Seasonal Exacerbations Research Articles

Through their eyes: Navigating life with limited eyelid closure in patients with Moebius syndrome

Moebius syndrome (MoS), a rare congenital condition caused by the underdevelopment of the sixth and seventh cranial nerves, presents with uni- or bilateral facial paralysis and lateral gaze palsy. Those with MoS often have incomplete eyelid closure (lagophthalmos). This study aimed to investigate the experiences of individuals living with incomplete eyelid closure due to MoS. Participants shared their experiences in semi-structured open-ended focus groups during the 2023 MoS Foundation Conference. Data were analyzed thematically using Nvivo. The Terzis and Bruno scoring system was used to grade participant eyelid closure (range: 1 being no eyelid closure with full scleral show to 5 being complete eyelid closure with no scleral show) and blink (from 1 being no blink to 5 being synchronous and complete blink present). Marginal reflex distances 1 and 2 (MRD1 and MRD2) were measured to grade for ptosis and lid retraction, respectively. Fifteen participants participated in two focus groups, comprising adults (n=12) and adolescents (n=3). All participants had lagophthalmos with some scleral show, ptosis, and lid retraction. The median eyelid closure score was 3 (incomplete eye closure with 1/3 scleral showing). Five key themes were identified: social stigma and misunderstanding, daily life impacts, seasonal exacerbations, different attitudes toward surgical intervention between adults and adolescents, and a prevailing sense of self-acceptance regarding their condition. Incomplete eyelid closure poses significant social challenges for individuals with MoS, especially around social encounters. Our findings show the importance of developing tailored communication tools to support those living with this facial difference.

Post-pandemic seasonal dynamics of hospitalised COPD exacerbations and aetiologies in the COPD population.

This study uncovered a reversal of seasonal variation in hospitalised COPD exacerbation events after the COVID-19 pandemic. Investigation of updated seasonal exacerbation patterns and triggers can help initiate preventive strategies effectively. https://bit.ly/3wN71h0.

Evaluation of the correlation of serological and intradermal allergen testing with clinical history in 29 dogs with atopic dermatitis.

Limited information exists about the correlation between clinical history and positive serum (SAT) and intradermal allergen test (IDAT) results in atopic dogs. To evaluate the correlation between clinical history and SAT/IDAT results in atopic dogs. Twenty-nine client-owned dogs with nonseasonal atopic dermatitis with or without seasonal exacerbation were enrolled. IDAT, SAT (immunoglobulin (Ig)M antibody capture enzyme-linked immunosorbent assay [MacELISA] with bromelain CCD inhibitor) and clinical information collected in a questionnaire regarding seasonal variations in pruritus affecting the dogs were performed on the same day. Two independent investigators (Inv A and Inv B) recorded IDAT results. The kappa coefficients agreement for positive IDAT scores between Inv A and B was substantial. The agreement between IDAT and SAT results at different ELISA absorbance units (EAU) cut-offs (>79 and ≥300) was slight and fair for both investigators, respectively. A higher agreement was observed between IDAT and SAT (≥300 EAU) than between IDAT and SAT (>79 EAU) with the exception of mite and flea allergens. There was a statistically significant association between clinical history and positive IDAT results for seasonal allergens (Inv A and Inv B, p = 0.016). There was no significance between positive SAT results and clinical history. Five (IDAT) and 12 of 13 (SAT) atopic dogs without clinical seasonal exacerbation showed positive results for seasonal allergens. The agreement between IDAT and SAT ≥300 EAU results was fair and the agreement between IDAT and SAT >79 EAU results was slight for all allergens. Only positive IDAT results significantly correlated with clinical history.

COPD Exacerbations Before and During COVID-19 in France, Germany, Italy, the UK and the US.

Exacerbations of chronic obstructive pulmonary disease (COPD) were reported less frequently during the COVID-19 pandemic. We report real-world data on COPD exacerbation rates before and during this pandemic. Exacerbation patterns were analysed using electronic medical records or claims data of patients with COPD before (2017-2019) and during the COVID-19 pandemic (2020 through early 2022) in France, Germany, Italy, the United Kingdom and the United States. Data from each country were analysed separately. The proportions of patients with COPD receiving maintenance treatment were also estimated. The proportion of patients with exacerbations fell 45-78% across five countries in 2020 versus 2019. Exacerbation rates in most countries were reduced by >50% in 2020 compared with 2019. The proportions of patients with an exacerbation increased in most countries in 2021. Across each country, seasonal exacerbation increases seen during autumn and winter in pre-pandemic years were absent during the first year of the pandemic. The percentage of patients filling COPD prescriptions across each country increased by 4.53-22.13% in 2019 to 9.94-34.17% in 2021. Early, steep declines in exacerbation rates occurred in 2020 versus 2019 across all five countries and were accompanied by a loss of the seasonal pattern of exacerbation.

