Atf3 deficiency promotes genome instability and spontaneous tumorigenesis in mice

Mice lacking genes involving in the DNA damage response (DDR) are often tumor prone owing to genome instability caused by oncogenic challenges. Previous studies demonstrate that activating transcription factor 3 (ATF3), a common stress sensor, can activate the tumor suppressor p53 and regulate expression of p53 target genes upon DNA damage. However, whether ATF3 contributes to the maintenance of genome stability and tumor suppression remains unknown. Here we report that Atf3-deficient (Atf3^-/-) mice developed spontaneous tumors, and died significantly earlier than wild-type (Atf3^+/+) mice. Consistent with these results, Atf3^-/- mouse embryonic fibroblasts (MEFs) had more aberrant chromosomes and micronuclei, and were genetically unstable. Whereas we demonstrated that ATF3 activated p53 and promoted its pro-apoptotic activity in mouse thymi and small intestines, the chromosomal instability caused by Atf3 deficiency was largely dependent on the regulation of p53 by ATF3. Interestingly, loss of Atf3 also promoted spontaneous tumorigenesis in Trp53^+/- mice, but did not affect tumor formation in Trp53^-/- mice. Our results thus provide the first genetic evidence linking ATF3 to the suppression of the early development of cancer, and underscore the importance of ATF3 in the maintenance of genome integrity.

[Clinical efficacy of acute intraoperative encephalocele prevention strategy for severe traumatic brain injury]

Objective: To explore the clinical efficacy of prevention strategy for acute intraoperative encephalocele of patients with severe traumatic brain injury (sTBI). Methods: A total of 173 patients with sTBI, who treated in Emergency Neurosurgery Department of Shandong University Qilu Hospital from January, 2011 to September, 2015 were collected and divided into research group and control group, according to their therapeutic strategy.The clinical data during hospitalization and prognosis 1 year after injury was analyzed retrospectively to clarify the effect of acute encephalocele prevention strategy. Results: There were no statistically significant differences in sex, age, preoperative Glasgow coma scale score and imaging type of lesion between patients from the two groups.The highest intraoperative intracranial pressure in the research group and control group were (35.71±4.13) mmHg and(34.85±3.81) mmHg, respectively.The acute encephalocele incidence of the research group (7 cases, 6.5%) was significantly lower than that of the control group (13 cases, 19.7%) (P<0.01). Subgroup analysis showed that the incidence of acute encephalocele in patients with only unilateral lesions was low (1.3%), while higher (19.4%) in patients with both unilateral lesions and other secondary lesions or diffuse brain swelling.The prognosis of the patients was evaluated by Glasgow Outcome Scale according to the follow-up 1 year after injury, and it was suggested that the percentage of patients with good outcome in the research group (62 cases, 57.9%) was remarkably higher than that in the control group (26 cases, 39.4%) (P=0.018). Conclusions: For sTBI patients with high risk of acute encephalocele, prevention strategy was found to be able to retard the progression of delayed hematoma and diffuse brain swelling, prevent the acute encephalocele during operation, and then significantly improve the prognosis.

[Comparison of clinical features of hemorrhagic cystitis after haploidentical and matched sibling donor allogeneic hematopoietic stem cell transplantation]

Objective: To compare incidence and clinical features of hemorrhage cystitis (HC) after haploidentical donor (HID) allogeneic hematopoietic stem cell transplantation (HSCT) and matched sibling donor (MSD) HSCT. Methods: Medical records of 609 (including 406 HID-HSCT and 203 MSD-HSCT cases) hematologic malignancies patients treated with HSCT undergoing myeloablative conditioning regimen from January 2011 to December 2012 were analyzed retrospectively. Results: HC occurred 183 in HID and 17 ones in MSD respectively. The cumulative incidence of HC in HID group was higher than in MSD group[ (45.6±2.5) % vs (8.5±2.0) %, χ(2)=77.331, P<0.001], and the cumulative incidence of severe HC (grade 3-4) in HID cases was also higher than in MSD ones[ (11.2±1.9) % vs (2.1±1.1) %, χ(2)=12.883, P<0.001]. All HCs were occurred within 180 days in both groups. The median time to onset in two groups were 27 days after HSCT (range 0-177 days) and 29 days after HSCT (range 6-72 days) respectively (P=0.766) . The median duration of HC in two groups were 21 days (range 3-157 days) and 13 days (range 5-67 days) , respectively (P=0.182) . The total efficiency of treatment in two groups were 69.9% and 70.6% respectively (χ(2)=0.003, P=1.000) . Conclusion: The cumulative incidences of HC and severe HC were higher in HID cases than in MSD ones. The median time to onset and median duration of HC and therapeutic outcome between HID and MSD were comparable.

