Atherosclerosis subclinical and inflammatory markers in obese and nonobese children and adolescents

Carotid artery intima-media thickness values in obese or overweight children: a meta-analysis

OBJECTIVE

Carotid artery intima-media thickness (IMT) is a non-invasive ultrasound marker of early atherosclerosis. This systematic review and meta-analysis aim to report the published differences in IMT values in children living with overweight or obesity compared to controls with normal weight.

METHODS

This review was conducted according to PRISMA guidelines, including only cohorts with normal controls. Inclusion criteria were IMT measured using B-mode or radiofrequency (RF) techniques and based on the four consensuses: American Heart Association, Association for European Pediatric Cardiology, Mannheim Consensus, and American Society of Echocardiography. We used the body mass index based on the World Health Organization growth standard definitions of obesity in children. Relevant articles were extracted from PubMed, Cochrane Library, Embase, and Web of Science searched from inception to February 2024. A meta-analysis was done by a biostatistician using the R-software version 4.0.2.

RESULTS

We obtained 15 B-mode-based and two RF echo-tracking-based IMT measurement studies. IMT is significantly increased in children living with obesity. The mean IMT was 0.041 mm, 95% confidence interval (CI): 0.052; 0.031 higher in children with overweight/obesity, using the B-mode technique, and 0.045 mm, 95% CI: 0.062; 0.029 higher in children with overweight/obesity using RF technique.

CONCLUSION

This meta-analysis shows that IMT is significantly increased in children with obesity compared to normal-weight children according to both techniques.

KEY POINTS

Question IMT measured according to known consensuses is significantly increased in children living with obesity. Findings Mean IMT was 0.041 mm higher in children living with obesity using the B-mode technique and 0.045 mm using the RF technique. Clinical relevance There are different techniques to measure IMT in children. This meta-analysis, using cohorts of children living with obesity compared to normal weight controls, shows a significantly increased IMT in children living with obesity.

Monocyte-to-Neutrophil Ratio as an Immunological Marker of Left Ventricular Hypertrophy in Children with Primary Hypertension

Background/Objectives: Activation of the immune system and subclinical inflammation participate in the pathogenesis of primary hypertension (PH) and the formation of hypertension-mediated organ damage. Our study aimed to investigate the relationship between subclinical inflammation and left ventricular hypertrophy (LVH) in pediatric patients with PH. Methods: In 34 untreated children with PH (15.1 ± 2.1 years, 28 boys, 6 girls), we investigated markers of subclinical inflammation (high-sensitivity CRP, interleukin 18, and complete blood count-derived indices), parameters of the left ventricle from 2D-echocardiography, office and ambulatory blood pressure, and selected clinical and biochemical parameters. Results: LVH was revealed in 12 (35.3%) patients, and abnormal relative wall thickness (RWT) was found in 6 (17.6%) children. Left ventricular inner dimension at end diastole (LVEDd) Z-score correlated negatively with neutrophils (r = -0.583, p = 0.001), neutrophil-to-lymphocyte ratio (NLR) (r = -0.562, p = 0.002), and positively with monocyte-to-neutrophil ratio (MNR) (r = 0.605, p = 0.001) and left ventricular mass (LVM) for lean body mass Z-score, while LVMI [g/m2] correlated positively with MNR (r = 0.495, p = 0.005 and r = 0.433, p = 0.011). RWT correlated positively with neutrophil count (r = 0.356, p = 0.039 and r = 0.347 p = 0.044) and with monocyte count (r = 0.378, p = 0.027 and r = 0.365, p = 0.034). Patients with LVH had significantly lower NLR (1.430 ± 0.409 vs. 1.797 ± 0.521, p = 0.043) and higher MNR ratios (0.171 ± 0.031 vs. 0.144 ± 0.037, p = 0.042). The receiver operating characteristic analysis demonstrated good diagnostic profiles for mean platelet volume (MPV), NLR, and MNR as predictors of LVH. In multivariate analysis, MNR was the only significant predictor of LVH (OR: 1.329, 95CI: 1.007-1.756). Conclusions: Monocyte-to-neutrophil ratio may be an easily accessible marker of left ventricular hypertrophy in children with primary hypertension.

