Olfactory function assessment of migraine patients by using the Sniffin' sticks test: A clinical study

OBJECTIVE

This as a cross-sectional controlled clinical study. We hypothesis that the olfactory functions in migraine patients may differ from the healthy controls. In this study, we evaluated the olfactory functions by using a Sniffin' Sticks test battery, which is a reliable and semi quantitative test to evaluate for olfactory dysfunction.

METHODS

Patients above 18 years of age who had migraine received a definitive diagnosis of migraine from experienced headache specialists based on the criteria of The International Classification of Headache Disorders-3 were included. Odor threshold, discrimination, and identification parameters were assessed using the "Sniffin' Sticks" test.

RESULTS

One-hundred and one migraine patients (age [mean ± SD], 36.9 ± 10.4 years; range, 18-60 years) and sixty healthy volunteers (age 34.5 ± 13.2 years, range 18-65 years) participated in our study. The median odor threshold score [percentiles 25th-75th] was 8.3 [6.5-9.8] for the migraine group during attack free period and 4.5[3.6-6.0] for the control group. It was found that the migraine group had a median odor discrimination score of 10.0 [10.0-13.0] and the control group 12.0 [11.0-13.0]. These differences were statistically significant (p < 0.001 and p = 0.032 respectively). The median odor discrimination and identification scores were statistically significant higher for the participants with higher educational level group than in those of lower educational group (p < 0.0001). The median odor discrimination and identification scores of those without allodynia (12.0 [10.0-14.0] and 13.0 [10.0-13.0] respectively) were higher than that of those with allodynia (11.0 [9.0-12.0] and 11.0 [10.0-13.0] respectively) (p = 0.037 and p = 0.034 respectively).

CONCLUSIONS

We found that the odor thresholds, discrimination and identification scores of the migraine group demonstrate differences from those of the healthy group and in relation to allodynia.

Long-term outcomes of facial nerve decompression by transmastoid versus middle cranial fossa approach for traumatic facial paralysis

OBJECTIVES

To evaluate and compare the long-term results of patients who underwent facial nerve decompression surgery with either transmastoid-supralabyrinthine (TMSL) or combined transmastoid- middle cranial fossa (MCF) approach for traumatic facial nerve paralysis.

MATERIALS AND METHODS

This is a single-center retrospective case-control study. The medical records of traumatic facial paralysis patients with House Brackmann (HB) Grade 6 who underwent facial nerve decompression surgery at via either TMSL or MCF approach between January 2011 and December 2017 were reviewed. The patients who had otic capsule involvement and total sensorineural hearing loss, therefore underwent translabyrinthine facial nerve decompression, and the patients follow-up period has not yet reached four years were excluded from the study. Postoperative HB score and hearing status were compared.

RESULTS

Eleven patients were operated with MCF approach (group 1), while 9 patients with TMSL approach (group 2). Average age of patients was 20.04 + 15.2 (range:4-47) years. Three (15 %) patients were female, while 17 (85 %) was male. Geniculate ganglion (90 %) was the most affected segment of the facial nerve. Facial nerve edema was observed in all cases, while intraneural hematoma were encountered in 4 (20 %) cases. Statistically significant improvement in median HB scores were reached in both groups, and no significant difference was observed in post-operative HB scores between both techniques. No significant difference in median AC 0,5-4 khZ and BC 0,5-3 kHz thresholds was observed between both techniques.

CONCLUSION

Even middle fossa approach is the best surgical technique to explore geniculate ganglion and labyrinthine segment of facial nerve, the functional results of transmastoid supralabrynthine approach, which is not needed craniotomy with low complication rate are as successful as middle fossa approach in selected patients.

Does sarcopenia predict perioperative mortality in patients with advanced ovarian cancer?

OBJECTIVE

The aim of this study was to assess prognostic value of frailty for the prediction of surgical complications and mortality in women with end-stage ovarian cancer subjected to curative oncological surgery and its value for long-term follow-up.

PATIENTS AND METHODS

A total of 75 advanced-stage consecutive ovarian cancer patients who underwent elective surgery were investigated. The demographic data and clinical information related to the oncologic treatment were collected in the electronic and physical case records and included the following: age, ethnic group, comorbidities, staging of cancer, surgical procedure details, lymphadenectomy, American Society of Anesthesiology (ASA) grade, anesthetic technique, operative blood loss, operative time, and residual disease. A radiologist, who was blinded to patient outcomes, performed quantitative assessment of psoas muscle areas using the available computed tomography scan images at the caudal end of the third lumbar vertebra.

