Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
They are not much of practical and hence may invite trouble for themselves buy 10mg duphaston otc, leading a dreamy life cheap duphaston 10 mg visa. They need to realize that this great potential that they have been endowed with order on line duphaston, also hands them great responsibility towards others. Usually, they are of high intellect and easily make themselves renowned as scholars. This might lead them into many unwanted hustles both in professional and personal lives. They need to train themselves to be little less impatient with people and situations around themselves so that they can obtain better results. They do not find it easy to mingle with other people and they need to put effort in that direction. Also, this snob nature may land them up in some trouble as their relatives may make the most of this particular weakness of theirs. They have high interpersonal intelligence and are much carefree when it comes to enjoying life with same aged people. As they reach the prime of their ages, they crave for emotional dependency on others as their whole emotional make up is based upon people from very young age. They need to make a stable career for themselves so that they need not get vulnerable at very old age. However, their high confidence in themselves, coupled with good amount of confidence. Although, it is a matter of bigger concern that things such a person want from life, mostly turn out to be vague and abstract. Although, it can all can be overcome by using more of other abilities with steadiness and patience. However, they need to work hard during initial years to enjoy the perks later in life. Also, they are highly creative and make reputable names for themselves in related careers. This aggression can act against them as far as interpersonal interactions are concerned. If they however overcome this particular stance, they can soar up above in their professional growth. They also need to work hard upon their communication and oratory skills if they are involved in related occupations. They need to be cautious getting betrayed in business or conned by others they trust. They easily get help from influential people because of their jovial nature towards people. However, their association with people of importance aides in getting up the ladder of success. Although it can be overcome if he/she works in this prospect and maintain harmony among others. They need to accept the fact that companionship of others are necessary as one moves further ahead in life. They need to take mature step towards this prospect with help of some counselling. However, they lack the skills required for doing business and understanding the twists and turns of commercial sector. However, due to their enhanced inner conscience and jovial attitude towards life, they succeed at being good teachers or scholars. They can also be spiritual masters as they have enhanced understanding of existence, purpose of life and values, morals and meanings of life. Unconsciously, they may hurt others, especially those whom are in important positions in his/her lives. They too have the chances of offending the wrong kind of people due to this straight forward nature. However, by the prime of their age they rise up the success ladder to important position. The role multiple intelligence plays in categorising people with highly developed intelligence into the profession that suits their innate potentials. Hundreds of educational institutes all over the world have adapted a screening method based on a childs fingerprints. It guides the faculty to teach the subject in a manner he/she has been created with. Also, if it becomes known that which career prospect is most suitable for a child according to his/her prominent innate intelligence, then it becomes easier for the child to pursue such career path which in most cases, also turns out to be rewarding. Also, in most of the cases of adults, who are helplessly stuck in jobs that they are unable to relate with, dermatoglyphics is their key to recognise their inherent potentials. The unnecessary pressure an individual goes through while building a career out of something he/she is not made for, can be averted. Also, people with disabilities can delve into jobs that they are skilled of, from birth. The neural correlates to the various types of intelligences and personality types have a profound connectionwith specific areas of human brain. The left and right brain halves are not completely isolated from each other and so does the logical intelligence not remain unaffected from the emotional intelligence quotient and vice versa. The fingerprints are the way to understand how our brain is wired up since our births.
