Pneumococcal pneumonia and other respiratory...

Pneumonia vaccine

not only prevents bacterial infections and injections seem to significantly reduce the risk of heart attacks in adults, Canadian researchers. Pneumococcal pneumonia vaccination or associated with a reduction of more than 50 per cent rate of heart attacks after two years, Dr. Danielle Pilon of the University of Sherbrooke and her colleagues reported in the issue during Tuesday at Canadian Medical Association Journal. Researchers compared the history of the disease, about 1,000 people who suffered a heart attack around 4000, which were strattera dosage not, but at high risk for another. The participants had an average age about 60 years. "We compared the level of vaccination in two groups, found that patients who did end up getting a heart attack are less likely to have been vaccinated," study author Dr. François LaMontagne said. Researchers knew that vaccination could change one stage atheroslerosis - the accumulation of cholesterol, fat, calcium from the blood within the arteries, which can harden and lead to heart attacks or strokes. "The hypothesis that vaccination may change if one of the steps in the formation of atherosclerosis, perhaps, it may reduce the risk of heart attack," said Pilon. "And this is what we found."

Assumption that vaccination can protect against heart attacks and strokes by preventing pnemonia is intelligent, Dr. Mohammed Majid from Texas Heart Institute in Houston said in the magazine notes the study. Pneumococcal pneumonia and other respiratory infections such as influenza and SARS, have been shown to cause a heart attack in some patients, said Majid. Majid suggested that doctors focus on increasing vaccination against pneumonia and influenza in high risk groups, as well as the level of vaccination far below targets in Canada and the USA, Canada, pneumoccocal vaccine for free, but only 39 percent of those who should receive the vaccine do so. Tom Mayo, 75, St. John's has heart disease and bypass surgery for its treatment. While Mayo said he does not like to receive the needle, it gets pneumoccocal vaccine, knowing that being older and increases his risk. "My wife is a nurse, and she watches me, and ensures that I get a regular needle," said Mayo. Results of case-control study should be confirmed, the pilot warned. If the results are correct, vaccination may go a long way to reduce heart attacks, says Dr. Chris Glover from the University of Ottawa Heart Institute. The question is whether to vaccinate the general population to reduce heart attacks? "I think it is a very interesting question," Glover said. .

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My treatment patientbђ ™ s and the corresponding...

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1 Our goal is to discuss the background, epidemiology, pathogenesis and aspiration pneumonia. We will also go to risk factors, diagnosis and treatment of pneumonia, and how we control our patientBЂ ™ s response to treatment. Finally, I will discuss these objectives patient case. Aspiration is the inhalation of oropharyngeal or gastric contents into the lower respiratory tract. Aspiration is a relatively common event, and it is estimated that approx. 50% of healthy adults aspiration in a dream, but not all people develop pneumonia. There are two factors that must be present to pneumonia results from aspiration. Number 1 represents a compromise inherent protective mechanisms, such as cough, gag reflex, active tsylyarnoy transport and immune response. # 2 bacterial burden aspiration should be high enough to cause infection. True aspiration pneumonia caused by bacteria that are commonly found in the oral cavity, nasopharynx or gastrointestinal tract. These bacteria are usually not pathogenic, however, under certain circumstances they can cause infection. Incidence of aspiration pneumonia in the general population is not clear, because the definition aspiration pneumonia was not always consistent. However, aspiration pneumonia is reported to be the 2nd most common diagnosis among hospitalized patients and Medicare. Most community acquired infections and monomicrobial usually caused by mouth anaerobes. Hospital infections caused by anaerobes also, however, these infections are usually polymicrobial and often caused by aerobic as well. Risk factors for aspiration pneumonia include reduction of consciousness, which threatens the cough and gag reflexes. Neurological deficits that lead to dysphagia. GI disorders such as gastric reflux disease or bowel obstruction. Anesthesia respiratory tract that is to insert the endotracheal tube. Prolonged vomiting, and a large amount of tube feeding, resulting in high residues. The most important feature of aspiration pneumonia is predraspolahayuschym condition for aspiration. We also see, putrid sputum, which may indicate anaerobic infection, and we also see the common symptoms of pneumonia. We diagnose pneumonia presence of infiltrates on chest x-rays in combination with signs of infection without any other reason. We must also obtain samples for culture from the lower respiratory tract. Guidelines for hospital pneumonia suggest that these samples will be obtained broncheoalveolar lavage or protected brush specimen. Once the sample mean he should be sent for culture and sensitivity test. Treatment of aspiration pneumonia include providing oxygen support and correction of the main causes of desire. There are no guidelines to guide us in choosing an empirical antibiotic treatment, but based on what we know about this type of infection, we know that should cover anaerobes. If infection HA, we must also provide coverage for multidrug-resistant pathogens because hospitalized patients are populated by these bacteria for several days. If infection CA, we can use narrow spectrum antibiotics. The way we control our patientBЂ ™ s response to therapy by checking their Tmax, HR, and WBC each of which must fall. We should see improvement in their chest X-ray and oxygenation. His medical history is significant for colon cancer, atrial fibrillation, hip OA, HTN, iron deficiency anemia, and diverticulosis. He is allergic to Lortab, Percocet and carvedilol. It is tobacco and alcohol and denies IVDA. His outpatient medications are furosemide, metoprololtartrate, oksybutynyn, potassium chloride, simvastatin, and Kumadina. His hospital drugs 11/20 were Protonix IV, heparin drip, digoxin IV, metoprolol IV, Cardizem drip and dilaudid ATP. 11/20, his staff was erratic, ranging from 106-158, his blood pressure was also unstable low dimension being 81/42. His respiratory rate was 26 and his oxygen saturation is 90% from 100% FIO2 due to non-rebrizer mask. His blood pH 7. 199, partial pressure of carbon dioxide in the blood were 46 and oxygen 71. His Tmax at 11/20 was 102. 3