RESULTS

The mean age was 61.2 ± 18.2 years, and the percentage of patients over 65 years was 78%. Comorbidities (hypertension, diabetes, chronic obstructive pulmonary disease, renal insufficiency) were seen in 37 patients (49%). Histological types were adenocarcinoma in all patients (0) mostly serous adenocarcinoma (62%) and stage 3 (58%). According to psoas muscle measurement, 55 patients (73%) were nonsarcopenic and 20 patients (26%) were sarcopenic. Debulking procedures were performed on all patients. Also, bowel resection was applied in 40% of patients. Preoperative anesthetic examinations had shown that they were mostly ASA score 2 (44 patients). Moreover, 26 patients were ASA score 3. Generally, total operative time was between 121-240 minutes, and total blood loss was generally under 500 ml. Postoperative complications were seen in 26% of the patients. Non-surgical complications were observed in 14% of the patients, while non-surgical complications were observed in 12%. Length of the hospital stay >10 days was seen in 10 patients. Mortality was seen in 1 patient 30 days after operation. Nonsurgical complications (pneumonia, urinary tract infections, cardiac complications) were significantly higher in comparison to nonsarcopenic patients. However surgical complications were comparable between each group. Mortality after hospitalization and length of hospital stay were significantly higher in sarcopenic patients in comparison with the nonsarcopenic group.

CONCLUSIONS

The use of the value of the psoas muscle region is considered to be a method to predict the in-hospital mortality when there is an available abdominal CT scan that has already been performed for ovarian cancer patients with a significant comparable clinical and laboratory background. According to the findings, patients had worse surgical outcomes and higher postoperative nonsurgical complication rate when sarcopenic patients were compared to nonsarcopenic patients. Moreover, postoperative mortality and length of hospital stay were significantly higher in sarcopenic patients in comparison to non-sarcopenic group.

Psychometric Properties of the Turkish Version of the Coronavirus-Related Health Literacy Scale

Background

This study aims to assess the validity and reliability of the Coronavirus-Related Health Literacy Questionnaire adapted to Turkey and examine the levels of coronavirus-related health literacy among the adults.

Methods

This cross-sectional study was carried out in Turkey. The tools were applied to a total sample population of 452 people. Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were calculated to determine the construct validity of the questionnaire with the IBM SPSS Amos program version 24.0.

Results

The validity and reliability analyses of the Coronavirus-Related Health Literacy (HLS-COVID-Q22) questionnaire were adapted to Turkish. Internal consistency was very high (α = 0,963) and construct validity suggests a sufficient model fit, making HLS-COVID-Q19 a feasible tool for assessing coronavirus-related health literacy in population surveys. The findings show that the questionnaire is a valid and reliable tool consisting of 19 items and 3 subdivisions. The mean coronavirus-related health literacy score of the participants was found to be 2.92 (±0.51), meaning that it was on average. The coronavirus-related health literacy level of 18.8% of the participants was found to be ‘inadequate’ while 37.8% had ‘problematic’ and 43.4% ‘sufficient’ health literacy. The HLS-COVID-Q19-TR scores of those in the young age group (18-29 years old), married, employed, university graduates, and vaccinated against COVID-19 were found to be higher, and a statistically significant difference was found (p = 0.049, p = 0.009, p = 0.029, p = 0.012 and p = 0.051, respectively).

Conclusions

The results of the research reveal that the HLS-COVID-Q19-TR is a valid and reliable tool. In this study, more than half of the participants were found to have “inadequate” or “problematic” coronavirus-related health literacy levels. For this reason, studies aimed at improving society's coronavirus-related health literacy should be conducted.

Key messages

Paranasal Sinus Fungus Ball, Anatomical Variations and Dental Pathologies: Is There Any Relation?

Objective:

The purpose of this study was to investigate the relationship between anatomical variations and the fungus ball (FB), and the association between odontogenic etiologies and the maxillary sinus FB.