Butyrate and retinoic acid imprint mucosal-like dendritic cell development synergistically from bone marrow cells

Accumulating data show that the phenotypes and functions of distinctive mucosal dendritic cells (DCs) in the gut are regulated by retinoic acid (RA). Unfortunately, the exact role of butyrate in RA-mediated mucosal DC differentiation has not been elucidated thoroughly to date. Mucosal-like dendritic cell differentiation was completed in vitro by culturing bone marrow cells with growth factors [granulocyte-macrophage colony-stimulating factor (GM-CSF/interleukin (IL)-4], RA and/or butyrate. The phenotypes, cytokine secretion, immune functions and levels of retinal dehydrogenase of different DCs were detected using quantitative polymerase chain reaction (qPCR), enzyme-linked immunosorbent assay (ELISA) and flow cytometry, respectively. The results showed that RA-induced DCs (RA-DCs) showed mucosal DC properties, including expression of CD103 and gut homing receptor α₄ β₇ , low proinflammatory cytokine secretion and low priming capability to antigen-specific CD4⁺ T cells. Butyrate-treated RA-DCs (Bu-RA-DCs) decreased CD11c, but increased CD103 and α₄ β₇ expression. Moreover, the CD4⁺ T priming capability and the levels of retinal dehydrogenase of RA-DCs were suppressed significantly by butyrate. Thus, butyrate and retinoic acid have different but synergistic regulatory functions on mucosal DC differentiation, indicating that immune homeostasis in the gut depends largely upon RA and butyrate to imprint different mucosal DC subsets, both individually and collectively.

Surfactant reduced the mortality of neonates with birth weight ⩾1500 g and hypoxemic respiratory failure: a survey from an emerging NICU network

OBJECTIVE

We evaluated the efficacy of surfactant therapy and assisted ventilation on morbidity and mortality of neonates with birth weight (BW) ⩾1500 g and hypoxemic respiratory failure (HRF).

STUDY DESIGN

We retrospectively analyzed 5650 patients with BW ⩾1500 g for incidence, management and outcome of HRF, defined as acute hypoxemia requiring mechanical ventilation and/or nasal continuous positive airway pressure ⩾24 h. The patients were allocated into groups of moderate preterm (1735, 30.7%), late preterm (1431, 25.4%), early term (ETM, 986, 17.5%), full term (1390, 24.6%) and post term (79, 1.4%), with gestational age ⩽33, 34 to 36, 37 to 38, 39 to 41 and ⩾42 weeks, respectively.

RESULTS

In the five groups, 66.9, 42, 21.6, 12.8 and 5.1% had respiratory distress syndrome (RDS). For pneumonia/sepsis and meconium aspiration syndrome (MAS), the proportion was 13.8%, 25.4%, 38.0%, 52.5% and 76.0%, respectively. Surfactant was given to 21.9% (n=1238) of HRF and 51.2% (n=1108) of RDS. Survival rates of RDS were 82.2%, 87.8%, 84.5%, 77.1% and 75.0%, respectively (numbers needed to treat was 8 to 11 for surfactant benefit). Overall mortality rate of HRF was 21%, or 17.9%, 14.7%, 25.6%, 28.9% and 39.2%, respectively. Mortalities of MAS and pneumonia/sepsis were 29.4 and 27.6%. Relative risk of death was associated with initial disease severity, female gender, mechanical ventilation and congenital anomalies by multivariate logistic regression analysis.

CONCLUSION

Surfactant was effective for infants with RDS and BW ⩾1500 g, and different incidences and outcome of HRF among GA groups reflected standard of perinatal and respiratory care in emerging neonatal intensive care unit network.

