The effects of onion extract on hypertrophic and keloid scars

OBJECTIVE

To evaluate the therapeutic activity of topical onion extract in gel form on hypertrophic and keloid scars, focusing on problems such as elevation, redness, hardness, itching and pain.

METHOD

This comparative prospective study assigned 60 patients to three groups. Group I was treated with onion extract alone, group 2 with silicon gel sheet alone and 3 group with a combination of onion extract and silicon gel sheet.

RESULTS

In the group comparisons, a significant difference was observed at the end of six months in the colour parameter between group I and group 2 and in the height parameter between group I and group 3 (ANOVA post-hoc Tukey's test, p<0.01 and p<0.05 respectively). The onion extract was more effective in relation to scar colour, while the silicon gel sheet was superior in decreasing the height of scar (paired sample t-test, p<0.001). In addition, the most effective therapeutic results were obtained when the silicon gel sheet treatment was combined with onion extract in group 3.

CONCLUSION

Onion extract improved hypertrophic and keloids scars via multiple mechanisms. However, it was statistically ineffective in improving scar height and itching. For this reason, onion extract therapy should be used in combination with an occlusive silicon dressing to achieve a satisfying decrease in scar height.

[New approach in the treatment of newborn calves' dyspepsia and its controlling by the analysis of phospholipids of blood]

It's known that in newborn calves with dyspepsia in lipids leucocytes, erythrocytes, plasma and serum extracted from blood occur violation of parity between separate classes phospholipids in compare with healthy calves. It's revealed increasing of lipophosphatidilholin, sphingomielin, phosphatidilholin and decreasing of amount of phosphatidilserin, lizophosphatidic and phosphatidic acids in quantitative contents of phospholipids extracted from blood components. Indicated violations could be recovered after the treatment of ill calves by enterosgel in doze, which we developed and tested.

An active wound dressing for controlled convective mass transfer with the wound bed

Conventional wound dressings-gauze, plastic films, foams, and gels-do not allow for spatial and temporal control of the soluble chemistry within the wound bed, and are thus limited to a passive role in wound healing. Here, we present an active wound dressing (AWD) designed to control convective mass transfer with the wound bed; this mass transfer provides a means to tailor and monitor the chemical state of a wound and, potentially, to aid the healing process. We form this AWD as a bilayer of porous poly(hydroxyethyl methacrylate) (pHEMA) and silicone; the pHEMA acts as the interface with the wound bed, and a layer of silicone provides a vapor barrier and a support for connecting to external reservoirs and pumps. We measure the convective permeability of the pHEMA sponge, and use this value to design a device with a spatially uniform flow profile. We quantify the global coefficient of mass transfer of the AWD on a dissolvable synthetic surface, and compare it to existing theories of mass transfer in porous media. We also operate the AWD on model wound beds made of calcium alginate gel to demonstrate extraction and delivery of low molecular weight solutes and a model protein. Using this system, we demonstrate both uniform mass transfer over the entire wound bed and patterned mass transfer in three spatially distinct regions. Finally, we discuss opportunities and challenges for the clinical application of this design of an AWD.

Endoscopic intranasal reduction of the orbit in isolated blowout fractures

CONCLUSION

Endoscopic intranasal reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel packing, provided good functional results and definite advantages. We suggest that these techniques are another surgical alternative for isolated orbital floor or medial wall blowout fractures that do not accompany any associated fractures of the orbital rim.

OBJECTIVES

Extended applications of endoscopic sinus surgery have reported endoscopic intranasal reduction or reconstruction of the orbital wall with good functional and cosmetic results. We present our experience with endoscopic intranasal reduction of the orbit in isolated orbital floor and/or medial wall blowout fractures, treated by reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel packing.

SUBJECTS AND METHODS

Floor reduction: After creating a wide middle meatal antrostomy, herniated orbital contents and fracture-displaced floor are mobilized and reduced. The orbital floor is supported by a saline filled balloon, which is connected with an infant feeding catheter and passed through the middle meatal antrostoma. After confirming the reduction of the orbital floor by postoperative CT, the catheter is ligated and cut in short to keep it in the nasal cavity. Medial wall reduction: After completing an intranasal ethmoidectomy, herniated orbital contents and fractured lamina papyracea are mobilized and reduced. The shape of the medial orbital wall is fixed by a silastic sheet and Merocel packing saturated with an antibiotic solution. Surgery was performed when the eye function could be accurately assessed, usually at 7 to 10 days following the injury. Temporary supporting of the orbital wall with a detachable temporary balloon, or a silastic sheet and Merocel packing was removed 4 weeks after surgery in the out-patient clinic.