Methods:

We analyzed the clinical records of 66 patients who underwent endoscopic sinus surgery for FB. The anatomical variations determined were nasal septal deviation (NSD) and direction, presence of Onodi and Haller cell, concha bullosa and lateral recess of the sphenoid sinus. Further, dental X-ray records were reviewed to detect any possible odontogenic etiologies in patients with maxillary sinus FBs.

Results:

There were 41 female and 25 male patients. Positive fungal culture was found in 60 patients (91%) and the causative fungus was Aspergillus species in all cases. The correlation between NSD and localization of the maxillary sinus FB was statistically significant (p=0.0409). Maxillary sinus FB was more common on the concave side of the NSD. Presence of dental pathologies was significantly associated with maxillary sinus FB compared to the healthy side (p=0.0011). For sphenoid sinus FB, NSD was detected in a similar number for both the affected and unaffected side and there were no significant correlations (p>0.05). However, the relationship between sphenoid sinus FB and presence of lateral recess was significant (p=0.0262).

Conclusion:

Our study revealed that the maxillary sinus FB was more common on the concave side of the deviated septum. Also, dental pathologies or a presence of dental treatment history were associated with maxillary sinus FB.

Evaluation of Patients with Post-Traumatic Hearing Loss: A Retrospective Review of 506 Cases

Objectives:

The purpose of the study is to evaluate the audiological, radiological, and examination findings of patients who have been treated for hearing loss (HL) due to head trauma and evaluated in terms of causality to reveal current data, and to highlight the steps to be taken.

Methods:

We retrospectively reviewed the reports of cases that had applied for disability with HL due to head injury and had been evaluated by the Forensic Medicine Institute between January 01, 2009 and January 01, 2019.

Results:

Of the total cases of head trauma, 52.42% were not vehicle-related, and cases were observed to be concentrated in the age range of 19-40 (55.92%; n = 283). Although otorrhagia/otorrhea was the most common finding in all types of trauma, TM perforation was the most common finding in blast-type injuries. While the rate of newly developed unilateral HL was 84.2%, 72.7% of the patients had sensorineural hearing loss (SNHL) . Temporal bone fractures were detected in 59.3% of the cases, and 60.2% of them were of the longitudinal type. Facial paralysis (FP) was detected in 28.6% of the cases, and there was no statistically significant difference between the groups in terms of HL compared to those without FP. Other nerve palsy was detected in 4.9% of the cases, and N. Abducens paralysis was the most common.

Conclusion:

Accompanying intracranial nerve injury, temporal fracture, and intracranial pathologies are considerably high in patients who develop HL following head trauma. The first examination requires a multidisciplinary approach to guide future disability applications.

Determining the number and distribution of intraparotid lymph nodes according to parotidectomy classification of European Salivary Gland Society: Cadaveric study

BACKGROUND

To investigate the distribution of the parotid gland's intraglandular lymph nodes using the parotidectomy zones determined by the parotidectomy classification of the European Salivary Gland Society (ESGS).

MATERIALS AND METHODS

A total of 128 parotid glands were dissected from 64 fresh cadavers, by bilateral parotidectomy without additional incision within the standard autopsy procedure, and categorized.

RESULTS

Eighty-six percent of the IGLNs were located in the superficial lobe and 14% in the deep lobe. An average of 7.09 ± 3.55 IGLNs were found for each of the gland; there were 6.11 ± 3.28 in the superficial lobe and 0.98 ± 1.46 in the deep lobe. While the most common lymph nodes were found in level 2 with 47.7%, only 5% of IGLNs were at level 4. According to the proposed modification, the most common lymph nodes (35.24%) were located at level 2B.

CONCLUSION

Level 2B was found to contain significantly more lymph nodes than other levels, which has not been evaluated before in literature.

Most Cited Articles in Head and Neck Oncology

OBJECTIVES

The number of citations an article receives is an important indication of its impact. The main objectives of this investigation provide readers with a practical guide in evaluating head and neck oncology literature and determine the characteristics of trends in ORL.

METHODS

This was a retrospective bibliometric analysis that did not involve human participant. The Thomson Reuters Web of Science was searched to determine the citations of all published HNO articles. Most cited 300 article analyzed and a total of 100 articles were included in our investigation under the topic search "Head AND NECK AND (cancer OR carcinoma OR oncology)." Articles include malignancies other than head and neck are excluded. The top 100 cited articles were selected and analyzed by 2 independent investigators. Country, Institution, First Author, Journal name, study design, cites per year information gathered and analyzed.

