Overwhelming Postsplenectomy Infection Research Articles

Children with asplenia or hyposplenia: Preventing overwhelming post splenectomy infection

The spleen's ability to prevent overwhelming post-splenectomy infection (OPSI) is mainly given by its capacity to filter and phagocyte bacterial elements from the blood, remove foreign elements from it, and the early production of opsonins. The anatomic absence of the spleen is usually secondary to a surgical resection, but it could also be congenital. Streptococcus pneumoniae has been identified as the main agent of OPSI in asplenic patients with an extremely high global mortality associated. This article is an exhaustive review of the current evidence and recommendations available for prevention of invasive infections in asplenic patients.

Splenectomy for patients with β-thalassemia major: long-term outcomes

Background/aim The use of splenectomy for thalassemia major is restricted over concerns of its long-term outcome. The aim of this study was to assess the long-term outcomes of splenectomy for patients with β-thalassemia major. Patients and methods This study included 70 patients with β-thalassemia major. Patients were classified into two groups: 35 patients underwent splenectomy (S group) and 35 patients did not undergo splenectomy (NS group). Patients were assessed by review of medical records, assessment of medical history, and a clinical examination. In addition to complete blood count, liver function tests and serum ferritin were performed. Assessment of lymphocyte populations was carried out by flow cytometry. These investigations were performed at least 2 years after splenectomy in the S group. Results The mean age of the patients who underwent splenectomy was 6.68 ± 2.54 years and the mean postoperative follow-up period was 6.26 ± 3.03 years. Splenectomy improves anemia, but does not reduce iron burden; more patients were found to be on regular iron chelation after splenectomy. Hematocrit and red blood cell indices were significantly increased after splenectomy. Platelet count increased significantly in the S group (644.700 ± 299.400/mm 3 ). There were no significant differences in T-lymphocyte populations between both groups. IgM memory B lymphocytes were lower in the S group compared with the NS group. No overwhelming postsplenectomy infection was reported in this series. Postsplenectomy portal vein thrombosis was reported in one (2.9%) case. Conclusion With long-term follow-up after splenectomy for treatment of thalassemia major, thrombocytosis and the risk of thromboembolic persist. Splenectomy improves anemia, but does not reduce iron burden or the requirement for blood transfusion. Proper preoperative vaccination can reduce the risk of overwhelming postsplenectomy infection.

Critical care issues in solid organ injury: Review and experience in a tertiary trauma center

Background and Aim:Solid organ (spleen and liver) injuries are dreaded by both surgeons and anesthesiologists because of associated high morbidity and mortality. The purpose of this review is to describe our experience of critical care concerns in solid organ injury, which otherwise has been poorly addressed in the literature.Materials and Methods:Retrospective cohort of solid organ injury (spleen and liver) patients was done from January 2010 to December 2011 in tertiary level trauma Center.Results:Out of 624 abdominal trauma patients, a total of 212 patients (70%) were admitted in intensive care unit (ICU). Their ages ranged from 6 to 74 years (median 24 years). Nearly 89% patients in liver trauma and 84% patients in splenic trauma were male. Mechanism of injury was blunt abdominal trauma in 96% patients and the most common associated injury was chest trauma. Average injury severity score, sequential organ failure assessment, lactate on admission was 16.84, 4.34 and 3.42 mmol/L and that of dying patient were 29.70, 7.73 and 5.09 mmol/L, respectively. Overall mortality of ICU admitted solid organ injury was 15.55%. Major issues of concern in splenic injury were hemorrhagic shock, overwhelming post-splenectomy infection and post-splenectomy vaccination. Issues raised in liver injury are damage control surgery, deadly triad, thromboelastography guided transfusion protocols and hemostatic agents. Conclusions: A protocol-based and multidisciplinary approach in high dependency unit can significantly reduce morbidity and mortality in patients with solid organ injury.

