Case Report: Insulin hypersensitivity in youth with type 1 diabetes

Objective

Immediate type I, type III, and delayed type IV hypersensitivity reactions to insulin are rare, but potentially serious complications of exogenous insulin administration required for the treatment of type 1 diabetes (T1D).

Methods

We present four cases of insulin hypersensitivity reactions occurring in youth with T1D and a literature review of this topic.

Results

Insulin hypersensitivity reactions included types I, III, and IV with presentations ranging from localized urticaria, erythematous nodules, and eczematous plaques to anaphylaxis with respiratory distress. Reactions occurred in youth with newly diagnosed T1D and in those with long-standing T1D who were using both injection and insulin pump therapy. Multidisciplinary care involving pediatric endocrinology and allergy/immunology utilizing trials of many adjunct therapies yielded minimal improvement. Despite the use of various treatments, including antihistamines, topical therapies, immunosuppressant medications, desensitization trials, and intravenous immune globulin, cutaneous reactions, elevated hemoglobin A1c levels, and negative effects on quality of life remain persistent challenges. One patient became one of the youngest pancreas transplant recipients in the world at age 12 years due to uncontrollable symptoms and intolerable adverse effects of attempted therapies.

Conclusion

Although rare, insulin hypersensitivity reactions negatively affect glycemic control and quality of life. These cases demonstrate the varying severity and presentation of insulin hypersensitivity reactions along with the limited success of various treatment approaches. Given the life-sustaining nature of insulin therapy, further studies are needed to better understand the underlying pathophysiology of insulin hypersensitivity and to develop targeted treatment approaches.

Pearls and pitfalls in food protein-induced enterocolitis syndrome (FPIES)

Background: Food protein-induced enterocolitis syndrome (FPIES) is a rare, non-immunoglobulin E (IgE) mediated gastrointestinal food hypersensitivity. It is a clinical diagnosis commonly characterized by profuse vomiting 1 to 4 hours after ingestion of the triggering food(s). Objective: The objective was to increase awareness of FPIES and review the epidemiology, clinical presentation, pathogenesis, diagnosis, and management of FPIES. The lack of availability of a definite biomarker or diagnostic tool often leads to a delay in diagnosis. Methods: A literature search of salient articles that described case reports and case series of FPIES and their management were analyzed. Results: A case of FPIES with a literature review is presented with emphasis on clinical pearls and pitfalls. FPIES is a diagnosis of exclusion and the mainstay of treatment is avoidance of the trigger food(s) for at least 12-18 months from the last exposure. Conclusion: As FPIES is a non-IgE-mediated reaction, allergy testing via skin-prick test or blood tests to measure food IgE antibodies is not routinely recommended. Many children outgrow FPIES by 3-4 years of age. Supervised oral food challenge is recommended to assess acquisition of tolerance.

Soil bacterial community dynamics in plots managed with cover crops and no-till farming in the Lower Mississippi Alluvial Valley, USA

AIMS

Assess bacterial community changes over time in soybean (Glycine max) crop fields following cover crop (CC) and no-till (NT) implementation under natural abiotic stressors.

METHOD AND RESULTS

Soil bacterial community composition was obtained by amplifying, sequencing, and analysing the V4 region of the 16S rRNA gene. Generalized linear mixed models were used to assess the effects of tillage, CC, and time on bacterial community response. The most abundant phyla present were Acidobacteria, Actinobacteria, Bacteroidetes, and Verrucomicrobia. Bacterial diversity increased in periods with abundant water. Reduced tillage (RT) increased overall bacterial diversity, but NT with a CC was not significantly different than RT treatments under drought conditions. CCs shifted abundances of Firmicutes and Bacteroidetes depending on abiotic conditions.

CONCLUSIONS

In the Lower Mississippi Alluvial Valley (LMAV), USA, NT practices lower diversity and influence long-term community changes while cover crops enact a seasonal response to environmental conditions. NT and RT management affect soil bacterial communities differently than found in other regions of the country.

The immunologic response to severe acute respiratory syndrome coronavirus 2

Background: The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has precipitated the worst global pandemic in a century, which has caused millions of infections and deaths as well as massive economic repercussions. Objective: As with any pathogenic virus, it is crucial to understand its unique interactions with the human immune system so that pharmaceutical and prophylactic interventions can be deployed to effectively control the pandemic. Methods: A literature search by using PubMed was conducted in 2020 with variants of the terms "COVID-19," "SARS-CoV-2," and "immunological response." English language articles that presented original data about the immunologic response to coronavirus disease 2019 (COVID-19) were selected for review. This article reviewed the current understanding of the innate and adaptive immune responses to SARS-CoV-2 infection, including their relationship to current therapeutic and diagnostic strategies. Results: SARS-CoV-2 uses several unique molecular techniques to evade detection by the innate immune system early in the course of infection, and upregulation of these innate immune pathways may possibly accelerate the time to recovery and prevent severe disease. Although the majority of cases results in the patients' recovery, a significant proportion of infections result in deaths prompted by the host's inflammatory overreaction to the infection, a response that can be attenuated with corticosteroids and potentially other immune modulators. Conclusion: Current work by the scientific community to further understand how SARS-CoV-2 interacts with the human immune system will be invaluable to our response and preparedness for future coronavirus pandemics.

Hematopoietic Cell Transplantation Cures Adenosine Deaminase 2 Deficiency: Report on 30 Patients

PURPOSE

Deficiency of adenosine deaminase 2 (DADA2) is an inherited inborn error of immunity, characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure (BMF). Tumor necrosis factor (TNF-α) blockade is the treatment of choice for the vasculopathy, but often fails to reverse refractory cytopenia. We aimed to study the outcome of hematopoietic cell transplantation (HCT) in patients with DADA2.

METHODS

We conducted a retrospective study on the outcome of HCT in patients with DADA2. The primary outcome was overall survival (OS).

RESULTS

Thirty DADA2 patients from 12 countries received a total of 38 HCTs. The indications for HCT were BMF, immune cytopenia, malignancy, or immunodeficiency. Median age at HCT was 9 years (range: 2-28 years). The conditioning regimens for the final transplants were myeloablative (n = 20), reduced intensity (n = 8), or non-myeloablative (n = 2). Donors were HLA-matched related (n = 4), HLA-matched unrelated (n = 16), HLA-haploidentical (n = 2), or HLA-mismatched unrelated (n = 8). After a median follow-up of 2 years (range: 0.5-16 years), 2-year OS was 97%, and 2-year GvHD-free relapse-free survival was 73%. The hematological and immunological phenotypes resolved, and there were no new vascular events. Plasma ADA2 enzyme activity normalized in 16/17 patients tested. Six patients required more than one HCT.

