Laparoscopic Burch colposuspension

PURPOSE OF REVIEW

This review will describe the recent literature regarding laparoscopic Burch colposuspension.

RECENT FINDINGS

A 2006 Cochrane review found laparoscopic Burch colposuspension to be equivalent to open Burch colposuspension regarding subjective cure rate, but a reduced objective cure rate was reported. Three subsequent randomized trials have not identified any significant difference between the two procedures with respect to subjective or objective cure rates. Three additional prospective cohorts found cure rates of 76-95%. Another randomized controlled trial found laparoscopic Burch colposuspension with mesh and staples to be inferior to using sutures. There have been no new trials comparing laparoscopic Burch colposuspension and tension-free slings since the Cochrane review.

SUMMARY

Laparoscopic Burch colposuspension is an effective treatment for stress urinary incontinence and is equivalent to open Burch colposuspension. Success is affected by the surgeon's experience and surgical technique. No difference in subjective cure rates has been identified in comparison with tension-free slings; however, objective cure rates favor tension-free slings. We believe that laparoscopic Burch colposuspension is the procedure of choice in women undergoing pelvic-floor repair and concomitant retropubic surgery, and in young women, because it avoids the potential complications of mesh. More research comparing the two procedures is indicated.

Narrow ridge waveguide high power single mode 1.3-μm InAs/InGaAs ten-layer quantum dot lasers

Ten-layer InAs/In_0.15Ga_0.85As quantum dot (QD) laser structures have been grown using molecular beam epitaxy (MBE) on GaAs (001) substrate. Using the pulsed anodic oxidation technique, narrow (2 μm) ridge waveguide (RWG) InAs QD lasers have been fabricated. Under continuous wave operation, the InAs QD laser (2 × 2,000 μm²) delivered total output power of up to 272.6 mW at 10 °C at 1.3 μm. Under pulsed operation, where the device heating is greatly minimized, the InAs QD laser (2 × 2,000 μm²) delivered extremely high output power (both facets) of up to 1.22 W at 20 °C, at high external differential quantum efficiency of 96%. Far field pattern measurement of the 2-μm RWG InAs QD lasers showed single lateral mode operation.

Nitric oxide mediates the inhibitory effect of ethanol on the motility of isolated longitudinal muscle of proximal colon in rats

The aim of the present study was to investigate the effect of ethanol on colon motility in rats and to test the possibility that nitric oxide (NO) mediates this effect. Proximal colon longitudinal muscle strips (LM) (8 x 3 mm) cut parallel to the longitudinal muscle fibres of the colon were isolated and mounted in an organ bath. Ethanol (0.57, 0.87 and 1.30 mmol L(-1)) dose-dependently inhibited the motility of LM. Longitudinal muscle strips from female rats were more sensitive to the inhibitory effect of ethanol than that from male rats. L-NAME (N-nitro-L-arginine methyl ester) (100 micromol L(-1)), AG (aminoguanidine) (10 micromol L(-1)), ODQ (1H-[1,2,4]Oxadiazolo[4,3-a]quinoxalin-1-one) (10 micromol L(-1)) and PTIO (2-Phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl 3-oxide) (200 micromol L(-1)) partly blocked the inhibitory effect of ethanol on LM. Pretreatment with L-NAME, AG, ODQ and PTIO abolished the sex difference of the inhibitory effect of ethanol on LM. Tetrodotoxin (TTX) (10 micromol L(-1)) partly blocked the inhibitory effect but did not influence the sex difference. The relaxation of LM induced by SNP (sodium nitroprusside) (0.1-10 micromol L(-1)) in female rats was greater than that in male rats. In conclusion, ethanol inhibited the colon motility in vitro. This inhibitory effect on LM was mediated by NO through the iNOS - NO - cGMP pathway.