[Epidemiology of febrile neutropenia in patients with hematological disease-a prospective multicentre survey in China]

目的

了解中国血液病患者中性粒细胞缺乏（粒缺）伴发热的发生率、临床和微生物学特征及危险因素。

方法

前瞻性研究2014年10月20日至2015年3月20日来自全国11家血液病中心发生粒缺伴发热的连续血液病患者发热情况及危险性因素。

结果

1 139例患者共发生784例次粒缺伴发热，粒缺持续21 d时发热的累积发生率为81.9%。多因素分析显示中心静脉置管（P<0.001，HR= 3.407，95% CI 2.276~4.496）、胃肠道黏膜炎（P<0.001，HR=10.548, 95% CI 3.245~28.576）、既往90 d内暴露于广谱抗生素（P<0.001，HR=3.582，95% CI 2.387~5.770）和粒缺持续时间>7 d（P<0.001，HR= 4.194，95% CI 2.572~5.618）是粒缺伴发热的危险因素。无任何危险因素、具备1项、2项、3~4项危险因素患者发热的累计发生率依次增加（35.4%、69.2%、86.1%及95.6%，P<0.001）。784例次粒缺伴发热中，不明原因发热253例次（32.3%），临床证实的感染429例次（54.7%），微生物学证实的感染102例次（13.0%）。最常见的感染部位依次为肺（388例次，49.5%）、上呼吸道（159例次，16.0%）、肛周组织（77例次，9.8%）、血流（60例次，7.7%）。最常见的病原菌为革兰阴性菌（44.54%），其次为革兰阳性菌（37.99%）和真菌（17.47%）。发热与未发热患者相比，两组之间总体病死率差异无统计学意义（9.2%对4.8%，P=0.099）。多因素分析显示年龄>40岁（P=0.047，HR=5.000，95% CI 0.853~28.013）、血流动力学不稳（P=0.001，HR=13.185, 95% CI 2.983~54.915）、既往耐药菌的定植或感染（P=0.005，HR=28.734，95% CI 2.921~313.744）、血流感染（P=0.038，HR=9.715, 95% CI 1.110~81.969）和肺部感染（P=0.031，HR=25.905, 95% CI 1.381~507.006）是与总体死亡相关的危险因素。

结论

发热是血液病患者粒缺期常见的合并症，不同部位的感染有不同的致病菌谱。粒缺持续时间>7 d、中心静脉置管、胃肠道黏膜炎和既往90 d内暴露于广谱抗生素是粒缺伴发热发生的危险因素。

A review of the clinical approach to persistent pain following total hip replacement

Total hip arthroplasty is effective in reducing pain and improving functional outcome for a variety of hip pathologies. Approximately 27% patients, however, complain of pain at 6 months' follow-up following surgery. The pain may worsen over time and can become severe and chronic in around 4% of patients who ultimately require revision surgery. Therefore, it is important for clinicians to comprehensively assess patients undergoing total hip arthroplasty in order to identify the underlying pathology of a painful hip and then offer prompt treatment. Causes of hip pain after total hip arthroplasty are analysed in this article, as well as the systematic approach to evaluation and appropriate diagnostic investigations.

[Laparoscopic reoperation for recurred antireflux surgery of gastroesophageal reflux disease]

OBJECTIVE

To investigate the safety and effectiveness of laparoscopic reoperation for patients with gastroesophageal reflux disease (GERD) recurred form previous anti-reflux surgery.

METHODS

Totally 19 patients received laparoscopic reoperation for symptomatic and anatomic recurred GERD in Department of Gastroesophageal Reflux Disease, Rocket Force General Hospital from January 2008 to September 2015 were retrospectively analyzed. There were 12 male and 7 female patients. The average reoperation age was (48±14) years, the average duration of reoperation from original ones was (43±38) months. The patients underwent preoperative barium, endoscopy, manometry and 24-hour pH studies. Laparoscopic hiatal hernia repair plus fundoplication was carried out for reoperation. Gastroesophageal reflux related symptoms (reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation) before and after surgery were compared by a questionnaire. The patients' medication consumption, complications and satisfaction of the reoperation were investigated as well. The repeated measures analysis of variance was used for statistical comparison of data preoperatively and postoperatively.