Climate in the Treatment of Pulmonary Tuberculosis in the First Half 19th Century: The Case of Frederic Chopin

Abstract Background The famous Polish composer Frederic Chopin (1810–1849) suffered almost all his short life from pulmonary tuberculosis. Physical treatment and climate therapy are the only aspect of Chopin’s disease history that has not yet been thoroughly studied. The etiology of tuberculosis in Chopin’s time was not yet known, so physical means and changes in climate in the first half of the 19th century were the most important part of the physicians’ therapeutic arsenal in the treatment of pulmonary tuberculosis. Objectives are to study the use of physical methods and climate therapy in the treatment of Frederic Chopin. Methods Scopus, WoS, MedLine, and PubMed data-bases, electronic archives were searched without time restriction for information on the use of physical methods and climate therapy in the treatment of pulmonary tuberculosis in the first half of the 19th century in Europe. The analysis was also made of Chopin’s letters and the work of his most respected biographers in order to identify information about physical therapy in his treatment. Results Chopin’s disease had been actively progressing since 1835. According to the proper 19th-century tuberculosis treatment plan which was set out in the treatises of prominent European physicians, Chopin was treated with physical means: blister plasters, cupping, creosote inhalations, sulfur baths, opium and belladonna plasters. Changing the climate in winter (southern France or Italy) was also a standard recommendation. In October 1838, Chopin, who was still recovering from another seasonal exacerbation of pulmonary tuberculosis, took a trip to Mallorca, where he spent the winter. Conclusions Chopin had the advanced stage of consumption, which was already regarded at that time as a contraindication to climate change. The destination was also unsuitable for patients with pulmonary tuberculosis: winter climate of Majorca, characterized by high humidity and strong winds, negatively affected Chopin’s health. The disease was manifested by fever, hemoptysis, shortness of breath and exhaustion, which indicated tuberculosis intoxication and destruction of lung tissue. Chopin’s trip to Majorca 1838/1839 will forever go down in the history of climate therapy as an example of the negative consequences of ignoring contraindications to climate change.

A Patient-Centered Approach to Vernal Keratoconjunctivitis (VKC): A Podcast.

Vernal keratoconjunctivitis (VKC) is a rare yet severe form of allergic conjunctivitis predominantly affecting children, mainly boys, with a global prevalence and a higher incidence in certain geographical regions. The disease is characterized by seasonal exacerbations. VKC presents with ocular surface inflammation leading to various distressing symptoms such as itching, redness, mucous discharge, and pain. The disease primarily manifests bilaterally, though it may initially appear unilaterally. If left untreated, VKC can result in corneal complications, including shield ulcers and vision impairment, affecting daily activities and psychosocial well-being, especially in children. The diagnosis of VKC involves identifying key clinical findings on the ocular surface such as Tranta dots, giant papillae, or shield ulcers. Management follows a stepwise approach, including anti-allergic eye drops, steroid eye drops, and topical medications like cyclosporine, which may take up to 3months to show efficacy. Allergic sensitization, often to inhaled allergens like pollen and house dust mites, is associated with VKC in half of the cases. Understanding and managing these allergies through measures such as avoidance, sensitization control, and co-treatment of associated conditions like asthma and rhinoconjunctivitis are essential in VKC management. Atopic keratoconjunctivitis (AKC), a related condition associated with atopic dermatitis and asthma, shares similarities with VKC but typically affects young adults. However, there is an observed spectrum between the two diseases, indicating similar treatment strategies for both. VKC treatment requires a patient-centered approach, involving informed and supported parents, considering economic factors due to costly eye drops, and ensuring accessibility and practicality of treatment, especially in children. A multidisciplinary team collaboration, including ophthalmologists, pediatricians, and dermatologists, optimizes patient care. The rewarding aspect of VKC treatment lies in witnessing children regain their quality of life, overcome vision challenges, and thrive in their daily activities. In conclusion, understanding VKC, its associated allergies, and employing a comprehensive, patient-centered approach are crucial in managing this challenging condition, particularly in children, to enhance their vision and overall well-being.