CONCLUSION

HCT was an effective treatment for DADA2, successfully reversing the refractory cytopenia, as well as the vasculopathy and immunodeficiency.

CLINICAL IMPLICATIONS

HCT is a definitive cure for DADA2 with > 95% survival.

A 79-year-old man with persistent eosinophilia and elevated immunoglobulin E

The differential diagnoses for eosinophilia include allergic, infectious, autoimmune, and neoplastic diseases. We presented the case of a 79-year-old man with eosinophilia and elevated immunoglobulin E that persisted despite adequate treatment for possible environmental exposures. Further specialized testing based on his initial workup led to his diagnosis. This case highlights the importance of sequential and targeted testing to evaluate for rare causes of eosinophilia.

Clinical presentation of hereditary angioedema

Hereditary angioedema (HAE) is a rare, autosomal dominant disease caused by a deficiency in the C1-inhibitor protein. It is characterized by recurrent episodes of nonpruritic, nonpitting, subcutaneous or submucosal edema that typically involves the extremities or the gastrointestinal tract. However, the genitourinary tract, face, oropharynx, and/or larynx may be affected as well. Symptoms often begin in childhood, worsen at puberty, and persist throughout life, with unpredictable severity. Patients who are untreated may have frequent attacks, with intervals that can range from every few days to rare episodes. Minor trauma and stress are frequent precipitants of swelling episodes, but many attacks occur without clear triggers. HAE attacks may be preceded by a prodrome and/or be accompanied by erythema marginatum. The swelling typically worsens over the first 24 hours, before gradually subsiding over the subsequent 48 to 72 hours. Although oropharyngeal swelling is less frequent, more than half of patients have had at least one episode of laryngeal angioedema during their lifetime. Attacks may start in one location and spread to another before resolving. HAE attacks that involve the abdomen or oropharynx have been associated with significant morbidity and mortality. Abdominal attacks can cause severe abdominal pain, nausea, and vomiting. Bowel sounds are often diminished or silent, and guarding and rebound tenderness may be present on physical examination. These findings may lead to unnecessary abdominal imaging and procedures. Fluid shifts into the interstitial space or peritoneal cavity can cause clinically significant hypotension. Laryngeal edema poses the greatest risk for patients with HAE. Although prompt diagnosis and treatment improves outcomes, the variable presentation of HAE can make it difficult to diagnose.

The Future of Telehealth in Allergy and Immunology Training

With emerging interest in the use of telemedicine, allergy-immunology should be at the forefront of adoption and implementation of these services. Patients report a greater desire for telemedicine services as well as satisfaction with video-based visits with their providers. Interim virtual visits can accommodate overscheduled clinics, reduce burdens of travel to distant sites, improve access to subspecialty care, and increase adherence during monitoring of chronic allergic conditions. The outpatient nature of allergy-immunology coupled with the ease of conducting many aspects of a routine visit via telemedicine makes the incorporation of telehealth training into fellowship programs highly desirable. The short-term closure of hospital-affiliated clinics, in particular, for vulnerable or immunodeficient patients, in the setting of a global pandemic demonstrates the timeliness of this topic.

A framework for implementing telemedicine into the allergy-immunology curriculum, training faculty on appropriate supervision, providing elective clinical experience in the form of continuity clinics, and simulating telemedicine delivery is discussed. Proposed telemedicine competencies desired for the independent practice of telemedicine are suggested.

Experience with Intravenous Plasma-Derived C1-Inhibitor in Pregnant Women with Hereditary Angioedema: A Systematic Literature Review

Consensus guidelines recommend plasma-derived C1 inhibitor (C1-INH) as first-line treatment in pregnant women with hereditary angioedema (HAE). We conducted a systematic review of the literature that describes experience with plasma-derived C1-INH during pregnancy. A literature search of PubMed was conducted in November 2018 using variants of "hereditary angioedema" and "pregnancy." English language articles that presented original data about the use of plasma-derived C1-INH during pregnancy were selected for data extraction. The search returned 253 unique records, of which 40 described the use of C1-INH during pregnancy (91 patients, 136 pregnancies). When the number of doses was reported, a total of 1562 doses were administered ranging from 500 to 3000 IU. Infusions were administered during all 3 trimesters and were most commonly administered during the third trimester. Overall, 1,490,500 IU of plasma-derived C1-INH were administered during pregnancy. Of the 128 fetuses for which outcomes were reported, 3 (2%) resulted in spontaneous abortion, 1 (1%) was stillborn, and 1 (1%) was a vanishing twin. Use of plasma-derived C1-INH in women with HAE during pregnancy has been widely reported in the scientific literature and has a favorable safety profile, supporting treatment guideline recommendations.

Long-term efficacy and safety of subcutaneous C1-inhibitor in women with hereditary angioedema: subgroup analysis from an open-label extension of a phase 3 trial

Background

Women with hereditary angioedema due to C1-inhibitor deficiency (HAE-C1INH) experience more frequent and severe angioedema attacks compared with men. Fluctuations in female sex hormones can influence HAE attack frequency and severity. Subcutaneous C1-INH (C1-INH [SC]) is indicated as routine prophylaxis to prevent HAE attacks. In this post hoc subgroup analysis, we evaluated the efficacy and safety of C1-INH (SC) in female subjects with HAE-C1INH enrolled in an open-label extension of the pivotal phase III COMPACT trial.

Methods

In this multicenter, randomized, parallel-arm trial, eligible subjects (age ≥ 6 years with ≥ 4 attacks over 2 consecutive months) received C1-INH (SC) 40 IU/kg or 60 IU/kg twice weekly for 52 to 140 weeks. Analyses of efficacy endpoints were performed for all female subjects and those of childbearing age (age ≥ 15 to ≤ 45 years), including subjects who became pregnant during the evaluation period.

