Connect with us

health

AAT Deficiency: What You Need to Grasp About Health Concern

Published

on

AAT Deficiency

Introduction

AAT Deficiency (Alpha-1) is a genetic disorder that significantly impacts lung and liver function. This comprehensive guide aims to provide an in-depth understanding of Alpha-1, covering its origins, symptoms, diagnosis, treatment options, preventive measures, and the outlook for individuals living with this condition.

Overview

What is Alpha-1 Antitrypsin Deficiency?

Alpha-1 Antitrypsin Deficiency, often referred to simply as Alpha-1, is an inherited genetic disorder characterized by low levels of a crucial protein known as Alpha-1 antitrypsin (AAT). This protein plays a vital role in protecting the lungs from damage. The deficiency increases the risk of developing severe diseases, including emphysema (damage to air sacs in the lungs), cirrhosis (liver scarring), and panniculitis (an uncommon skin condition). In some cases, these conditions can be life-threatening.

Who Does Alpha-1 Affect?

Alpha-1 primarily affects individuals who inherit two copies of the SERPINA1 gene, responsible for producing an abnormal type of the Alpha-1 protein. Genes serve as instructions for the body’s functioning, and variations in these genes can lead to low levels or the absence of AAT in the lungs. Even individuals with one abnormal copy of the gene (known as Alpha-1 carriers) can experience symptoms and an increased risk of lung damage, particularly if they smoke.

AAT Deficiency

Photo by: unsplash.com

How Common is Alpha-1?

Among people of European ancestry, Alpha-1 is one of the most prevalent genetic disorders, with 1 in 25 individuals having at least one abnormal copy of the gene. In the United States, approximately 1 in 3,500 people have both genes for AAT in an abnormal state, putting them at risk for severe organ damage. About 75% of individuals with two malfunctioning genes eventually develop lung function issues.

Symptoms and Causes

How Does Alpha-1 Affect Lungs and Liver?

Alpha-1 antitrypsin (AAT) is a crucial protein produced in the liver and transported through the bloodstream to the lungs. Its primary function is to inhibit an enzyme called neutrophil elastase, which is essential for combating lung infections. When AAT is deficient due to gene mutations, elastase continues to break down elastin, a protein that provides strength to the small air sacs in the lungs (alveoli). This leads to conditions like emphysema, where the alveoli lose their shape, making breathing and oxygen absorption difficult.

Gene mutations can also cause AAT to accumulate in the liver, leading to scarring. The inability of AAT to move to the bloodstream and lungs results in various health issues.

Advertisement
AAT Deficiency

Image by: redcliffelabs.com

Is Alpha-1 a Terminal Illness?

Alpha-1 is not necessarily a terminal illness. Many individuals with Alpha-1, especially those who do not smoke, can lead a normal lifespan. The prognosis varies among individuals, and factors such as early diagnosis, lifestyle choices, and the severity of organ damage play crucial roles.

Symptoms

What are the Symptoms of Alpha-1 Antitrypsin Deficiency?

Lung diseases caused by Alpha-1 exhibit symptoms similar to Chronic Obstructive Pulmonary Disease (COPD). These symptoms typically emerge between the ages of 30 and 50 and include:

  • Shortness of breath, especially during exercise or exertion.
  • Wheezing, characterized by a whistling sound during breathing.
  • Chronic cough, often accompanied by mucus.
  • Extreme fatigue.
  • Frequent chest colds.

Approximately 10% of infants and 15% of adults with Alpha-1 develop liver disease, manifesting through symptoms such as:

  • Jaundice, indicated by yellowing of the skin and eyes.
  • Itchy skin.
  • Swelling in the legs or abdomen (ascites).
  • Vomiting blood.

In rare instances, the initial symptoms of Alpha-1 may include painful, red bumps on the skin, known as panniculitis. These bumps can move around the body and may break open, leaking fluid or pus.

AAT Deficiency

Image by: depositphotos.com

Diagnosis and Tests

How is Alpha-1 Antitrypsin Deficiency Diagnosed?

Diagnosing Alpha-1 involves various tests, as its symptoms can resemble those of other illnesses. Blood tests are conducted to measure AAT levels, and if low levels are detected, genetic testing is performed to identify gene differences associated with Alpha-1. Imaging techniques, such as X-rays and CT scans, help visualize signs of Alpha-1 in the lungs, while pulmonary function tests assess lung function. Liver ultrasound or elastography may be conducted if liver issues are suspected, and in severe cases, a liver biopsy may be performed.