RESULTS

The journal with the highest number of top 100 cited articles was New England Journal Of Medicine with 19 paper, followed by The Journal of Clinical Oncology(17) and Cancer Research (12). The top article on the list (Radiotherapy plus cetuximab for squamous cell carcinoma of the head and neck-NEJM) has 2243 citations. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles (P < .05). The United States had the highest number of articles (63). John Hopkins is differed from other institutions with 15 contributing articles.

CONCLUSION

Our analysis provides an insight into the citation frequency of top cited articles published in HNO to help recognize the quality of the works, discoveries and the trends steering the study of HNO. This is also a modern reading list for young HNO scientist.

Malignant Transformation of Parotid Gland Non-sebaceous Lymphadenoma: Case Report and Review of Literature

Non-sebaceous lymphadenoma is a sporadic benign tumor of salivary glands. Histopathologic and immunohistochemical properties, diagnostic criteria, and theories for the histologic origin of the disease have been defined and well-discussed in the literature. However, none of the cases showed malignant transformation to date. We reported a case of 54 years old female patient with a right preauricular mass. Magnetic resonance imaging demonstrated a 2 cm, well-defined contrast-enhanced mass in the right parotid gland. Fine needle aspiration cytology was undiagnostic but suspicious for malignancy. Total parotidectomy with facial nerve preservation was done. In the histopathological examination, non-sebaceous lymphadenoma regions and malignant cells with abundant cytoplasm, large vesicular nuclei, and prominent nucleoli, which occupied approximately 70% of the mass, were seen. The diagnosis was undifferentiated carcinoma arisen from non-sebaceous lymphadenoma. Adjuvant radiotherapy was given. No recurrence was detected during ten months of follow-up. This case is the first case of a malignancy developed from non-sebaceous lymphadenoma.

Work patterns, sleeping hours and excess weight in commercial drivers

BACKGROUND

Work and sleep patterns for commercial motor vehicle (CMV) drivers often include long working hours, shift work and diminished sleep duration and quality, which have been linked to overweight, obesity and other problems.

AIMS

To explore possible connections between work, sleep and obesity among CMV drivers.

METHODS

Survey and anthropometric data were collected from male long-haul CMV drivers in central North Carolina, USA, over a period of 6 months. Drivers' body mass index (BMI) was used as a measure of total body obesity and sagittal abdominal diameter (SAD) as a measure of central adiposity.

RESULTS

Among the 260 study subjects, mean BMI was 33.1 (64% were obese or morbidly obese) and mean SAD was 32.3cm, classifying 89% of drivers as being at high or very high cardiometabolic risk. About 83% of drivers worked an irregular daily schedule, 64% worked irregular total daily hours, 32% worked irregular days of the week and 46% reported getting <7h of sleep during work nights. Significant predictors of BMI included the number of hours worked daily (P < 0.05) and the age (P < 0.01) of the driver, while age was also a significant predictor for SAD (P < 0.05). Significant predictors of sleep quality included the extent of shift work (P < 0.05) and sleep duration (P < 0.001).

CONCLUSIONS

Work and sleep configurations appear to affect the weight status of CMV drivers. Shift work and sleep duration are both associated with the weight status of CMV drivers, and both appear to function as indicators of their sleep quality.

The effect of topical doxycycline usage on gingival crevicular fluid MMP-8 levels of chronic and aggressive periodontitis patients: a pilot study

The aim of this study was to evaluate the efficacy of topical subgingival application of doxycycline hyclate (DH) gel adjunctive to non-surgical periodontal therapy on gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 levels in chronic and aggressive periodontitis patients. Forty teeth of 10 chronic periodontitis patients and 32 teeth of eight aggressive periodontitis patients were screened for 6 months. Scaling and root planing (SRP) was applied to the control sites and DH gel adjunctive to SRP was applied to the test sites of each patient simultaneously. GCF MMP-8 levels were analysed at baseline, 7 days; and at 1, 3 and 6 months by Sandwich Elisa Method. At 1, 3 and 6 months, probing depth (P < 0.0051) and plaque scores and bleeding on probing values (P = 0.000) significantly decreased in each group when compared with the baseline, but there was no statistically significant difference between the test and control sites. GCF MMP-8 levels reduced presenting statistically significant differences on 7 days, 1, 3 and 6 months in four of the groups (P < 0.05); however, intergroup differences were not statistically significant. Developing functional and immunological-based chair-side MMP tests might serve as useful adjunctive diagnostic tools when monitoring the effects of DH gel application.