RESULTS

We have experienced 40 cases of endoscopic intranasal reduction of the orbit in blowout fractures. CT scan confirmed isolated orbital floor fracture in 11 patients, isolated medial wall fracture in 17 patients, and combined fractures of the orbital floor and the medial wall in 12 patients. Twenty five patients had diplopia, 20 patients had limitation of eye movement, and 14 patients developed enophthalmos. Thirty three of the 40 patients recovered completely without any residual eye symptoms or complications.

[The penis prolongation and augmentation combined with autologous granular fat injection and silicone implantation]

OBJECTIVE

To prevent the retraction of the penis after prolongation and augmentation.

METHODS

After all the superficial and part of the deep suspensory ligament amputation, we implanted the silicon sheet (the length 2.3-3.6 cm, the width 1.5-2.5 cm, the thickness 2-3 mm) and injected autologous granular fat (30-48 ml) into penis.

RESULTS

16 patients (age 22-63 years, averagely 38 years) underwent this kind operation, the prolongation length is 1.8-5.1 cm, the average was 2.91 cm, the increased diameter of penis was 0.6-1 cm, the average is 0.85 cm, the following period is 3 months to 2 years. The results are satisfactory with the penis retraction less than 8%, and less than 10% decrease in diameter.

CONCLUSIONS

This method is an ideal way of the penis prolongation and augmentation, the implantation of the silicon sheet is effective way to prevent the retraction of the penis.

Artificial reduction in transepidermal water loss improves skin barrier function

BACKGROUND

Artificial reduction of abnormal transepidermal water loss (TEWL) is considered to improve skin diseases associated with a defective barrier function. Treatment of the skin with moisturizers is also known to influence skin barrier function. Whether or not differences in occlusion between creams contribute to their effects on the skin barrier function is unknown.

OBJECTIVES

To investigate the long-term effects of a semipermeable membrane on the skin barrier function in normal skin. In addition, the occlusive properties of two creams were studied.

METHODS

The study was randomized, controlled and evaluator-blind using measurement of TEWL and skin susceptibility to sodium lauryl sulphate as indicators of skin barrier function.

RESULTS

Coating of the skin with a silicone membrane for 23 h per day for 3 weeks improved skin barrier function, whereas no significant changes were found after using the membrane for 8 h per day.

CONCLUSIONS

Differences between creams in terms of their effect on skin barrier function cannot be solely explained by their occlusive properties.

Long-term results of perianal silicone injection for faecal incontinence

OBJECTIVE

Perianal injection of bulking agents is a simple method for treating passive faecal incontinence. To date only short-term results of treatment are available. This study is the first to determine the efficacy of silicone biomaterial (PTQ; Uroplasty BV, Geleen, The Netherlands) injection in the long term.

METHOD

Six patients, median age 53 years at the time of injection with PTQ, were followed up at 61 months. A validated faecal incontinence score, treatment-specific questionnaire and SF-36 health survey questionnaire were completed.

RESULTS

At 61-month follow up one patient had undergone a colostomy for faecal incontinence. In the remaining five patients the incontinence score was little changed: 11 (8-20) vs 13 (9-19) [pre v at 61 months, median (range)]. However, there was a substantial improvement in physical and social function on the SF-36 scores. Satisfaction scores were high at a median 7 of 10 (range: 0-8). Subjectively, three patients were improved; one of these had undergone a further set of injections and one improved after a course of biofeedback. After the follow-up period one of the five patients had a colostomy for recto-vaginal fistula.

CONCLUSION

The results of perianal injection of PTQ for passive faecal incontinence are variable in the long term. More extensive evaluation in the short term, and possibly repeated treatment, may be required.

Short-term results of incremental penile girth enhancement using liquid injectable silicone: words of praise for a change

AIM

To report our experience with penile girth augmentation using liquid injectable silicone.

