Symptoms range from none at first to fever, jaundice, fatigue, and a tender, painful, and enlarged liver, then to more serious problems such as bleeding in the digestive tract and deterioration of brain function. o [ pediatric abdominal pain ] How do you get rid of salivary gland pain? It can also identity whether iron has accumulated in the liver. National Health Insurance Sharing Service. o [teenager OR adolescent ], , MD, University of Colorado School of Medicine. Can alcohol cause swollen salivary glands? Benzodiazepines (sedatives) are used to treat withdrawal symptoms (see Emergency treatment Emergency treatment Alcohol (ethanol) is a depressant (it slows down brain and nervous system functioning). Conclusion Patients often display various nonspecific neurological symptoms. The NHIS provides a representative sample database with a substantial volume of representative information that does not require privacy regulation for public health research and policy development. Can alcohol make your jaw hurt? Why do the sides of my mouth hurt when I drink alcohol? In addition, alcohol leads to the accumulation of pathological microbes within the mucosa, leading to chronic infection. Ethanol diffuses rapidly into saliva during the drinking, and immediately after its salivary concentration is temporarily much higher than in plasma. nutritional aspects of cirrhosis in alcoholism: effect of . Cohort profile: the national health insurance service-national health screening cohort (NHIS-HEALS) in Korea. Seong SC, Kim YY, Park SK, Khang YH, Kim HC, Park JH, et al. Look no further. People may have a fever, jaundice, and a tender, painful, enlarged liver. Oral and facial pain can affect eating, talking, and many other activities that involve the head, neck, mouth, and throat. 2008 Apr;32(4):652-6. doi: 10.1111/j.1530-0277.2007.00613.x. The .gov means its official. Most alcohol, after being absorbed in the digestive tract, is processed (metabolized) in the liver. Accessed Feb. 16, 2017. This site needs JavaScript to work properly. Waszkiewicz N, Zalewska-Szajda B, Chojnowska S, Szajda SD, Zalewska A, Konarzewska B, Szulc A, Wojtulewska-Supron A, Kpka A, Kna M, adny JR, Milewski R, Zwierz K. Dis Markers. Many conditions can damage the liver read more and cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. In this study, we estimated the odds ratios (ORs) of smoking, alcohol consumption and obesity in sialolithiasis patients compared to participants in a 1:4 matched control group. In contrast to hospital-based studies, we used participants from a large representative nationwide population who had undergone health screening examinations. Synergistic effect of alcohol drinking and smoking on in vivo acetaldehyde concentration in saliva. Fourth, we did not have data from patients who were younger than 40years old because the health screening examinations were performed in individuals older than 40years. Please note that THE MANUAL is not responsible for the content of these resources. If you've noticed persistent dry mouth signs and symptoms, make an appointment with your doctor. National Library of Medicine Unauthorized use of these marks is strictly prohibited. Obesity was measured using body mass index (BMI, kg/m2), which was categorized as <18.5 (underweight), 18.5 and<23 (normal), 23 and<25 (overweight), 25 and<30 (obese I), and30 (obese II). Unable to load your collection due to an error, Unable to load your delegates due to an error. Xerostomia (dry mouth). Different types of beverages contain different percentages of alcohol. Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma, read more ). Only about half the people with these complications are still alive after 5 years. Dry mouth - Symptoms and causes - Mayo Clinic While drinking does not commonly cause the swelling of lymph nodes, it may cause pain in those areas. information is beneficial, we may combine your email and website usage information with The exact pathogenesis of stone formation in the salivary gland remains unclear. Dry Mouth. Alcohol can irritate the digestive system and change how the body absorbs fluids. Inflammation can cause pneumonia, bronchitis or other problems in your lungs; lead to problems . Liver biopsy Biopsy of the Liver Doctors can obtain a sample of liver tissue during exploratory surgery, but more often they obtain a sample by inserting a hollow needle through the person's skin and into the liver. However, there are no reports on the incidence rate of sialolithiasis in Korea. People may vomit blood or have bloody or dark, tarry stools. It occurs in more than 90% of people who drink too much alcohol. Crude and adjusted odds ratios (95% confidence interval) for smoking, drinking alcohol, and obesity in sialolithiasis patients in each stratified group according age and sex, Conditional model including age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia history, Model adjusted for obesity, smoking status (current or past smoker vs. nonsmoker), and frequency of alcohol consumption ( 1 time per week compared to <1 time per week). Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients and a review of the literature. After cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. Sialolithiasis, which is the presence of a salivary duct stone, is the most common cause of major salivary gland swelling and pain in the ipsilateral salivary gland, typically when eating [1, 2]. GUID:BFDE4AFC-2F93-450E-B213-8262330A951E, GUID:654B997E-AB15-4CA9-BC2B-E70C45A2ECE6, Sialolithiasis, Smoker, Alcohol, Obesity, Nested case-control study. A population-based study on the association between chronic periodontitis and sialolithiasis. Surgeon. The rate of tobacco smoking was higher in the sialolithiasis group (32.4% [307/947]) than in the control group (29.1% [1103/3788], P=0.047, Table1). Smoking and alcohol together increase salivary acetaldehyde production by ~100% as compared with non-smokers and moderate alcohol consumers. Small spiderlike blood vessels (spider angiomas) may appear in the skin of the upper body. . There are three pairs of major salivary glands parotid, sublingual and submandibular. In heavy drinkers, thiamin deficiency Thiamin Deficiency Thiamin deficiency (causing beriberi and other problems) is most common among people whose diet mainly consists of white rice or highly processed carbohydrates in countries with high rates of read more can lead to Wernicke encephalopathy Wernicke Encephalopathy Wernicke encephalopathy is a brain disorder that causes confusion, eye problems, and loss of balance and results from thiamin deficiency. Allergy symptoms are often more painful and uncomfortable than alcohol intolerance symptoms. A clinical link between the chronic consumption of alcohol and head and neck cancer has been observed for decades. Chronic consumption of alcoholic beverages is an accepted social custom worldwide. Therefore, a vicious cycle that accelerates the formation of salivary gland stones ensues. ; Sjgren's syndrome: This autoimmune disease affects moisture-producing glands in the body and causes swelling and dry mouth; Diabetes: High blood glucose (sugar) may cause salivary gland enlargement and lower saliva production. Additional analyses of these groups according to sex and age did not show any differences. Cirrhosis (scarring that distorts read more : The vein that brings blood to the liver may be narrowed or blocked, increasing blood pressure in that vein. Obesity in relation to oral health behaviors: an analysis of the Korea National Health and nutrition examination survey 2008-2010. When saliva cant exit through the ducts, it backs up into the gland, causing pain and swelling. The adjusted ORs for the association between smoking and sialolithiasis were 1.34 (95% CI=1.081.66, P=0.007 among those with a duration of smoking 20years and 1.24 (95% CI=0.941.63, P=0.123, S3 table) among those with a duration of smoking <20years. Epub 2013 Oct 22. People may become undernourished because drinking too much alcohol, which has calories but little nutritional value, decreases the appetite. Dry mouth. The link you have selected will take you to a third-party website. Similar to tobacco smoking, alcohol consumption and obesity play an important role in oral health. Int J Cancer. Having hepatitis B or hepatitis C or fatty liver disease, or drinking read more are done. A review of the relationship between alcohol and oral cancer. 