Co-ligation of surface IgM and CD40 on naive B lymphocytes generates a blast population with an ambiguous extrafollicular/germinal centre cell phenotype

We have previously shown that dual occupancy of sigM and CD40 - essential receptors in T-dependent B cell responses - by antibodies held on CD32-L cells results in the rapid proliferation of resting human B lymphocytes in a cytokine-independent manner. Here we report the detailed phenotype of the blast population emerging in such cultures. By 3 days the levels of CD19 and CD20 have increased 4- and 2-fold respectively: such high level expression of these two pan-B markers is characteristic of cells of germinal centre (GC) origin. B cells co-stimulated via sIgM and CD40 express low level CD23 and almost half become CD5(+); they also acquire CD38 and - importantly - CD77, both of these being selective markers of GC B cells. Expression of sigM and IgD is down-regulated on these cells and a minor, but significant, population of IgG+ cells appears. In marked contrast to GC B cells, the population proliferating in response to dual occupancy of sigM and CD40 has up-regulated and strongly expresses CD44. Morphologically, the cells are heterogeneous but there is a dominant blastic cell type with relatively scanty cytoplasm and having multiple nucleoli, both of which are characteristic of centroblasts; nevertheless, these cells remain morphologically distinct from freshly isolated GC B cells and do not show hallmark features of centrocytes. Although there is substantial cell death occurring by days 6-7 in these cultures, there is no morphological evidence for apoptosis. Thus, the proliferating population that emerges from the dual engagement of antigen receptor and CD40 on resting B cells appears to be bestowed with some features of GC B cells but has others which are incompatible with that particular stage of differentiation. The possibility that it might represent (i) a blast stage that is transitional between activation in T zones and entry into the follicle or (ii) a precursor population that colonizes the primary follicle prior to GC formation is discussed.

Laser-Doppler flowmetry measurements of subcortical blood flow changes after fluid percussion brain injury in rats

Laser-Doppler flowmetry (LDF) was used to record subcortical cerebral blood flow in hippocampus and striatum immediately following parasaggital fluid percussion brain injuries of mild to moderate severity (2.58 +/- 0.09 atm, 10-11 msec duration) in spontaneously breathing anesthetized rats. At 5 min postinjury, mean blood flow decreased bilaterally by 20-30% in both brain structures, and remained significantly reduced during the remainder of the 60 min postinjury recording interval. Blood flow did not change in the sham-injured rats. Subsequent beam-walk, beam-balance, and rope-hang assessments revealed significant neurological impairments in the injured rats but not in the sham controls. The magnitude of the blood flow changes and the severity of the ensuing neurological impairment were significantly correlated. Histopathological assessments revealed hemorrhagic contusions within ipsilateral cortical regions, occasional neuronal necrosis within underlying thalamus and CA3 and CA4 sectors of the hippocampus, and neuronal cell loss in the hilus of the dentate gyrus. In a second series of experiments, radiolabeled microspheres were used to validate the LDF blood flow measurements. The microsphere measurements revealed that the preinjury baseline and postinjury right hippocampal blood flow changes were not significantly altered by the intrahippocampal presence of an LDF probe, verifying that the LDF probe was not by itself an unacceptably disruptive influence on local cerebrovascular reactivity. Moreover, when right hippocampal blood flow was simultaneously evaluated in injured rats by both techniques, the relative blood flow changes were significantly correlated. These results indicate that laser-Doppler flowmetry provides a potentially useful means to appreciate acute regional cerebrovascular changes relative to other measures of outcome after brain trauma.

An economic evaluation of laparoscopic versus open inguinal hernia repair

BACKGROUND

The rapid and widespread introduction of minimal access surgery has major implications for the National Health Service. It cannot be assumed that replacing an open procedure with a minimal access alternative will be cost-effective. Laparoscopic inguinal hernia repair is a procedure for which the potential economic benefits are particularly unclear. It is currently being adopted in many centres, although limited evidence on its clinical and cost-effectiveness exists.

METHODS

This economic comparison of laparoscopic versus open hernia repair was undertaken on data collected on 104 patients undergoing surgery on a day case basis, in the context of a randomized controlled trial.