Results

Overall, 91% (69/76) of female subjects were classified as responders (≥ 50% reduction in HAE attacks relative to the pre-study period); 82% experienced < 1 attack/4 weeks. The median number of attacks/month was 0.10, with 96% median reduction in attacks relative to the pre-study period. Results were similar in the subgroup of subjects of childbearing age. Four women who became pregnant during the trial and were exposed to C1-INH (SC) during the first trimester delivered healthy babies with no congenital abnormalities.

Conclusions

C1-INH (SC) prophylaxis was safe and effective in women with HAE-C1INH, including those of childbearing age. Four women exposed to C1-INH (SC) during the first trimester had uneventful pregnancies and delivered healthy babies.

Trial registration Clinicaltrials.gov identifier NCT02316353 (Registered December 10, 2014); https://clinicaltrials.gov/ct2/show/NCT02316353.

Etoposide phosphate for pediatric orthopedic malignancies after intravenous etoposide hypersensitivity

Background

Hypersensitivity reactions to etoposide have been reported and patients have been safely transitioned to etoposide phosphate for continued therapy. However, the safety and efficacy of substituting etoposide phosphate for etoposide has not been well established in pediatric orthopedic malignancies. The aim of this study is to determine whether etoposide phosphate can be substituted for etoposide in pediatric orthopedic malignancies.

Methods

A chart review of pediatric patients who developed hypersensitivity reactions to etoposide while being treated for orthopedic malignancies was performed at a large academic medical center. Three patients were identified, two with Ewing sarcoma and one with an osteosarcoma. All three patients experienced hypersensitivity reactions to their first doses of etoposide and were switched to etoposide phosphate for further therapy.

Results

After premedication, all three patients tolerated full doses of etoposide phosphate without a graded dose challenge or desensitization. Two of the patients were premedicated with diphenhydramine alone, while the third received diphenhydramine and dexamethasone.

Conclusions

Etoposide phosphate is a potentially safe alternative for pediatric patients with orthopedic malignancies who experience etoposide hypersensitivity. However, caution is needed as there are cases of etoposide phosphate hypersensitivity.

Decay rates of zoonotic pathogens and viral surrogates in soils amended with biosolids and manures and comparison of qPCR and culture derived rates

AIMS

The purpose of this study was to establish inactivation decay constants of foodborne pathogens and coliphage in clay and sandy soils for future "downstream" analyses such as quantitative microbial risk analysis and to compare cultivation-dependent and -independent (e.g. qPCR) methods.

METHODS AND RESULTS

Salmonella enterica, Campylobacter jejuni, Listeria monocytogenes, Escherichia coli O157:H7, and Clostridium perfringens, were seeded together with MS2 and ØX174 phages, into three waste matrices (Class B biosolids, swine lagoon effluent, cattle manure), and phosphate buffered saline (PBS) as a control, and applied to two soil types (sandy loam, clay loam) using two management practices (incorporated, surface applied). S. enterica and L. monocytogenes inactivation rates were positively affected (e.g. slower rate) by solid wastes, while C. jejuni was quickly inactivated by day 7 regardless of waste type. The use of qPCR provided more conservative inactivation rates, with qPCR-based rates typically twice as slow as cultivation-based. The effect of soil type and management were less apparent as rates were variably affected. For instance, incorporation of waste negatively impacted (e.g. faster rate) inactivation of Salmonella when measured by qPCR, while the opposite was true when measured by cultivation. Inactivation rates were organism∗waste∗soil∗management dependent since the interactions of these main effects significantly affected most combinations.

CONCLUSIONS

Class B biosolids and cattle manure most often slowed inactivation when measured by cultivation, but the complex interactions between variables and organism made sweeping conclusions difficult. On the contrary cultivation-independent inactivation rates were negatively affected by solid wastes. Inactivation rates developed by cultivation-dependent and -independent assays needs further scrutiny as interprerations can vary by orders of magnitude depending on the organism∗environment combination.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study compares decay rate data based on waste, soil, management and assay type which can be further used in risk assessments.

Idiopathic CD4 lymphocytopenia

BACKGROUND

Idiopathic CD4 lymphocytopenia (ICL) is a rare disorder of unknown etiology. Diagnostic criteria include a persistent CD4 T-cell lymphopenia with no underlying primary or secondary immune deficiencies and a CD4 T-cell count of 300 cells/mL or 20% total lymphocyte on multiple occasions.

OBJECTIVE

To increase awareness of ICL and to provide a review of the clinical characteristics, diagnosis, and management of this disease process. Presently, many of these patients receive prophylactic treatment similar to other T-cell deficient conditions, most notably patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome; however, the same indications may not necessarily apply to this patient population because the T cells are not affected by a virus as in HIV.

METHODS

A literature search of salient articles that describe case reports and case series of ICL and their management were analyzed.

RESULTS

A case of ICL with a literature review is presented with emphasis on clinical pearls and pitfalls. The patients with ICL are usually identified with a CD4 count of 200 cells/mL when complications develop. Opportunistic infections are the most common initial manifestations. Current therapies used to increase CD4 levels include interleukin 2, interferon gamma, interleukin 7, and allogeneic hematopoietic stem cell transplantation, with variable results.

CONCLUSION

ICL is a diagnosis of exclusion when there is no identifiable underlying cause for a low CD4 count. Although the nature of the T-cell problem is not the same in ICL and HIV, in the absence of specific guidelines, patients receive the same prophylactic treatment as patients with HIV.

Cultivation and qPCR Detection of Pathogenic and Antibiotic-Resistant Bacterial Establishment in Naive Broiler Houses

Conventional commercial broiler production involves the rearing of more than 20,000 broilers in a single confined space for approximately 6.5 wk. This environment is known for harboring pathogens and antibiotic-resistant bacteria, but studies have focused on previously established houses with mature litter microbial populations. In the current study, a set of three naive houses were followed from inception through 11 broiler flocks and monitored for ambient climatic conditions, bacterial pathogens, and antibiotic resistance. Within the first 3 wk of the first flock cycle, 100% of litter samples were positive for and , whereas was cultivation negative but PCR positive. Antibiotic resistance genes were ubiquitously distributed throughout the litter within the first flock, approaching 10 to 10 genomic units g. Preflock litter levels were approximately 10 CFU g for heterotrophic plate count bacteria, whereas midflock levels were >10 colony forming units (CFU) g; other indicators demonstrated similar increases. The influence of intrahouse sample location was minor. In all likelihood, given that preflock levels were negative for pathogens and antibiotic resistance genes and 4 to 5 Log lower than flock levels for indicators, incoming birds most likely provided the colonizing microbiome, although other sources were not ruled out. Most bacterial groups experienced a cyclical pattern of litter contamination seen in other studies, whereas microbial stabilization required approximately four flocks. This study represents a first-of-its-kind view into the time required for bacterial pathogens and antibiotic resistance to colonize and establish in naive broiler houses.