METHODS

Between August 2003 and July 2006, 324 men (mean age 35 years, range 19-65 years) received a series of liquid silicone subcutaneous injections between the penile skin and the corpora cavernosa on the dorsal and lateral aspects of the penile shaft, under local anesthesia. Digital photographs taken pre- and post-procedure (n = 324), and penile contour measurements (n = 30) yielded objective results. Subjective results were derived from patient and partner testimony of satisfaction. Follow-up averaged 20 months (range 1-36 months).

RESULTS

Three hundred and twenty-four procedures were primary augmentations. Most men (61%) were married, 7% were accompanied by their partners, and 93% were circumcised. The mean measured penile circumference was 9.5 cm (7.5-11.5 cm) pretreatment and 12.1 cm (10.3-15.3 cm) post-treatment (mean increase of 27% in circumference and 0.84 cm in diameter). Patient and partner satisfaction was already expressed after the first two treatments. Sexual activity could be resumed after 8 h. Complications (mild bruising) were easily resolved.

CONCLUSION

Penile girth augmentation using liquid injectable silicone yields very satisfactory short-term results with no immediate or short-term complications.

Effects of a single Silastic® contraceptive implant containing nomegestrol acetate (Uniplant) on endometrial morphology and ovarian function for 1 year

PURPOSE

This study was undertaken to evaluate the effects of a subdermal implant containing nomegestrol acetate (Uniplant) on endometrial histology and ovarian function.

METHODS

Twenty healthy female volunteers of reproductive age were included and completed a menstrual diary throughout the study. Hysteroscopy, transvaginal sonography and blood sampling were performed prior to implant insertion (control cycle) and following 6 and 12 months of Uniplant use. Transvaginal sonography was performed every other day from Day 8 of the cycle up to the obtainment of sonographic evidence of a 12-mm follicle, then every day until the obtainment of sonographic evidence of follicular rupture and thereafter every other day until the next menstrual bleeding. Blood samples were taken for the measurement of estradiol, follicle-stimulating hormone, luteinizing hormone and progesterone on the same days on which transvaginal sonography was performed. The implants were removed after 1 year.

RESULTS

Twenty percent of cycles were ovulatory, and 80% were anovulatory. The development of persistent nonluteinized follicle occurred in 40% of all cycles studied, inadequate luteal phase occurred in 20% of cycles and no follicular development occurred in 40%. Endometrial thickness remained below 8 mm in all cycles studied. Alterations in endometrial vascularization were observed in all treated cycles.

CONCLUSION

Our results suggest that this long-acting contraceptive method affects follicular growth and endometrial vascularization, disrupts endometrial architecture and leads to inadequate luteal phase.

[Efficacy in endoscopic treatment of secondary vesicoureteral reflux with polydimethylsiloxane]

OBJECTIVE

To value the efficacy in endoscopic treatment of the vesicoureteral reflux (VUR).

MATERIAL AND METHOD

We have realized a prospective study in patients with RVU treated with endoscopic polydimethylsiloxane, from January 1999 until December 2001, analyzing the results after an average pursuit of 30 months. We included 144 patients, 92 girls and 52 children, with 213 VUR (124 primary ones and 89 of secondary etiology). The initial efficacy of the treatment was defined as the finished absence of RVU in the isotopic cystography, realized three months after the puncture.

RESULTS

The global efficacy of the endoscopic treatment in secondary etiology reflux was lower than the reached one in the treatment of the primary RVU (77.7% against 86.2%) but the differences did not reach statistical significance (p=0,226). We do not also find significant differences on having compared the injected volume and the valuation of resolution of the ebb between the different causes of secondary RVU (p=0.361). We found recurrence in patients with RVU due to lower urinary tract dysfunction (4.34%).

CONCLUSIONS

Endoscopic treatment of the secondary VUR is a minimally invasive skill, presents scarce morbidity and it is effective in chosen patients. The risk of a long term recurrence is grater in VUR secondary to functional alterations (neurogenic bladder and functional instability), for what, pursuit has to be established according to the base pathology.