Multi‐Decadal Coastal Acidification in the Northern Gulf of Mexico Driven by Climate Change and Eutrophication

AbstractCoastal waters often experience enhanced ocean acidification due to the combined effects of climate change and regional biological and anthropogenic activities. Through reconstructing summertime bottom pH in the northern Gulf of Mexico from 1986 to 2019, we demonstrated that eutrophication‐fueled respiration dominated bottom pH changes on intra‐seasonal and interannual timescales, resulting in recurring acidification coinciding with hypoxia. However, the multi‐decadal acidification trend was principally driven by rising atmospheric CO2 and ocean warming, with more acidified and less buffered hypoxic waters exhibiting a higher rate of pH decline (−0.0023 yr−1) compared to non‐hypoxic waters (−0.014 yr−1). The cumulative effect of climate‐driven decrease in pH baseline is projected to become more significant over time, while the potential eutrophication‐induced seasonal exacerbation of acidification may lessen with decreasing oxygen availability resulting from ocean warming. Mitigating coastal acidification requires both global reduction in CO2 emissions and regional management of riverine nutrient loads.

Seasonal changes in melatonin in peptic ulcer disease

Melatonin is the main neuroendocrine hormone of the pineal gland. A distinctive feature of melatonin indole is its ability to regulate physiological processes related to the circadian rhythm. Numerous scientific data demonstrate the importance of melatonin in the development of organic and functional pathologies of the gastrointestinal tract (GIT), due to the close relationship between the hormone and intestinal structures. The paper presents the results of our study and shows dynamic variations in seasonal gradations of melatonin levels in patients with gastric and duodenal ulcers. The studies have shown that in patients with gastric and duodenal ulcers, the level of the hormone melatonin varied depending on the season. During the period of long daylight hours (spring and summer), the content of indole in the blood was ≥1 pg/ml, while during the period of minimal daylight (autumn and winter), the content of melatonin was ≤1 pg/ml. Therefore, if the melatonin level is less than 1 pg/ ml in spring and summer, and more than 1 pg/ml in autumn and winter, it can be concluded that an individual does not have peptic ulcer disease. Thus, the melatonin shift in the blood at different time limits relative to light illumination can be used as a laboratory biomarker of desynchronosis associated with the risk of developing acid-related diseases, in particular seasonal exacerbation of gastric and duodenal ulcers. Accordingly, revealing the causes and mechanism of development of seasonal exacerbation of peptic ulcer disease can help in early prediction and prevention of this nosology.

Practical issues of using emollients for the prevention of exacerbations of atopic dermatitis during the flowering season: expert resolution

In February 2023, a meeting of the Council of Experts was held, attended by leading specialists in the fields of allergology, pediatrics and dermatology. The Working Group discussed the problem of sensitization to pollen allergens in patients with atopic dermatitis and exacerbation of the disease during the pollination season of plants, as well as the formation of epicutaneous sensitization through a damaged epidermal barrier. The experts comprehensively considered the criteria that a modern emollient used for the care of atopic dermatitis patients’ skin should meet, discussed the role of moisturizers in preventing seasonal exacerbations of atopic dermatitis based on previously conducted research, and developed unified recommendations on the principles of managing this type of patients. Suggestions were made for further informational and organizational measures aimed at expanding the knowledge of patients and medical specialists about the problem of epicutaneous sensitization to aeroallergens in atopic dermatitis patients, their role in the development of seasonal exacerbations of atopic dermatitis, and the possibility of their prevention using modern emollients.

Practical issues of using emollients for the prevention of exacerbations of atopic dermatitis during the flowering season: expert resolution

In February 2023, a meeting of the Council of Experts was held, attended by leading specialists in the fields of allergology, pediatrics and dermatology. The working group discussed the problem of sensitization to pollen allergens in patients with atopic dermatitis (AD) and exacerbation of the disease during the pollination season of plants, as well as the formation of epicutaneous sensitization through a damaged epidermal barrier. The experts comprehensively considered the criteria that a modern emollient used for the care of AD patients' skin should meet, discussed the role of moisturizers in preventing seasonal exacerbations of AD based on previously conducted research, and developed unified recommendations on the principles of managing this type of patients. Suggestions were made for further informational and organizational measures aimed at expanding the knowledge of patients and medical specialists about the problem of epicutaneous sensitization to aeroallergens in AD patients, their role in the development of seasonal exacerbations of AD, and the possibility of their prevention using modern emollients.