Vagal modulation of intestinal afferent sensitivity to systemic LPS in the rat

The central nervous system modulates inflammation in the gastrointestinal tract via efferent vagal pathways. We hypothesized that these vagal efferents receive synaptic input from vagal afferents, representing an autonomic feedback mechanism. The consequence of this vagovagal reflex for afferent signal generation in response to LPS was examined in the present study. Different modifications of the vagal innervation or sham procedures were performed in anesthetized rats. Extracellular mesenteric afferent nerve discharge and systemic blood pressure were recorded in vivo before and after systemic administration of LPS (6 mg/kg iv). Mesenteric afferent nerve discharge increased dramatically following LPS, which was unchanged when vagal efferent traffic was eliminated by acute vagotomy. In chronically vagotomized animals, to eliminate both vagal afferent and efferent traffic, the increase in afferent firing 3.5 min after LPS was reduced to 3.2 +/- 2.5 impulses/s above baseline compared with 42.2 +/- 2.0 impulses/s in controls (P < 0.001). A similar effect was observed following perivagal capsaicin, which was used to eliminate vagal afferent traffic only. LPS also caused a transient hypotension (<10 min), a partial recovery, and then persistent hypertension that was exacerbated by all three procedures. Mechanosensitivity was increased 15 min following LPS but had recovered at 30 min in all subgroups except for the chronic vagotomy group. In conclusion, discharge in capsaicin-sensitive mesenteric vagal afferents is augmented following systemic LPS. This activity, through a vagovagal pathway, helps to attenuate the effects of septic shock. The persistent hypersensitivity to mechanical stimulation after chronic vagal denervation suggests that the vagus exerts a regulatory influence on spinal afferent sensitization following LPS.

Prevalence of infraumbilical adhesions in women with previous laparoscopy

BACKGROUND AND OBJECTIVE

The aim of this study is to evaluate the prevalence of intraabdominal adhesions to the umbilicus following gynecologic laparoscopy through an umbilical incision.

METHODS

A retrospective review was performed of all gynecologic laparoscopic procedures in a private practice setting to identify patients with a repeat laparoscopy who had a history of a previous laparoscopy through an umbilical incision. Patients with a history of other surgeries were excluded. All repeat laparoscopies used a left upper quadrant entry technique where the abdominal cavity was surveyed for adhesions. We also reviewed adverse events attributable to the left upper quadrant entry approach.

RESULTS

We identified 151 patients who underwent a second laparoscopy and had a previous umbilical scar. Thirty-two of the 151 (21.2%) patients with a history of a laparoscopy had evidence of adhesions to the umbilical undersurface. No adverse events or injuries were attributed to the left upper quadrant entry technique.

CONCLUSIONS

Adhesions to the umbilical undersurface occur in 21.2% of patients who have undergone a prior laparoscopy through an umbilical incision. For this reason, we recommend an alternate location for entry in patients with an umbilical scar from a previous laparoscopy.

Comparative analysis of cavity length-dependent temperature sensitivity of GaInNAs quantum dot lasers and quantum well lasers

Self-assembled GaInNAs/GaAsN single-layer quantum dot (QD) lasers, grown using solid source molecular beam epitaxy, have been fabricated and characterized. A high output power of 40.76 mW/facet was obtained from a GaInNAs QD laser with dimensions of 50 × 700 µm(2) at 10 °C. Temperature-dependent measurements were carried out on the GaInNAs QD lasers of different cavity lengths. For comparison, temperature-dependent measurements were also performed on GaInNAs single quantum well (SQW) and triple QW (TQW) lasers. Unlike the relationship between cavity length and T(0) in GaInNAs SQW/TQW lasers, longer-cavity GaInNAs QD lasers (50 × 1700 µm(2)) showed a lower T(0) of 65.1 K, which is believed to be due to non-uniformity of the GaInNAs QD layer. Furthermore, compared to GaInNAs SQW lasers, a significant improvement in temperature sensitivity was observed in the TQW GaInNAs lasers. This is attributed to a reduction in the relative contribution of the Auger recombination current and suppression of heavy-hole leakage in the TQW laser structures.

A survey on the preference for continuing professional dental education amongst general dental practitioners who attended the 26th Asia Pacific Dental Congress

AIMS

To identify the subjects of interest and to examine the modes as well as means of study for continuing professional dental education amongst general dental practitioners who attended the 26th Asia Pacific Dental Congress, 28 May-1 June 2004, Hong Kong.

METHODS

A total of 381 general dental practitioners as the registered conference delegates from Hong Kong, Mainland China and other Asia-Pacific regions were randomly selected for the present survey. The survey was conducted through face-to-face interviews by a group of practising dentists in Hong Kong.