RESULTS

No major complication and death occurred. Six cases (32%) had complications such as diarrhea, increased passing wind, flatulence, dysphagia and abdominal pain. The GERD related symptom score of reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation all significantly decreased (F: 25.0 to 56.7; P: 0.000 to 0.001) after the reoperation, with 68% good outcome of all the patients. After a follow-up of (33±22) months after reoperation, 1 case had partial recurrence at the 3(rd) month after reoperation. For all the patients, 12 cases felt very satisfied or satisfied with the reoperation.

CONCLUSION

Laparoscopic reoperation is generally effective with acceptable morbidity rates for patients with esophageal and extraesophageal symptoms recurred form previous hiatal repair and (or) fundoplication.

Increased glycogen synthase kinase-3β and hexose-6-phosphate dehydrogenase expression in adipose tissue may contribute to glucocorticoid-induced mouse visceral adiposity

BACKGROUND

Increased adiposity in visceral depots is a crucial feature associated with glucocorticoid (GC) excess. The action of GCs in target tissue is regulated by GC receptor (GR) and 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) coupled with hexose-6-phosphate dehydrogenase (H6pdh). Glycogen synthase kinase-3β (GSK3β) is known to be a crucial mediator of ligand-dependent gene transcription. We hypothesized that the major effects of corticosteroids on adipose fat accumulation are in part medicated by changes in GSK3β and H6pdh.

METHODS

We characterized the alterations of GSK3β and GC metabolic enzymes, and determined the impact of GR antagonist mifepristone on obesity-related genes and the expression of H6pdh and 11ß-HSD1 in adipose tissue of mice exposed to excess GC as well as in in vitro studies using 3T3-L1 adipocytes treated with GCs.

RESULTS

Corticosterone (CORT) exposure increased abdominal fat mass and induced expression of lipid synthase ACC and ACL with activation of GSK3β phosphorylation in abdominal adipose tissue of C57BL/6J mice. Increased pSer⁹ GSK3β was correlated with induction of H6pdh and 11ß-HSD1. Additionally, mifepristone treatment reversed the production of H6pdh and attenuated CORT-mediated production of 11ß-HSD1 and lipogenic gene expression with reduction of pSer⁹ GSK3β, thereby leading to improvement of phenotype of adiposity within adipose tissue in mice treated with excess GCs. Suppression of pSer⁹ GSK3β by mifepristone was accompanied by activation of pThr³⁰⁸ Akt and blockade of CORT-induced adipogenic transcriptor C/EBPα and PPARγ. In addition, mifepristone also attenuated CORT-mediated activation of IRE1α/XBP1. Additionally, reduction of H6pdh by shRNA showed comparable effects to mifepristone on attenuating CORT-induced expression of GC metabolic enzymes and improved lipid accumulation in vitro in 3T3-L1 adipocytes.

CONCLUSION

These findings suggest that elevated adipose GSK3β and H6pdh expression contribute to 11ß-HSD1 mediating hypercortisolism associated with visceral adiposity.

Artesunate protects pancreatic beta cells against cytokine-induced damage via SIRT1 inhibiting NF-κB activation

AIM

Artesunate (ART) has been known as the most effective and safe reagents to treat malaria for many years. In this study, we explored whether ART could protect pancreatic beta-cell against cytokine-induced damage.

MATERIALS AND METHODS

The production of nitrite (NO) was detected with the Griess Assay Kit. SIRT1 and inducible nitric oxide synthase (iNOS) expression were determined with Western blot. The transcriptional activity of NF-κB was evaluated by luciferase reporter assay. The expression of Sirt1 was silenced by RNA interference. Glucose-stimulated insulin secretion (GSIS) and potassium-stimulated insulin secretion (KSIS) assays were performed to measure the effect of ART on pancreatic beta-cells' function. The effect of ART on beta-cells apoptosis was evaluated by using Hochest/PI staining and TUNEL assay.

RESULTS

ART enhanced GSIS (KSIS) and reduced apoptosis of pancreatic beta-cells induced by IL-1β. Further study showed that ART inhibited IL-1β-induced increase of NF-κB activity, iNOS expression, and NO production. Moreover, ART up-regulated SIRT1 expression in INS-1 cells and islets exposed to IL-1β. Inhibition of SIRT1 expression could partially abolished the inhibitory effect of ART on NF-κB activity in IL-1β-treated beta-cells. More importantly, the protective effect of ART on cytokine-induced damage was reversed by silencing SIRT1 expression.