A mathematical interpretation for outbreaks of bacterial meningitis under the effect of time-dependent transmission parameters.

We consider a SIR-type compartmental model divided into two age classes to explain the seasonal exacerbations of bacterial meningitis, especially among children outside of the meningitis belt. We describe the seasonal forcing through time-dependent transmission parameters that may represent the outbreak of the meningitis cases after the annual pilgrimage period (Hajj) or uncontrolled inflows of irregular immigrants. We present and analyse a mathematical model with time-dependent transmission. We consider not only periodic functions in the analysis but also general non-periodic transmission processes. We show that the long-time average values of transmission functions can be used as a stability marker of the equilibrium. Furthermore, we interpret the basic reproduction number in case of time-dependent transmission functions. Numerical simulations support and help visualize the theoretical results.

Seasonal variations in gut microbiota and disease course in patients with inflammatory bowel disease.

Environmental factors are associated with onset and course of inflammatory bowel disease (IBD). Our previous study by about 1,100 IBD patients revealed half of the patients experienced seasonal exacerbation of disease. We investigated the seasonality of fecal microbiota composition of IBD patients. Fecal samples were consecutively collected in each season from IBD outpatients and healthy controls between November 2015 and April 2019. Participants who were treated with full elemental diet or antibiotics within 6 months or had ostomates were excluded. Bacterial profiles were analyzed by 16S rRNA sequencing, and the changes between the diseases and seasons were compared. A total of 188 fecal samples were analyzed from 47 participants comprising 19 Crohn's disease (CD) patients, 20 ulcerative colitis (UC) patients, and 8 healthy controls (HC). In CD patients, the phylum Actinobacteria and TM7 were both significantly more abundant in autumn than in spring and winter, but not in UC patients and HC. Moreover, the genera Actinomyces, a member of Actinobacteria, and c_TM7-3;o_;f_;g_ (TM7-3), that of TM7, were significantly more abundant in autumn than in spring, and the abundance of Actinomyces was significantly correlated with that of TM7-3 throughout the year in CD patients, but not in UC patients and HC. CD patients with high abundance of TM7-3 in the autumn required significantly fewer therapeutic intervention than those without seasonal fluctuation. Oral commensals Actinomyces and its symbiont TM7-3 were correlatively fluctuated in the feces of CD patients by season, which could affect the disease course.

Efficacy of dupilumab in the prevention of seasonal exacerbations in patients with and without evidence of an allergic asthma phenotype

Efficacy of dupilumab in the prevention of seasonal exacerbations in patients with and without evidence of an allergic asthma phenotype

Seasonal Changes in Serum Metabolites in Multiple Sclerosis Relapse.

Multiple sclerosis (MS) is a debilitating chronic disease of unknown etiology. There are limited treatment options due to an incomplete understanding of disease pathology. The disease is shown to have seasonal exacerbation of clinical symptoms. The mechanisms of such seasonal worsening of symptoms remains unknown. In this study, we applied targeted metabolomics analysis of serum samples using LC-MC/MC to determine seasonal changes in metabolites throughout the four seasons. We also analyzed seasonal serum cytokine alterations in patients with relapsed MS. For the first time, we can demonstrate seasonal changes in various metabolites in MS compared to the control. More metabolites were affected in MS in the fall season followed by spring, while summer MS was characterized by the smallest number of affected metabolites. Ceramides were activated in all seasons, suggesting their central role in the disease pathogenesis. Substantial changes in glucose metabolite levels were found in MS, indicating a potential shift to glycolysis. An increased serum level of quinolinic acid was demonstrated in winter MS. Histidine pathways were affected, suggesting their role in relapse of MS in the spring and fall. We also found that spring and fall seasons had a higher number of overlapping metabolites affected in MS. This could be explained by patients having a relapse of symptoms during these two seasons.