RESULTS

The mean total health service cost of laparoscopic repair was 1074 pounds versus 489 pounds for open repair [mean difference in total health service costs 583 pounds; 95 percent confidence interval (CI) 265 pounds-904 pounds]. This difference was largely accounted for by the difference in theatre costs. Laparoscopic repair remained significantly more expensive for most but not all of the scenarios explored in the sensitivity analysis. The direction of the cost-effectiveness ratio was not sensitive to assumptions about long-term recurrence. Neither was it sensitive to halving the operating time in the laparoscopic arm of the trial. When both operating time and the costs of consumables were reduced, laparoscopic repair remained more expensive, but results for this scenario did not achieve statistical significance on this sample size.

CONCLUSIONS

Laparoscopic hernia repair appears an expensive option in most plausible situations. Furthermore, many uncertainties still exist about long-term outcome after the procedure and about the conditions necessary to maximize cost-effectiveness. Large-scale randomized studies to evaluate laparoscopic hernia repair are currently under way to address these issues. We suggest that further evidence is awaited before this technology is further diffused.

Transforming growth factor-beta 1 cooperates with anti-immunoglobulin for the induction of apoptosis in group I (biopsy-like) Burkitt lymphoma cell lines

Group I Burkitt lymphoma (BL) cell lines, which retain the original biopsy phenotype, have been shown to enter apoptosis in response to a number of external stimuli including serum deprivation, thermal shock, addition of calcium ionophore, and ligation of surface immunoglobulin (Ig) by antibody. Transforming growth factor-beta 1 (TGF beta 1) is known to cause growth arrest in BL lines. Here we show that while it is by itself capable of promoting some degree of apoptosis in group IBL cells, TGF beta 1 cooperates with anti-immunoglobulin to this end. Trimeric soluble recombinant human CD40 ligand (sCD40L) was able to inhibit apoptosis induced by the combination of agonists to some degree, but such rescue proved to be short-lived. Both TGF beta 1 and anti-Ig individually caused BL cells to undergo growth arrest at the G1 phase of cell cycle before their entry into apoptosis: the consequence of sCD40L addition was to maintain the cells in cycle for longer. No induction of the apoptosis-protecting gene, bcl-2, occurred in the presence of sCD40L. These findings are discussed, particularly highlighting the relationship existing between survival and the cell cycle. The strong cooperative effects observed between anti-Ig and TGF beta 1 in promoting apoptosis and the inability of CD40 to signal for long-term rescue raise the potential for a novel therapeutic attack on B-cell lymphoma.

Cerebral demyelination syndrome in a patient treated with 5-fluorouracil and levamisole. The use of thallium SPECT imaging to assist in noninvasive diagnosis--a case report

BACKGROUND

The use of 5-fluorouracil (5-FU) and levamisole in patients with Stage III adenocarcinoma of the colon has now become standard. There have been several reports of a multifocal cerebral demyelination syndrome following 5-FU and levamisole administration.

METHODS

We describe a patient who developed focal neurologic symptoms while being treated with levamisole and 5-FU in whom the diagnosis of central nervous system (CNS) metastases was considered.

RESULTS

A magnetic resonance imaging (MRI) scan showed a diffuse, multifocal white matter process. Diagnostic evaluation did not support a diagnosis of CNS metastasis. 201Thallium chloride single photon emission computed tomography (SPECT) study was cold. A stereotactic brain biopsy disclosed demyelination but not tumor. The patient had complete functional resolution of symptoms with 1 month of dexamethasone therapy, although follow-up MRI scans have shown persistent abnormality on T2-weighted images.

CONCLUSIONS

In patients receiving 5-FU and levamisole who develop focal neurologic symptoms with an abnormal MRI scan, the diagnosis of CNS metastasis should not be made without a thorough diagnostic evaluation. We suggest the use of 201thallium chloride SPECT imaging to support the diagnosis of multifocal leukoencephalopathy related to 5-FU and levamisole. In atypical cases, a stereotactic brain biopsy may be required for confirmation.

Signals for survival and apoptosis in normal and neoplastic B lymphocytes

B lymphocytes are subject to selection within germinal centers following somatic hyper-mutation on immunoglobulin variable region genes based on their ability to bind antigen with high affinity. Non-selected cells die by apoptosis. Tumors with features of germinal center B cells include follicular center cell lymphoma and Burkitt's lymphoma. We have used the latter extensively as a neoplastic model of germinal center cells and have compared directly the behaviour of cell lines derived from biopsy material with that of the normal counterparts. Here we describe some of our findings in the two systems with regard to signals regulating survival and apoptosis.