A 73-year-old woman with persistent diarrhea and onychomycosis

We present a case of a 73-year-old woman who presented with chronic watery diarrhea, weight loss, and frequent sinus and nail fungal infections. Her previous workup with a gastroenterologist failed to reveal any causative agent for her symptoms. She considered herself healthy until a thymic tumor was discovered and removed years ago. Subsequently, she developed multiple sinus infections refractory to treatment. Relevant immunology laboratory tests were conducted, which led to the diagnosis. This case illustrated the need for a detailed history and thorough immunologic assessment, and the requirement to maintain a broad differential diagnosis.

Using broiler litter and swine manure lagoon effluent in sawdust-based swine mortality composts: Effects on nutrients, bacteria, and gaseous emissions

Disposition of mortalities challenges confined animal feeding operations (CAFOs), especially sow (farrowing) farms, which experience mortalities daily. Regulations and transportation costs may preclude incineration, landfill burial, and rendering; therefore, swine CAFOs in Mississippi in the Mid-South U.S. often compost mortalities. In this study, a farm-standard composting mix of sawdust (S) and water (W) was compared with mixes where N was supplied by broiler litter (L) and water was replaced with swine lagoon effluent (E). The objective was to assess the effects of these manure byproducts: 1) on nutrients and bacteria in composts destined for land application; and 2) on emissions of ammonia and greenhouse gases. Three replications of four mixes (SW, SLW, SE, SLE) were compared in microcosms comprising modified plastic recycling bins. The experiment was repeated three times in different seasons in one year. Mixes were compared for differences in temperature, water content, nutrients (C, N, P, K, Ca, Mg, Na, Mn, Fe, Cu, Zn), bacteria (Gram-, Gram+, Clostridium perfringens, Salmonella, Listeria, Escherichia coli), and emissions (NH3, CO2, CH4, N2O). Litter addition increased composting temperatures initially and after aerations; increased nutrient concentrations, except C, in start mixes and all except C and N, in finish mixes; increased Gram+ bacteria, Salmonella, and E. coli in start mixes, but only Gram+s in finish mixes; and increased emissions. Effluent addition increased early composting temperatures; had no effect on nutrients or bacteria, except increased C. perfringens in start, but not finish mixes; and had no effect on emissions. Nutrients in finish composts did not differ among mixes for N (average 3.3%), but litter composts had more P and K, and lower N:P than composts without litter. Improving mortality composting is of global importance as increasing livestock populations and intensive animal production systems require practical, safe, environmentally sound disposal of carcasses.

Ammonia and nitrous oxide emissions from a commercial broiler house

Complex variation in gas emissions from animal facilities has been shown in recent research reports. Uncertainties in these emission estimates are driving research activities concerning different animal species across the globe. Greenhouse gas (NO and CO) and NH concentrations were measured in a modern, tunnel-ventilated, commercial broiler house in Mississippi during five flocks (spanning approximately 1 yr). These were flocks 9 through 13 on reused pine shavings litter, representing litter reuse beyond 2 yr. Gas concentrations obtained from a photoacoustic multigas analyzer were coupled with ventilation measurements of air flow through the house to develop NH and NO emission rates. Ammonia emission during a flock (43 d) averaged approximately 14.8 ± 9.8 kg d in the commercial house (equivalent to 23.5 g bird marketed or 0.54 g bird d). Nitrous oxide emission averaged 2.3 ± 1.7 kg d in the house (equivalent to 3.64 g bird marketed or 0.085 g bird d). Emission rates increased with time from Day 1 to Day 43 and reached average values on Day 23 and 24 for NH and NO. Even with extended litter reuse, estimates of NH emissions from the broiler house agree well with recently published research that reused litter in eight or fewer flocks. This is important information for farmers who may not be able to afford to replace the litter with fresh bedding material annually.

A new sampler for stratified lagoon chemical and microbiological assessments

A sampler was needed for a spatial and temporal study of microbial and chemical stratification in a large swine manure lagoon that was known to contain zoonotic bacteria. Conventional samplers were limited to collections of surface water samples near the bank or required a manned boat. A new sampler was developed to allow simultaneous collection of multiple samples at different depths, up to 2.3 m, without a manned boat. The sampler was tethered for stability, used remote control (RC) for sample collection, and accommodated rapid replacement of sterile tubing modules and sample containers. The sampler comprised a PVC pontoon with acrylic deck and watertight enclosures, for a 12 VDC gearmotor, to operate the collection module, and vacuum system, to draw samples into reusable autoclavable tubing and 250-mL bottles. Although designed primarily for water samples, the sampler was easily modified to collect sludge. The sampler held a stable position during deployment, created minimal disturbance in the water column, and was readily cleaned and sanitized for transport. The sampler was field tested initially in a shallow fresh water lake and subsequently in a swine manure treatment lagoon. Analyses of water samples from the lagoon tests showed that chemical and bacterial levels, pH, and EC did not differ between 0.04, 0.47, and 1.0 m depths, but some chemical and bacterial levels differed between winter and spring collections. These results demonstrated the utility of the sampler and suggested that future manure lagoon studies employ fewer or different depths and more sampling dates.

Runoff quality from no-till cotton fertilized with broiler litter in subsurface bands

Surface broadcast of broiler litter to no-till row crops exposes the litter and its nutrients to risks of loss in runoff water and volatilization and may limit the potential benefit of litter to the crops. Subsurface banding of litter could alleviate these risks. A field study was conducted in 2008 and 2009 on an upland Falkner silt loam soil to determine the effect of broiler litter placement on runoff nutrient losses from no-till cotton ( L.). Treatments included surface broadcast broiler litter applied manually, subsurface-banded litter applied by tractor-drawn equipment, and no broiler litter, all in combination with or without winter wheat ( L.) cover crop residue. Broiler litter rate was 5.6 Mg ha. The experimental design was a randomized complete block with a split-plot arrangement of treatments replicated three times. In 2008, simulated rainfall was used to generate runoff 27 d after litter application. Subsurface-banded litter reduced runoff total C, N, P, NH, NO, Cu, Zn and water-soluble P (WP) concentrations by 72, 64, 51, 49, 70, 36, 65, and 77%, respectively, compared with surface broadcast. The reductions were greater in 2009 where runoff occurred 1 d after litter application. Bacterial runoff was decreased by one log with subsurface-banded litter compared to surface broadcast. Except for C, NH, N, and WP, the presence of winter cover crop residue did not affect the load or runoff nutrient concentrations in either year. The results indicate that subsurface banding litter to no-till cotton substantially reduces nutrient and bacterial losses in runoff compared with surface broadcasting.