AS developed acute respiratory distress syndrome secondary to aspiration pneumonia. He developed septic shock, acute renal failure, and postoperative ileus. The plan is to provide oxygen and IV support, panculture and start empirical antibiotics. His regime was the antibiotic vancomycin, metronidazole, meropenem, fluconazole, levofloxacin, and that de-escalation simply meropenema and levofloxacin. In total he received 15 days of antibiotic therapy. Cultures obtained on 11/20 showed rapid growth of Escherichia coli and Klebsiella pneumonia, each of which was pansensitive. Cultures of blood, urine and stool were negative for bacterial growth. In 7-day treatment with antibiotics he rush, his HR is under control and the WBC were tendencies to normal. In addition, we began to see improvement in chest X-ray. When he was transferred to the intensive care unit, he was requiring high FIO2 and PEEP and 8-day therapy, we can reduce the FIO2, and he is now separate from the fan. My patientBЂ ™ with risk factors for aspiration were his postoperative ileus. He also had signs and symptoms consistent with pneumonia. He had a cough with phlegm, which produced purulent sputum, his oxygenation refused, he had a fever, and his chest X-ray showed abnormalities. He remains in intensive care. He is still on ventilator, but was CPAP trial for 2:00 12/11. He woke up and responds to commands. He was started on tube feeding he had a low tolerance residues. Unfortunately, he developed DVTs in the left upper extremity and right lower extremity, and he also developed a ventilator associated pneumonia and urinary tract infection indicates sputum and urine, which grew Pseudomonas. My treatment patientBЂ ™ s and the corresponding aspiration pneumonia. He was supported with oxygen and antibiotics empirically chosen provided coverage for what eventually grew in the sputum. However, I feel that levofloxacin could be suspended along with other antibiotics and strattera dosage meropenem could be left alone as well as organisms pansensitive. I felt that the identification and correction of obstruction is one of the most important aspects of treatment. His bowel obstruction treated with metoclopramide and erythromycin. Thus, in future, if I never asked what I would recommend for aspiration pneumonia, community acquired, I would recommend levofloxacin to cover drug-resistant pneumococcus metronidazole for anaerobic coverage. For hospital acquired, I would recommend metronidazole with meropenem for Pseudomonas coverage and double coverage aztreonam Pseudomonas. .