Engagement of CD20 suppresses apoptosis in germinal center B cells

In a screen of 67 monoclonal antibodies (mAb) included in the Blind Panel of B cell antibodies for the 5th International Workshop on Human Leukocyte Differentiation Antigens, only the CD20 mAb--included as a positive control for immunophenotyping studies--was found to suppress the spontaneous apoptosis which occurs in human germinal center (GC) B cells when placed in tissue culture at 37 degrees C. Further detailed study using the 1F5 mAb confirmed this observation, showing that rescue from apoptosis via CD20, while not as efficient as that obtained on ligating CD40, was of similar magnitude to that achieved on engagement of surface immunoglobulin (sIg) by immobilized antibody. Also similar to anti-Ig, the CD20 mAb rescued from apoptosis without priming for the proliferation of GC B cells: this was quite different to its action on resting, non-GC B cells, where it provides a potent priming signal for cell cycle progression in response to IL-4 or anti-CD40. Unlike the survival signal engendered via sIg, CD20 engagement neither mobilized Ca2+ from intracellular stores or opening of a Ca2+ channel with 1F5, nor did it affect the ability of anti-Ig to open a Ca2+ gate in GC B cells. An unexpected feature of CD20-mediated rescue of GC B cells from apoptosis was a failure to turn on Bcl-2 expression.

The normal cell cycle activation program is exploited during the infection of quiescent B lymphocytes by Epstein-Barr virus

B lymphocytes in the peripheral circulation are maintained in a non-proliferative state. Antigen recognition stimulates limited proliferation, whereas infection with Epstein-Barr virus (EBV) results in continual proliferation and the outgrowth of immortal cell lines. Because it is not clear at which point in cell cycle the peripheral B lymphocytes are arrested, we characterized the expression of several cell cycle-associated genes in quiescent and stimulated cells. We show that the expression of four cell genes, cdc-2, cyclin E, CD23, and cyclin D2, are up-regulated approximately 100-fold as a result of EBV-mediated immortalization. Because these genes play a positive role in cell proliferation, we suggest that this regulatory switch contributes to controlling entry into the cell cycle. Transient stimulation of quiescent B lymphocytes with either a cocktail of anti-CD40, anti-IgM, and IL4, or EBV results in the rapid expression of the same four genes, suggesting that, after infection, EBV exploits the normal program of B-lymphocyte cell cycle activation.

The delayed hypersensitivity response and host resistance in surgical patients. 20 years later

OBJECTIVE

A 20-year follow-up was conducted on research into the implications of a lack of a delayed-type hypersensitivity (DTH) skin test response among surgical patients.

SUMMARY BACKGROUND DATA

The authors' original report showed that a failed DTH response was associated with increased hospital mortality, but the role of specific and nonspecific host defense elements, comorbid factors, nutritional supplementation, and the mechanism for anergy in this adverse outcome was unknown.

METHODS

A data base of 4292 patients was analyzed and reported on individual studies designed to answer some of the above questions.

RESULTS

Prospective studies showed a strong association between the DTH response and mortality: reactive patients, 2.9% (75/2576); anergic patients, 20.9% (239/1142, chi square = 265, p < 0.0000001). Antibody response to protein antigens was reduced in anergic patients. Antibody response to polysaccharide antigens was normal in all patients. The hallmark of anergy is a lack of T cells in the skin, as measured by mRNA signal (CD3) for T cells. The nonspecific component of host defense, as measured by circulating and exudate polymorphonuclear cell function, showed no statistically significant difference between elective reactive and elective anergic patients. Notwithstanding some mild malnutrition in anergic patients, parental nutrition failed to correct the DTH response or many of the cellular immune functions measured.

CONCLUSIONS

Over the last 5 years, because of a reduction in overall patient mortality, the contribution of a reduced DTH response to septic related mortality has lost statistical significance in elective surgical patients. A reduced DTH response maintains its strong association to sepsis-related mortality in intensive care/trauma patients, and this is the group on which future research efforts should be concentrated.