Massive systemic silicone embolism: a case report and review of literature

Subcutaneous injections of inert or quasi-inert plastic material designed to smooth out wrinkled skin or to create a more esthetically sought appearance have become very popular with the American public in general, and, in particular, with certain groups highly focused on their physical image. The case of the injection procedure has attracted into the field of plastic medicine a substantial number of illegal, incompetent, and unscrupulous operators. Their ignorance of involved medical risks and procedures not uncommonly results in severe complications, disfigurement, and death of patients. We report the typical pathological and chemical findings of a systemic fatal silicone embolism in a 53-year-old heterosexual woman following illegal chronic injections of silicone in her hips and buttocks. The injected subcutaneous silicone apparently migrated rapidly from the interstitial subcutaneous tissue into the general blood stream resulting in a fatal systemic silicone embolism. An analysis of the presented case in conjunction with a review of the pertinent medical literature, including a recent article, revealed a marked similarity in the clinicopathologic findings between silicone embolism and fat embolism.

Evaluation of a covered-rod silicone implant containing ivermectin for long-term prevention of heartworm infection in dogs

OBJECTIVE

To evaluate use of covered-rod (CR) silicone implants containing ivermectin for long-term prevention of infection with Dirofilaria immitisin dogs.

ANIMALS

145 adult male and female dogs.

PROCEDURES

Dogs received implants of different sizes, and ivermectin concentrations and serum ivermectin concentrations were monitored for 16, 57, and 56 weeks, respectively, in 3 preclinical dose selection studies. Ability of implants to prevent infection with D immitis was evaluated in 2 further studies; dogs were challenged with 50 infective third-stage larvae 52 weeks after implant administration and necropsied 145 days after challenge, and the total number of adult heartworms was counted. A field study was then undertaken in which client-owned dogs received an implant and plasma samples were collected at intervals until week 52 for ivermectin analysis and heartworm antigen determination.

RESULTS

Use of the implants resulted in maintenance of an ivermectin concentration > or = 0.2 ng/mL for 12 months. In challenge studies, no treated dogs had adult heartworms, in contrast to untreated dogs, which all had adult heartworms at necropsy. In the field study, dogs treated with an implant had negative results of heartworm antigen testing for 12 months.

CONCLUSIONS AND CLINICAL RELEVANCE

The CR silicone implant containing 7.3 mg of ivermectin was 100% effective in preventing experimental infection with D immitislarvae and resulted in negative results for heartworm antigen in a field trial. This product has the potential to alleviate poor owner compliance with monthly prevention regimens.

What are the most powerful determinants of endoscopic vesicoureteral reflux correction? Multivariate analysis of a single institution experience during 6 years

PURPOSE

As the indications for endoscopic correction of vesicoureteral reflux continue to expand, the emergence of potential predictive variables has been noted. We used univariate and multivariate statistical analyses to find the most significant predictors of correction to improve patient selection.

MATERIALS AND METHODS

A consecutive series of patients treated at a single institution was reviewed. Between August 1998 and August 2004, 232 children endoscopically injected with polydimethylsiloxane were identified, representing 351 refluxing units. A total of 23 variables were subjected to statistical analysis to detect predictors of reflux correction after injection. All identified patients with complete data and followup evaluations were included irrespective of anatomical variations, previous interventions or comorbidities.

RESULTS

The overall success rate by patient and renal unit was 65% and 72%, respectively. In patients with a single system low grade (1-3) vesicoureteral reflux who did not previously undergo injection this success rate increased to 80%. Univariate analysis demonstrated that higher physician experience, low preoperative vesicoureteral reflux grade, absent renal scars and no previous injections were statistically significant predictors of vesicoureteral reflux correction (p <0.05). A history of febrile urinary tract infections and a duplex system did not attain significance (p = 0.069 and 0.076, respectively). On multivariate statistical evaluation only physician experience, preoperative vesicoureteral reflux grade and the number of previous injections remained significant.

CONCLUSIONS

Multivariate analysis of our data showed the most important determinants of vesicoureteral reflux correction after endoscopic injection. Prospective validation will allow us to generate nomograms to better select and counsel patients who would benefit from vesicoureteral reflux treatment.

An Overview of Permanent and Semipermanent Fillers

The demand for safe, effective, long-lasting, biocompatible dermal filler materials is increasing. Many products that include synthetic polymers and autologous tissue have emerged that attempt to meet these criteria. An overview of injectable permanent fillers, including ArteFill, Aquamid, and silicone, and semipermanent fillers, including Radiesse, Sculptra, and autologous fat, is presented. A discussion of their composition, histologic characteristics, antigenicity, U.S. Food and Drug Administration approval status, indications for use, efficacy, injection technique, and adverse effects is provided.

