radioreceptor assay. We conclude that premeasured insulin may safely be stored in plastic disposable syringes under selected conditions, especially in blind and handicapped diabetic patients, for 2 weeks.

Drug Stability↗
PubMed1996

Stability of therapeutic drug measurement in specimens collected in VACUTAINER plastic blood-collection tubes.

Recently Becton-Dickinson marketed a plastic serum-separator tube that uses the same serum-separator gel as the glass tubes. We studied the stability of therapeutic drugs stored in plastic tubes by comparing it with the stability of drugs stored in glass serum-separator tubes and plain red-top glass tubes. We observed no absorption of caffeine, primidone, N-acetylprocainamide, procainamide, theophylline, tobramycin, ethosuximide, acetaminophen, amikacin, valproic acid, methotrexate, salicylate, and cyclosporine in either plastic or glass serum-separator tubes. On the other hand, concentrations of lidocaine, quinidine, phenobarbital, and phenytoin were reduced after storing in both plastic and glass serum-separator tubes, especially with prolonged storage and small sample volume. The reduction in concentrations were due to slow absorption of those drugs by serum-separator gel.

Blood Specimen Collection↗
PubMed1996

Plasticity in the adult visual cortex: implications for the diagnosis of visual field defects and visual rehabilitation.

It has recently been shown that, contrary to long-held beliefs, sensory and motor maps are not stable in the adult cerebral cortex. Alteration of input from the periphery results in changes in topography in the cortex, including the primary visual cortex. Mechanisms involved consist mainly of reshaping the receptive field of cortical cells and increasing the sensitivity of deprived cells in the visual cortex. Cortical plasticity allows the brain to adapt to background modifications or to damage of the nervous system. It also underlies learning and attention processes. Cortical changes occurring after focal visual differentiation modify visual perception by filling in visual field defects with information from the area surrounding the scotoma. This modification causes affected subjects to ignore or underestimate their defects. With visual field defects, cortical plasticity also causes distortion in spatial perception. Although the effects of cortical plasticity are prominent in neuro-ophthalmological daily practice, they are usually unrecognized or greatly underestimated. These effects cause delay in recognizing visual field defects, and hence in receiving therapy, while affecting the results of some procedures for testing the visual field. Affected individuals who are unaware of their defects may have increased difficulty in coping with activities in everyday life. Up to now, phenomena related to plasticity in the visual system have been investigated mainly by psychophysicists and neurophysiologists. It is essential to start considering the various effects of cortical reorganization in clinical practice. It is especially important to introduce into clinics the concept of dissociation between actual and perceived defects in the visual field, resulting from the filling-in process, and the need to measure it. This dissociation should also be demonstrated to the affected subjects.

Adult↗
PubMed2005

Effects of mild hypothermia on blood coagulation in patients undergoing elective plastic surgery.

BACKGROUND: The aim of this prospective, controlled study was to evaluate the effects on coagulation function of active patient warming during elective plastic surgery. METHODS: Seventy-six patients undergoing elective plastic surgery (additive and reductive mastoplasty, rhinoplasty, and liposuction) were either covered with standard sterile drapes (control group, n = 38) or actively warmed during surgery with countercurrent fluid warming and forced-air skin warming (treatment group, n = 38). Complete evaluation of the coagulation activity was performed 1 hour before general anesthesia was induced and then at the end of surgery. RESULTS: Although no differences in preoperative core temperature were observed (36.0 +/- 0.5 degrees C in the control group and 36.1 +/- 0.4 degrees C in the treatment group; p = 0.12), core temperature was lower at the end of surgery in the control group (34 +/- 1.0 degrees C) than in the treatment group (36 +/- 0.6 degrees C) (p = 0.0005). No differences in prothrombin time and fibrinogen plasma concentrations were observed between the two groups. At the end of surgery, control group patients showed significantly larger activated partial thromboplastin times (36.8 +/- 3.5 seconds) and bleeding times (8.1 +/- 1.6 minutes) as compared with patients maintained normothermic during surgery (34.0 +/- 2.9 seconds and 4.3 +/- 1.1 minutes; p = 0.0005 and p = 0.0005, respectively). CONCLUSION: Actively maintaining intraoperative normothermia allows patients to maintain normal coagulation function during elective plastic surgery lasting longer than 2 hours, potentially reducing the occurrence of bleeding-related complications after plastic surgery.

Adult↗
PubMed2005

Who benefits from peer review? An analysis of the outcome of 100 requests for review by Plastic and Reconstructive Surgery.

BACKGROUND: Little is known of what is done with the comments on submitted manuscripts provided by peer reviewers or to what extent these comments benefit the editor in deciding to accept or reject the manuscript, the author(s) in revising their manuscript, or the readership at large. Furthermore, nothing is known of any possible benefits of the process to the peer reviewer. Finally, the peer-review process may even be maleficent because of its implicit delay of publication and a possible bias against manuscripts originating from non-Anglo-American countries. METHODS: The authors evaluated the benefits of the peer-review process to authors, editor, readers, and reviewers by a bibliometric analysis of the outcome of 100 requests for review made by the editor of Plastic and Reconstructive Surgery from 1992 through 2003. The publication delay and potential geographical bias were evaluated as potential disadvantages. RESULTS: The authors' reviewer advised acceptance of 56 percent of the manuscripts, and the editor mostly agreed with his advice. This suggests that the editor benefited from the review. The authors addressed 48 to 81 percent of the reviewer's constructive suggestions, and this suggests that they and the readers benefited also. Readers of Plastic and Reconstructive Surgery may further benefit because manuscripts rejected by Plastic and Reconstructive Surgery end up in less prestigious journals. The implicit delay of publication is limited, and the authors found no bias against non-Anglo-American submissions. The cost-effectiveness of the process for the peer reviewer remains unclear. CONCLUSIONS: The peer-review system of Plastic and Reconstructive Surgery, in general, is beneficial.