An enzyme-linked immunosorbent assay specific for transient (29-37-kDa) fragments of soluble CD23/IgE-binding factors

The low-affinity IgE receptor (Fc epsilon RII) of B cells and monocytes--also known as CD23--is released from the cell surface by proteolytic cleavage to yield a series of soluble fragments which can accumulate in cell culture supernatants and body fluids. Of these, the most stable is a 25-kDa molecule which is generated from transient intermediates ranging in size from 29 to 37 kDa. It has been claimed that these latter species act as IgE-promoting factors while the 25-kDa molecule is endowed with various cytokine-like activities which are independent of IgE binding. We describe here a novel enzyme-linked immunosorbent assay (ELISA) which allows for the distinction between these two classes of soluble CD23. It is based on the observation that the CD23 antibody EBVCS1 can capture recombinant 29-kDa and 37-kDa fragments of CD23 but does not bind to the 25-kDa species: when EBVCS5 is used as the capture antibody, all three fragments are bound. The availability of these differential ELISA should facilitate investigations on the biological properties of CD23 fragments in health and disease.

Real-time detection of DNA hybridization and melting on oligonucleotide arrays by using optical wave guides

The challenge of the Human Genome Project is to increase the rate of DNA sequence acquisition by two orders of magnitude to complete sequencing of the human genome by the year 2000. The present work describes a rapid detection method using a two-dimensional optical wave guide that allows measurement of real-time binding or melting of a light-scattering label on a DNA array. A particulate label on the target DNA acts as a light-scattering source when illuminated by the evanescent wave of the wave guide and only the label bound to the surface generates a signal. Imaging/visual examination of the scattered light permits interrogation of the entire array simultaneously. Hybridization specificity is equivalent to that obtained with a conventional system using autoradiography. Wave guide melting curves are consistent with those obtained in the liquid phase and single-base discrimination is facile. Dilution experiments showed an apparent lower limit of detection at 0.4 nM oligonucleotide. This performance is comparable to the best currently known fluorescence-based systems. In addition, wave guide detection allows manipulation of hybridization stringency during detection and thereby reduces DNA chip complexity. It is anticipated that this methodology will provide a powerful tool for diagnostic applications that require rapid cost-effective detection of variations from known sequences.

Learning a visuomotor transformation in a local area of work space produces directional biases in other areas

1. The dependence of directional biases in reaching movements on the initial position of the hand was studied in normal human subjects moving their unseen hand on a horizontal digitizing tablet to visual targets displayed on a vertical computer screen. 2. When initial hand positions were to the right of midline, movements were systematically biased clockwise. Biases were counterclockwise for starting points to the left. Biases were unaffected by the screen location of the starting and target positions. 3. Vision of the hand in relation to the target before movement, as well as practice with vision of the cursor during the movement, temporarily eliminated these biases. The spatial organization of the biases suggests that, without vision of the limb, the nervous system underestimates the distance of the hand from an axis or plane that includes its most common operating location. 4. To test the hypothesis that such an underestimate might represent an adaptation to a local area of work space or range effect, subjects were trained to reach accurately from right or left positions. After training, movements initiated from other locations, including ones that were previously error free, showed new biases that again represented underestimates of the distance of the initial hand position from the new trained location. 5. We conclude that hand path planning is dependent on learned representations of the location of the hand in the work space.

'Babies don't come with a set of instructions': running support groups for mothers

A successful bid to the health promotion department by an inner city Glasgow GP enabled two health promotion officers to offer support groups to mothers with young children. Jacki Gordon, Robbie Robertson and Margaret Swan describe their approach and how mothers benefited from this additional support.

CD40 and its ligand: central players in B lymphocyte survival, growth, and differentiation

This article brings together information garnered over the last 10 years on the B cell-associated CD40 surface glycoprotein. The discovery in 1992 of a natural counterstructure, the CD40 ligand (CD40L), which can be rapidly induced on T-cells has hastened research and increased interest in this area dramatically. It has become clear that CD40 and its ligand are central players in B cell responses to T-dependent antigens. The capacity of CD40 to deliver signals for B cell growth, differentiation and survival is covered together with discussion of the signal transduction pathways which operate to bring about these changes. Future issues surrounding this important receptor-ligand pair are discussed.