Risks: Global and Regional Burden of on Maternal and Child Nutrition generic 10mg duphaston with amex, Geneva buy discount duphaston 10 mg, Geneva buy duphaston 10mg with amex, United Nations, 1993. Effectiveness of vitamin of death in children, the Lancet, 2005, Iodine Deficiency: Progress since the A supplementation in the control of 365(9465), p. United Nations Interventions, Food and Nutrition 29 de Benoist B et al, Worldwide Administrative Committee on Bulletin, 2009, (30) 1. Agriculture Organization, Sustainable rice Corneal blindness: a global perspective, 53 Ibid. Strategy for Large-Scale Action, Practices Paper: Food Fortification, 58 Centers for Disease Control, Trends in September 2008, in press, p. Morbidity and Mortality Weekly Report, 2003 February 6; Marrakech, Morocco 46 Ibid. An ex-ante 79 Nepal, Ministry of Health and Population, Survival (Vitamin A and Zinc), assessment, 2007, HarvestPlus Working, Nepal Demographic and Health Survey Copenhagen Consensus Center, Paper No. Its mission is to develop, implement and monitor innovative, cost-effective and sustainable solutions Good nutrition, especially and 4) the rationale for investment and action in health and in the first several years of a childs life, profoundly affects nutrition. Investing in the future A united call to action on vitamin and mineral deficiencies Around the world, Cost-effective solutions Supplementation billions of people live are ready to be scaled-up • Where a population is at risk of vitamin A deficiency, providing young with vitamin and mineral Working together, national governments, children with vitamin A deficiencies donors, science and industry have made supplementation every six months huge strides in delivering cost-effective reduces mortality by an average Vitamins and minerals are vital solutions to vulnerable populations. However, billions of rehydration therapy, can reduce the • Fortifying flour and other staple foods people currently live with deficiencies in a duration and severity of acute with vitamin A, folic acid, iron and range of crucial vitamins and minerals – diarrhoea, one of the leading causes zinc has been an effective means of including vitamin A, iodine, iron, zinc and of death of children. The results of these deficiencies are significant: • Salt iodization reduces goitre and Worlds best investment improves cognitive development. In 2008, the Copenhagen deaths each year, accounting for one Consensus panel considered 30 options fifth of total maternal deaths. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care Quality of evidence assessment* I: Evidence obtained from at least one properly randomized A. There is fair evidence to recommend against the clinical preventive action places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with E. These associations may should be advised to follow the product label and not to take more require consideration before initiating folic acid supplementation. Additional tablets containing only folic acid should be taken to achieve the desired intake combined with a multivitamin/micronutrient supplement is dose. Women should be advised to maintain a healthy folate-rich diet; and for 4 to 6 weeks postpartum or as long as breast-feeding however, folic acid/multivitamin supplementation is needed to continues, continued daily supplementation should consist of a achieve the red blood cell folate levels associated with maximal multivitamin with 0. All women in the reproductive age group (12–45 years of age) a male partner with a personal history of neural tube defect, or who have preserved fertility (a pregnancy is possible) should history of a previous neural tube defect pregnancy in either partner require a diet of folate-rich foods and a daily oral supplement supplementation during medical wellness visits (birth control with 4. Because so many age, continuing throughout the pregnancy, and for 4 to 6 weeks pregnancies are unplanned, this applies to all women who may postpartum or as long as breast-feeding continues, continued daily become pregnant. The same dietary and supplementation regime should be followed if either partner has had a previous pregnancy or laboratory) are not required prior to initiating folic acid with a neural tube defect. Biology reduced folic acid Interference with Chloramphenicol activity erythrocyte maturation Methotrexate Other Metformin 2. Reduced folic acid levels Impaired absorption Sulfasalazine Increased metabolism Phenobarbital Phenytoin 3. As we, the Registrars, worked with the state distributed Guidelines we found that we needed more clarification this is a working document created for and by the Birth Registrars of the Finger Lakes Region. The following instructions are given to guide the entry of the information from hospital and physician records and notes into the New York State Certificate of Live Birth. The information contained herein will help to ensure that data gathered from different hospitals throughout the state will be consistent and will provide comparable statistics among various hospital settings. The next 2 pages contain sections of the New York State Public Health Law that governs the collection and distribution of birth certificate information. New York State Public Health Law, Section 4102, states any person shall be deemed guilty of a misdemeanor, and upon conviction shall be fined or be imprisoned or be both fined and imprisoned in the discretion of the court, who for himself or as an officer, agent, or employee of any other person, or of any corporation or partnership, shall: refuse or fail to furnish correctly any information in his possession, or shall furnish false information affecting any certificate or record, required by this article; or willfully alter, otherwise than is provided by this article, or shall falsify any certificate of birth or death, or any record established by this article; or being a registrar, deputy registrar or sub-registrar, shall fail, neglect or refuse to perform his duty as required by this article and by the instructions and directions of the commissioner thereunder. It further states whenever any physician, licensed midwife, or other person shall fail or neglect properly to record and file a certificate of birth as required by this article such person shall be liable to a fine, such person shall be guilty of a misdemeanor, punishable by a fine, or by imprisonment, or both. The physician in attendance or a physician acting in his behalf shall certify to the facts of birth and provide the medical information required by the certificate within five days after birth. New York State Public Health Law, Section 4152, states the certificate of birth shall contain such information, including the social security numbers of the parents, and be in such form as the commissioner may prescribe. The personal particulars called for shall be obtained from a competent person acquainted with the facts. The certificate shall be signed by the attending physician or licensed midwife, with date of signature and his or her address. It further states if there was no physician or licensed midwife, in attendance then the certificate of birth shall be signed by the father or mother of the child, householder, owner of the premises, director or other person in charge of the public or private institution where the birth occurred, or by any other competent person whose duty it is to notify the local registrar of such birth. The registrar shall enter the exact date of filing of the certificate of birth in his office attested by his official signature and registered number of birth. New York State Public Health Law, Section 4155, states there shall be no specific statement on the birth certificate as to whether the child is born in wedlock or out of wedlock or as to the marital name or status of the mother.