The effect of poultry manure application rate and AlCl(3) treatment on bacterial fecal indicators in runoff

Increasing costs associated with inorganic fertilizer have led to widespread use of broiler litter. Proper land application, typically limiting nutrient loss, is essential to protect surface water. This study was designed to evaluate litter-borne microbial runoff (heterotrophic plate count bacteria, staphylococci, Escherichia coli, enterococci, and Clostridium perfringens) while applying typical nutrient-control methods. Field studies were conducted in which plots with high and low litter rates, inorganic fertilizer, AlCl(3)-treated litter, and controls were rained on five times using a rain generator. Overall, microbial runoff from poultry litter applied plots was consistently greater (2-5 log(10) plot(-1)) than controls. No appreciable effect on microbial runoff was noted from variable litter application rate or AlCl(3) treatments, though rain event, not time, significantly affected runoff load. C. perfringens and staphylococci runoff were consistently associated with poultry litter application, during early rain events, while other indicators were unreliable. Large microbial runoff pulses were observed, ranging from 10(2) to 10(10) CFU plot(-1); however, only a small fraction of litter-borne microbes were recoverable in runoff. This study indicated that microbial runoff from litter-applied plots can be substantial, and that methods intended to reduce nutrient losses do not necessarily reduce microbial runoff.

Effect of surface incorporation of broiler litter applied to no-till cotton on runoff quality

Surface application of broiler litter to no-till cotton could lead to degradation of water quality. Incorporation of broiler litter into the top surface soil (0.05 m) could alleviate this risk. A 2-yr field study was conducted on a silt loam upland soil to determine the effect of incorporation of broiler litter into the soil surface on nutrient and bacterial transport in runoff. The experimental design was a randomized complete block with four treatments and three replications. Treatments were (i) unfertilized control; (ii) surface-appliedbroiler litter at 7.8 Mg ha(-1) without incorporation; (iii) surface-applied broiler litter at 7.8 Mg ha(-1) with immediate incorporation; and (iv) inorganic fertilizer N (urea ammonium nitrate, 32% N) and inorganic fertilizer P (triple superphosphate) at the recommended rate. Phosphorus was surface appliedat 25 kg ha(-1) and N was injected at 101 kg ha(-1) into the soil using a commercial liquid fertilizer applicator. Runoff was collected from small runoff plots (2.4 m by 1.6 m) established at the bottom side of main plots (13.7 m by 6.0 m). Incorporation of broiler litter reduced total N (TN), NO3-N, water soluble P (WSP), and total P (TP) concentrations in runoffby 35, 25, 61, and 64%, respectively, and litter-associated bacteria by two to three orders of magnitude compared with unincorporated treatment. No significant difference in total suspended solids (TSS) in runoffwas obtained between incorporated and unincorporated treatments. Incorporation of broiler litter into the surface soil in the no-till system immediately after application minimized the potential risk for surface nutrient losses and bacteria transport in runoff.

Spatial contrasts of seasonal and intraflock broiler litter trace gas emissions, physical and chemical properties

Comprehensive mitigation strategies for gaseous emissions from broiler operations requires knowledge of the litters' physical and chemical properties, gas evolution, bird effects, as well as broiler house management and structure. This research estimated broiler litter surface fluxes for ammonia (NH3), nitrous oxide (N2O), and carbon dioxide (CO2). Ancillary measurements of litter temperature, litter total N, ammonium (NH4+), total C content, moisture, and pH were also made. Grid sampling was imposed over the floor area of two commercial broiler houses at the beginning (Day 1), middle (Day 23), and end (Day 43) of a winter and subsequent summer flock housed on reused pine shavings litter. The grid was composed of 36 points, three locations across the width, and 12 locations down the length of the houses. To observe feeder and waterer (F/W) influences on the parameters, eight additional sample locations were added in a crisscross pattern among these automated supply lines. Color variograms illustrate the nature of parameter changes within each flock and between seasons. Overall trends for the NH3, N2O, and CO2 gas fluxes indicate an increase in magnitude with bird age during a flock for both summer and winter, but flux estimates were reduced in areas where compacted litter (i.e., caked litter or cake) formed at the end of the flocks (at F/W locations and in the fan area). End of flock gas fluxes were estimated at 1040 mg NH3 m(-2) h(-1), 20 mg N2O m(-2) h(-1), and 24,200 mg CO2 m(-2) h(-1) in winter; and 843 mg NH3 m(-2) h(-1), 18 mg N2O m(-2) h(-1)), and 27,200 mg CO2 m(-2) h(-1) in summer. The results of intensive sample efforts during winter and summer flocks, reported visually using contour plots, offer a resource to the poultry industry and researchers for creating new management strategies for improving production and controlling gas evolution. Particularly, efforts could focus on designing housing systems that minimize extremes in litter compaction. The extremes are undesirable with more friable litter prone to greater gas evolution and more compacted litter providing a slippery, disease-sustaining surface.