8600 Rockville Pike Review/update the Liver imaging tests are not routinely done. Association of sialolithiasis with cholelithiasis: a population-based study. What happens when you stop eating rice for a month? Barcia JM, Portols S, Portols L, Urdaneta AC, Ausina V, Prez-Pastor GM, Romero FJ, Villar VM. The proof is about twice the percentage of alcohol. The results were statistically analyzed using SPSS v. 22.0 (IBM, Armonk, NY, USA). Tobacco smoking showed a positive association with sialolithiasis in the population40years old. Systemic effects of alcohol interact with local changes in the morphology and function of the salivary glands. All authors read and approved the final manuscript. U.S. Food and Drug Administration. Thus, other factors are involved. Salivary Glands: Anatomy, Function, and Conditions - Verywell Health information and will only use or disclose that information as set forth in our notice of Therefore, obesity can be considered the cause of chronic inflammation, which can lead to the formation of salivary stone, but a normal amount of salivary flow and enzymes with high activity can interfere with the salivary stone formation. What causes inflammation of the parotid gland? Generally, the association between alcohol consumption and inflammation is known to depend on the amount of alcohol consumed. However, evidence of an association between alcohol consumption and sialolithiasis is lacking even though alcohol drinking is one of the most common causes of oral cavity and deep neck infection [15, 16]. official website and that any information you provide is encrypted In subgroup analyses performed according to age and sex, the adjusted OR for smoking with statistical significance was 1.36 and 1.27 for participants <60years old (95% CI=1.061.75, P=0.017) and for men (95% CI=1.031.56, P=0.023, Table3), respectively. Why do my lymph nodes hurt after drinking alcohol? Lee JW, You NY, Kim Y, Kim Y, Kim J, Kang HT. Mennella I, Fogliano V, Vitaglione P. Salivary lipase and -amylase activities are higher in overweight than in normal weight subjects: influences on dietary behavior. http://www.aaom.com/index.php?option=com_content&view=article&id=107:xerostomia&catid=22:patient-condition-information&Itemid=120. Obesity was measured using BMI (kg/m2) and was categorized as <18.5 (underweight), 18.5 and<23 (normal), 23 and<25 (overweight), 25 and<30 (obese I), and30 (obese II) following the WPRO 2000 guidelines [27]. Alcohol consumption and obesity were not statistically significantly related to sialolithiasis. A technique called ultrasound elastrography may be done to determine how stiff the liver is. Participants with sialolithiasis who had no history of health evaluations before the index date were excluded (n=89). After the formation of salivary duct stones, bacteria can ascend the duct more easily from the mouth and proliferate on the surface of the stones, contributing to the further development of sialolithiasis [11]. . Amylase is an enzyme, a type of protein that helps your body break down carbohydrates. American Dental Association. T Bone Steak Nutrition: Benefits And Nutritional Value Explained, Oberweiss Nutrition: A Comprehensive Overview Of The Brands Health Benefits, Kung Fu Tea Nutrition: What You Need To Know, Boars Head Turkey Nutrition: Health Benefits And Nutritional Information, Velveeta Nutrition Facts: What You Need To Know, Twizzlers Nutrition Facts: Ingredients, Calories, And More, Right Rice Nutrition: Everything You Need To Know, Budweiser Nutrition Facts: What You Need To Know, Hot Cheetos Nutrition Facts: Everything You Need To Know, Ginger Beer Nutrition Facts: What You Need To Know, Health Mutt: Your Guide To A Happy And Healthy Canine Companion. Bethesda, MD 20894, Web Policies To provide you with the most relevant and helpful information, and understand which American Academy of Oral Medicine. What effect does alcohol have on your health and your liver? Salivary Gland Cancer: Symptoms, Causes & Treatment - Cleveland Clinic Inflammatory disorders of the salivary glands. Please enable it to take advantage of the complete set of features! Dry mouth, or xerostomia (zeer-o-STOE-me-uh), refers to a condition in which the salivary glands in your mouth don't make enough saliva to keep your mouth wet. Often, if inflammation is severe, people are hospitalized and may need to be fed through a tube to receive adequate nutrition. health information, we will treat all of that information as protected health A salivary gland infection is also called sialadenitis and is caused by bacteria or viruses. Trauma to the inside of the mouth. The enlarged spleen traps and destroys more white blood cells and platelets than it normally does. The remaining 1 percent contains a multitude of components, such as sodium, calcium, magnesium, potassium, immunoglobulins, proteins, enzymes, and mucins. The common risk factor approach: a rational basis for promoting oral health. Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma, read more ). Background and data configuration process of a nationwide population-based study using the korean national health insurance system. Federal government websites often end in .gov or .mil. Sometimes it travels to the groin. Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma, read more .). Drug effects on salivary glands: dry mouth - Wiley Online Library The adjusted ORs for obesity in the sialolithiasis group were 0.56 (95% CI=0.311.01, P=0.055) for BMI<18.5; 1.00 for BMI18.5 to <23; 1.09 (95% CI=0.901.31, P=0.376) for BMI23 to <25; 0.98 (95% CI=0.811.17, P=0.800) for BMI25 to <30; and 1.36 (95% CI=0.931.98, P=0.119) for BMI30. For cirrhosis to develop, men usually must drink more than about 3 ounces of alcohol a day for more than 10 years. The site is secure. Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood read more and bleeding in the digestive tract Gastrointestinal Bleeding Bleeding may occur anywhere along the digestive (gastrointestinal or GI) tract, from the mouth to the anus. Accessed Feb. 15, 2017. As alcohol-related liver disease progresses to alcoholic hepatitis, symptoms may range from mild to life-threatening. Your parotid glands are located on the side of your face, between your ear and your jaw. Liver failure Liver Failure Liver failure is severe deterioration in liver function. Salivary stones and ductal inflammation increase the occurrence of sialolithiasis. The scar read more . Park JB, Nam GE, Han K, Ko Y, Park YG. 2015 Nov 5;5(4):2987-3008. doi: 10.3390/biom5042987. Overview What is parotitis? Kraaij S, Karagozoglu KH, Kenter YA, Pijpe J, Gilijamse M, Brand HS. The https:// ensures that you are connecting to the Why does alcohol cause parotid glands to swell? Stone sizes have been reported to be much larger in current smokers than in ex-smokers (12.4mm vs. 7.5mm, P=0.03) [13]. Accessed Feb. 15, 2017. Fatty liver Fatty Liver Fatty liver is an abnormal accumulation of certain fats (triglycerides) inside liver cells. Excessive drinking can cause a lot more than neck and shoulder pain. The submandibular glands are the most commonly . (See read more may be done if the damage is severe. In this reason, written informed consent was exempted by the Institutional Review Board. Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma, read more ). Oral micro-organisms in the etiology of cancer. Participants in the control group were sorted using a random number order and selected from top to bottom to prevent selection bias. Subjects were matched by age group, sex, income group, region of residence, and medical history (e.g., hypertension, diabetes, and dyslipidemia). Finally, 1:4 matching resulted in the inclusion of 947 participants with sialolithiasis and 3788 control participants. Many conditions can damage the liver read more ), which performs no function. Use for phrases Morita I, Okamoto Y, Yoshii S, Nakagaki H, Mizuno K, Sheiham A, et al. This study has several benefits. "Salivary gland cancer" is a term used to describe malignant tumors that affect your salivary glands. include protected health information. Frequent neck pain is only one of the signs of alcoholism. Liver cancer Hepatocellular Carcinoma Hepatocellular carcinoma is a cancer that begins in the liver cells and is the most common of the primary liver cancers. sharing sensitive information, make sure youre on a federal American Liver Foundation: Hosts community education programs that give an overview of all aspects of liver disease and wellness. and transmitted securely. However, there are no reports on the incidence rate of sialolithiasis in Korea. However, disulfiram has not been shown to promote abstinence and consequently is recommended only for certain people. http://www.fda.gov/forconsumers/consumerupdates/ucm254273.htm. However, if alcohol-related liver disease is advanced, sedatives are used in small doses or avoided because they can trigger portosystemic encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is deterioration of brain function that occurs in people with severe liver disease because toxic substances normally removed by the liver build up in the blood and reach read more . All insured Koreans who are at least 40years old and their dependents undergo no-cost biannual health evaluations. Parotid Swelling, Alcoholism and Cirrhosis | NEJM 1 When chronic heavy drinkers are intoxicatedand when they are withdrawing from alcohol intoxicationthey can experience mood swings, diminished cognitive abilities, memory loss, and. Jin YJ and Choi HG acquired the data and performed the analysis. However, liver disease does not develop in every person who drinks heavily for a long time. Why do my salivary glands hurt when I drink alcohol? Significance at P<0.05. Salivary