Treatment and prevention for overwhelming postsplenectomy infection (OPSI)

Treatment and prevention for overwhelming postsplenectomy infection (OPSI)

Spontaneous Rupture of Spleen (SRS) in Infectious Mononucleosis (IM) - Embolization of Splenic Artery to Save the Spleen

Purpose: Spontaneous rupture of spleen (SRS) is a rare but fatal complication of Infectious Mononucleosis (IM) with a reported incidence of 0.1 - 0.5%. Management usually consists of splenectomy in hemodynamically unstable patients and non-operative surveillance in stable patients. We report the successful use of splenic artery embolization as an alternative treatment in an unstable patient. Case: A previously healthy 18-year-old male admitted to the hospital with the sudden onset of left sided abdominal pain and pre-syncope after 1 week of fever and sore throat. On examination, he had BP of 86/46 and HR of 112 with severe left upper quadrant tenderness. Blood work showed Hemoglobin (Hb) of 12.3 which dropped to 6.4 in 6 hours of presentation and he was transfused with 2 units of packed RBCs. Abdominal CT scan revealed a grade III splenic laceration with large amount of blood in peritoneal cavity (Figure 1). Splenic artery arteriography along with embolization of the main splenic artery was performed (Figure 2). After the procedure his Hb stabilized, abdominal pain improved and fever resolved. Subsequently Epstein-barr virus serology was positive with a titer >160 u/ml. Repeat CT scan in 4 days after the procedure showed multiple regions of splenic infarction but the majority of the spleen was preserved. His Hb stabilized and was discharged on day 6 of his hospitalization.Figure 1Figure 2Discussion: Splenic artery embolization has not been studied well in cases of SRS secondary to IM. The majority of the literature is on splenectomy in unstable patients or non-operative watchfulness in stable patients. This methodology preserves spleen and prevents the dreadful complication of overwhelming post splenectomy infection, risks of laparotomy and the consequent morbidity and mortality in apslenic patients.

Specific Antibody in IV Immunoglobulin for Postsplenectomy Sepsis

Overwhelming postsplenectomy infection progresses rapidly and shows unacceptably high mortality even when treated with optimal antibiotics. Recent reports have described beneficial effects of intravenous immunoglobulin in sepsis. However, the underlying mechanisms, especially the roles of the pathogen-specific antibody fraction in intravenous immunoglobulin, remain unclear. We investigated the effects of intravenous immunoglobulin on overwhelming postsplenectomy infection and the role of pathogen-specific antibody. Prospective, controlled, and randomized animal study. University laboratory. Male C57BL/6JJcl mice. Mice underwent splenectomy or a sham operation at 8 weeks old. At 4 weeks after the operation, mice were injected intravenously with 106 colony-forming units pneumococcus. Intraperitoneal injection of 300 mg/kg IV immunoglobulins was conducted simultaneously with infection. Specific antibody-depleted IV immunoglobulin prepared using immunoprecipitation was also injected into the animals. IV immunoglobulin markedly improved splenectomized mice survival. Removal of pneumococcus-specific antibody canceled it completely. Fluorescence microscopy results indicated significantly increased phagocytosis of antibody-bound bacteria in the livers of splenectomized mice treated with intact IV immunoglobulins. Immunomodulation, including suppression of marginal zone B-cell activation, was induced by IV immunoglobulin. IV immunoglobulin showed a significantly protective effect on overwhelming postsplenectomy infection via enhancement of specific antibody-mediated phagocytosis in the liver. Specific antibody, more than immunological modulation, is crucial for effects of IV immunoglobulin on overwhelming postsplenectomy infection.

Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction

In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding. Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function. A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms. In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.