Once bloomberg school colleague down the hall with

Researchers at other institutions around the world reported

similar associations. In industrial poultry or pig farm

were drug-resistant bacteria colonizing agricultural workers

and their families. In 2003 and 2004, Kellogg Schwab

air samples on poultry farms where pigs were placed in 3000

two buildings. Samples contained enterococci, staphylococci, streptococci and

, and 98 percent of bacterial isolates

were resistant to two or more common drugs. In the paper

published in Environmental Health Perspectives

Schwab suggested that one way bacteria

could travel from animals to humans was workers breathing >> << that air. In another study from 2002 to 2004

Schwab samples of surface and ground water and upgradient

downgradient from the pig farm. He and his fellow researchers found

downgradient water, ie water in

stream from swine barn contained 17 times more >> << enterococci, 11 times more

Escherichia coli,

and 33 times more fecal bacteria Escherichia group as water

upgradient from the object. Downgradient

pathogens also were much more likely resistant to antibiotics. Once Bloomberg School colleague down the hall from

Silbergeld returned from the source on the east coast >> << complain about how disgusting it is found to drive behind trucks >> << transportation chicken processing

plants. Silbergeld says, "When someone says:

" disgusting ", I say," Wait, there must be something here

happens. " She and her two students, Anna

Terms and Shawn Evans, intended that they called >> << "Child, you can drive my car," the study. They loaded cars with

equipment for sampling, found that section

on the East Coast near the border of Virginia

is a lot of birds of trucks passing through on the way to

Purdue and Tyson processing plants, and went to the next >> << parking in the center of many shops. Whenever birds >> << truck stopped at a traffic light, the researchers

slide and follow its processors. They then

sample air inside the car and the car

exterior door handles and sealed soda can they fit in

coaster car. They found that air

machine and both surfaces have shown elevated levels of enterococci

once would drive by chicken trucks. Samples received in the car traveling truck

. does not contain resistant enterococci, a quarter

isolate the bacteria after the truck showed resistance

drugs, including tetracycline, erythromycin and streptomycin

This is not only research involved in a car. Jay

Graham, formerly one of the students Silbergeld in degrees, and now

in the U.S. Agency for International Development

studied the waste on the East Coast. He said that every time he returned to Baltimore, his car

was covered with flies, and this led him to wonder if flies

be spraying bacteria resistant

from poultry farms. Graham said Silbergeld, that he wanted to do

research. "I said," This is fine until you

bring no flies here. The next thing I knew we had these

two large banks full of flies in the lab, and I thought, "Yes

thanks for that." Graham flies trapped in poultry farms

on the East Coast and found resistant staphylococci and enterococci

on them. He analyzed how pathogens for

drug resistance genes in bacteria and found matches

taken from flies and bacteria taken from farm waste,

strong evidence that flies are a potential source

influence of bacteria resistant hiding in agriculture

waste. cientists

know that resistant pathogens can travel from farms by air,

water, birds, flies, chicken manure spreader or truck,

but they do not have a good answer as far as they can

travel and how long they can remain viable. Just because a researcher

detection of drug-resistant Staphylococcus aureus in the sample air

not prove that it can make any patient. But

means of transmission, which can cover long distances

, from person to person, an employee of the farm, such as

picks up bacteria in the chicken shed and passes it

family member, which transmits its member communities

which brings him to the clinic or hospital where he

settles and begins to cause antibiotic-resistant infections in

surgical patients with impaired immunity. For years, scientists, doctors and the public

considered more widespread drug-resistant infections in hospital

task (see

Johns Hopkins Magazine, February 2008). This is where dangerous germs as vancomycin-resistant enterococci

(VRE) and methicillin-resistant Staphylococcus aureus

(MRSA) hide and spread. But then

Hospital began to report more and more people

never been in a medical institution that passes through their doors

already colonized by resistant bacteria. Where people

raising error as MRSA, which currently kills more than

20000 people each year, more people than die from AIDS? About three years ago, Silbergeld began thinking about MRSA

and agriculture. It was not the only one. In

November 2006, Dutch scientists reported case >> << A young mother treat mastitis in October 2004. Culture

adopted its general practice showed, MRSA, which

then found her husband and small daughter. Her husband was a farmer

from 8000 pigs, and when the researchers tested

10 selected at random from farms, they found genetically identical

MRSA in eight of them, and the same error in focused on three

other workers from the farm. Otherwise, as well as

Holland, 63-year-old woman was admitted to hospital with MRSA

caused endocarditis. When the researchers introduced

her infection, they found not in accordance with

nosocomial strains of MRSA, or strains causing community acquired MRSA

skin infections in the United States

. What she did match MRSA isolated from Dutch pig farms.