Microbial and antibiotic resistant constituents associated with biological aerosols and poultry litter within a commercial poultry house

Poultry are known to harbor antibiotic resistant and pathogenic bacteria, and as such poultry litter and poultry house air can be contaminated with these bacteria. However, the presence of antibiotic resistant bacteria in biological aerosols and litter is largely not understood. The purpose of this study was to determine the amount of aerosolized bacteria and endotoxin, particularly fecal indicators, staphylococci, and enterococci, associated with poultry house and outdoor air. Aerosol samples were collected at multiple locations on the farm and in the house. Antibiotic resistance was investigated using the Kirby Bauer method on selected isolates using twelve different antibiotics spanning both narrow to broad spectrums of effectiveness. Overall there was a cyclical increase in bacterial concentrations as flocks progressed from pre-flock to late-flock, with >2 orders magnitude lower concentration during pre-flock periods (no chickens), in both the litter and aerosol samples. The house environment provided for significantly concentrated bacterial and endotoxin levels. It was estimated that Staphylococcus bacteria accounted for at least 90% of cultured aerobic bacteria and culture-independent 16S rRNA analyses demonstrated that significant population changes occurred from pre- to late-flock. Rarely was an isolate resistant to more than 4 antibiotic classes; however there was a trend upwards in overall resistance of enterococci as the flock cycle progressed. It appears that although levels of antibiotic resistant bacteria were highly concentrated within the house, levels were much lower outside of the house, and very little house escape occurred.

Influence of long-term land application of Class B biosolids on soil bacterial diversity

AIM

To evaluate the effect of long-term annual land applications of Class B biosolids on soil bacterial diversity at University of Arizona Marana Agricultural Field Center, Tucson, Arizona.

METHODS AND RESULTS

Following the final of 20 consecutive years of application of Class B biosolids in March 2005, followed by cotton growth from April to November 2005 surface soil samples (0-30 cm) were collected from control (unamended) and biosolid-amended plots. Total bacterial community DNA was extracted, amplified using 16S rRNA primers, cloned, and sequenced. All 16S rRNA sequences were identified by 16S rRNA sequence analysis and comparison to known sequences in GenBank (NCBI BlastN and Ribosomal Database Project II, RDP). Results showed that the number of known genera (identifiable > 96%) increased in the high rate biosolid plots compared to control plots. Biosolids-amended soils had a broad phylogenetic diversity comprising more than four major phyla: Proteobacteria (32%), Acidobacteria (21%), Actinobacteria (16%), Firmicutes (7%), and Bacteroidetes (6%) which were typical to bacterial diversity found in the unamended arid southwestern soils.

CONCLUSION

Bacterial diversity was either enhanced or was not negatively impacted following 20 years of land application of Class B biosolids.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study illustrates that long-term land application of biosolids to arid southwestern desert soils has no deleterious effect on soil microbial diversity.

Antibiotic resistant bacterial profiles of anaerobic swine lagoon effluent

Although land application of swine (Sus scrofa) manure lagoon effluent is a common and effective method of disposal, the presence of antibiotic-resistant bacteria, both pathogenic and commensal can complicate already understood issues associated with its safe disposal. The aim of this study was to assess antibiotic resistance in swine lagoon bacteria from sow, nursery, and finisher farms in the southeastern United States. Effluents from 37 lagoons were assayed for the presence of Escherichia coli, Campylobacter, Listeria, and Salmonella. Antibiotic resistance profiles were determined by the Kirby-Bauer swab method for 12 antibiotics comprising eight classes. Statistical analyses indicated that farm type influenced the amount and type of resistance, with nurseries and sow farms ranking as most influential, perhaps due to use of more antibiotic treatments. Finisher farms tended to have the least amount of antibiotic class resistance, signaling an overall healthier market pig, and less therapeutic or prophylactic antibiotic use. Many bacterial isolates were resistant to penicillin, cephalosporin, and tetracycline class antibiotics, while nearly all were susceptible to quinolone antibiotics. It appeared that swine farm type had a significant association with the amount of resistance associated with bacterial genera sampled from the lagoons; nurseries contributed the largest amount of bacterial resistance.

Scratching the surface--Managing the itch associated with burns: a review of current knowledge

The problems of itch in burns patients are well recognised, however none of the current standard therapies are very effective. The standard therapies include: antihistamines which are only effective in about 20% of patients and emollients which have limited effects. We review the current literature on the molecular mechanisms of itch and neuronal itch pathways, which supports the predictable lack of effect of anti-histamines. The published studies on therapeutic options to treat itch in burns are discussed and in addition we review the work on the treatment of itch in other pathological states. Finally a treatment algorithm is proposed stratifying possible therapeutic options to assist in the management of burns patients distressed by intractable itch.

Occurrence of antibiotic-resistant bacteria and endotoxin associated with the land application of biosolids

The purpose of this study was to determine the prevalence of antibiotic-resistant bacteria and endotoxin in soil after land application of biosolids. Soil was collected over a 15 month period following land application of biosolids, and antibiotic resistance was ascertained using clinically relevant antibiotic concentrations. Ampicillin, cephalothin, ciprofloxacin, and tetracycline resistance were all monitored separately for any changes throughout the 15 month period. Endotoxin soil concentrations were monitored using commercially available endotoxin analysis reagents. Overall, land application of biosolids did not increase the percentage of antibiotic-resistant culturable bacteria above background soil levels. Likewise, land application of biosolids did not significantly increase the concentration of endotoxin in soil. This study determined and established a baseline understanding of the overall effect that land application of biosolids had on the land-applied field with respect to antibiotic-resistant bacterial and endotoxin soil densities.

An analysis of erectile function after intensity modulated radiation therapy for localized prostate carcinoma

Radiation therapy for prostate cancer can cause erectile dysfunction (ED). Intensity Modulated Radiation Therapy (IMRT) can reduce the amount of radiation to surrounding tissues associated with ED. We characterize the incidence of and factors associated with ED in prostate cancer patients after IMRT at the National Naval Medical Center (NNMC). Patients potent by definition of the Sexual Health Inventory for Men (SHIM) before treatment completed the specific erectile questions of the SHIM after IMRT. Statistical analyses were performed to examine the relationships between several factors and ED. Thirty-two of 45 patients with mean age of 68.2 years (50-86 years) completed the SHIM. The median follow-up was 36.8 months (16-63.6 months) as defined by the time from completion of therapy to reassessment with the SHIM. Eight of 32 patients (25%) had no post-treatment ED (SHIM score 22-25), three of 32 (9%) had mild post-treatment ED (SHIM score 17-21), five of 32 (16%) had mild to moderate ED (SHIM score 12-16), five of 32 (16%) had moderate ED (SHIM score 8-11) and 11 of 32 (34%) had severe post-treatment ED (SHIM score<8). Post-treatment potency was significantly associated with the pre-treatment SHIM score (P=0.001) and history of hypertension (P=0.03). The mean radiation dose to the penile bulb and volume of penile bulb treated were not associated with post-treatment potency (P=0.38, 0.76, respectively). IMRT maintains potency in the majority of patients. This analysis compares favorably in preserving erectile function to previously reported series using conventional external beam radiation therapy techniques. The dose of radiation received by the penile bulb and volume of penile bulb were not associated with post-treatment ED in this analysis.