The prevalence and associated factors of seasonal exacerbation of subjective symptoms in Japanese patients with restless legs syndrome

ObjectivesTo elucidate the prevalence of seasonal exacerbation in patients with restless legs syndrome (RLS) and identify its associated factors. MethodsWe investigated the presence/absence of seasonal exacerbation of RLS by distributing self-administered questionnaires with an interval of three years. Patients who reported having seasonal exacerbation in both surveys were defined as having seasonal exacerbation. RLS severity was determined using the International Restless Legs Syndrome Rating Scale (IRLS). ResultsAmong 180 patients, 89 reported having seasonal exacerbation in the first survey. Among them, only two reported not having seasonal exacerbation in the second survey; thus, 87 (48.3%) patients were considered to have a seasonal exacerbation. Although many of them (68 out of 87, 78.2%) experienced exacerbation in spring or summer, 19 out of 87 (21.8%) reported that their symptoms worsened in fall or winter. All the patients in this study had mild to moderate degrees of RLS severity according to the IRLS score. Multiple logistic regression analyses revealed that having a family history of RLS (p < 0.05) and moderate RLS (p < 0.001) were significantly associated with the presence of seasonal exacerbation. ConclusionsThis study revealed that approximately half of all RLS patients had seasonal exacerbation of the symptoms and that about 80% of the exacerbation was observed during the spring/summer season. Moreover, seasonal exacerbation is likely to be present even in patients whose symptoms had been improved to moderate severity with pharmacological treatment.

Content of PD-1+ and PD-L1+ peripheral blood lymphocytes in individuals with pollen sensitization before and after allergen-specific immunotherapy

The available data on the contribution of the PD-1 and its ligands to immunoregulatory processes suggest their involvement into development of tolerance during immunotherapy. Currently, allergen-specific immunotherapy (ASIT) is the single treatment option that can influence the outcome of allergic diseases. Our purpose was to evaluate the PD-1/PD-L1 expression on the immune cells in patients with confirmed sensitization to plant pollen allergens in comparison with healthy controls before and after ASIT. The patients with bronchial asthma (BA) (n = 5, age 33.82.7), allergic rhinitis (AR) (n = 7, age 31.62.8), and healthy donors (n = 12, age 32.81.8) were included. Venous blood samples were obtained from the patients three times: before starting ASIT, upon completion of the ASIT course, and during the period of seasonal exacerbation. In patients with AR, the number of B lymphocytes was decreased, and the expression of PD-L1 by B lymphocytes increased after ASIT in comparison with donor parameters. At the same time, B lymphocyte counts were increased in BA patients before ASIT and returned to normal after ASIT. In AR, the CD8+PD-1+T lymphocyte count was reduced before ASIT, however, returning to normal values after ASIT was completed. Meanwhile, the reduced number of CD4+PD-1+T lymphocytes returned to normal only during the pollination season following ASIT. In BA patients, both before or after ASIT, PD-1 and PD-L1 expression on CD4+ and CD8+T lymphocytes did not differ from the donor parameters. The PD-1 expression in the T regulatory cells (Tregs) was decreased comparing with donors before ASIT in BA, and in the patients with AR, both before and after treatment. It was shown earlier that low PD-1 expression in the circulating CD4+ T cells is associated with high specific IgE concentrations. Thus, low PD-1 levels on CD4+ and CD8+T lymphocytes and regulatory T cells may indicate their functional disorders in allergic pathology. In summary, our results show a regulatory role of PD-1/PD-L1 axis in the immune response during ASIT and reflect differences in pathogenesis of allergic disorders, which are associated with imbalance of the cell activation and suppression. Further studies are required to establish the role of PD-1/PD-L1 interactions in the process of ASIT-induced modification of allergic responses.

Safety and efficacy of topical tacrolimus 0.03% in the management of vernal keratoconjunctivitis: a non-randomized controlled clinical trial.