Another study conducted in the Netherlands found the rate of MRSA colonization

among pig farmers be 760 times more >> << general public. A year ago, Canadian research

published in Veterinary Microbiology was the first >> << find MRSA pigs in North America and pig farmers;

scientists studied farms in Ontario and found MRSA In 25 percent of the

experimental pigs and 20 percent of workers

farms, which colonized animals purchase strattera. On farms that were free >> << Colonial pigs, no cases of human disease. Finally, the last

January study by the University of Iowa tests

299 pigs and 20 people from two farms in Iowa and Illinois. The researchers found, MRSA in 49 percent of the animals and << >> 45 percent of people. This was the first such search << >> in the United States, and voltage, ST398, was identical >> << to that found in Canada and the Netherlands. . << >>

Some are living in water and bottom sediments ...

How koliformnyh bacteria affect water quality? What koliformnyh bacteria? Koliformni

, is always present in the digestive tract of animals, including humans, and are in their waste. They are also found in plant material and soil. The most basic test for bacterial contamination of water is a challenge for all. Total counts of intestinal give an overview of the sanitary condition of water. Here's a look at koliformnyh bacteria in general: Total koliformnyh bacteria are bacteria that are in the soil, in water, which was under the influence, and in human or animal waste. Fecal coliforms are a group of general E. coli that are present particularly in the intestines and feces of warm-blooded animals. Because the sources of fecal bacteria koliformnyh is more specific than the more general common origin of the intestinal group of bacteria, fecal bacteria koliformnyh considered more accurate indication of animal or human waste than total koliformnyh bacteria. is the main group in fecal bacteria of the intestinal group. Of the five major groups of bacteria that are common E. coli, but E. coli is usually found to grow and multiply in the environment. Thus, E. coli bacteria is Escherichia strattera online coli, which is the best indicator of fecal contamination and the possible presence. There is a group of bacteria Escherichia coli harmful? Most groups of bacteria Escherichia coli do not cause disease. However, some rare strains of E. coli, including strain 0157: H7, can cause serious illness. Recent outbreaks of diseases caused by Escherichia coli 0157: H7, caused great public concern about this organism. Escherichia coli 0157: H7 was detected in cattle, chickens, pigs and sheep. Most cases of human to be associated with eating cooked in hamburger. Cases of E. coli 0157: H7, caused by contaminated drinking water are rare. Water pollution caused by fecal contamination is a serious problem because of the possibility of contracting diseases from pathogens (diseasecausing organisms). Often the concentration of fecal pathogen pollution are small, and the number of different possible pathogens great. As a result, it is not practical to test pathogens in each sample is collected. Instead, the presence of pathogens is determined by indirect evidence by testing for indicator organism such as bacteria E. coli. Koliformni came from the same sources as pathogenic organisms. Koliformni relatively easy to identify, usually present in large numbers, the more dangerous pathogens, and react to the environment and water as well, many pathogens. As a result of testing for E. coli bacteria may be reasonable instructions or other pathogenic bacteria may be present. The number of bacteria occur naturally in fresh water streams. Some are living in water and bottom sediments as photosynthetic autotrophs or saphrophytes live on dead matter. Others exist, or to other organisms as mutual symbionts (of any benefit to the host organism in exchange for housing), commensuals (no help or hurt the owner) or parasites (using host in a way that harms). Some bacteria that live in the gastrointestinal tract of animals are essential for recovering nutrients from digested food. Millions of these natural organisms that are transmitted from the body of fecal waste. If pathogenic (disease-causing) microorganisms are present, they can be transferred as well. When the flow of contaminated feces, pathogenic bacteria, viruses and parasites can be introduced, which are a threat to the health of those who come in contact with water. Municipal and water supply in rural areas can transmit human diseases such as cholera (Vibrio cholerae), typhoid (Salmonella typhoid fever), dysentery (Shigella), salmonellosis (Salmonella) and gastroenteritis (Campylobacter jejuni, Escherichia coli, Giardia lamblia). The threat of such transmission of the disease becomes more serious as population density increases and more polluting wastewater tap water, carrying with him a man of intestinal pathogens. Instead of water to test directly for pathogens that can be difficult, expensive and even hazardous, researchers use indicator organisms to assess the possibility of fecal contamination. Fecal bacteria Escherichia coli, the family Enterobacteriacae, including E. coli, Citrobacter, Enterobacter and Klebsiella species are often used as indicators. These gram-negative bacillus (rod form bacteria) found in the digestive tract of all warm-blooded animals. Most are not pathogenic. However, as they are removed from feces, sometimes they are associated with pathogens such as bacteria Vibrio cholera or form of the virus hepatitis, which is located in the gastrointestinal tract. The total number of bacteria Escherichia sometimes used to check contamination of water too. These organisms are less accurate, as indicators of fecal contamination, because many of them can live and reproduce in soil and water, without the human body. If a large number of fecal bacteria are koliformnyh in the sample water flow, we can conclude that there has been recent faecal contamination, although not necessarily of human origin. Other intestinal bacteria such as streptococci and enterococci may have a stronger correlation with individual wastewater, but the indicator was determined that only for people. Cigarette fecal streptococci intestinal used to be that determine human compared to animal fecal contamination. But it is not though to be reliable because streptococci are not stored long in the open water environment, making it difficult to estimate the true concentration. Enterococci bacteria, it seems, always associated with human sewage and subsequent disease, but testing for these organisms due to the long and complicated procedure. Although they can not be directly related to the pollution of human sewage, fecal bacteria koliformnyh is often used to regulate surface waters for recreational use, shellfishing, and potability (ability to be safe consumption). Federal law provides maximun allowable number of these bacteria for various purposes. If fecal counts of intestinal high (more than 200 colonies per 100 ml water sample) in a river or stream is a great likelihood that pathogens are often present. Man swimming in that water is more likely to get sick from swallowing disease-causing organisms or pathogens from entering the body through cuts in the skin, nose, mouth or ears. Illnesses and diseases such as typhoid, hepatitis, gastroenteritis, dysentery and ear infections can be contracted in waters with high fecal bacteria counts of the intestinal group. Read more:

Sk with nano-silver as soon as possible.

Kazerus but no information on how to restrict, prevent or combat exposure, either as a treat or identify. Not a very good article. February 2nd, 2012 at 4:11 pm

administrator Kazerus Good point. Mayo Clinic recommends washing hands, keeping buy strattera wounds and cuts covered, and bathe daily, to reduce chances of infection. The most common among people who have been in hospital recently. Most strains of MRSA still respond to certain antibiotics. In some cases, antibiotics may be needed. The doctor can asses this information. Here is a link that can help you Kazerus:

February 2, 2012 at 4:35 pm DieHradPatriot

This may be useful to mention the use Collodial silver. It should prevent almost any virus, germ, bacteria and treat almost everything with success. February 3rd, 2012 at 9:53

Bernard Weinstock, MD

MRSA carriers can be diagnosed with a simple nasal swab culture. This is usually done before surgery to pre-treatment with Bactroban ointment (intranasal) antibiotic (Septra DS, DS Bactria, clindamycin or rifampicin).

This does not eliminate the bacteria, but it does not suppress it reduces the risk of postoperative infection with MRSA. Good personal hygiene clean surface, home is the best way to reduce the risk of harboring bacteria. February 3rd, 2012 at 12:00

Rock MMS-Future antibiotics for survivalists to learn. Certainly not penicillin,,

February 3, 2012 at 1:09 pm

suggest anyone Sk with nano-silver as soon as possible. requirements to even kill MRSA, it is important to wash your hands very well, the gel can be quickly put in your nose when someone sneezes next to yours, you can spray into the eyes of humans and animals, ears well. Time to learn and prepare to reduce fear. I get it in the camping survival and I do not sell the same. Stock up now and buy the book, a real chance to DR. Peterson that documents the 300 + uses of this product. February 3rd, 2012 at 2:22 pm

Rosemary Campbell Rock. What is MMS stand? You can leave a website for explaln, please? February 4th, 2012 at 6:21.

Bacterial vaginosis (bv) is a bacterial...