Soriano F duphaston 10 mg free shipping, Rios R (1998) Gallium Arsenide Laser Treatment of chronic low back pain: a prospective randomised and double blind study duphaston 10 mg with amex. Several potential mechanisms of action of lumbar supports are reported in the literature that may support their use in the treatment of low back pain order duphaston online from canada. They are supposed to: (1) correct deformity; (2) limit spinal motion; (3) stabilize the lumbar spine; (4) reduce mechanical loading; and (5) provide miscellaneous effects such as massage, heat or placebo (1). In a more recent Cochrane review, the effects of lumbar supports for prevention and treatment of chronic low back pain were assessed (Jellema et al 2001). The remainder used either mixed populations (both acute and chronic) or populations that were not clearly defined and these studies were therefore not considered further. However, as only subjectively-rated “global improvement” was recorded (and no relevant outcomes such as pain, disability, quality of life or return to work), this study was also not considered further. Cost-effectiveness Unknown (no studies were found on this issue) Safety Adverse effects of lumbar supports which have been reported in the literature are: skin lesions, gastrointestinal disorders, muscle wasting, higher blood pressure and higher heart rates (Calmels and Fayolle-Minon 1996, Jellema et al 2001, McGill 1993). Subjects (indications) 61 Not having shown evidence of effectiveness, it is not possible to define indications for the use of lumbar supports. Comments None Summary of evidence There is no evidence for the effectiveness of lumbar supports compared with sham/placebo treatments in the treatment of chronic low back pain (level D). There is no evidence for the effectiveness of lumbar supports compared with other treatments in the treatment of chronic low back pain (level D). Recommendation We cannot recommend wearing a lumbar support for the treatment of non-specific chronic low back pain. Calmels P, Fayolle-Minon I (1996) An update on orthotic devices for the lumbar spine based on a review of the literature. The hypothesized working mechanism of this therapeutic application is the heating of tissues and the stimulation of tissue repair (Kitchen and Partidge 1992). Additional trials One additional trial was found which used sub-thermal shortwave diathermy as a control treatment in investigating the effectiveness of exercises and traction (Sweetman et al 1993). However, as no relevant outcomes such as pain, disability, quality of life or return to work were used, this study was not considered further. Cost-effectiveness Unknown (no studies were found on this issue) Safety Unknown (no studies were found on this issue) Subjects (indications) Not having shown evidence of effectiveness, it is not possible to define indications for shortwave diathermy. Comments None Summary of evidence There is no evidence for the effectiveness of shortwave diathermy compared with sham/placebo treatments in the treatment of chronic low back pain (level D). There is no evidence for the effectiveness of shortwave diathermy compared with other treatments in the treatment of chronic low back pain (level D). Kitchen S, Partidge C (1992) Review of shortwave diathermy continuous and pulses patterns. According to laboratory research, the application of ultrasound may result in an increase in cellular metabolic rate and increased visco-elastic properties of collagen tissue (Maxwell 1992). Ultrasound causes a rise in temperature which is assumed to be a mediating mechanism for tissue repair, the enhancement of soft tissue extensibility, promotion of muscle relaxation, augmentation of blood flow, and alleviation of inflammatory reactions of soft-tissue (Van der Windt et al 2003). There was no difference in pain improvement between the ultrasound group and a placebo group. There is limited evidence that therapeutic ultrasound is not effective in the treatment of chronic low back pain (level C). Effectiveness of therapeutic ultrasound vs other treatment Unknown (no studies were found on this issue) There is no evidence for the effectiveness of therapeutic ultrasound compared with other treatments in the treatment of chronic low back pain (level D). Cost-effectiveness Unknown (no studies were found on this issue) Safety Unknown (no studies were found on this issue) Subjects (indications) Not having shown evidence of effectiveness, it is not possible to define indications for therapeutic ultrasound. Comments None 65 Summary of evidence There is limited evidence that therapeutic ultrasound is not effective in the treatment of chronic low back pain (level C). There is no evidence for the