RESULTS

Overall, orthodontics and prosthodontics were the most popular subjects for clinical degree programmes, whilst oral implantology and cosmetic dentistry were the highly preferred subjects for continuing education courses. Concerning the preferred mode of study for degree programmes, the part-time study mode was chosen by 68.3% of the participating dentists. A didactic teaching approach was preferred by most of the participants (81.7%) for postgraduate study. The majority of the interviewees (76.5%) were interested in a proposed clinical degree programme to be offered jointly by The University of Hong Kong and a leading university in the Mainland. Overall, there was no marked difference in the preference for continuing dental education amongst the respondents from Hong Kong, Mainland China and other Asia-Pacific regions.

CONCLUSIONS

The present survey shows the currently preferred specialty areas and subjects for continuing professional dental education amongst the general dental practitioners who attended the 26th Asia Pacific Dental Congress, with didactic teaching as the most preferred mode of study on a part-time basis.

Self-assembled GaInNAs/GaAsN quantum dot lasers: solid source molecular beam epitaxy growth and high-temperature operation

Self-assembled GaInNAs quantum dots (QDs) were grown on GaAs (001) substrate using solid-source molecular-beam epitaxy (SSMBE) equipped with a radio-frequency nitrogen plasma source. The GaInNAs QD growth characteristics were extensively investigated using atomic-force microscopy (AFM), photoluminescence (PL), and transmission electron microscopy (TEM) measurements. Self-assembled GaInNAs/GaAsN single layer QD lasers grown using SSMBE have been fabricated and characterized. The laser worked under continuous wave (CW) operation at room temperature (RT) with emission wavelength of 1175.86 nm. Temperature-dependent measurements have been carried out on the GaInNAs QD lasers. The lowest obtained threshold current density in this work is ∼1.05 kA/cm²from a GaInNAs QD laser (50 × 1,700 µm²) at 10 °C. High-temperature operation up to 65 °C was demonstrated from an unbonded GaInNAs QD laser (50 × 1,060 µm²), with high characteristic temperature of 79.4 K in the temperature range of 10–60 °C.

A review of laparoscopic uterine suspension procedures for uterine preservation

PURPOSE OF REVIEW

The most appropriate surgical approach for uterine preservation still remains the subject of ongoing controversy. Uterine suspension procedures can be performed abdominally, vaginally, or laparoscopically. This article focuses on the three different laparoscopic approaches of uterine suspension for uterine preservation: suspension to the round ligaments; suspension to the uterosacral ligaments; and suspension to the anterior ligament of the sacral promontory. This article reviews the published studies in the literature, analyzes the results, discusses the differences, and compares the different laparoscopic techniques.

RECENT FINDINGS

A review of the literature reveals a paucity of research studies and publications on laparoscopic uterine suspension procedures. All the published studies are small, retrospective case series or case studies. Laparoscopic ventrosuspension using the round ligaments for uterine prolapse has a reported success rate of less than 50%. The ventrosuspension procedure has a very limited role and should not be employed. In comparison, laparoscopic uterine suspension procedures have a reported success rate ranging between 81 and 100%. The newest surgical technique is the laparoscopic sacral colpohysteropexy and there is only one reported case series on this procedure. The reported success rate for the sacral colpohysteropexy is 100%.

SUMMARY

The first surgical option for uterine preservation is uterine suspension to the uterosacral ligaments. If the uterosacral ligaments cannot be identified or the uterosacral ligaments are weak and unusable, then laparoscopic sacral colpohysteropexy is a reliable second option. Uterine suspension to the round ligaments has an unacceptably high failure rate and is not an effective, durable alternative.

Laparoscopic vaginal vault suspension using uterosacral ligaments: A review of 133 cases

The objective of our study was to describe the surgical technique of laparoscopic vaginal vault suspension using the uterosacral ligaments. In addition, we performed a retrospective analysis of this laparoscopic technique on 133 patients with advanced symptomatic vaginal vault prolapse to evaluate the efficacy and durability of this laparoscopic technique. Efficacy and anatomic outcome were assessed by the Baden-Walker halfway scoring system before and after the surgical procedure. Preoperatively, all patients showed evidence of grade 2 or greater prolapse (descent to the level of the hymen). Fifty-one patients (38.4%) had uterovaginal prolapse, and 82 patients (61.6%) had vaginal vault prolapse. The patients were reevaluated at 1, 6, and 12 months postoperatively and yearly thereafter. The postoperative follow-up ranged from 2.0 to 7.3 years. Postoperatively, 116 patients (87.2%) had no recurrence of prolapse, and 17 patients (12.8%) had recurrence of prolapse. The major complication rate was 2.25%. We conclude that laparoscopic vaginal vault suspension is a safe, efficacious, and durable alternative for the management of vaginal vault prolapse.