What is bacterial vaginosis? Once, for personal reasons, I am interested to know about bacterial vaginosis. And then I came to knowledge acquisition for BV and now I know enough that I can share with you. I am an ordinary person, not a doctor or health professional or medical qualifications. I researched online, and I made a personal study of bacterial vaginosis (BV). What I realized that BV is often a recurring problem because traditional treatment is often aimed at addressing the root causes and treat the symptoms - the reason most do not care and, thus, bacterial vaginosis (vaginitis) continues to come back in the long run. Using natural means to address the root causes is one of the best ways to treat, because so vaginosis is least likely to return. For me, this understanding is valuable for those who suffer from bacterial vaginosis, and especially if it is repeated, and. Bacterial vaginosis (BV) is a bacterial disease that affects the vagina of women. It is most often in women in the menstrual age - the stage of life, in which a woman gets periods. BV is shameful to return and repeat, despite the proposed treatment with antibiotics. In other words, antibiotics often failed to provide permanent relief from vaginitis. The main cause of abnormality is considered an imbalance of pH (acidity level) of the vagina, which leads to excessively fast growth of harmful bacteria as a result of unhealthy microflora of the vagina. Some people also refer to this condition as bacterial vaginitis and vaginal bactereosis. Man sees vagina balance good and bad bacteria and bacterial vaginosis occurs when harmful bacteria (anaerobes) grow beneficial bacteria causing problems. In fact, contrary to popular belief that fungal infections are more common, more than half of vaginal infections among women in a given time may be caused by bacteria, not yeast. In other words, many women find that once they are infected with yeast, but the reality is that they are infected. The fact that not one but several types of bacteria responsible for bacterial vaginosis makes it difficult to solve constantly. It is often observed that antibiotics temporary relief problems, but symptoms continue to return after a temporary improvement. There may be several reasons behind BV. One of the popular beliefs that the cause is sexual. School of thought that bacterial vaginosis are STDs that occurs in women with multiple sexual partners. While this is true in some cases, but in general bacterial vaginosis can occur for other reasons too. The problem is the imbalance of pH in the vagina, which leads to an imbalance in the desired level of bacteria inside the female reproductive tract. Menopause, thongs and anemia are known to cause BV. Here is more information. BV can lead to long-term serious problems if not treated. Proper treatment can quickly fix the problem, but if not treated, it can inflate the risk of one infected Pelvic inflammatory disease (PID), cervicitis (holes in the uterus) and endometritis. Bacterial vaginosis during pregnancy increases the complexity, and can stand the risk of pregnancy before undesirale results. Pregnant women are known to premature birth and stillbirth, consequently, have BV during pregnancy. Bacterial vaginosis is sometimes mistaken as some people have other issues, such as yeast infection and trichomoniasis. Many people mistakenly believe, BV is sexually transmitted diseases (STD) caused by sexually active with multiple partners. BV is not known directly harmful to the uterus or fallopian tubes. Furthermore, this bacterial vaginal issue is not related to other issues of reproductive organs, such as genital warts (caused by human papilloma virus - HPV) and other women suffering from BV, however, become more suspectible other STDs such as herpes, Chlamydia HIV and gonorrhea, and HIV can pass easily her partner. It was also found in the study, which is associated with

357% increase in cervical intraepithelial neplasia (CIN), cervial cell abnormalities that can lead to cervical cancer. It is therefore important for the treatment of bacterial vaginosis and fix it as soon as possible to prevent further complications. In a nutshell,

Bacterial vaginosis (BV) is an infection caused by high growth of harmful bacteria. The reasons are still not very clear, and was the subject of discussions and experiments to date, but the infringement occurs when the pH (acidity) balance in the human vagina is not at the desired level. It is very curable with proper treatment - in fact some of the best natural remedies can quickly stop and cure the problem constant vaginal discharge level of the level of acidity. Health advisers usually prescribe antibiotics such as metronidazole and clindamycin to treat the problem. These antibiotics kill bacteria, including vaginal violator of them, resulting in temporary control and prevention, rather than continuous treatment. In cases in which the vagina heals itself, harmful bacteria constantly gets eliminated, resulting in the permanent elimination of BV and healthy vagina. If vaginal discharge is not self-heal, the treatment is not permanent. BV is the issue that is known to have returned. Chronic BV is very often the situation, despite full conventional treatment. However, women face this problem, and especially those who suffer from chronic version cheap strattera of this problem is an alternative treatment - natural treatment work well to eliminate all kinds of BV including recurring ones. As expected, start to eliminate bacterial vaginosis early is the best option to prevent future complications. In addition, a healthy lifestyle can prevent BV return easily. Many women suffer from chronic forms of vaginal problems were better able to treat their problems as a whole through the use of natural elements for treatment. .