effectiveness of therapeutic ultrasound compared with other treatments in the treatment of chronic low back pain (level D). Recommendation We cannot recommend therapeutic ultrasound as a treatment for chronic low back pain. Philadelphia (2001) Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. By these mechanisms it may result in relaxation, pain relief and improvement in functional disability. Results of search Systematic reviews Two systematic reviews were found: one was part of the evidence review by the Philadelphia Panel on selected rehabilitation interventions (Philadelphia 2001) and the other was part of a review on traction for low back pain (van der Heijden et al 1995). No trials were found in either review that had examined the effects of thermotherapy (alone) for chronic low back pain. Effectiveness of thermotherapy vs sham/placebo procedures Unknown (no studies were found on this issue) There is no evidence for the effectiveness of thermotherapy compared with sham/placebo treatments in the treatment of chronic low back pain (level D). Cost-effectiveness Unknown (no studies were found on this issue) Safety Unknown (no studies were found on this issue) Subjects (indications) Not having shown evidence of effectiveness, it is not possible to define indications for thermotherapy. Comments None Summary of evidence There is no evidence for the effectiveness of thermotherapy compared with sham/placebo treatments in the treatment of chronic low back pain (level D). There is no evidence for the effectiveness of thermotherapy compared with other treatments in the treatment of chronic low back pain (level D). Philadelphia (2001) Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. The applied force must be at least 25% of the body weight (weaker forces are considered as placebo). The duration and level of exerted traction can be varied in a continuous or intermittent mode (van der Heijden et al 1995). There is limited evidence that lumbar traction is not more effective than sham traction (level C). Effectiveness of traction vs other treatments Unknown (no studies were found on this issue) There is no evidence for the effectiveness of lumbar traction compared with other treatments in the treatment of chronic low back pain (level D).
If the primary narrative that a physician or institution selects to understand medical error is one that casts medical error in terms of risk of legal liability buy generic duphaston canada, a resolute nondisclosure policy quite predictably follows purchase 10mg duphaston. In this approach buy on line duphaston, adopting a “circle the wagons” mentality is common; as such, any patient-supportive activity that might increase the risk of malpractice exposure will be discouraged. Numerous explanations have been offered for the professional wall of silence that relate to and are distinct from fear of legal liability. It is important to acknowledge that the current system of tort-based compensation is dysfunctional. It can and does occasionally unfairly devastate a physicians career, and it costs insurers and institutions money. Even though civil litigation is 78 generally not organized to be punitive, it can have that effect on clinicians forced into defending themselves. Formal findings of malpractice potentially have negative downstream consequences in terms of credentialing, obtaining hospital privileges, and securing affordable insurance coverage. As such, clinicians quite naturally might focus on how the error affects them personally, rather than thinking of disclosure as a respectful, patient-centered, professional duty. What structural, sociologic, and psychological barriers exist that make breaking the wall of silence difficult Physicians are acculturated into a system that poorly prepares them to deal with their mistakes; the training of medical professionals takes place in a hierarchical system, within which trainees must perform to the satisfaction of their superiors. Trainees are socialized early to use certain coping mechanisms in the face of error, such as denial, discounting, and distancing. Acknowledging vulnerability and the possibility of mistakes is not encouraged or rewarded. This often translates into a need to project confidence, even in the face of uncertainty, and appear objective, even in situations that engender confusion and distress. Thus, it becomes easier not only to hide errors from patients and colleagues but also to develop strong psychological defense mechanisms and not recognize them as such as time goes by. Admitting error becomes akin to acknowledging a personal failing, which risks triggering strong feelings of inadequacy, let alone guilt and remorse. There is also a preoccupation with