HIV-risk behaviours of American spring break vacationers: a case of situational disinhibition?

Young adults are at high risk for acquiring STDs/HIV due primarily to multiple sex partners, unprotected sex, and substance use combined with sexual activity. Contranormative settings--such as the annual spring break vacation--provide ideal conditions for the potentially lethal interaction between alcohol, drugs, and sexual risk-taking. As a steadily growing form of youth travel and characterized by binge drinking, illicit drug use, and unsafe sexual practices, spring break has become a North American institution involving large numbers of travellers. In this study, the theory of interpersonal behaviour was used to explain college students' health-risk behaviours in the context of spring break and pre- and post-spring break surveys were used to examine casual sex and condom use behaviours. Multivariate analyses revealed peer influences, prior experiences with casual sex, alcohol consumption prior to sex, and impulsivity to be significant predictors of casual sex, while impulsivity and condom availability were significant predictors of students' use of condoms during casual sex.

Effects of norepinephrine on NMDA-induced neurotoxicity in cerebellar granular cell culture of rat pups

In this study, norepinephrine was tested in 0.1, 1, 10, 25 and 50 microM doses in 100 microM NMDA toxicity on cerebellar granular cell culture of rats. NMDA in 100 microM concentration induced cell death significantly with respect to controls. Death cell population was 1.08 +/- 0.44% in control and 22.15 +/- 2.46% in 100 microM NMDA (P < 0.0001). None of the norepinephrine concentrations administrated 15 min prior to NMDA was able to reduce death cell scores to control levels. Results were 8.75 +/- 0.83% in 0.1 microM, 7.0 +/- 1.01% in 1 microM, 17.25 +/- 1.31% in 10 microM, 35.5 +/- 1.38% in 25 microM and 17.9 +/- 1.72% in 50 microM norepinephrine plus 100 microM NMDA administrated groups (P < 0.0001 for all with respect to control). Labetalol, as an alpha and beta blocker in 0.5 microM concentration which was given 15 min prior to norepinephrine was able to block the effects of it. In comparison with 100 microM NMDA administered group, only low doses of norepinephrine reduced the death cell scores significantly (for 0.1 and 1 microM norepinephrine plus NMDA groups; P < 0.0001). For 10 and 50 microM norepinephrine plus NMDA groups, death cell scores were found statistically insignificant from the NMDA-administered group (P > 0.05 for both) while for the 25 microM norepinephrine plus NMDA group, the death cell score was found to be statistically increased (P < 0.0001).

Response to nimodipine in caffeine-induced neurotoxicity in cerebellar granular cell culture of rat pups

Methylxanthines (theophylline, theobromine and caffeine) are widely used as central nervous system stimulants and caffeine is used in the treatment of apnea in newborns. Plasma therapeutic concentration of caffeine is around 110 microM. Caffeine diffuses the blood brain barrier easily, increasing oxygen consumption in neurones and leading to cell death. In the present study, 4-7-day-old rats were used to obtain cerebellar granular cell cultures. Caffeine was used 50, 150, 250 and 350 microM concentrations and the most toxic dose for it was found to be 350 microM. Death cell scores were 0.9+/-0.63 for control, 1.1+/-0.63 for 50 microM, 0.89+/-0.47 for 150 microM (P>0.05 for both), 3.84+/-0.8 for 250 microM (P=0.024) and 6.2+/-0. 86 for 350 microM (P=0.001) caffeine concentrations. The role of voltage-dependent calcium channels in caffeine-induced neurotoxicity was tested with the doses of 100 and 200 microM nimodipine 45 min before or after the 350 microM caffeine. Both doses of nimodipine after caffeine administration were found to be ineffective in blocking neurotoxicity. Doses administered 45 min prior to caffeine, reduced death cell score to 0.89+/-0.23 (P=0.000) for 100 microM nimodipine and 2.35+/-0.96 (P=0.000) for 200 microM nimodipine administration into the cultures. A dose-dependent manner of nimodipine in ischemic states is well-known. In the light of these results, nimodipine may be used in the treatment of newborn apneas together with caffeine to prevent neurotoxic side effects of high or repeated doses of it.