Sensitivity to change of health status measures in a randomized controlled trial: comparison of the COOP charts and the SF-36

This study compared the sensitivity to change of comparable dimensions of a multi-item multi-dimensional health status measure (the SF-36) with the equivalent single item domains on the Dartmouth COOP charts. One hundred and twenty nine patients were randomized to either day case laparoscopic surgery (n = 60) or open inguinal hernia repair (n = 69). Respondents completed the SF-36 and COOP charts at baseline (prior to surgery) and at follow up at 10 days and 6 weeks. Equivalent dimensions of physical functioning, mental health/emotional condition, social activities, pain and overall condition/general health on the two questionnaires were compared. Despite slightly different pictures of change provided by the physical functioning and 'overall condition/general health' dimensions the general picture of change provided by the two instruments was similar. At 10 days, patients who underwent open surgery reported far greater levels of dysfunction than those who underwent laparoscopic surgery on both questionnaires. At 6 weeks the pain dimension of both questionnaires indicated a large improvement from baseline, whilst no other domain on either questionnaire for either group indicated such improvement. The general picture of change provided by the two measures was similar. The results suggest that both the SF-36 and the COOP charts may prove suitable for the assessment of health perception outcomes in surgical clinical trials. Differences on certain domains were caused in large measure by the nature of the questions posed. The study once again highlights the importance of checking item content to determine the suitability of any particular measure for a given study.

Simultaneous analysis of mutant and normal alleles for multiple cystic fibrosis mutations by the ligase chain reaction

The ligase chain reaction (LCR) involves repetitive cycles of ligation of two adjacent pairs of oligonucleotides to form longer ligated products in a template-dependent manner. This study demonstrates the application of LCR for analysis of multiple small mutations. We adapted the technology for the simultaneous determination of the normal and mutant alleles in a competition format, as well as multiple mutations in a multiplex format. For these purposes, we used mutations causing cystic fibrosis, namely the delta F508, W1282X, and G551D mutations. Blunt ligation was compared to a strategy with a single base gap on one or both strands to be filled by thermostable polymerase prior to ligation. Blunt or gap strategies worked well for detection of the delta F508 mutation. Detection of the W1282X mutation worked well with a blunt strategy when high K+ concentration (180-220 mM) was used to reduce template-independent ligation. For reliable detection of the G551D mutation, we used mismatches in the oligonucleotides 2-5 bp away from the ligation site and hot start of the reaction to achieve allele specificity. Excellent discrimination of mutations was achieved using competitive LCR with six oligonucleotides (two common on one side of the mutation plus two wild type and two mutant on the opposite side with the mutation site at the end adjacent to the common oligonucleotides) and with multiplex-competitive LCR using 12 oligonucleotides to detect both alleles for two mutations in a single tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Contrast-dependent responses in the human visual system: childhood through adulthood

Visual evoked potentials (VEPs) to temporal modulation of spatial patterns, recorded from humans ranging in age from 4-42 years, demonstrated that contrast-dependent responses exist in early childhood and change dramatically throughout childhood. Bright or dark isolated-check stimuli were used to emphasize contributions from ON or OFF pathways to the VEP. (ON and OFF pathways constitute one major pair of parallel subsystems, which process brightness [positive-contrast] and darkness [negative-contrast] information, respectively.) The developmental effects observed for each pathway were similar in magnitude and time course, suggesting maturation of a common physiological mechanism dependent on spatial contrast. Children's responses were more variable and larger than those of adults, and exhibited a relative phase lag. In addition, we recorded transient VEPs to a conventional contrast-reversing checkerboard pattern. The latency of the major positive wave (P100) was found to decrease, while the latency of the initial positive wave (P60) was found to increase, with increasing age. We propose a vector-summation model, which posits a relative decrease in cortical excitation with increasing age, to explain our major findings.

Impairments of reaching movements in patients without proprioception. I. Spatial errors