professional perfection, which sets up a false expectation that clinicians who are well-trained cannot and do not make mistakes. Some believe that imagining the physician as infallible may provide comfort to a vulnerable patient, but there is an important difference between appropriately having confidence in a professionals competency and mistakenly believing doctors are infallible. Are the collection of potentially serious negative consequences (legal and nonlegal) to medical professionals enough to partially or completely justify nondisclosure in cases of clear medical error on the part of individuals or systems What is important is to notice that rather than being a given, it is debatable whether any of the accurate descriptive explanations mentioned previously are adequate to serve as ethical justification. On the one side are the professional self-interests of physicians and health care institutions; on the other are patients claims to be treated with respect (ie, honesty and transparency). For the purposes of case discussion, participants will hopefully recognize that the harmful consequences that may flow to individual physicians are in competition with best patient care practices, and these latter considerations deserve much more attention than they typically receive. Offering an apology after one has played a causal role in an accident or error that harms something of value to another person not only seems polite and courteous, it also expresses respect and empathy. Yet in cases of medical error in which a patient is harmed, as in this case, many physicians feel ambivalent about offering an apology. An apology need not be an admission of guilt or causal responsibility, although it is hard to control whether it is interpreted as such. For this reason, it may be useful to distinguish saying, “Im sorry for what has happened to you,” from an apology that entails personal or institutional accountability for error. Arguably, the act of saying, “Im sorry,” allows physicians to reclaim 79 their natural capacity for caring and kindness. Of note, numerous state legislatures have passed so-called apology laws that are intended to encourage formal acknowledgment while simultaneously insulating such statements from use in subsequent malpractice litigation. However, it is at least possible that such laws actually detract from the perceived sincerity of an apology in this context. What evidence exists concerning the effect of apologies or admissions of error on risk of liability Several small lines of evidence suggest that an open disclosure policy may reduce the risk of liability under the current tort system and save hospitals and insurers money. There, it was found that poor communication and a failure of accountability were the root causes of initiating local malpractice suits. In 2002, the hospital adopted a new approach that included acknowledging cases in which a patient was hurt because of medical error and quick and fair compensation of those patients, defending cases thought to be without merit, and studying adverse events to determine how procedures could be improved. In a 4-year time frame, the university was able to demonstrate a drop in its annual litigation costs from $3 million to $1 1 million and a drop in the number of claims and lawsuits from 2001 to 2005 from 262 to 114. On the other side, there is an obvious concern that if more patients and families are informed about potentially actionable errors, more will decide to sue. The basic point is that there are a huge number of claims out there that have never been filed because patients were never made aware of them. Once this can of worms is opened, even if only a minority of patients end up suing, the potential overall costs to the system may increase. One group of investigators has concluded based on its modeling studies that a widely adopted open disclosure policy would at least double the number of claims and lawsuits, open disclosure would reduce the size of awards by an average of 40%, and the overall effect of disclosure would be an increase in 2 compensation costs from $5. Even if overall malpractice claims and costs increase, is that a sufficient ethical reason to discourage the practice of open disclosure This is a final opportunity to challenge the participants to think through the range of negative financial, professional, and personal consequences that might follow from being sued or losing a civil suit in court, and ask if all of those undeniable bad outcomes are enough to warrant nondisclosure of errors or prevent an apology that is heartfelt and empathetic and need not amount to an admission of guilt.
Purchase duphaston online. Neuropsychological Assessment of Alzheimer's Disease.