Management and Treatment

How is Alpha-1 Treated?

For individuals with lung conditions resulting from Alpha-1, healthcare providers may prescribe COPD medications and therapies like bronchodilators and pulmonary rehabilitation. Augmentation therapy, involving the infusion of normal AAT collected from blood donors, may be recommended for those with emphysema due to extremely low levels of Alpha-1. While augmentation therapy can slow the progression of emphysema, it does not prevent liver damage.

Liver issues associated with Alpha-1 may be managed symptomatically, but a liver transplant is the only cure for Alpha-1, restoring normal AAT production.

Medications and Treatments

Treatment options vary based on the affected organs:

  • Augmentation therapy: This involves intravenous infusion of supplemental normal AAT to increase levels and prevent future lung damage.
  • Medication: Inhaled corticosteroids and bronchodilators can ease breathing by reducing inflammation and opening airways.
  • Oxygen therapy: If oxygen levels are low, supplemental oxygen may be prescribed.
  • Pulmonary rehabilitation: Breathing exercises and physical therapy can improve breathing.
  • Smoking cessation therapy: Individuals who smoke are advised to quit to reduce complications.
  • Lung and liver transplants: Severe damage may necessitate organ transplants to improve quality of life.
AAT Deficiency

Photo by: unsplash.com

Prevention

How Can Alpha-1 Be Prevented?

Since Alpha-1 is an inherited condition, it cannot be prevented. However, certain measures can reduce the risk of organ damage:

  • Avoid smoking and secondhand smoke exposure.
  • Use safety equipment if working with chemicals or dust to minimize lung irritants.
  • Limit or avoid alcohol use, especially if certain types of Alpha-1 are present.
  • Get vaccinated against infectious diseases, including respiratory illnesses and liver infections.
  • Consider testing for family members if Alpha-1 is present in the family.

Outlook / Prognosis

What Can I Expect if I Have Alpha-1?

Prognosis varies based on factors such as early diagnosis, the type of Alpha-1, organ damage severity, and lifestyle choices. Some individuals may never experience symptoms or related organ damage, especially if they avoid smoking, while others may face life-threatening complications.

Complications of Alpha-1

Potential complications include progressive lung conditions, permanent damage to airways, pulmonary hypertension, cirrhosis, liver cancer, and inflammation of the fat under the skin (panniculitis). The impact on different organs can significantly affect an individual’s health.

Advertisement

Life Expectancy of Someone with Alpha-1 Antitrypsin Deficiency

Life expectancy varies widely. Factors such as quick diagnosis, the type of Alpha-1, organ damage severity, lung function, disease progression, and smoking habits significantly influence life expectancy. Smoking, in particular, reduces life expectancy for individuals with Alpha-1.

AAT Deficiency

Image by: www.freepik.com

Living With

How Do I Take Care of Myself with Alpha-1?

Taking care of oneself with Alpha-1 involves avoiding factors that can damage the lungs and liver. This includes abstaining from smoking, minimizing exposure to lung irritants, Treatment for other health Problems avoiding certain medications, and following healthcare provider recommendations for a healthy lifestyle.

When Should I See My Healthcare Provider?

Seek medical advice if experiencing symptoms of Alpha-1 or if there is a family history of the condition. Early diagnosis is crucial, especially for those with COPD or asthma, as an Alpha-1 test may be recommended.

Summary

In summary, Alpha-1 Antitrypsin Deficiency is a complex genetic disorder with varying impacts on individuals. Understanding its symptoms, diagnostic procedures, treatment options, and lifestyle recommendations is crucial for managing the condition effectively. Early diagnosis and proactive management can significantly improve the outlook for individuals living with Alpha-1.

Author

Continue Reading
Advertisement

health

The Role of AI in Tackling the Global Mental Health Crisis

Published

on

By

Reviewed
By Marek Dudas

How Mental Health Apps are Changing Therapy Access

In recent years, the global mental health crisis has emerged as a significant public health concern, affecting millions of people worldwide. With mental health disorders becoming increasingly prevalent, the need for innovative solutions has never been more urgent. Enter Artificial Intelligence (AI), a powerful tool that is poised to revolutionize the way mental health issues are diagnosed, treated, and managed. This article explores the role of AI in addressing the global mental health crisis, highlighting its potential benefits and challenges.