Smoking cessation among Hong Kong Chinese smokers attending hospital as outpatients: impact of doctors' advice, successful quitting and intention to quit

To identify factors affecting current smokers' intention to quit smoking and factors associated with successful quitting among ex-smokers in Hong Kong. A cross-sectional survey of Chinese patients attending medical and surgical Specialist Outpatient Clinics (SOPCs) of public hospitals in Hong Kong, using a structured questionnaire. Results of the 642 respondents, 21% were current smokers, 9% were ex-smokers and 69% were non-smokers. 74% of the smokers reportedly received quitting advice from doctors. Among the current smokers, past quitting attempts, receiving information from sources other than doctors, believing that doctor's advice was useful, believing that all smokers should quit smoking and a positive attitude towards quitting were associated with intention to quit. Among those who had attempted to quit, being older (aged 50 or above), being retired/unemployed and consuming more than 10 cigarettes per day were associated with successful quitting. We found that advice from doctors on quitting smoking did not have any impact on Chinese smokers quitting or future intention to quit and reflect the inadequacy of advice given by Hong Kong doctors. The predictors of intention to quit and successful quitting identified in the study could be used to design future smoking cessation services.

Safe entry techniques during laparoscopy: Left upper quadrant entry using the ninth intercostal space—A review of 918 procedures

Surgeons performing sophisticated endoscopic operations must be well versed in alternate laparoscopic access methods to address evolving patient expectations and safety requirements. The safety of left upper quadrant laparoscopic entry in patients with prior surgeries and abdominal adhesions was evaluated. Laparoscopic surgery was performed for various indications on patients with prior surgical scars and anticipated risk of adhesions at the primary umbilical port site. All laparoscopies performed from July 1998 through June 2004 were analyzed. Of the 918 laparoscopies, 504 patients (54.9%) were found to have involvement of their umbilicus with adhesions that could have affected the traditional umbilical primary port entry. Left ninth intercostal space was used for Veres needle entry, and the primary trocar was placed in the left upper quadrant space. Of the 504 potentially risky entries, there were two (0.39%) Veres-needle related and zero trocar-related injuries. All surgical procedures were accomplished laparoscopically, and all entries were accomplished by the left upper quadrant entry technique. Therefore left upper quadrant entry technique is a safe and easily learned alternate access technique.

ApoEε4 allele is associated with incidental hallucinations and delusions in patients with AD

Of 135 patients with Alzheimer disease (AD), 56 without psychiatric symptoms at the first visit were followed for a mean period of 51.9 +/- 10.3 months to identify incident psychiatric symptoms. The hazard ratios of ApoE epsilon4 allele in developing psychiatric symptoms were calculated by Cox regression hazard analyses. The presence of the ApoE epsilon4 allele carried a 19.0-fold risk for developing hallucinations and a 3.4-fold risk for delusions.

Microinjection of glutamate into dorsal motor nucleus of the vagus excites gallbladder motility through NMDA receptor - nitric oxide - cGMP pathway

We have reported that both glutamate and nitric oxide (NO) participated in the regulation of gallbladder motility in dorsal motor nucleus of the vagus (DMV). The aim of this study is to investigate the type of receptor in DMV that mediates the excitatory effect of glutamate on gallbladder motility and the correlation between the glutamate and NO. A frog bladder connected with a force transducer was inserted into the gallbladder to record the change of gallbladder pressure. Glutamate (65 mmol L(-1), 100 nL) microinjected into DMV significantly increased the strength of gallbladder phasic contraction. This effect was abolished by ketamine (180 mmol L(-1), 100 nL), the specific N-methyl-d-aspartic acid (NMDA) receptor antagonist, but was not influenced by 6-cyaon-7-nitroquinoxaline-2,3-(1H,4H)-dione (CNQX) (180 mmol L(-1), 100 nL), the non-NMDA ionotropic receptor antagonist. N(G)-nitro-l-arginine-emthyl (l-NAME) (1 mol L(-1), 100 nL), the nitric oxide synthase (NOS) inhibitor, reversed the excitatory effect of glutamate on gallbladder motility. Microinjection of sodium nitroprusside (SNP), the NO donor, into DMV enhanced the gallbladder motility, and this effect was not modulated by ketamine. Microinjection of NMDA (5 mmol L(-1), 100 nL) increased the strength of gallbladder phasic contraction, and this effect was attenuated by methylene blue (100 mmol L(-1), 100 nL), the soluble guanylate cyclase inhibitor. These results suggest that glutamate regulate the gallbladder motility through the NMDA receptor - NO - cGMP pathway in DMV.