Early-life anthropometry and colorectal cancer risk in adulthood: Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis of prospective studies

While adult anthropometric measures are well-studied in relation to colorectal cancer (CRC) risk, the impact of early-life anthropometry remains unclear. We conducted a systematic literature review and meta-analysis examining early-life anthropometry, including birth size, height and adiposity and adult CRC risk. We searched Medline, Embase, Web of Science and CENTRAL. Early-life stages were categorised as at birth, infancy (0 to <2 years), childhood (2 to 9 years), adolescence (10 to 19 years) and young adulthood (18 to 25 years). Random-effects meta-analyses were conducted when ≥3 prospective observational studies provided sufficient information; otherwise, results were descriptively synthesised. We included 37 publications, and evidence was graded by the Global Cancer Update Programme Expert Panel. Higher birthweight (relative risk [RR] per 1000 g: 1.09, 95% confidence interval [CI] 1.01-1.16; 8 studies, 8134 cases) and young adult body mass index (BMI, RR per 5 kg/m2: 1.12, 95% CI 1.07-1.17; 16 studies, 20,365 cases) were associated with higher CRC risk. Associations for young adult BMI were most pronounced for colon cancer (RR per 5 kg/m2: 1.15, 95% CI: 1.06-1.24). Descriptive synthesis showed that childhood and adolescent BMI were also associated with higher colon and/or CRC risk. Evidence for all the above associations was graded by the Expert Panel as "strong-probable." Additionally, there was "limited-suggestive" evidence linking higher birthweight to higher colon cancer risk, taller childhood height to higher CRC risk, early-life adiposity-measured by BMI pictograms-to higher colon and CRC risk and higher young adult BMI to rectal cancer risk. Other exposure-outcome associations were graded as "limited-no conclusion." Altogether, these results imply that larger body size during early life is associated with higher adult CRC risk.

Association of Subclinical Inflammation Markers with Primary Hypertension in Children-A Systematic Review with Meta-Analysis

Background/Objectives: This systematic review and meta-analysis aimed to determine whether there is an association between low-grade inflammation markers and primary hypertension (PH) in children. Methods: The MEDLINE, EMBASE, and Cochrane databases were searched up to March 2025 for cohort, cross-sectional, and case-control studies; additional references were obtained from reviewed articles. The studies needed to investigate an association between any inflammation markers and PH. Participants of the study were children (<18 years old) with PH and healthy controls. This meta-analysis included 13 studies published between 2005 and 2024, enrolling 1306 patients (745 with PH and 561 healthy controls). The data were analyzed using Review Manager. Pooled mean difference (MD) with a 95% confidence interval (95% CI) was used to assess the differences in inflammation markers. Results: There was a significant difference between hypertensive and control groups in high-sensitivity C-reactive protein (hs-RCP) concentration (mean difference (MD): 0.07 95%CI (0.04, 0.09)), intercellular adhesion molecule 1 (ICAM-1) (MD: 85.28 95%CI: (50.57-119.99)), vascular cell adhesion molecule 1 (VCAM-1) (MD: 259.78 95%CI: (22.65-496.91)), neutrophil count (MD: 0.90 95%CI (0.66-1.14)), monocyte count (MD: 0.08 95CI%: (0.04-0.11)), platelet count (MD: 20.24 95CI%: (4.27-36.21)), neutrophil-to-lymphocyte ratio (MD: 0.48 95%CI: (0.34-0.62)), and lymphocyte-to-monocyte ratio (MD: -0.52 95%CI: (-1.02--0.02)). There was no difference in terms of interleukin 6 (IL-6), lymphocyte count, mean platelet volume (MPV), or platelet-to-lymphocyte (PLR) ratio. Conclusions: Some easily accessible markers of low-grade inflammation might be used as an additional tool for diagnosis and screening for hypertension in children. These results should be validated in large and well-conducted studies.