1. This paper introduces a series of studies in which we analyze the impairments in a planar reaching task in human patients with severe proprioceptive deficits resulting from large-fiber sensory neuropathy. We studied three patients, all of whom showed absence of discriminative tactile sensation, position sense, and stretch reflexes in the upper extremities. Muscle strength was normal. We compared the reaching movements of the patients with those of normal control subjects. The purpose of this first paper was no characterize the spatial errors in these patients that result primarily from impairments in the planning and execution of movement rather than in feedback control. This was done by using a task in which visual feedback of errors during movement was prevented. 2. Subjects were instructed to move their hand from given starting positions of different targets on a horizontal digitizing tablet. Hand position and targets were displayed on a computer screen. Subjects could not see their hand, and the screen display of hand position was blanked at the signal to move. Thus visual feedback during movement could not be used to achieve accuracy. Movement paths were displayed as knowledge of results after each trial. 3. Compared with controls, the patients made large spatial errors in both movement direction and extent. Directional errors were evident from movement onset, suggesting that they resulted from improper planning. In addition, patients' hand paths showed large curves and secondary movements after initial stops. 4. The overall control strategy used by patients appeared the same as that used by controls. Hand trajectories were approximately bell shaped, and movement extent was controlled by scaling a trajectory waveform in amplitude and time. However, both control subjects and patients showed systematic errors in movement extent that depended on the direction of hand movement. In control subjects, these systematic dependencies of extent on direction were small, but in patients they produced large and prominent errors. Analysis of the hand trajectories revealed that errors were associated with differences in velocity and acceleration for movements in different directions. In an earlier study, we showed that in subjects with normal sensation that the dependence of acceleration and velocity on direction results from a failure to take the inertial properties of the limb into account in programming the initial trajectory. In control subjects, these differences in initial acceleration are partially compensated by direction-dependent variations in movement time.(ABSTRACT TRUNCATED AT 400 WORDS)

Impairments of reaching movements in patients without proprioception. II. Effects of visual information on accuracy

1. The aim of this study was to determine how vision of a cursor indicating hand position on a computer screen or vision of the limb itself improves the accuracy of reaching movements in patients deprived of limb proprioception due to large-fiber sensory neuropathy. In particular, we wished to ascertain the contribution of such information to improved planning rather than to feedback corrections. We analyzed spatial errors and hand trajectories of reaching movements made by subjects moving a hand-held cursor on a digitizing tablet while viewing targets displayed on a computer screen. The errors made when movements were performed without vision of their arm or of a screen cursor were compared with errors made when this information was available concurrently or prior to movement. 2. Both monitoring the screen cursor and seeing their limb in peripheral vision during movement improved the accuracy of the patients' movements. Improvements produced by seeing the cursor during movement are attributable simply to feedback corrections. However, because the target was not present in the actual workspace, improvements associated with vision of the limb must involve more complex corrective mechanisms. 3. Significant improvements in performance also occurred in trials without vision that were performed after viewing the limb at rest or during movements. In particular, prior vision of the limb in motion improved the ability of patients to vary the duration of movements in different directions so as to compensate for the inertial anisotropy of the limb. In addition, there were significant reductions in directional errors, path curvature, and late secondary movements. Comparable improvements in extent, direction, and curvature were produced when subjects could see the screen cursor during alternate movements to targets in different directions. 4. The effects of viewing the limb were transient and decayed during a period of minutes once vision of the limb was no longer available. 5. It is proposed that the improvements in performance produced after vision of the limb were mediated by the visual updating of internal models of the limb. Vision of the limb at rest may provide configuration information while vision of the limb in motion provides additional dynamic information. Vision of the cursor and the resulting ability to correct ongoing movements, however, is considered primarily to provide information about the dynamic properties of the limb and its response to neural commands.

Occupational lead poisoning: who should conduct surveillance and training?

This commentary challenges the current employer-controlled model for delivering occupational health services. Problems emanating from traditional employer-based medical surveillance and worker education programs for occupational lead poisoning are identified. A new public health model for delivering these services is proposed. This model utilizes a case-based and hazard-based method for bringing workplaces and employers into the program and features direct delivery of surveillance and training services by public health agencies.

Measurement of nucleoside diphosphate kinase-Nm23 activity by anion-exchange high-performance liquid chromatography

A first-order assay to detect the activity of nucleoside diphosphate kinase (NDP-kinase; EC 2.7.4.6) was developed. In this assay, the activity of NDP-kinase is measured using various deoxy- and ribonucleotide triphosphates as phosphate donors and dADP as phosphate acceptor. The enzyme activity is determined by quantifying, after anion-exchange HPLC, the amount of newly synthesized dATP. Contrary to the most common coupled enzymic assays or isotopic assays the use of different donor-acceptor pairs is not restricted. The resolution of the procedure described is limited only by the chromatographic separation of substrate and product pairs participating in the reaction.