Liquid Injectable Silicone: A Review of Its History, Immunology, Technical Considerations, Complications, and Potential

For over five decades, liquid injectable silicone has been used for soft-tissue augmentation. Its use has engendered polarized reactions from the public and from physicians. Adherents of this product tout its inert chemical structure, ease of use, and low cost. Opponents of silicone cite the many reports of complications, including granulomas, pneumonitis, and disfiguring nodules that are usually the result of large-volume injection and/or industrial grade or adulterated material. Unfortunately, as recently as 2006, reports in The New England Journal of Medicine and The New York Times failed to distinguish between the use of medical grade silicone injected by physicians trained in the microdroplet technique and the use of large volumes of industrial grade products injected by unlicensed or unskilled practitioners. This review separates these two markedly different procedures. In addition, it provides an overview of the chemical structure of liquid injectable silicone, the immunology of silicone reactions within the body, treatment for cosmetic improvement including human immunodeficiency virus lipoatrophy, technical considerations for its injection, complications seen following injections, and some considerations of the future for silicone soft-tissue augmentation.

Patient-perceived outcomes in the treatment of stress urinary incontinence: focus on urethral injection therapy

Intervention for stress urinary incontinence (SUI) is generally focused on minimizing urinary leakage. However, the overall impact of SUI therapy on patients' quality of life is, arguably, more important than leakage outcomes. We performed a literature search to investigate the effect of urethral injection therapy on quality of life. Significant quality-of-life improvements have been observed with a number of injectable agents, while there is a distinct lack of correlation between subjective and objective outcomes. Two studies comparing urethral injection therapy with surgical intervention found superior objective efficacy with surgery, but no significant differences in quality-of-life improvements. Personal goals of patients undergoing urethral injection are yet to be explored, but there may be willingness to trade a lower success rate in favor of a more minor treatment procedure. In conclusion, quality-of-life improvements after urethral injection appear significant and comparable to those obtained with surgery. Further study of patients' own perceptions, pre- and posttreatment, would be valuable.

Sonographic and mammographic findings of breast liquid silicone injection

PURPOSE

To describe the sonographic and mammographic features of patients whose breasts have been injected with silicone.

METHODS

Between July 1997 and August 1999, 14 patients with a history of breast injection of liquid silicone underwent physical, mammographic, and sonographic examination. Mammographic findings were classified as macronodular, micronodular, or mixed striated patterns. Sonographic appearances were classified as macronodular, micronodular, mixed, or snowstorm patterns.

RESULTS

Eighty-six percent of the patients had abnormal physical examination. Well-defined nodules were palpable in 4 patients, 6 patients had diffusely heterogeneous breasts on palpation, and 2 patients had a combination of heterogeneous texture with dominant nodules. Sonographic examination revealed the presence of marked echogenicity (i.e., snowstorm pattern) in all 14 patients; in 11 patients it was associated with macronodules and/or micronodules, whereas in 3 patients only snowstorm appearance was noted. Mammographic patterns were macronodular in 7 patients and mixed macronodular and micronodular in 6 patients.

CONCLUSIONS

Both mammography and sonography can help identify free silicone injected directly into the breast.

Stress incontinence injection therapy: what is best for our patients?

OBJECTIVE

Urethral injection (periurethral/intraurethral bulking) is an established, minimally invasive therapy for stress urinary incontinence (SUI). This review aims to determine which women should potentially benefit from, and be considered as candidates for, injection therapy and to elucidate what we are trying to achieve.

METHODS

Based on MEDLINE database searches, all aspects of urethral injection were examined, including patient selection, safety, injection technique, efficacy, quality of life, goals and cost.

RESULTS

Such therapy has a low complication rate, improves or cures about 3 out of 4 women, as shown in mainly short-term studies, and improves patients' quality of life. It can be used in the majority of patients with uncomplicated SUI. Therefore, injection therapy may be considered as a first-line treatment option for patients who have failed conservative therapy such as pelvic floor exercises and who decline or have a contraindication for pharmacological treatment. However, the decision of whether to use this type of treatment must be based on an informed discussion between the physician and patient--this dialogue should incorporate questions about patients' own treatment goals. Injection therapy appears to have the profile required to meet patients' goals, based on the findings that a procedure with an improvement in incontinence, minimal short-term risk, no long-term risk, and performed in a clinic, would be acceptable.