Vernal keratoconjunctivitis (VKC) is a bilateral, recurrent, chronic conjunctival inflammatory disease with seasonal exacerbations. This study aimed to assess the efficacy and safety of tacrolimus 0.03% eye ointment in the management of chronic VKC. This was an open-label, prospective, non-randomized, comparative interventional study that enrolled 50 patients with chronic VKC, who were allocated to one of two groups. The first group was treated with tacrolimus 0.03% eye ointment twice daily for 2 months then once daily for 2 months, followed by once every other day for another 2 months. The control group was treated with standard anti-allergic drugs, topical fluorometholone 0.1% eye drops three times daily for 2 weeks and gradually tapered for another 2 weeks, with topical olopatadine 0.1% administered twice daily during the follow-up period. Disease severity was assessed using a four-point scale for symptoms and signs. Treatment efficacy was assessed by analyzing changes in symptoms and signs, and by clinical photography. Fifty patients with bilateral chronic VKC completed the follow-up. The mean (standard deviation) ages of the tacrolimus and control groups were comparable (16.20 [5.10] years versus 16.48 [4.19] years, P > 0.05). The most commonly reported symptom was itching, and the most common signs were papillary hypertrophy and conjunctival hyperemia. All symptoms and signs were significantly reduced after treatment in both groups. The tacrolimus group showed a more significant improvement at 3 and 6 months in the mean composite symptom score (both P < 0.05) and in the mean composite sign score (both P < 0.05). Regarding complications, one case of increased intraocular pressure occurred in the control group (4%) after 2 weeks of steroid treatment, while there were no complications in the tacrolimus group, except for some reports of stinging sensation, which was well tolerated. Treatment of chronic bilateral VKC with tacrolimus 0.03% eye ointment is effective and safe. It could be considered an alternative treatment to reduce steroid-associated complications in patients with chronic VKC. Future double-blinded clinical trials with a longer follow-up period are necessary to confirm our findings and to determine the long-term safety of topical tacrolimus 0.03% ointment in VKC.

Trigeminal‐mediated headshaking: A diagnostic challenge

Trigeminal‐mediated headshaking: A diagnostic challenge

Invasive Growth of Ailanthus altissima Trees is Associated with a High Rate of Sensitization in Atopic Patients

PurposeAilanthus altissima is one of the world’s most invasive species with a globally problematic spread. Pollen is dispersed locally and partially airborne. We aimed at investigating if (i) A. altissima pollen can be detected in relevant quantity in the air and if (ii) sensitization to A. altissima can be detected in patients with seasonal exacerbation of atopic diseases.Patients and MethodsWe recorded distribution of A. altissima in Leipzig, Germany. In 2019 and 2020, pollen was collected with a Hirst-type pollen trap placed on the roof of the University Hospital. Specific IgE investigations were performed in children and adults with history of atopic diseases with deterioration between May and July. We analysed specific IgE for A. altissima, Alternaria sp., birch, grasses, profilins, polcalcins and crossreacting carbohydrates.ResultsWe found abundant growth of A. altissima and pollen was detected from early June to mid-July with a maximum pollen concentration of 31 pollen/m3. Out of 138 patients (63 female, 69 children/adolescents), 95 (69%) had seasonal allergic rhinitis, 84 (61%) asthma, and 43 (31%) atopic dermatitis. Sensitization to A. altissima was shown in 59 (42%). There were no significant differences between age groups. In 59% of patients sensitized (35/59), there was no sensitization to possibly cross-reacting structures.ConclusionSensitization to A. altissima pollen could be detected in 42% of our patients with atopic diseases, suggesting allergenic potential of this neophyte. In the context of further spread with climate change, eradication strategies and population-based sensitization studies are needed.

Seasonal exacerbation of rheumatoid arthritis detected by big claims data analysis: A retrospective population study.

The objective of the study was to determine the seasonal changes in the initiation of biological disease-modifying antirheumatic drugs (bDMARDs) and methotrexate (MTX) using big claims data. We counted the monthly number of initial administrations of each bDMARD and MTX in patients with rheumatoid arthritis (RA) between April 2010 and March 2017. Data were collected from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. This database covers more than 95% of Japanese citizens. Seasonal changes in the number of initiations were determined. Patient claims were also classified according to drugs, districts, gender, and ages. The initiation of bDMARDs and MTX administration varied according to the season in a sine curve shape, with the highest numbers in May to July and the lowest numbers in November to January. The same changing pattern was observed among each bDMARD, district, gender, and age groups particularly when the number was on the higher side. We noted an apparent seasonal change in the number of bDMARDs initiated, with a peak during spring, suggesting an exacerbation of RA in the spring in Japan. These changes are overlooked in daily practice and are only visible using big data.