CONCLUSIONS

ART can elicit a protective effect on beta-cells exposed to IL-1β by stimulating SIRT1 expression, which resulted in the decrease of NF-κB activity, iNOS expression, and NO production. Hence, ART might be an effective drug for diabetes.

Loss of ATF3 promotes hormone-induced prostate carcinogenesis and the emergence of CK5(+)CK8(+) epithelial cells

Steroid sex hormones can induce prostate carcinogenesis, and are thought to contribute to the development of prostate cancer during aging. However, the mechanism for hormone-induced prostate carcinogenesis remains elusive. Here we report that activating transcription factor 3 (ATF3) – a broad stress sensor – suppressed hormone-induced prostate carcinogenesis in mice. While implantation of testosterone and estradiol (T+E₂) pellets for 2 months in wild-type mice rarely induced prostatic intraepithelial neoplasia (PIN) in dorsal prostates (1 out of 8 mice), loss of ATF3 led to the appearance of not only PIN but also invasive lesions in almost all examined animals. The enhanced carcinogenic effects of hormones on ATF3-deficient prostates did not appear to be caused by a change in estrogen signaling, but were more likely a consequence of elevated androgen signaling that stimulated differentiation of prostatic basal cells into transformation-preferable luminal cells. Indeed, we found that hormone-induced lesions in ATF3-knockout mice often contained cells with both basal and luminal characteristics, such as p63⁺ cells (a basal cell marker) showing luminal-like morphology, or cells double-stained with basal (CK5⁺) and luminal (CK8⁺) markers. Consistent with these findings, low ATF3 expression was found to be a poor prognostic marker for prostate cancer in a cohort of 245 patients. Our results thus support that ATF3 is a tumor suppressor in prostate cancer.

Why do Hong Kong patients need total hip arthroplasty? An analysis of 512 hips from 1998 to 2010

INTRODUCTION

The number of patients undergoing total hip replacement surgeries has increased as a result of a rise in the ageing population. This study reviewed the demographics and disease spectrum leading to primary total hip replacement in the Chinese population from 1998 to 2010.

METHODS

This case series was conducted in a university teaching hospital in Hong Kong. Data from the prospective joint registry of all patients who underwent primary total hip replacement from January 1998 to December 2010 were reviewed. Patients' age and sex, diagnosis, as well as the Harris Hip Scores before operation and at the last follow-up were described.

RESULTS

There were 512 primary total hip replacements performed on 419 patients (43.4% males) during the study period. All had clinical follow-up for at least 2 years. The mean age of the patients was 57.6 (standard deviation, 16.6) years. In males, the main aetiology was osteonecrosis (50.9%), ankylosing spondylitis (19.5%), and post-traumatic arthritis (8.5%). For females, it was osteonecrosis (33.0%), primary osteoarthritis (18.8%), and post-traumatic arthritis (15.8%). Alcohol-induced (52.5%) and idiopathic (40.7%) was the most common cause of osteonecrosis in males and females, respectively. The mean preoperative Harris Hip Score and that at last follow-up was 43.9 (standard deviation, 18.3) and 89.7 (standard deviation, 13.0), respectively.

CONCLUSIONS

Osteonecrosis was the most common aetiology leading to total hip replacement although there were different causes in both sexes leading to it. The clinical result in terms of Harris Hip Score was good for all patients who required total hip replacement.

RNF126 promotes homologous recombination via regulation of E2F1-mediated BRCA1 expression

RNF126 is an E3 ubiquitin ligase. The deletion of RNF126 gene was observed in a wide range of human cancers and is correlated with improved disease-free and overall survival. These data highlights the clinical relevance of RNF126 in tumorigenesis and cancer therapy. However, the specific functions of RNF126 remain largely unknown. Homologous recombination (HR)-mediated DNA double-strand break repair is important for tumor suppression and cancer therapy resistance. Here, we demonstrate that RNF126 facilitates HR by promoting the expression of BRCA1, in a manner independent of its E3 ligase activity but depending on E2F1, a well-known transcription factor of BRCA1 promoter. In support of this result, RNF126 promotes transactivation of BRCA1 promoter by directly binding to E2F1. Most importantly, an RNF126 mutant lacking 11 amino acids that is responsible for the interaction with E2F1 has a dominant-negative effect on BRCA1 expression and HR by suppressing E2F1-mediated transactivation of BRCA1 promoter and blocking the enrichment of E2F1 on BRCA1 promoter. Lastly, RNF126 depletion leads to the increased sensitivity to ionizing radiation (IR) and poly (ADP-ribose) polymerase (PARP) inhibition. Collectively, our results suggest a novel role of RNF126 in promoting HR-mediated repair through positive regulation on BRCA1 expression by direct interaction with E2F1. This study not only offers novel insights into our current understanding of the biological functions of RNF126 but also provides a potential therapeutic target for cancer treatment.