Understanding the Global Mental Health Crisis

Before delving into the role of AI, it is essential to understand the magnitude of the global mental health crisis. According to the World Health Organization (WHO), approximately 1 in 4 people worldwide will experience a mental health disorder at some point in their lives. Depression, anxiety, and other mental health conditions contribute significantly to the global burden of disease, impacting individuals’ quality of life and productivity.

The COVID-19 pandemic has exacerbated this crisis, with increased rates of mental health issues reported across the globe. Social isolation, economic uncertainty, and health-related fears have led to a surge in mental health concerns, overwhelming healthcare systems and highlighting the urgent need for effective interventions.

AI: A Game Changer in Mental Health Care

Artificial Intelligence, with its ability to analyze vast amounts of data and identify patterns, offers promising solutions to some of the most pressing challenges in mental health care. Here are several ways AI is being leveraged to tackle the global mental health crisis:

Early Detection and Diagnosis

One of the most significant advantages of AI in mental health care is its potential for early detection and diagnosis. AI algorithms can analyze data from various sources, such as social media activity, wearable devices, and electronic health records, to identify early signs of mental health issues. For example, changes in language patterns, sleep disturbances, or social withdrawal can be detected by AI systems, allowing for timely intervention before conditions worsen.

Advertisement

Personalized Treatment Plans

AI can also play a crucial role in developing personalized treatment plans for individuals with mental health disorders. By analyzing data from diverse sources, AI can help clinicians tailor interventions to meet the specific needs of each patient. This personalized approach can improve treatment outcomes and enhance the overall effectiveness of mental health care.

Enhancing Access to Care

Access to mental health care remains a significant barrier for many individuals, particularly in low- and middle-income countries where resources are limited. AI-powered tools, such as chatbots and virtual therapists, can provide affordable and accessible support to individuals who may not have access to traditional mental health services. These tools can offer immediate assistance, monitor symptoms, and provide coping strategies, helping to bridge the gap in mental health care access.

Reducing Stigma

Stigma surrounding mental health is a pervasive issue that prevents many individuals from seeking help. AI has the potential to reduce stigma by normalizing conversations about mental health and providing anonymous support options. Online platforms powered by AI can offer a safe space for individuals to discuss their mental health concerns without fear of judgment, encouraging more people to seek the help they need.

The Role of AI in Tackling the Global Mental Health Crisis

Photo by Total Shape on Unsplash

Challenges and Ethical Considerations

While the potential of AI in addressing the global mental health crisis is immense, it is not without challenges. Several ethical considerations must be addressed to ensure the responsible use of AI in mental health care:

Privacy and Data Security

The use of AI in mental health care involves the collection and analysis of sensitive personal data. Ensuring the privacy and security of this data is paramount to maintaining trust and protecting individuals’ rights. Robust data protection measures and transparent data usage policies are essential to mitigate privacy concerns.

Bias and Fairness

AI algorithms are only as good as the data they are trained on. If the data used to train AI systems is biased, the outcomes may perpetuate existing inequalities in mental health care. Efforts must be made to ensure that AI systems are trained on diverse and representative data sets to avoid biased outcomes and promote fairness.

Advertisement

Human Oversight

While AI can enhance mental health care, it should not replace human clinicians. Human oversight is crucial to ensure that AI-powered interventions are accurate and appropriate. Clinicians should work alongside AI systems, using their expertise to interpret AI-generated insights and make informed decisions about patient care.

Future Directions

The integration of AI into mental health care is still in its early stages, but the potential for growth and innovation is vast. As technology continues to advance, AI could play an even more significant role in addressing the global mental health crisis. Future developments may include:

  • Advanced Predictive Models: AI systems could become more sophisticated in predicting mental health issues, allowing for even earlier interventions and prevention strategies.
  • Integration with Other Technologies: Combining AI with other emerging technologies, such as virtual reality (VR) and augmented reality (AR), could enhance therapeutic experiences and offer new avenues for treatment.
  • Global Collaboration: International collaboration and knowledge sharing could accelerate the development and implementation of AI solutions in mental health care, ensuring that innovations benefit individuals worldwide.