CONCLUSION

Investigating and trying to achieve patients' own treatment goals will ultimately enable us to do what is best for our patients, but current evidence suggests that injection therapy is a valid option worth discussing with many patients.

Liquid Silicone for Soft Tissue Augmentation

BACKGROUND

The use of liquid silicone for soft tissue augmentation has been associated with a great deal of controversy and negative publicity. It is hoped that this monograph will clarify some of the substantive issues behind the controversy.

OBJECTIVE

To outline and discuss the history, legal status, indications, contraindications, technique, and complications associated with the use of liquid silicone for soft tissue augmentation.

METHODS

Impressions derived from a 22-year experience involving the treatment of over 3000 patients using liquid silicone are presented, along with data abstracted from the scientific and the lay literature.

CONCLUSION

Pure liquid silicone may be superior to any currently available agent in properly selected patients for permanent correction of certain types of defects. Physicians who use it, however, must be advised that the misuse of this agent or other materials masquerading as liquid silicone have created a pervasive climate of distrust and a veritable minefield of extraordinarily unpleasant medicolegal possibilities.

Lip Augmentation with Liquid Silicone

BACKGROUND

Many fillers have been used to augment the lips. One of these that has provided long-term satisfactory results is liquid silicone.

OBJECTIVE

To demonstrate the efficacy and safety of lip augmentation with liquid silicone.

METHOD

Following a discussion of the benefits and risks of the procedure and the benefits and risks of alternatives and after answering all of the patients' questions, an informed consent form was signed. After obtaining anesthesia with a regional nerve block of the infraorbital and mental nerves, 0.25 to 0.5 cc of liquid silicone (1,000 centistokes) was injected using the microdroplet technique into the vermilion border of both the upper and lower lips. Depending on the desire of the patient, the procedure was repeated monthly. The augmentation of the lips was documented with histology, micrometry, and digital photography.

RESULTS

Lip augmentation was achieved gradually during the months following liquid silicone injections into the vermilion border of the lips in the 608 patients studied. Most of the patients requested a second and third injection session. The results were most dramatic in the patients with type I and type II lips and less satisfactory in patients with type III lips. Bruising occurred in the majority of the patients. Eleven patients (2%) developed small palpable granulomas. These granulomas either required no treatment, responded to steroid injections, or were excised.

CONCLUSION

The use of liquid silicone remains an effective method of lip augmentation. It returns the adolescent vermilion curl to the lips.

HIV Facial Lipoatrophy: Causes and Treatment Options

BACKGROUND

Human immunodeficiency virus (HIV)-associated facial lipoatrophy is becoming epidemic and may seriously affect quality of life.

OBJECTIVE

To review the possible causes and treatment options for HIV facial lipoatrophy.

METHODS

This article is based on a review of the medical literature and the author's clinical experience in treating HIV facial

CONCLUSION

Although absorbable injectable fillers and implants are helpful in treating HIV facial lipoatrophy, they are limited by cost and the short duration of correction. Newer forms of longer-lasting fillers (poly-L-lactic acid [Sculptra]) and permanent injectable fillers (liquid injectable silicone) are proving useful for treatment of this condition.

Calcinosis cutis with siliconomas complicated by hypercalcemia

OBJECTIVE

To report a case of extensive calcinosis cutis presumably caused by silicone injections, which was complicated by hypercalcemia.

METHODS

A long-standing case of calcinosis cutis with subsequent development of hypercalcemia is presented, and possible mechanisms for the underlying metabolic dysfunction are discussed.

RESULTS

A 78-year-old woman presented with severe hypercalcemia and was found to have extensive subcutaneous calcifications on the anterior chest wall and abdomen, likely related to previous silicone injections. The hypercalcemia was treated with intravenously administered pamidronate and aggressive rehydration. Resection of the extensive long-standing calcific deposits was not a viable option. The hypercalcemia resolved with treatment, but the patient died of urinary tract sepsis.

CONCLUSION

Extensive calcinosis cutis can result in hypercalcemia, possibly attributable to granulomatous reaction and vitamin D excess.