Dietary Patterns, Nutritional Status and Inflammatory Biomarkers in Adolescents from the RPS Birth Cohort Consortium

This study aimed to identify the dietary patterns (DPs) of adolescents and assess indicators of subclinical inflammation. It was a cross-sectional study aligned with the RPS cohort with data from São Luís, Maranhão, Brazil. We evaluated 511 adolescents between 18-19 years old. DPs were identified with a factor analysis of the principal components. Nutritional status was assessed with body mass index and body fat percentages. Hierarchical modeling was performed using a linear regression to estimate the beta coefficient (β) of the independent variables with the dependent variables interleukin-6 and high-sensitivity C-reactive protein (hs-CRP). Five DPs were identified: energy-dense, sugar-sweetened beverages and breakfast cereals, prudent, traditional Brazilian and alcoholic and energy beverages. Greater adherence to the prudent DP was associated with a lower concentration of interleukin-6 (β = -0.11; p value = 0.040). Greater adherence to the DP "traditional Brazilian" and "alcoholic and energy beverages" were associated with increased IL-6, mediated by the nutritional status. A higher BMI (β = 0.36; p value = <0.001) and %BF (β = 0.02; p value = 0.014) were associated with higher hs-CRP concentrations. The nutritional status and "prudent" pattern were associated with inflammatory biomarkers. These findings show that a higher consumption of fresh and minimally processed foods and the adequacy of the nutritional status are protective factors for the inflammatory process.

Hypertension Predisposition and Thermoregulation Delays in Adolescents with Polycystic Ovary Syndrome: A Pilot Study

Background: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder in which clinical, sonographic, and endophenotypic features have been underinvestigated or inconclusive, especially in the early stages of the disease (adolescence/young adulthood). Objective: This prospective pilot study focused on the differences of multiple physiological functions between Greek adolescent/young adult females suffering from PCOS and age- and body mass index (BMI)- matched healthy controls. Study design: Nineteen PCOS patients and eighteen healthy controls (aged 13 to 23 years) were studied for: (i) biochemical and hormonal dysfunction by measuring circulating glucose, insulin, and androgen levels; (ii) arterial stiffness with pulse wave analysis (PWA) by Sphygmocord; (iii) intima-media thickness (IMT) by ultrasound; (iv) heart rate variability (HRV) by Task Force Monitor; and (v) QT, QRS, QT, P, QRSD by electrocardiogram (ECG). Statistical analysis included Hedge’s g correction for small samples bias, and the results are shown using the Hedge’s g effect size and 95% CI, in line with precision medicine prerequisites. Results: Significant differences in pulse wave velocity (PWV) (g = 0.964 [0.296, 1.632]), subendocardial viability ratio (SEVR) carotid (g = −0.679 [−1.329, −0.030]), pulse pressure (PP) carotid (g = 0.942 [0.275, 1.608]), systolic pressure (SP) carotid (g = 0.785 [0.129, 1.440]), free-testosterone (g = 0.677 [0.042, 0.312]), and Delta4-androstenedione (g = 0.735 [0.097, 0.373]) were observed between PCOS patients and controls. No differences were detected in the remaining endocrine and PWA or ECG biomarkers. Conclusions: Our multidisciplinary approach showed early onset of vascular dysfunction, predisposition to hypertension, thermoregulation delays, and metabolic syndrome changes in adolescent/young adult PCOS.

Pediatric Obesity-Related Asthma: The Role of Nutrition and Nutrients in Prevention and Treatment

Childhood obesity rates have dramatically risen in numerous countries worldwide. Obesity is likely a factor in increased asthma risk, which is already one of the most widespread chronic respiratory pathologies. The pathogenic mechanism of asthma risk has still not yet been fully elucidated. Moreover, the role of obesity-related inflammation and pulmonary overreaction to environmental triggers, which ultimately result in asthma-like symptoms, and the importance of dietary characteristics is well recognized. Diet is an important adjustable element in the asthma development. Food-specific composition of the diet, in particular fat, sugar, and low-quality nutrients, is likely to promote the chronic inflammatory state seen in asthmatic patients with obesity. An unbalanced diet or supplementation as a way to control asthma more efficiently has been described. A personalized dietary intervention may improve respiratory symptoms and signs and therapeutic response. In this narrative review, we presented and discussed more recent literature on asthma associated with obesity among children, focusing on the risk of asthma among children with obesity, asthma as a result of obesity focusing on the role of adipose tissue as a mediator of systemic and local airway inflammation implicated in asthma regulation, and the impact of nutrition and nutrients in the development and treatment of asthma. Appropriate early nutritional intervention could possibly be critical in preventing and managing asthma associated with obesity among children.