Overwhelming Postsplenectomy Sepsis Presenting as Purpura Fulminans due to Streptococcus Suis Infection

Splenectomised patients are more likely to suffer from severe infections, such as sepsis and meningitis. This condition is called overwhelming postsplenectomy infection (OPSI) syndrome. The risk of OPSI is greatest in the early months, and even years, after the operation, but never disappears entirely. The course of OSPI is rapid, the clinical presentations serious, and the prognosis poor. We present here a case of OPSI in a posttraumatic splenectomised adult who had features of fulminant sepsis such as hypotension, renal and liver failure, coagulopathy, and generalised skin rash presented as purpura fulminans. The culprit was found to be Streptococcus suis by the polymerase chain reaction technique. By reporting this case, we hope to emphasize the importance of preventive strategies: vaccination, antibiotic prophylaxis, and patient education. The management of Streptococcus suis infection and the use of 16S rRNA gene sequencing for bacterial identification were also highlighted.

Gestion du risque infectieux chez le splénectomisé

Each year in France 6000 to 9000 patients are splenectomised or spleen embolized. As spleen has immunological functions, it contributes to protect against infections. Thus, hypo or asplenia increase the risk of infection, especially the risk of Overwhelming Post-Splenectomy Infection (OPSI). OPSI is a medical emergency, characterized by aspecific symptoms, which may rapidly progress to fulminant infection and death in 50% of cases within 48h. Encapsulated bacteria as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis are most of the time responsible of these infections in asplenic patients. To prevent OPSI, several measures are essential and must begin before a scheduled surgery or just after an urgent splenectomy. Patients must carry a card. The first proposed prevention measure is to enhance partial surgery when it's possible. Then, the two other measures, antibiotic prophylaxis and vaccination, shall be implemented whatever is the indication of surgery. Postoperative antibiotic prophylaxis by phenoxymethyl-penicillin is prescribed for two years minimum and lifelong prophylaxis should be offered to high risk of pneumococcal infection patients. Pneumococcal, H. influenzae type b and meningococcal vaccination should be administered 2 to 6 weeks before scheduled splenectomy and 2 weeks after urgent surgery. Yearly, patients must receive Influenza vaccination. As an interindividual variation exists in vaccinal response, measurement of serotype-specific antibodies can be used, if available, to individualized risk patients and to organize revaccination. Finally, to prevent OPSI, patient and next-of-kin must be educated about prevention measures and infectious risk to optimize patient's compliance.

Elektive Splenektomie bei Erwachsenen – Vorbereitung, Durchführung und Nachbetreuung

Elective splenectomy in adults is often performed after failure of conservative treatment in patients with hematologic, neoplastic, or autoimmune disorders. The indication to perform a splenectomy should be discussed in an interdisciplinary team and the surgeon should not make the decision on his own. Laparoscopic splenectomy is nowadays established as the gold-standard treatment due to low morbidity and mortality and - compared to open surgery - lower postoperative pain, less intraoperative blood loss and shorter hospital stay. Every patient with planned splenectomy must undergo vaccination against pneumococci and meningococci at least two weeks prior to the operation, which helps reducing the risk of the "overwhelming post-splenectomy infection" (OPSI). Beside re-vaccination against pneumococci and meningococci during follow-up, every patient should be informed about the increased risk of infection, receive a personal post-splenectomy pass and emergency antibiotics in case of infection.