Conclusion

The global mental health crisis demands urgent and innovative solutions, and AI offers a promising path forward. By enhancing early detection, personalizing treatment, increasing access to care, and reducing stigma, AI has the potential to transform mental health care on a global scale. However, it is essential to address the ethical challenges associated with AI to ensure its responsible and equitable use. With continued research, collaboration, and investment, AI could play a pivotal role in alleviating the global mental health crisis and improving the lives of millions.

Author

Continue Reading

health

Personalized Nutrition in Cancer Care: Enhancing Treatment Outcomes

Published

on

By

Reviewed
By Mark Peterson

The Role of Nutrition in Managing Chronic Illnesses

In recent years, the medical community has witnessed a transformative shift in how cancer treatment is approached, with personalized nutrition plans emerging as a pivotal component in patient care. This evolution reflects a broader trend towards personalization in medicine, where treatments and interventions are tailored to the unique characteristics of each patient. The integration of personalized nutrition into cancer care holds promise for improving patient outcomes, enhancing quality of life, and potentially even influencing the course of the disease.

Understanding Personalized Nutrition

Personalized nutrition refers to the customization of dietary recommendations based on an individual’s specific health needs, genetic makeup, lifestyle, and preferences. This approach contrasts with the traditional “one-size-fits-all” dietary guidelines, acknowledging that everyone metabolizes nutrients differently and may have distinct nutritional requirements.

In the context of cancer, personalized nutrition takes into account the type and stage of cancer, the patient’s treatment plan, and their overall health status. It aims to provide a nutritional strategy that supports the body’s ability to fight cancer, manage symptoms, and cope with the side effects of treatment.

The Role of Nutrition in Cancer Care

Nutrition plays a critical role in cancer care, influencing both the progression of the disease and the patient’s ability to tolerate treatment. Adequate nutrition can help maintain body weight, preserve muscle mass, and support immune function, all of which are crucial for patients undergoing chemotherapy, radiation, or surgery.

Cancer and its treatment can lead to various nutritional challenges, including:

Advertisement
  • Loss of Appetite: Many cancer patients experience a reduced desire to eat, which can result in weight loss and malnutrition.
  • Taste Changes: Treatments can alter taste perception, making it difficult for patients to enjoy food.
  • Digestive Issues: Nausea, vomiting, and diarrhea are common side effects that can hinder nutrient absorption.
  • Increased Energy Needs: Some patients may require more calories to maintain their weight and energy levels.

Personalized nutrition plans aim to address these challenges by providing tailored dietary recommendations that align with the patient’s needs and preferences.

The Science Behind Personalized Nutrition for Cancer Patients

The development of personalized nutrition plans for cancer patients is grounded in scientific research that explores the relationship between diet, genetics, and cancer. Advances in genomics and nutrigenomics—the study of how genes and nutrients interact—have paved the way for more precise dietary interventions.

For example, certain genetic variations can affect how individuals metabolize specific nutrients, such as folate or omega-3 fatty acids. By understanding these genetic differences, healthcare providers can recommend diets that optimize nutrient intake and support cancer treatment.

Moreover, research has shown that certain dietary patterns may influence cancer risk and progression. Diets rich in fruits, vegetables, whole grains, and lean proteins are associated with a lower risk of cancer, while high consumption of processed foods and red meats has been linked to an increased risk. Personalized nutrition plans leverage this knowledge to promote dietary choices that may help reduce the risk of cancer recurrence or progression.

Personalized Nutrition in Cancer Care: Enhancing Treatment Outcomes

Image by: https://www.healthline.com/nutrition/is-fruit-good-or-bad-for-your-health

Implementing Personalized Nutrition in Cancer Care

Implementing personalized nutrition plans in cancer care involves a multidisciplinary approach that includes oncologists, dietitians, genetic counselors, and other healthcare professionals. The process typically involves several key steps:

  1. Assessment: A comprehensive assessment of the patient’s medical history, dietary habits, genetic profile, and treatment plan is conducted to identify nutritional needs and challenges.
  2. Goal Setting: Clear, achievable goals are established to guide the development of the nutrition plan. These goals may focus on maintaining weight, managing side effects, or enhancing treatment efficacy.
  3. Plan Development: A personalized nutrition plan is created, taking into account the patient’s preferences, lifestyle, and any dietary restrictions. The plan may include specific meal plans, recipes, and recommendations for supplements if needed.
  4. Monitoring and Adjustment: Regular monitoring of the patient’s nutritional status and treatment progress is essential. The nutrition plan is adjusted as needed to address any changes in the patient’s condition or treatment regimen.