Laparoscopic suburethral sling procedure

STUDY OBJECTIVE

To describe the technique of laparoscopic suburethral sling and discuss patient satisfaction and subjective continence rates over 7 years.

DESIGN

Retrospective analysis (Canadian Task Force classification III).

SETTING

Private practice.

PATIENTS

Sixty-three consecutive patients.

INTERVENTION

Laparoscopic sling procedure using either autologous or donor fascia.

MEASUREMENTS AND MAIN RESULTS

The space of Retzius is entered laparoscopically. Then from a vaginal approach, a small midline vertical incision is made below the urethra, and vaginal epithelium is dissected off underlying periurethral and paravesical fascia. Material for the sling is passed underneath the urethra and secured laparoscopically to Cooper's ligaments bilaterally. Over 7 years, 63 laparoscopic suburethral sling procedures were performed. Overall, patients reported 88.9% satisfaction rate and 81.0% subjective continence rate.

CONCLUSION

The laparoscopic approach is an acceptable alternative to other suburethral sling procedures.

RT-PCR detection of the expression of the polymerase gene of a novel reptilian herpesvirus in tumor tissues of green turtles with fibropapilloma

An alpha-herpesvirus has recently been associated with green turtle fibropapilloma (FP). To further understand the etiological role of this newfound green turtle herpesvirus (GTHV) in the pathogenesis of FP, expression of GTHV polymerase ( pol) gene was determined in tumors and normal-appearing nontumor tissues and organs from five green turtles suffering multiple fibropapillomas, using reverse transcription-polymerase chain reaction (RT-PCR). Amplification of RNA prepared from tumor tissues evidenced the substantial expression of GTHV DNA pol gene in all specimens tested (15/15). However, GTHV pol gene expression in normal-appearing tissues and organs of affected animals was limited (4/45), and GTHV mRNA was detected only in periorbital tissue (1/2), gall bladder (2/5) and lung (1/5) by nested RT-PCR. By contrast, RT-PCR evaluation of RNA isolated from non-tumored turtles revealed undetectable expression of this herpesvirus gene. cDNA sequence analysis revealed that GTHV gene sequences were identical in different tumors. Our data represent the first evidence of the replication of this putative turtle herpesvirus in affected green turtles and fibropapilloma tissues are always active sites of GTHV mRNA synthesis. These findings extend and substantiate the pathogenic association of GTHV with FP.

Structural and biochemical evidence of mitochondrial depletion in pigs with hypertrophic cardiomyopathy

Pig hearts with naturally occurring hypertrophic cardiomyopathy (HCM) were isolated to investigate the effects of mitochondrial deficiency at biochemical and molecular levels. Enzyme activities of mitochondrial-encoded cytochrome c oxidase and NADH dehydrogenase in the HCM hearts (n=12) were lower than that in the controls (n=12) by 41+/-29% (P<0.01) and 43+/-21% (P<0.001), respectively. Additionally, Southern blot analysis was conducted to quantify the relative amount of mitochondrial DNA (mtDNA) from the HCM and controls. The relative amount of mtDNA in the HCM hearts was significantly 57+/-19% (P<0.001) lower than that in the controls. Both mitochondrial enzyme deficiency and mtDNA depletion were significantly correlated with the degree of cardiac hypertrophy judged based on the ratio of heart/body weight. In conclusion, our results reveal that a secondary effect of tissue-specific mtDNA depletion and mitochondrial dysfunction is in response to the HCM.

Laparoscopic appendectomy

STUDY OBJECTIVE

To evaluate the effectiveness of laparoscopic appendectomy in women with chronic pelvic pain and to identify histopathology of the appendix.