High frequency of sister chromatid exchanges in lymphocytes of the patients with Behçet's disease

Behçet's disease (BD) (OMIM 109650) is an immunogenetically based multisystem disease, characterized by iridocyclitis, arthritis, orogenital ulcerations and pustular skin lesions. Viral and autoimmune etiologies have been suggested and HLA-B5 has been found to predominate in BD. The disease is most seen in Turkey and Japan. Although familial cases have been reported, the mode of inheritance is not clear. To determine the genetic instability in BD, sister chromatid exchange (SCE) analysis has been performed on peripheral lymphocytes in 23 patients and 20 healthy controls. We found significantly higher SCE rates in the patient group (p < 0.0001). Our results may indicate that genetic impairment and genetic instability may play an important part in the etiology of BD.

Sister chromatid exchange analysis in patients exposed to low dose of iodine-131 for thyroid scintigraphy

To determine the genotoxic risk associated with diagnostic exposure to low doses of iodine 131 (131I), sister chromatid exchange (SCE) analysis was performed in lymphocytes of 18 non-smoking women who received 370 kBq (10 microCi) intravenous 131I sodium iodide as an adjuvant for scintigraphy for diagnosing thyroid nodularity. SCE frequencies were measured before and after 131I administration. SCE results in the pre-treated phase were regarded as control. Although SCE values 24 h after 131I administration did not show a significant increment (p > 0.05), there was a significant increase 72 h after treatment (p < 0.05). These results indicate that genetic damage might be induced by low dose of 131I.

Sister chromatid exchange analysis in the lymphocytes of patients with ankylosing spondylitis

OBJECTIVE

This study investigated whether any genomic change occurs in DNA level in ankylosing spondylitis (AS) by measuring sister chromatid exchange (SCE) frequency.

METHODS

SCE frequency was detected on metaphase chromosomes obtained from peripheral blood lymphocyte cultures in 15 patients diagnosed as having AS. SCE values were also obtained from 15 healthy subjects as a control group. SCE frequencies were detected from metaphases obtained from standard blood cultures by using bromodeoxyuridine and staining by Giemsa.

RESULTS

SCE frequencies of AS were statistically higher than those of the control group (p < 0.005).

CONCLUSION

These results suggest that genetic factors may play a more important part than realised in the aetiology of AS.

Nimodipine improves kainic acid induced neurotoxicity in cerebellar granular cell culture: a double-blind dose-response study

The neuroprotective role of nimodipine was tested in kainic acid (50 and 100 microM) induced neurotoxicity in cerebellar granular cell cultures of 4 to 7 day-old rat pups. Nimodipine was applied in 50, 100 and 200 microM concentrations. Kainate, in either dose, induced cerebellar granular cell death in respect to controls and the results were statistically significant (P = 0.000 for both doses). However, kainic acid in 100 microM concentration led to higher rates of cell death than 50 microM (P = 0.017). The neuroprotective role of nimodipine in kainate induced neurotoxicity was dose dependent. Kainate toxicity in 50 microM concentration was blocked by 50 and 100 microM nimodipine concentrations (P = 0.006 and P = 0.002, respectively) while 200 microM nimodipine was found ineffective. The most effective nimodipine dose for 100 microM kainic acid neurotoxicity was 200 microM (P = 0.000) while 50 and 100 microM concentrations of nimodipine were found ineffective. In this study, we have proven the dose-dependent neuroprotective role of nimodipine in kainate induced neurotoxicity in cerebellar granular cell cultures of rat pups.

Choriocarcinoma associated with ectopic pregnancy after tubal sterilisation

A 33-year-old highly parous woman developed severe abdominal pain and signs of circulatory collapse 10 months after tubal sterilisation in the absence of symptoms of pregnancy. A ruptured ectopic pregnancy sited interstitially in the right tube and extending into the myometrium and parametrium was found at laparotomy. Histopathologic examination revealed an ectopic pregnancy consisting of choriocarcinoma--a rare but life-threatening combination in a sterilised woman.