Benefits of Personalized Nutrition for Cancer Patients

The benefits of personalized nutrition plans for cancer patients are multifaceted. By addressing individual nutritional needs, these plans can:

  • Improve Treatment Tolerance: Adequate nutrition helps patients better tolerate the side effects of cancer treatment, potentially reducing the need for dose reductions or treatment delays.
  • Enhance Quality of Life: Personalized nutrition can alleviate symptoms such as fatigue, nausea, and pain, improving overall well-being and quality of life.
  • Support Immune Function: Proper nutrition bolsters the immune system, which is crucial for fighting infections and supporting recovery.
  • Promote Healing and Recovery: Nutrient-rich diets support tissue repair and recovery after surgery or other treatments.
  • Potentially Influence Disease Outcomes: While more research is needed, there is evidence to suggest that personalized nutrition may impact cancer progression and survival rates.

Challenges and Future Directions

Despite the promising potential of personalized nutrition in cancer care, several challenges remain. One of the primary obstacles is the need for more robust scientific evidence to guide specific dietary recommendations for different types of cancer. Additionally, the integration of personalized nutrition into standard cancer care requires significant resources and coordination among healthcare providers.

Moreover, access to personalized nutrition services can be limited by factors such as cost, availability of trained professionals, and healthcare coverage. Efforts to address these barriers are essential to ensure that all cancer patients can benefit from personalized nutrition plans.

Looking ahead, continued research and technological advancements will likely enhance the precision and effectiveness of personalized nutrition. Innovations in areas such as artificial intelligence and machine learning may enable more accurate predictions of individual dietary needs and responses.

Advertisement

Conclusion

The rise of personalized nutrition plans for cancer patients represents a significant advancement in oncology care. By tailoring dietary interventions to the unique needs of each patient, personalized nutrition has the potential to improve treatment outcomes, enhance quality of life, and offer new hope in the fight against cancer. As research and technology continue to evolve, personalized nutrition is poised to become an integral part of comprehensive cancer care, offering a brighter future for patients and their families.

Author

Continue Reading

health

The Future of AI in Emergency Medicine: Faster Diagnostics

Published

on

By

Reviewed
By Eli Small

The Future of AI in Emergency Medicine: Faster Diagnostics

Artificial Intelligence (AI) has been making headlines across various sectors, and healthcare is no exception. In particular, the role of AI in emergency medicine is rapidly evolving, promising to revolutionize diagnosis and treatment processes. By automating routine tasks, predicting patient outcomes, and accelerating diagnostics, AI has the potential to transform emergency medicine into a more efficient and patient-centric field.

AI in Emergency Medicine: An Overview

Emergency medicine is a high-pressure field where time is of the essence. Every second count in diagnosing and treating patients, and delays can lead to adverse outcomes. AI can play a crucial role in this context by enabling faster and more accurate diagnostics. By leveraging machine learning algorithms and predictive analytics, AI can assist physicians in making swift and informed decisions.

AI-powered tools leverage advanced algorithms to rapidly process and interpret immense data sets, enabling healthcare professionals to generate valuable insights that can guide decision-making and enhance patient care. By swiftly analyzing a patient’s comprehensive medical history, symptoms, and diagnostic test results, AI can identify subtle patterns and correlations that may not be immediately apparent to a human observer.

This predictive capability empowers physicians to tailor treatment plans based on individual risk factors, optimize resource allocation, and anticipate potential health outcomes with greater accuracy.

Furthermore, AI’s ability to continuously monitor and analyze data in real-time allows for proactive intervention and personalized care delivery. By constantly evaluating and updating patient information, AI algorithms can alert healthcare providers to potential complications or changes in a patient’s condition, enabling timely interventions and preventative measures. This proactive approach not only improves patient outcomes but also reduces healthcare costs by minimizing unnecessary hospitalizations and emergency room visits.