Birth Size as a Determinant of Cardiometabolic Risk Factors in Children

The association between birth size and cardiometabolic disease risk may be U-shaped. Being born small for gestational age (SGA) has a definitive association with later cardiovascular risk, but the impact of being born large for gestational age (LGA) on cardiometabolic health is more controversial. In addition to birth size, early postnatal growth pattern and later weight gain affect cardiometabolic risk in adulthood. Most SGA-born children have catch-up and LGA-born children have catch-down growth during the first years of life. The extent of this early compensatory growth may contribute to the adverse health outcomes. Both SGA- and LGA-born children are at an increased risk for overweight and obesity. This may have a long-term impact on cardiometabolic health as overweight tends to track to adulthood. Other cardiometabolic risk factors, including alterations in glucose metabolism, dyslipidemia, hypertension, and low-grade inflammation are associated with birth weight. Many of these risk factors are related to overweight or adverse fat distribution. Since later cardiometabolic risk is often mediated by early growth pattern and later overweight in SGA and LGA children, it is important to focus on staying normal weight throughout life. Hence, effective interventions to reduce cardiometabolic risk in LGA and SGA children should be developed.

Childhood obesity: Aetiology, comorbidities, and treatment

Obesity is currently considered a global epidemic, and its implications in mortality and morbidity in a paediatric patient and in adulthood are increasingly important. The objective of this article is to review in detail the definition of obesity according to age group, and, in turn, the epidemiology of this entity worldwide and in South America. Available evidence about pathophysiology and, additionally, associated comorbidities are reported in some of the most important and clinically relevant body systems. The recommendations on pharmacological and nonpharmacological management through changes in lifestyle and relevant aspects of bariatric surgery in the paediatric population are also described.

CHEMERIN AND FACTORS RELATED TO CARDIOVASCULAR RISK IN CHILDREN AND ADOLESCENTS: A SYSTEMATIC REVIEW

OBJECTIVE

To review findings on chemerin and factors related to cardiovascular risk in children and adolescents.

DATA SOURCE

A systematic review was performed, according to the standards proposed by the PRISMA guideline, on PubMed, Science Direct, and Lilacs databases. The descriptor "chemerin" was used in combination with "children" and "adolescent", no time limit applied. The research encompassed only original articles written in English, conducted with human subjects - the adult and elderly populations excluded -, as well as literature reviews, brief communications, letters, and editorials.

DATA SYNTHESIS

After independent analyses of the studies by two reviewers, seven articles meeting the eligibility criteria, published between 2012 and 2016, remained for the review. Cross-sectional, prospective, cohort, and case-control studies were included. The importance of chemerin adipokines on the risk factors for cardiovascular disease is demonstrated by its association with obesity and diabetes mellitus, as well as clinical, anthropometric, and biochemical parameters. However, the strength of evidence from these studies is relatively low, due to their heterogeneity, with several limitations such as small samples and consequent lack of representativeness, lack of standardization in dosage methods, cross-sectional design of most studies, and impossibility of extrapolating results.

CONCLUSIONS

The deregulation of chemerin caused by increased adipose tissue may contribute to the development of cardiovascular diseases, suggesting that this adipokine may play a significant role in early identification of individuals at risk.

Association of Childhood Obesity and the Immune System: A Systematic Review of Reviews

The growing prevalence of childhood obesity has become a serious health problem over the past decades. As the immune system is greatly affected by excess weight, in this review of reviews, we discuss the findings of review articles about the relationship between childhood/maternal obesity and children's immune system. We searched English-language articles in PubMed, Scopus, ISI Thomson Reuters, and Google Scholar databases. All relevant reviews, either systematic or narrative, were retrieved. Then their quality was assessed by using the Assessment of Multiple Systematic Reviews and International Narrative Systematic Assessment tools, respectively. In the final step, 26 reviews were included. Our review suggests that childhood obesity is associated with extensive changes in the serum levels of inflammatory and anti-inflammatory cytokines and proteins, as well as the number of immune cells and their behavior. Therefore, it might cause or exacerbate diseases such as asthma, allergy, atopic dermatitis (AD), and obstructive sleep apnea syndrome. Moreover, childhood obesity may reduce the immune system responsiveness to vaccines and microorganisms. Furthermore, studies suggest that maternal obesity increases the risk of asthma in offspring. Future studies are needed to determine different associations of childhood obesity with allergy, atophic dermatitis, and autoimmune diseases.