Die Milz bei nicht-malignen hämatologischen Erkrankungen

The spleen functions as a filter of the circulating blood, removing aging or abnormal red blood cells, intraerythrocyte inclusions as well as foreign particals. As the spleen is composed of lymphocytic tissue, circulatory elements and mononuclear phagocytic cells it plays an important role in the nonspecific as well as the specific immune response. Additionally, the spleen serves as a reservoir for circulating blood cells, especially platelet sequestration by the spleen is well do cumented. The spleen produces blood cells during fetal development and in certain haematological disorders such as myelofibrosis. The destruction of red blood cells within the splenic cords releases iron in the circulation, which is recycled and used to manufacture new erythrocytes in the bone marrow. In several non-malignant haematological disorders antibody-coated cells are cleared from the circulation by phagocytic cells of the spleen. This involves erythrocytes in autoimmunhaemolytic anaemias, platelets in immunthrombocytopenia and neutrophils in Felty syndrome. In hereditary spherocytosis the spleen destroys the resulting defective, spherical red cells. In pyruvate kinase deficiency impaired production of adenosine triphosphate leads to destruction of red blood cells in the spleen or in the liver. In sickle cell anaemia the defective erythrocytes cause sludging and thrombosis in small vessels with infarcts for instance in the spleen, which over time can result in autosplenectomy. In thalassaemia major abnormal haemoglobin forms protein precipitates in the red cells with development of a severe hypochromic anaemia with haemolysis and intramedullary inef fective erythropoiesis. Therapeutic splenectomy can be an option in all of these mentioned non-malignant haematological disorders. The rationale and the pathophysiology of its role in thrombotic thrombocytopenic purpura is probably at least well understood. The use of new and effective drugs such as the monoclonal antibody rituximab or thrombopoietin agonists in immunthrombocytopenia as well as the option of a laparoscopic rather than an open splenectomy have changed our view on benefits and risks of splenectomy in recent years. To minimize these risks such as overwhelming postsplenectomy infection or abdominal vein thrombosis, prophylactic vaccination, postoperative thromboembolism prophylaxis and patient education is mandatory.

Partial spleen resection with a radiofrequency needle device—a pilot study

Total splenectomy leads to an immunocompromised state, with an increased lifetime risk of infection. The lifetime risk of developing overwhelming postsplenectomy infection is 5 %, with a mortality rate of approximately 50 %. In addition to vaccination and antibiotic prophylaxis, partial splenectomy is believed to improve patient safety. We performed partial splenectomy in seven patients using a radiofrequency (RF) technique with Habib® needles. In seven patients, an open access partial splenectomy was performed. In three patients, a partial splenectomy was performed simultaneously with intraabdominal tumour resection. In two patients, the upper pole of the spleen was removed due to tumours of the spleen. In one patient, a large symptomatic splenic cyst was resected and in another patient, a partial splenectomy was performed due to trauma. RF was applied using Habib® needles (AngioDynamics, Manchester, GA, 31816, USA). The partial splenectomy procedures were easy and safe in all seven patients. The RF application with the Habib® needles led to primary haemostasis. The blood loss was less than 50 ml in all cases. After a minimum follow-up of 1 year, there were no cases of infections or other adverse events related to the previous partial splenectomy. In our experience, partial splenectomy with Habib® needles is easy to perform and safe for the patient. Thus, radiofrequency resection is a good alternative to total splenectomy in many patients and reduces the risk of postsplenectomy infections.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7%). Splenomegaly (interpole diameter (ID) >20cm) was observed in 12 cases (25%) and massive splenomegaly (ID >25cm) in 3 cases (6.25%). Conversion to laparotomy occurred in two patients (4.16%), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138±22min. Mean hospital stay was 4.5days. Postoperative morbidity rate was 8.8% for the benign group and 35.7% in the malignant group. Mortality occurred in 1/48 patients (2.08%), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.

Prevalence of Howell-Jolly Bodies Caused by Partial Splenic Embolization for Portal Hypertension

Postsplenectomy sepsis (PSS) and overwhelming postsplenectomy infection (OPSI) following splenectomy or the development of hyposplenism are associated with a high mortality rate. The presence of Howell-Jolly bodies (HJBs) in peripheral erythrocytes is attracting attention as a parameter of hyposplenism. To date, whether HJBs appear following partial splenic embolization (PSE) has not been investigated. Therefore, we examined the prevalence of HJBs in patients who have undergone PSE. Whether HJBs were present in 95 patients who underwent PSE between November 2007 and August 2012 was assessed. No serious complications occurred due to PSE; however, 17 of the 95 patients (17.89%) exhibited HJBs during the follow-up. The residual spleen volume and splenic infarction rate did not differ significantly compared to those observed in the HJB-negative group. With the recent increase in the use of autoanalyzers, the opportunities to perform microscopic examinations have been decreasing. Therefore, the presence of HJBs, which can only be confirmed visually, may be overlooked, and the clinical significance of these bodies tends to be disregarded. However, the presence of HJBs is associated with a risk of PSS and OPSI due to hyposplenism. Because HJBs are common in the peripheral erythrocytes of patients who have undergone PSE, irrespective of the residual spleen volume or splenic infarction rate, the presence or absence of HJBs should be assessed visually. In HJB-positive patients, preventing serious infections, for example, by administering the pneumococcal vaccine, is important.