DESIGN

Retrospective review over 6.5 years (Canadian Task Force classification II-3).

SETTING

Laparoscopic center and community hospital.

PATIENTS

Three hundred seventeen women.

INTERVENTION

Laparoscopic appendectomy in conjunction with other procedures.

MEASUREMENTS AND MAIN RESULTS

Of 317 patients who underwent appendectomy, 14 (4.4%) had involvement of the appendix with endometriosis, 12 (3.78%) had early acute appendicitis, 4 (1.26%) had carcinoid tumors of the appendix, 2 (0.63%) had a large mucocele, and 1 (0.9%) each had Enterobius vermicularis infection, benign neuroma, and mucinous cystadenoma. Seventy-eight women (24.6%) had obliteration of the appendiceal lumen and 22 (6.93%) had entrapping fibrous adhesions. Thirty-two patients (10%) reported relief of chronic pelvic pain in the absence of other pathology just by having diagnostic laparoscopy with appendectomy.

CONCLUSION

The appendix is a key organ in the evaluation of undiagnosed chronic pelvic pain.

Minimally invasive management of urinary incontinence

Stress urinary incontinence is defined as the loss of urine at the time of an increase in abdominal pressure in the absence of a detrusor contraction. A nearly 50% prevalence of urinary incontinence in women and estimated treatment costs of more than 10 billion US dollars annually in the United States warrant an effective, successful and minimally invasive treatment. Nearly 200 different operations have been described in the literature, with cure rates reported ranging from 40% to 95%, clearly suggesting that the optimal surgical procedure has yet to be developed. Genuine stress urinary incontinence can result from either hypermobility of the bladder neck and proximal urethra or intrinsic sphincteric deficiency, which may occur alone or in combination with anatomic defects. In reviewing the recent literature and surgical modalities we present our opinion on minimally invasive surgical management of urinary incontinence.

Clinical characteristics of Group G streptococcal bacteremia in Taiwan

The results of this retrospective study showed that Group G streptococcal bacteremia was an acute febrile disease with low mortality. Most patients were > 60 y old but there was a strong association between age < 60 y and malignancy. Cases clustered in summer and the most common port of entry was the skin.

Complementary signaling pathways regulate the unfolded protein response and are required for C. elegans development

The unfolded protein response (UPR) is a transcriptional and translational intracellular signaling pathway activated by the accumulation of unfolded proteins in the lumen of the endoplasmic reticulum (ER). We have used C. elegans as a genetic model system to dissect UPR signaling in a multicellular organism. C. elegans requires ire-1-mediated splicing of xbp-1 mRNA for UPR gene transcription and survival upon ER stress. In addition, ire-1/xbp-1 acts with pek-1, a protein kinase that mediates translation attenuation, in complementary pathways that are essential for worm development and survival. We propose that UPR transcriptional activation by ire-1 as well as translational attenuation by pek-1 maintain ER homeostasis. The results demonstrate that the UPR and ER homeostasis are essential for metazoan development.

TGFbeta2 in corneal morphogenesis during mouse embryonic development

To examine the roles of TGFbeta isoforms on corneal morphogenesis, the eyes of mice that lack TGFbetas were analyzed at different developmental stages for cell proliferation, migration and apoptosis, and for expression patterns of keratin 12, lumican, keratocan and collagen I. Among the three Tgfb(-/-) mice, only Tgfb2(-/-) mice have abnormal ocular morphogenesis characterized by thin corneal stroma, absence of corneal endothelium, fusion of cornea to lens (a Peters'-like anomaly phenotype), and accumulation of hyaline cells in vitreous. In Tgfb2(-/-) mice, fewer keratocytes were found in stroma that has a decreased accumulation of ECM; for example, lumican, keratocan and collagen I were greatly diminished. The absence of TGFbeta2 did not compromise cell proliferation, nor enhance apoptosis. The thinner stroma resulting from decreased ECM synthesis may account for the decreased cell number in the stroma of Tgfb2 null mice. Keratin 12 expression was not altered in Tgfb2(-/-) mice, implicating normal corneal type epithelial differentiation. Delayed appearance of macrophages in ocular tissues was observed in Tgfb2(-/-) mice. Malfunctioning macrophages may account for accumulation of cell mass in vitreous of Tgfb2 null mice.