Urinary biomarkers as indicator of chronic inflammation and endothelial dysfunction in obese adolescents

Background

Obesity is a pro-inflammatory state that may predispose patients to acute coronary syndrome characterized by chronic low grade inflammation resulting in endothelial dysfunction (ED). The aim of the study was to evaluate urinary biomarkers of inflammation and ED in adolescents with obesity.

Methods

Sixty three subjects were recruited for the study. Twenty healthy adolescents with normal body mass (NW), 14 overweight (OW), 29 obese (OA) subjects were selected. An EndoPat 2000 device was used to measure the reactive hyperemia index (RHI). First morning fasting urine samples were tested for interleukin 6 (IL-6), endothelin 1 (ET-1), alpha-1-acid glycoprotein (AGP), tumor necrosis factor- α (TNF-α) and corrected to urinary creatinine.

Results

Urinary TNF-α was significantly higher in OA group (52.4 ± 15.3 pg/mg) compared to adolescents with NW (14.1 ± 1.2 pg/mg, P = 0.04). ET-1 levels were found to be higher in OW (5.18 ± 1.6 pg/mg) compared with NW (3 · 47 ± 0.3 pg/mg, P = 0.24); and higher in OA (8.48 ± 3.1 pg/mg) compared to both NW (P = 0.19) and OW (P = 0.40). Similarly a higher AGP level was observed in OW (864.8 ± 156 ng/mg) and OA (808.3 ± 186 ng/mg) compared to NW (653 ± 69 ng/mg) (P = 0.16 & 0.49 respectively). Inflammatory markers namely, TNF-α, IL-6 and AGP significantly and positively correlated with each other and with ET-1, a marker for endothelial dysfunction. This significant correlation was also observed when tested separately in the subgroups (NW, OW and OA). There were no differences in RHI levels among the study groups.

Conclusion

Urinary TNF-alpha is significantly elevated in obese adolescents and correlates with urinary ET-1, which is recognized as a biomarker for endothelial dysfunction. Since obesity is a chronic inflammatory state, elevated urinary TNF-alpha might be used as a non invasive tool to monitor the level of that inflammation.

White blood cell count may identify abnormal cardiometabolic phenotype and preclinical organ damage in overweight/obese children

BACKGROUND AND AIMS

Subclinical inflammation is a central component of cardiometabolic disease risk in obese subjects. The aim of the study was to evaluate whether the white blood cell count (WBCc) may help to identify an abnormal cardiometabolic phenotype in overweight (Ow) or obese (Ob) children.

METHODS AND RESULTS

A cross-sectional sample of 2835 Ow/Ob children and adolescents (age 6-18 years) was recruited from 10 Italian centers for the care of obesity. Anthropometric and biochemical variables were assessed in the overall sample. Waist to height ratio (WhtR), alanine aminotransferase (ALT), lipids, 2 h post-load plasma glucose (2hPG), left ventricular (LV) geometry and carotid intima-media thickness (cIMT) were assessed in 2128, 2300, 1834, 535 and 315 children, respectively. Insulin resistance and whole body insulin sensitivity index (WBISI) were analyzed using homeostatic model assessment (HOMA-IR) and Matsuda's test. Groups divided in quartiles of WBCc significantly differed for body mass index, WhtR, 2hPG, HOMA-IR, WBISI, lipids, ALT, cIMT, LV mass and relative wall thickness. Children with high WBCc (≥8700 cell/mm(3)) showed a 1.3-2.5 fold increased probability of having high normal 2hPG, high ALT, high cIMT, or LV remodeling/concentric LV hypertrophy, after adjustment for age, gender, pubertal status, BMI and centers.

CONCLUSIONS

This study shows that WBCc is associated with early derangements of glucose metabolism and preclinical signs of liver, vascular and cardiac damage. The WBCc may be an effective and low-cost tool for identifying Ow and Ob children at the greatest risk of potential complications.

Prediabetes and Cardiovascular Parameters in Obese Children and Adolescents

OBJECTIVE

In this study, our aim was to determine cardiovascular risk and cardiac function in prediabetic obese children and adolescents.