The measurement of aerosolized endotoxin from land application of Class B biosolids in Southeast Arizona

The purpose of this study was to determine aerosolized endotoxin concentrations downwind of a biosolids land application site. Aerosol samples were collected from biosolids land application sites, tractor operation, and an aeration basin located within an open-air wastewater treatment plant. Aerosolized endotoxin above background concentrations was detected from all sites, at levels ranging from below detection up to 1800 EU m–3 of air. Biosolids loading operations resulted in the greatest concentrations of endotoxin (mean 344 EU m–3). As downwind (perpendicular to wind vector) distance increased from sources (2–200 m), levels of endotoxin decreased to near background (without biosolids application) concentrations. Overall, the detected levels of aerosolized endotoxin were within past proposed aerosolized endotoxin limits (250–2000 EU m–3) by other occupational exposure studies. Occasionally, peak concentrations were found to be above these limits. Sites in which soil was being aerosolized resulted in greater concentrations of endotoxin with or without biosolids, which suggested that the majority of endotoxin may in fact be of soil origin. This study evaluated the presence of aerosolized endotoxin from the land application of biosolids and showed that these levels were within ranges for concern suggested by other studies and that this area of research needs further investigation. Key words: biosolids, endotoxin, aerosol, bioaerosol, lipopolysaccharide.

A national study on the residential impact of biological aerosols from the land application of biosolids

AIMS

The purpose of this study was to evaluate the community risk of infection from bioaerosols to residents living near biosolids land application sites.

METHODS AND RESULTS

Approximately 350 aerosol samples from 10 sites located throughout the USA were collected via the use of six SKC Biosamplers. Downwind aerosol samples from biosolids loading, unloading, land application and background operations were collected from all sites. All samples were analysed for the presence of HPC bacteria, total coliform bacteria, Escherichia coli, Clostridium perfringens, coliphage, enteroviruses, hepatitis A virus and norovirus. Total coliforms, E. coli, C. perfringens and coliphage were not detected with great frequency from any sites, however, biosolids loading operations resulted in the largest concentrations of these aerosolized microbial indicators. Microbial risk analyses were conducted on loading and land application operations and their subsequent residential exposures determined.

CONCLUSIONS

The greatest annual risks of infection occurred during loading operations, and resulted in a 4 x 10(-4) chance of infection from inhalation of coxsackievirus A21. Land application of biosolids resulted in risks that were <2 x 10(-4) from inhalation of coxsackievirus A21. Overall bioaerosol exposure from biosolids operations poses little community risk based on this study.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study evaluated the overall incidence of aerosolized micro-organisms from the land application of biosolids and subsequently determined that microbial risks of infection were low for residents close to biosolids application sites.

Estimation of bioaerosol risk of infection to residents adjacent to a land applied biosolids site using an empirically derived transport model

AIM

The purpose of this study was to develop an empirically derived transport model, which could be used to predict downwind concentrations of viruses and bacteria during land application of liquid biosolids and subsequently assess microbial risk associated with this practice.

METHODS AND RESULTS

To develop the model, coliphage MS-2 and Escherichia coli were aerosolized after addition to water within a biosolids spray application truck, and bioaerosols were collected at discrete downwind distances ranging from 2 to 70 m. Although coliphage were routinely detected, E. coli did not frequently survive aerosolization. Data on aerosolized coliphage was then used to generate a virus transport model. Risks of infection were calculated for various ranges of human virus concentrations that could be found in biosolids.

CONCLUSIONS

A conservative estimate at 30.5 m (assumed to be nearest adjacent residences) downwind, resulted in risks of infection of 1 : 100,000, to the more realistic 1 : 10,000,000 per exposure. Conservative annual risks were calculated to be no more than 7 : 100,000 where as a more realistic risk was no greater than 7 : 10,000,000. Overall, the viral risk to residences adjacent to land application sites appears to be low, both for one time and annual probabilities of infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrated a simple approach towards modelling viral pathogens aerosolized from land applied liquid biosolids, and offers insight into the associated viral risk.

The rights of blood recipients should supersede any asserted rights of blood donors

Some gay men have argued that the laboratory testing of blood is so accurate that continued deferrals based upon sexual activity are unnecessary and unjust. They also assert that they have a right to donate blood. There has been much debate over altering the rule barring donation from men who have had sex with other men since 1977, with blood organizations disagreeing over the best course of action. Two studies have indicated that changing the rule would increase the risk of human immunodeficiency virus (HIV) transmission. This dilemma is part of a broader issue, namely: what are the responsibilities of blood services to blood donors and recipients? Blood services should base decisions regarding donor suitability on science rather than on their donors' desires. Blood services must recognize that the rights of blood recipients should supersede any asserted rights of blood donors.

Bioaerosols from the land application of biosolids in the desert southwest USA

This study evaluated bioaerosol emissions during land application of Class B biosolids in and around Tucson, Arizona, to aid in developing models of the fate and transport of bioaerosols generated from the land application of biosolids. Samples were collected for 20 min at distances between 2 m and 20 m downwind of point sources, using an SKC BioSampler impinger. A total of six samples were collected per sampling event, which consisted of a biosolid spray applicator applying liquid biosolids to a cotton field. Each application represented one exposure. Samples were collected in deionised water amended with peptone and antifoam agent. Ambient weather conditions were also monitored every 10 min following initiation of sampling. Concurrently with downwind samples, background (ambient) air samples were collected to compensate for any ambient airborne microorganisms. In addition, biosolids samples were collected for analysis of target indicator and pathogenic organisms. Soil samples were also collected and analysed. Significant numbers of heterotrophic plate count (HPC) bacteria were found in air samples collected during the biosolid application process. These could have arisen from soil particles being aerosolised during the land application process. Aerosolised soil may contribute significantly to the amount of aerosolised microorganisms. Soil particles may be able to more readily aerosolise, due to their low density, small particle size and low mass. Aerosolised HPC bacteria found during biosolids land application were similar to those found during normal tractor operation on non-biosolids applied fields. Coliforms and coliphages were not routinely detected even though they were found to be present in the biosolids at relatively high concentrations, 10(6) and 10(4)/g (dry weight) of biosolids respectively. This could be due to the die-off rate of aerosolised Gram-negative bacteria or sorption to the solid portion of the biosolids. Low numbers of aerosolised coliphages may likewise be due to sorption phenomena. We theorise that only organisms in the aqueous phase of the biosolids were available to desorb and be aerosolised. Animal viruses, which were not detected in the biosolids, were likewise not detected in the aerosol samples. Clostridium perfringens was detected in only a small percent of aerosol samples although it was detected during all weather conditions; other microorganisms were detected during more favourable environmental conditions (relative humidity >10%). Despite the fact that many of these organisms were present in the biosolids at significant concentrations, their presence in bioaerosols generated during the land application of biosolids was limited to only a small percentage of samples. Bacteria as well as viruses may sorb to biosolids, which contain a high percentage of organic matter, and desorption during land application of biosolids may not readily take place; therefore, these microorganisms may not be readily aerosolised.