Gland Disorders - Ear, Nose, and Throat Disorders - MSD Manual Federal government websites often end in .gov or .mil. Additionally, it contains carcinogens, which can cause certain cancers. Parotid enlargement is frequently observed in heavy drinkers with and without chronic liver disease. National Institute of Dental and Craniofacial Research. Can Drinking Cause Swollen Lymph Nodes? Biomolecules. It occurs when the liver attempts to repair and replace damaged cells. Statin use and site-specific risk of colorectal cancer in individuals with hypercholesterolemia from the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS). Because you have many other salivary glands, removing this one doesn't adversely affect the amount of saliva you produce. Chronic alcohol consumption has been correlated with an increased risk of cancer and increased mortality in a dose-effect relationship. Also, nutritional deficiencies probably cause or contribute to peripheral nerve damage. Drinking alcohol and smoking or chewing tobacco can increase dry mouth symptoms. Such people are likely to live longer. Peripheral nerves (nerves outside the brain and spinal cord) may be damaged, causing loss of sensation and strength. Please enable it to take advantage of the complete set of features! For the subgroup analyses, we divided the participants by age and sex (<60years, 60years; male and female). There are three pairs of major salivary glands parotid, sublingual and submandibular. Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ - NCI Parotid enlargement due to alcoholism Louis Mandel, DDS Harold Baurmash, DDS, Bronx, NY Chronic swelling of the parotid glands can be a result of alcoholism even in patients who do not have cirrhosis of the liver. Genetic makeup is thought to be involved because alcohol-related liver disease often runs in families. It is known that the oral mucosal surface is the home of numerous normal flora microorganisms and is the portal of entry for the majority of pathogens. Treatment for dry mouth depends on the cause. A number of diseases can affect your salivary glands. We used alcohol consumption to define alcohol consumption 1 time per week compared to alcohol consumption <1 time per week. The most common infection which affects the salivary glands is mumps. If the salivary glands are damaged or aren't producing enough saliva, it can affect taste, make chewing and swallowing more difficult, and increase the risk for . How to Find Relief for a Blocked Salivary Gland | Banner Exposure-dependent effects of ethanol on the innate immune system. Portal hypertension leads to an enlarged spleen, which also decreases the number of platelets. 1999 Aug;23(8):1409-15. Fatty liver may completely resolve within 6 weeks. . However, the association of alcohol consumption and obesity with sialolithiasis did not reach statistical significance. We selected the frequency of alcohol consumption in this study. Liver failure is caused by a disorder or substance that damages the liver. In the United States, over 1 million people have read more (a hereditary disorder that results in absorption of too much iron) or when they drink fortified wines that contain iron. 1Department of Otorhinolaryngology-Head & Neck Surgery, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, South Korea, 2Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, South Korea, 3Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, South Korea, 4Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do 14068 Republic of Korea. The etiology of the development of a salivary stone is still not clear. In the United States, over 1 million people have read more . The age groups were classified using 5-year age intervals: 4044, 4549, 5054, , and 85+ years old. Damage to the oral tissues seems to be ascribed mostly to the action of acetaldehyde, although some acute effects depend on a direct action of ethanol and formation of reactive oxygen species (ROS) and fatty acid ethyl esters (FAEEs). 