Efficacy and safety of hylan G-F 20 injection in treatment of knee osteoarthritis in Chinese patients: results of a prospective, multicentre, longitudinal study

OBJECTIVE

To study the efficacy and safety of single intra-articular injection of 6-mL hylan G-F 20 in Chinese patients with symptomatic knee osteoarthritis.

DESIGN

Prospective case series.

SETTING

Six government hospitals in Hong Kong.

PATIENTS

Patients with primary knee osteoarthritis were recruited from six government hospitals from 1 October 2010 to 31 May 2012. All patients received 6-mL intra-articular injection of hylan G-F 20.

MAIN OUTCOME MEASURES

Pain visual analogue scale, functional visual analogue scale, and 5-point Likert scale on change of pain and function were assessed. Adverse events were checked. Radiographs were taken pre-injection and at 3 months and 1 year.

RESULTS

A total of 110 knees of 95 patients with primary knee osteoarthritis were treated. The mean age of the patients was 62 (standard deviation, 9.8) years. All patients completed 1 year of follow-up. The mean pain visual analogue scale, functional visual analogue scale, and Likert value for pain and function showed statistically significant improvements at 6 weeks, 3 months, 6 months, and 1 year compared with the pre-injection values. No significant correlations were found between changes in visual analogue scale and age, body mass index, pre-injection radiological osteoarthritis severity, serum erythrocyte sedimentation rate, or C-reactive protein. Serial radiographs did not show any changes in the radiological severity of knee osteoarthritis. Overall, 16.4% of the patients experienced mild and self-limiting adverse events.

CONCLUSION

Hylan G-F 20 is a safe and effective therapy to relieve pain and improve function for up to 1 year in Chinese patients with knee osteoarthritis.

International Mycoplasma pneumoniae typing study: interpretation of M. pneumoniae multilocus variable-number tandem-repeat analysis

Typing of Mycoplasma pneumoniae by multiple-locus variable-number tandem repeat analysis (MLVA) is increasingly in use. However, no specific internationally agreed guidance is available. Thirty M. pneumoniae DNA samples including serial dilutions of a type strain were sent to six international laboratories to perform MLVA and results were compared. Good correlation was observed, indicating that this methodology can be robustly performed in multiple sites. However, differences due to interpretation of fragment size, repeat sequence identification and repeat numbering led to inconsistency in the final profiles assigned by laboratories. We propose guidelines for interpreting M. pneumoniae MLVA typing and assigning the number of repeats.

Dysregulated choline metabolism in T-cell lymphoma: role of choline kinase-α and therapeutic targeting

Cancer cells have distinct metabolomic profile. Metabolic enzymes regulate key oncogenic signaling pathways and have an essential role on tumor progression. Here, serum metabolomic analysis was performed in 45 patients with T-cell lymphoma (TCL) and 50 healthy volunteers. The results showed that dysregulation of choline metabolism occurred in TCL and was related to tumor cell overexpression of choline kinase-α (Chokα). In T-lymphoma cells, pharmacological and molecular silencing of Chokα significantly decreased Ras-GTP activity, AKT and ERK phosphorylation and MYC oncoprotein expression, leading to restoration of choline metabolites and induction of tumor cell apoptosis/necropotosis. In a T-lymphoma xenograft murine model, Chokα inhibitor CK37 remarkably retarded tumor growth, suppressed Ras-AKT/ERK signaling, increased lysophosphatidylcholine levels and induced in situ cell apoptosis/necropotosis. Collectively, as a regulatory gene of aberrant choline metabolism, Chokα possessed oncogenic activity and could be a potential therapeutic target in TCL, as well as other hematological malignancies with interrupted Ras signaling pathways.