Thermal imaging in the detection of bowel ischemia

PURPOSE

The aim of this study was to introduce thermal imaging in the intraoperative detection of bowel ischemia by comparing thermal imaging with conventional techniques in detecting acutely ischemic bowel, using histologic evidence for intestinal necrosis as the standard.

METHODS

A prospective study was performed using a porcine model. Laparotomy was performed on four pigs under general anesthesia. A 25-cm segment of mid jejunum was tagged with proximal and distal sutures, and its mesentery was ligated and divided. Thermal imaging, visual inspection, Doppler ultrasound, and fluorescence with Wood's lamp after fluorescein were used to estimate the extent of bowel ischemia five minutes after ligation of the mesentery. Measurements were taken in reference to both the proximal and distal tags to obtain two data points per animal for each method. After two hours of warm ischemia, the jejunum was harvested and sectioned longitudinally. Comparisons were made between the estimated region of necrosis for each method and microscopic evidence of necrosis.

RESULTS

Visual inspection was the only method unable to detect a difference between vascularized and devascularized bowel for each of the eight data points. Fluorescein dye missed 3 cm of ischemic bowel. Doppler ultrasound and thermal imaging were 100 percent sensitive for necrotic bowel, with thermal imaging overestimating necrosis to a greater extent than Doppler ultrasound. The positive predictive value of fluorescein dye, Doppler ultrasound, and thermal imaging for determining nonviable bowel was 91.8, 80.8, and 69.5 percent, respectively.

CONCLUSIONS

Thermal imaging has the potential to be a useful adjunct in the intraoperative determination of bowel ischemia. Further studies are indicated to study this technique.

In-service training with videotape is useful in teaching transfusion medicine principles

BACKGROUND

Failure to follow the basics of patient identification caused the ABO-incompatible transfusion and death of an anesthetized patient. An investigation found that the medical center's transfusion policy, while adequate, was not being disseminated uniformly to all personnel.

STUDY DESIGN AND METHODS

With the help of the hospital's medical media department, a 23-minute videotape was produced emphasizing the importance of patient identification during phlebotomy and blood administration. Each department involved in blood transfusion was separately trained for a total of 182 persons trained. To assess whether learning had occurred, a 10-question quiz was administered both before and after the video was presented. A one-tailed t test was performed, and p < 0.05 was considered significant.

RESULTS

The overall pre-video test mean was 8.0 and the post-video test mean was 9.5. The difference was highly significant at p < 0.00005. Except for the Transfusion Medicine Service, which had a perfect score on the pre-video test, all departments improved their scores with p values ranging from less than 0.00005 to 0.014.

CONCLUSION

This study demonstrates that learning did occur. Videotape is useful for in-service training and can be used for teaching on a variety of topics in transfusion medicine.

Suggestions for management training of residents

In addition to having medical expertise, physicians must possess managerial skills to deal with the ever-changing business environment of the practice of medicine. This article addresses the need for management training of physicians and calls for management training during residency and medical school. It also describes one residency program's efforts to provide comprehensive management training to its residents in pathology.

Ultrasound guided seminal vesicle biopsies in men with suspected prostate cancer

PURPOSE

The histology of ultrasound guided seminal vesicle biopsies is assessed and the results are correlated with clinical or pathological stage of prostate cancer.

MATERIALS AND METHODS

A total of 517 consecutive men underwent bilateral (515) or unilateral (2) seminal vesicle biopsy during sextant biopsy of the prostate.

RESULTS

Seminal vesicle epithelium and muscularis were identified in 490 of 1,032 biopsy specimens (47%) and smooth muscle consistent with seminal vesicle muscularis was identified in 393 (38%). The seminal vesicle biopsy was positive for cancer in 7 of 123 patients (6%) with with clinical stages T1c and T2 tumors, 27 of 60 (45%) with stages T3 to 4 disease and 9 of 13 (69%) with metastatic cancer. Of 39 patients who underwent radical prostatectomy 1 of 36 (3%) without and 0 of 3 (0%) with seminal vesicle invasion had a positive seminal vesicle biopsy.

CONCLUSIONS

Seminal vesicle epithelium and muscularis or smooth muscle consistent with the seminal vesicle muscularis can be procured in most patients using contemporary ultrasound guided biopsy techniques. However, apparently false-negative seminal vesicle biopsies are not uncommon and seminal vesicle biopsies contribute little to the staging of T1c and T2 tumors.

Twelve cases of glottic carcinoma in situ treated by radiotherapy: an observation on clinical course versus response

Carcinoma in situ (CIS) of the glottis is an uncommon and poorly understood condition with few, large, long-term studies. Twelve cases are presented which were treated with radiotherapy. At three-year follow-up all the patients are disease free and in 83 per cent the mucosa has returned to normal. The alternative methods of treatment are discussed.

Health care organization drug testing

Health care managers are being required to respond to the growing concerns of the public about alcohol and drug use in the health care workplace. To this end, the following recommendations are offered. A drug testing policy should be developed with input from and support of employees and unions. "For cause" testing should be used because it results in more definitive results and better employee acceptance. Unless there are compelling reasons for random testing, "for cause" testing is the preferable method. All levels of employees and the medical staff should be subject to the drug-testing policy. Rehabilitation rather than punishment should be emphasized in dealing with employees with alcohol and drug problems.