胃癌術後反復性脾摘後重症感染症の1救命例

胃癌術後に繰り返して発症した脾摘後重症感染症（OPSI:overwhelming postsplenectomy infection）の1救命例を報告する．症例は52歳女性．胃噴門部の進行胃癌に対し胃全摘，脾摘術を施行した．術後第6病日に40.1℃の発熱が出現し，播種性血管内凝固（DIC）を認めた．抗生剤と免疫グロブリン製剤などの投与にて一旦症状が改善した．術後第13病日に再度発熱が出現し，翌日DICと肺胞出血を認め，3次救急救命センターへ転院となり改善を得た．その後，外来通院中の術後9カ月目に40.2℃の発熱が出現した．多臓器不全とDICを認めたが，集中治療にて救命しえた．血液培養から有莢膜細菌が検出され，その病態からOPSIと診断した．OPSIは発症後急激な経過をとる致死率の高い病態であるが，本邦での認識や啓蒙は十分ではない．脾摘後はOPSIを念頭に置いた対応が肝要であると考えられた．

Fatal overwhelming postsplenectomy infection caused by Streptococcus pneumoniae in mothers within 1 year after delivery: case report

Invasive pneumococcal disease (IPD) has a high mortality. Although preventive strategies including vaccination have been established for children, less attention has been devoted to pregnant and postnatal women and to mothers caring for their infants. As a significant number of women have either undergone splenectomy or are in a hyposplenic state and have not received adequate pneumococcal vaccinations, they can potentially develop overwhelming postsplenectomy infections. A 34-year-old woman with an 8-month-old baby, who underwent splenectomy at the age of 10 for benign pancreatic tumor, presented with fever and petechial eruption. Despite extensive treatment, she died 17h after admission. A 40-year-old woman with a 11-month-old baby, who underwent splenectomy at 2years of age for hemolytic anemia, was admitted for septic shock and disseminated intravascular coagulation. Despite extensive treatment, she died 2h after admission. Blood cultures from both women were positive for Streptococcus pneumoniae and neither of them had been vaccinated against the bacterium. IPD rapidly progressed and developed to multiple organ dysfunction syndromes in mothers caring for their infants, particularly those who had undergone splenectomy or were in a hyposplenic state. Thus, routine pneumococcal vaccination is recommended for pregnant women. In addition, we suggest a thorough medical interview and checkup for splenectomy or hyposplenism in prenatal women.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

IntroductionThe goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.MethodsFor this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.ResultsWe identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.ConclusionsNOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

21st Century Approach to Splenic Injury

ABSTRACTRecent trends of splenic injury management in the 21st century emphasizes nonoperative treatment in children and adults. The clinician must base his treatment on clinical criteria on hemodynamic stability and associated injuries. The risk of overwhelming post-splenectomy sepsis is very low and should not influence the decision to operate, if the clinical condition demands it.How to cite this articleLucas CE. 21st Century Approach to Splenic Injury. J Trauma Critical Care Emerg Surg 2013;2(3): 116-125.

迅速 な治療開始で劇症化を防いだ脾摘後遺伝性球状赤血球症の 1 例

迅速 な治療開始で劇症化を防いだ脾摘後遺伝性球状赤血球症の 1 例

Preserved function after angioembolisation of splenic injury in children and adolescents: A case control study

BackgroundNon-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study. MethodsA total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell–Jolly bodies (H–J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen. ResultsOn average 4.6 years after SAE (range 1–8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H–J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls. ConclusionThis case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.