Bibliometrics↗
PubMed2005

Certificate-of-Need regulation in outpatient surgery and specialty care: implications for plastic surgeons.

For plastic surgeons, independent development of outpatient surgical centers and specialty facilities is becoming increasingly common. These facilities serve as important avenues not only for increasing access and efficiency but in maintaining a sustainable, competitive specialty advantage. Certificate of Need regulation represents a major hurdle to plastic surgeons who attempt to create autonomy in this fashion. At the state level, Certificate of Need programs were initially established in an effort to reduce health care costs by preventing unnecessary capital outlays for facility expansion (i.e., managing supply of health care resources) in addition to assisting with patient safety and access to care. The purpose of this study was to examine the effect of Certificate of Need regulations on health care costs, patient safety, and access to care and to discuss specific implications of these regulations for plastic surgeons. Within Certificate of Need states, these regulations have done little, if anything, to control health care costs or affect patient safety. Presently, Certificate of Need effects coupled with recent provisions in the Medicare Modernization Act banning development of specialty hospitals may restrict patient access to ambulatory surgical and specialty care. For the plastic surgeon, these effects not only act as an economic barrier to entry but can threaten the efficiencies gained from providing surgical care in an ambulatory setting. An appreciation of these effects is critical to maintaining specialty autonomy and access to fiscal policy.

Certificate of Need↗
PubMed2004

Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents.

OBJECTIVE: To evaluate the efficacy of a self-expanding plastic stent in the treatment of thoracic leaks after esophagectomy for cancer. SUMMARY BACKGROUND DATA: Anastomotic leaks are a major cause of morbidity and mortality after esophageal resection. Treatment options range from aggressive surgery to conservative management, but there remains much controversy on the best treatment. METHODS: Over a 6-year period (1998-2003), esophagogastric leaks were observed in 19 of 204 patients (9.3%) after esophagectomy. Between 1998 and 2000, anastomotic leaks were managed by reexploration (n = 7) or by conservative treatment (n = 3). Since 2001, insertion of self-expanding plastic stents was performed for all anastomotic leaks (n = 9). The short-term efficacy and long-term outcome of both treatments were analyzed. RESULTS: Self-expanding plastic stents were successfully placed in all patients without procedure-related morbidity. Immediate leak occlusion was obtained in 8 of 9 patients. The mean healing time (time to stent removal) was 29 days. Compared with the conventional treatment group, patients who were treated with stents had earlier oral intake (11 days versus 23 days), a less extensive intensive care course (25 days versus 47 days), and shorter hospital stay (35 days versus 57 days). In-hospital mortality was 0% (0 of 9 patients) in the stent group and 20% (2 of 10 patients) in the other group. After a mean follow-up of 12 months, none of the patients developed a stricture after stenting, but a stricture occurred in 1 patient after conservative treatment. CONCLUSIONS: Self-expanding plastic stents can reduce leak-related morbidity and mortality after esophagectomy and may be considered a cost-effective treatment alternative.

Adult↗
PubMed2005

Drivers of brain plasticity.

PURPOSE OF REVIEW: Neural plasticity represents a crucial mechanism of the human brain to adapt to environmental changes in the developing and adult human central nervous system. This property of the central nervous system contributes to learning and functional recovery from neurological diseases such as stroke. Novel interventional approaches have been proposed and are under investigation to modulate neural plasticity, enhance it when it plays an adaptive role and downregulate it when it is considered maladaptive. RECENT FINDINGS: One of the purposes of research in neurorehabilitation has been to develop interventional approaches to enhance the beneficial effects of training. Procedures like cortical stimulation, administration of central nervous system active drugs and modulation of afferent input have been evaluated as drivers of neural plasticity in healthy subjects and in small groups of patients with stroke. So far, these studies have shown promising results and translation into the clinic is under investigation. SUMMARY: Cortical stimulation and purposeful changes in afferent input that modulate neural plasticity impact on behavioral markers of performance, learning and functional recovery and represent promising tools in neurorehabilitation.

Animals↗
PubMed2006

Scopolamine attenuates tinnitus-related plasticity in the auditory cortex.

High doses of salicylate induce a temporary hearing deficit and a temporary subjective tinnitus in humans and animals. In animals, salicylate suppresses activity in the ascending auditory system but generates activity and plasticity in the auditory cortex and central amygdala. In addition to changes in the auditory system evoked by hearing impairment, enhanced stress may be crucial for the salicylate-induced alterations in the auditory cortex. The central amygdala responds to stress, and may influence cortical excitability and plasticity through cholinergic mechanisms. We investigated whether salicylate-induced plasticity in the auditory cortex is prevented by blocking cortical cholinergic receptors with the muscarinic antagonist scopolamine. Scopolamine suppresses salicylate-induced plasticity in the auditory cortex and, therefore, may be effective in suppressing the tinnitus sensation.

Animals↗