Advertisement

In summary, AI-powered tools represent a transformative force in healthcare by harnessing the power of data analytics to drive more informed decision-making and deliver personalized care. By augmenting the capabilities of healthcare professionals, AI has the potential to revolutionize the way medical diagnoses are made, treatments are administered, and patient outcomes are predicted. As the technology continues to evolve and mature, its impact on the healthcare industry is expected to grow exponentially, ultimately leading to improved quality of care and better health outcomes for patients worldwide.

The Future of AI in Emergency Medicine: Faster Diagnostics

Picture by: Yandex.com

The Potential of AI in Faster Diagnostics

One of the primary ways AI can transform emergency medicine is through faster diagnostics. Traditionally, diagnosing a patient involves a series of steps – taking a medical history, performing a physical examination, ordering and interpreting tests, and finally, making a diagnosis. This process can be time-consuming and prone to human error, especially in high-pressure emergency situations.

AI has the potential to streamline this process by automating certain steps and providing physicians with real-time, data-driven insights. For instance, AI algorithms can analyze imaging scans to detect anomalies, reducing the time taken to interpret results. Similarly, AI can analyze lab results and patient symptoms to suggest possible diagnoses, reducing the time taken to reach a diagnosis.

Moreover, AI can also help in predicting the likelihood of certain conditions based on a patient’s symptoms and medical history. This can allow physicians to prioritize patients based on their risk levels and ensure that those in most need receive immediate attention.

The Role of AI in Predictive Analytics

Predictive analytics is another area where AI can make a significant impact in emergency medicine. By analyzing historical and real-time data, AI can predict patient outcomes and help physicians make informed decisions.

For instance, AI can predict the likelihood of a patient developing complications or needing hospitalization based on their symptoms, medical history, and other relevant data. This can help physicians to make proactive decisions and take preventive measures.

Advertisement

For example, AI algorithms can analyze various factors such as a patient’s medical history, demographics, and current health status to predict the likelihood of them requiring a specific treatment or intervention in the future. By accurately forecasting these needs, healthcare providers can proactively allocate resources such as medical supplies, equipment, and staff to ensure that they are readily available when needed. This predictive capability can greatly improve efficiency in healthcare operations and ultimately lead to better patient outcomes. For instance, if an AI system predicts that a certain number of patients will require a particular surgery in the upcoming weeks, hospitals can adjust their schedules and staffing levels accordingly to accommodate this demand. This proactive approach can reduce wait times for patients, minimize disruptions in care delivery, and optimize the utilization of resources within the healthcare system. Furthermore, AI can also help healthcare organizations in long-term resource planning by identifying trends and patterns in patient data. By analyzing historical data, AI systems can forecast future healthcare needs and facilitate strategic decision-making in terms of resource allocation and investment. This can help healthcare providers in optimizing their budgets, streamlining operations, and improving overall service delivery. In conclusion, AI-powered predictive analytics in healthcare can revolutionize how resources are allocated and utilized, leading to more efficient and effective healthcare delivery. By leveraging AI technology, healthcare organizations can better anticipate and address the needs of patients, ultimately enhancing the quality of care and outcomes for individuals.

The Future of AI in Emergency Medicine

The future of AI in emergency medicine looks promising. As AI technologies continue to evolve, they are expected to become an integral part of emergency medicine, enabling faster and more accurate diagnostics.

However, the integration of AI in emergency medicine also poses certain challenges. Ensuring the accuracy and reliability of AI algorithms is critical, as errors can have serious consequences in emergency situations. Moreover, there are also ethical and legal considerations related to the use of AI in healthcare, such as issues of data privacy and informed consent.

Despite these challenges, the potential benefits of AI in emergency medicine are significant. By enabling faster diagnostics, predictive analytics, and data-driven decision-making, AI can help to improve patient outcomes and enhance the efficiency of emergency medicine. As we move into the future, the role of AI in emergency medicine is expected to grow, transforming the way we diagnose and treat patients in emergency situations.

In conclusion, the future of AI in emergency medicine is one of promise and potential. By harnessing the power of AI, we can look forward to a future where diagnostics are faster, more accurate, and more efficient, ultimately leading to better patient outcomes and a more effective healthcare system. However, as we continue to integrate AI into this critical field, it is essential to address the challenges and ensure that these technologies are used responsibly and ethically.

Advertisement

Author

Continue Reading

Readers like you help support Contrank. When you make a purchase using links on our site, we may earn an affiliate commission. Read More.

Advertisement

Trending