The investigators found that divalproex oral loading and haloperidol were equally effective in improving manic symptoms order duphaston with a mastercard. The findings of this study suggested that divalproex sodium was as effective as haloperidol discount duphaston 10 mg with mastercard, not only in terms of reductions in manic symptoms order duphaston 10mg online, but also of psychotic symptoms; with both drugs showing significant improvement after 3 days of treatment. The investigators concluded that divalproex sodium was as effective as haloperidol, but offered a more benign adverse effect profile. The investigators found that, by week one, 32% of patients randomized to haloperidol and 23% randomized to chlorpromazine showed significant improvement. Tohen penthixol and haloperidol found that the two drugs were equally effective in overall efficacy and action in acute mania (Baastrup et al. Primozide One of the most potent typical antipsychotic drugs, primozide, has also been studied in the treatment of acute mania. The investigators found an initially faster response with the use of chlorpromazine, as mea sured by the Beigel–Murphy Mania Rating Scale. The authors concluded that the initial effects of chlorpromazine appeared to be related to sedative effects. In summary, typical antipsychotic agents have been used in the treatment of mania since they first appeared in the early 1950s. High-potency typical antipsychotics such as haloperidol or primozide appear to be more effective and have a faster onset of action than chlorpromazine. A major concern that remains regarding the use of typical antipsychotics is their adverse effect profile, including tardive dyskinesia, hyperprolactinaemia, and neuro leptic malignant syndrome. In addition, typical antipsychotics have been found to be depressogenic (Kukopulos et al. Considering their possible depressogenic effects, the use of typical anti psychotics in acute mania appears limited as they have only a unidirectional therapeutic effect. The latter is defined as an improvement of the symptoms of acute mania, but lack of improvement in the symptoms of depression or even worsening of depressive symptoms. This limitation has restricted the use of typical antipsychotic agents to the acute phase of the condition. It has been estimated that more than 85% of patients with acute mania receive a typical antipsychotic agent (Tohen et al. With the availability of the newer antipsychotic agents that provide a more benign adverse effect profile, and possibly mood-stabilizing proper Antipsychotics in acute mania 377 ties, there has been renewed interest in the use of antipsychotic agents in the treatment of acute mania. Some investigators have suggested that bipolar patients may have an increased risk of developing acute dystonia, akathisia, and tardive dyskine sia (Nasrallah et al. An additional risk associated with the typical antipsychotic agents is neuroleptic malignant syndrome. A possible association between affective disorders and tardive dyskinesia has been reviewed by a number of investigators. Kane and Smith (1982) found that the cumulative risk of developing tardive dyskinesia after being exposed to neuroleptics for at least 6 years was 26% for bipolar patients, compared to 18% for patients with schizophrenia. On the other hand, other investigators have not found a higher risk treating affective disorder patients. Specifically, Morgenstern and Glazer (1993), in a 5-year, follow-up study of close to 300 patients, found that psychiatric diagnosis was not a risk factor. In terms of severity of tardive dyskinesia, Glazer and Morgenstern (1988) discovered that patients with affective disorders had a more severe form of tardive dyskinesia. To summarize, although there is some literature suggesting that affective disorders may be a risk factor for developing tardive dyskinesia in patients exposed to typical antipsychotics, the findings are not compelling. Another consideration is to consider outcome as the severity of tardive dyskinesia rather than the relative risk of developing the condition. In this regard it is possible that patients with affective disorders who may develop tardive dyskinesia may be more incapacitated. Nonetheless, with the availability of other compounds such as lithium, anticonvulsants, or the atypical anti psychotic agents, the use of typical antipsychotics in affective disorders needs to be clearly justified. The superiority of the atypical agents also includes a more benign adverse effect profile with a lower risk of extrapyramidal side-effects, lower risk of tardive dyskinesia, lower risk of hyperprolactinaemia, and lower risk of anticholinergic side-effects. In addition to safety concerns the atypical agents appear to have a wider therapeutic spectrum in patients with schizo phrenia. Tohen agents, due to an affinity to serotonin and norepinephrine receptors, may have mood-altering properties. Clozapine Reports of the efficacy of clozapine in bipolar and schizoaffective disorder first appear in literature in the early 1970s (Faltus et al. A number of publications have found clozapine to be highly effective in the treatment of bipolar disorder. However, the vast majority of those studies have been case reports or open-label trials. The authors identified a limited number of controlled studies that included patients with psychotic mood disorders or schizoaffective disorders. Of note, a double-blind com parison study was recently published by Barbini et al. The authors concluded that patients receiving clozapine had a faster onset of action than those receiving chlorpromazine. The difference was statistically significant at the first assessment at week two, and remained significant at week three. The review included two double blind studies, eight open-label, 10 retrospective studies and 10 case reports.