METHODS

The study was conducted on 198 obese children and adolescents 6-18 years of age. Anthropometric measurements, blood pressure measurements, oral glucose tolerance test, lipid profile, and HbA1c levels of patients were assessed. Prediabetes was defined according to American Diabetes Association criteria. Left ventricular mass index (LVMi), carotid intima-media thickness (c-IMT), and tissue Doppler measurements records were used.

RESULTS

LVMi was found to be significantly higher in the prediabetes group (p=0.03). There were no statistically significant differences in right ventricular tissue Doppler measurements between the prediabetic and non-prediabetic groups. Left ventricular tissue Doppler measurements were significantly higher in the prediabetes group: LVEEM (left ventricular E/e ratio) (p=0.04); LVEM (left ventricular myocardial velocity cm/s) (p=0.035). LVMi was found to positively correlate with triglyceride level, diastolic blood pressure, waist circumference, body weight standard deviation score and to negatively correlate with high-density lipoprotein cholesterol (p=0.043, r=0.15; p=0.039, r=0.15; p=0.025, r=0.17; p=0.009, r=0.19; p=0.038, r=-0.15, respectively). LVEM was correlated with glucose (p=0.046, r=0.15) and LVEEM was correlated with systolic blood pressure (p=0.035, r=0.15). In linear regression analysis for clinical cardiovascular risk factors, fasting glucose level was the best predictor of LVEM.

CONCLUSION

In this study, deterioration of cardiac function in prediabetic obese children and adolescents was shown. We recommend determining cardiovascular risk and cardiac dysfunction at early stages in prediabetic obese children and adolescents.

Cardiovascular Risk Factors in Obese Children and Adolescents

The aim of the study was to analyze cardiometabolic risk factors andcarotid intima-media thickness (IMT) in obese children. We studied 122 obese children fulfilling the criteria of the International Obesity Task Force and 58 non-obese children. Anthropometric parameters, blood pressure, lipid profile, C-reactive protein, and adiponectin were assessed in all children. Glucose and insulin during the oral glucose tolerance test were assessed in obese children. The IMT was determined using ultrasound B-mode imaging in 81 obese and 32 non-obese children. We found that obese children had significantly higher levels of lipid andother non-lipid atherogenic indicators, but lower levels of adiponectin compared with non-obese children. The difference in the mean carotid IMT was insignificant in the two groups. Taking the combined groups, the level of adiponectin correlated negatively with body mass index and lipid atherogenic indicators. The IMT strongly correlated with systolic blood pressure in obese children. In the children fulfilling the criteria of metabolic syndrome, 17 out of the 84 obese children older than 10 years of age, IMT was greater than in those who did not fulfil these criteria. We conclude that the coexistence of abdominal obesity with abnormal lipid profile and hypertension leads to the early development of atherosclerosis accompanied by increased carotid intima-media thickness. Obesity initiates the atherosclerotic processes in early childhood.

Endothelial wall thickness, cardiorespiratory fitness and inflammatory markers in obese and non-obese adolescents

BACKGROUND

Increased carotid intima-media thickness (c-IMT) is considered a marker of early-onset atherosclerosis and it has been found in obese children and adolescents, but the risk factors associated with this population remain to be elucidated.

OBJECTIVE

To compare and verify the relationship between c-IMT, metabolic profile, inflammatory markers, and cardiorespiratory fitness in obese and non-obese children and adolescents.

METHOD

Thirty-five obese subjects (19 boys) and 18 non-obese subjects (9 boys), aged 10-16 years, were included. Anthropometry, body composition, blood pressure, maximal oxygen consumption (VO2max), and basal metabolic rate were evaluated. Serum glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), blood lipids, C-reactive protein (CRP), and adiponectin were assessed. c-IMT was measured by ultrasound.

RESULTS

The results showed that c-IMT, triglycerides, insulin, HOMA-IR, and CRP values were significantly higher in the obese group than in the non-obese group, and high-density lipoprotein cholesterol (HDL-c), adiponectin, and VO2max values were significantly lower in the obese group than in the non-obese group. The c-IMT was directly correlated with body weight, waist circumference, % body fat, and HOMA-IR and inversely correlated with % free fat mass, HDL-c, and VO2max.

CONCLUSIONS

Our findings show that c-IMT correlates not only with body composition, lipids, insulin resistance, and inflammation but also with low VO2max values in children and adolescents.