2003 Aug;17(4):575-92. doi: 10.1016/s1521-6918(03)00034-9. Parotid Enlargement Due to Alcoholism - ScienceDirect The predominant prevalence in the submandibular gland occurs because Whartons duct has a longer course and a larger diameter than Stensons duct; thus, saliva flows against gravity and has a more viscous composition with a higher calcium and mucin content in this gland than in other salivary glands [9, 10]. These regions were regrouped into urban (Seoul, Busan, Daegu, Incheon, Gwangju, Daejeon, and Ulsan) and rural (Gyeonggi, Gangwon, Chungcheongbuk, Chungcheongnam, Jeollabuk, Jeollanam, Gyeongsangbuk, Gyeongsangnam, and Jeju) areas. The adjusted OR for smoking in the sialolithiasis group was 1.31 (95% CI=1.081.59, P=0.006, Table2). American Academy of Oral Medicine. The best ways to stop drooling Change sleeping positions. (See read more , abstinence is the only treatment that can slow or reverse alcohol-related liver disease. Summary. General characteristics of the participants, *Chi-square test. FOIA Diabetes, frequency of exercise, and mortality over 12 years: analysis of the National Health Insurance Service-health screening (NHIS-HEALS) database. FOIA In hard liquor, the alcohol concentration is often described as proof. Alcohol is a corrosive substance that can deteriorate the esophagus, stomach, intestines lining, mouth, and throat. The https:// ensures that you are connecting to the Also, the damage caused by alcohol can interfere with the absorption and processing of nutrients. Can drinking cause lymph nodes to hurt? All rights reserved. These glands may not work properly as the result of: If you don't have enough saliva and develop dry mouth, this can lead to: Mayo Clinic does not endorse companies or products. The datasets analyzed during the current study are in the public domain and are freely available from http://nhiss.nhis.or.kr/ with permission. In this study, we used the most recent health evaluation data before the index date. Therefore, participants in the control group who died before the index date were excluded. Long-Term Effects of Alcohol on the Intestines | Alcohol Detox Blood may be easily seen by the naked eye (overt), or blood may be present in amounts read more ) develop, the prognosis is worse. Accessed Feb. 15, 2017. For example, an 80-proof hard liquor contains 40% alcohol. This content does not have an Arabic version. Escudier M, McGurk M. Economics: symptomatic sialoadenitis and sialolithiasis in the English population, an estimate of the cost of hospital treatment. The https:// ensures that you are connecting to the An official website of the United States government. Background. PMC FOIA https://naturalmedicines.therapeuticresearch.com. Waszkiewicz N, Szajda SD, Jankowska A, Zwierz P, Czernikiewicz A, Szulc A, Zwierz K. Alcohol Clin Exp Res. 2005;23(3-4):195-203. doi: 10.1159/000090166. Work in certain occupations, including plumbing, rubber products manufacturing, asbestos . In cirrhosis, a large amount of normal liver tissue is permanently replaced with scar tissue (called fibrosis Fibrosis of the Liver Fibrosis is the formation of an abnormally large amount of scar tissue in the liver. We found the similar results when we analyzed these factors according to the duration of smoking and the amount of alcohol consumed. Xerostomia. These dysfunctions may result in Too little clotting, leading to abnormal read more : People tend to bleed and bruise more easily because the damaged liver does not produce enough of the substances that make blood clot (coagulate). Within 30 minutes, salivary ethanol concentration equilibrates with the plasma level, thus suggesting that ethanol easily penetrates the whole body, including oral cavity tissues and salivary glands. A tannic red could cause jaw pain because of an intense parotid gland stimulation just like sour tastes can. Can alcohol cause swollen salivary glands? Inclusion in an NLM database does not imply endorsement of, or agreement with, In this study, alcohol consumption and obesity did not differ between the sialolithiasis and control groups. Click here for an email preview. The general characteristics (age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia) of the participants were the same due to the matching procedure (P=1.000). Chronic consumption of alcoholic beverages is an accepted social custom worldwide. Therefore, we hypothesized that obesity might also be related to sialolithiasis. Many conditions can damage the liver read more . If ultrasonography or computed tomography is done for other reasons, doctors may see evidence of fatty liver or portal hypertension Portal Hypertension Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Sialosis mainly affects the major salivary glands, particularly the parotid glands, but occasionally affects the submandibular glands and rarely, the minor salivary glands.6 Several causes have been recorded7-17 (Table 1), most of which are associated with nutrition, metabolism, or drugs, and have a unifying feature in autonomic neuropathy.18-20 Changes in salivary aquaporin water channels .