2008.02.01 — Unintended Errors Leave Many Newborns Vulnerable
February 01, 2008
Unintended Errors Leave Many Newborns Vulnerable
FRIDAY, Feb. 1 (HealthDay News) — Iatrogenic events (IEs) — unintended harm or suffering caused by health care — occur frequently in newborn babies in hospitals, according to new French research.
These IEs are sometimes serious and often preventable, said the researchers at La Conception Hospital in Marseille, France.
They looked at 388 newborns admitted to a neonatal center in France between January and September 2005. During 10,346 patient days, there were 267 IEs in 116 of the newborns, a rate of 25.6 per 1,000 patient days. For this study, IEs were defined as any event that compromised the safety margin of a patient, whether or not they suffered harm.
Of the IEs recorded in the study, 92 (34 percent) were preventable, and 78 (29 percent) were severe. Two IEs were fatal, but neither was preventable. IEs most likely to be severe were nosocomial infections — 49 of 62 were severe (79 percent) — and respiratory events — 9 of 26 (35 percent] ). Of the 34 adverse drug IEs, 19 were medication errors.
The researchers found that the leading risk factors for an IE among newborns were: low birth weight and gestational age; length of hospital stay; a central venous line; mechanical ventilation, and support with continuous positive airway pressure.
“A third of all iatrogenic events and more than a quarter of severe iatrogenic events were preventable. Iatrogenic events seem to be less preventable in neonates than in adults and children, in whom 40 to 60 percent of adverse events are preventable,” the study authors wrote.
“The high risk of iatrogenic events draws attention to the importance of developing, testing, and implementing effective error-prevention strategies in pediatric medicine. Prospective, anonymous incident reporting offers both a means to monitor and prevent iatrogenic events, and an educational advantage to staff. Reduction of the rate of iatrogenic events in vulnerable, neonatal patients should be one of the main aims in providing best possible quality of health care for children,” they concluded.
Their report is published in the Feb. 2 issue of The Lancet.
More information
The U.S. National Library of Medicine has more about infant and newborn care.
– Robert Preidt
SOURCE: The Lancet, news release, Jan. 31, 2008
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2008.02.01 — Sorafenib Slows Growth of Some Leukemias
February 01, 2008
Sorafenib Slows Growth of Some Leukemias
FRIDAY, Feb. 1 (HealthDay News) — The drug sorafenib shows promise in the treatment of people with acute myeloid leukemia who have specific gene mutations, say U.S. researchers.
Previous research has shown that sorafenib — currently used to treat kidney and liver cancer — is effective against acute myeloid leukemia cells that have internal tandem duplication (ITD) mutations of the Fms-like tyrosine kinase 3 (FLT3) gene, according to background information in the study.
Researchers at the University of Texas M.D. Anderson Cancer Center in Houston looked at sorafenib’s effect on leukemia cells that express either the common or mutant copies of FLT3. They also gave the drug to mice with leukemia cells with known FLT3 mutations and to leukemia patients with and without the FLT3 mutation.
Sorafenib slowed growth and induced cell death in the FLT3 mutant leukemia cells and increased survival of the mice with FLT3 mutant leukemia. The drug also reduced the percentage of leukemia cells in the blood and marrow of leukemia patients with the FLT3 mutation but not in leukemia patients without the mutation.
“Our findings imply that sorafenib is a potent anti-leukemic agent in patients with FLT3-ITD mutant [acute myeloid leukemia], a form of [the disease] that responds poorly to traditional chemotherapy,” the study authors concluded.
The findings were published in the Jan. 29 issue of the Journal of the National Cancer Institute.
More information
The American Cancer Society has more about acute myeloid leukemia.
– Robert Preidt
SOURCE:Journal of the National Cancer Institute, news release, Jan. 29, 2008
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2008.02.01 — Social Networking Sites Safer Than IM or Chat Rooms
February 01, 2008
Social Networking Sites Safer Than IM or Chat Rooms
FRIDAY, Feb. 1 (HealthDay News) — While social networking Web sites such as MySpace and Facebook have been singled out as places where teens could face sexual harassment, most of the unwanted solicitation actually happens in chat rooms and via instant messaging, a new study finds.
Even there, only 15 percent of children experience unwanted sexual solicitation and only a third report being harassed online, according to a new study in the February issue of Pediatrics.
“There has been a recent concern about the risks posed by social networking to young people,” said lead researcher Michele Ybarra, founder of Internet Solutions for Kids, a company that helps design safe Web sites for children. “But we found that instant messaging was more frequently cited than social networking sites as places for unwanted sexual solicitation and harassment,” she said. “And chat rooms were more frequently cited than social networking sites.”
In the study, Ybarra’s team collected data on 1,588 children aged 10 to 15 years old. In a survey, the children were asked about their online experiences over the past year. Among these children, 15 percent said they had an unwanted sexual solicitation. Only one-fourth of these occurred on a social networking site, Ybarra noted.
In addition, 33 percent said they were harassed online. About one-fourth of the incidents occurred on a social networking site.
However, 43 percent of unwanted sexual solicitations occurred via instant messaging, and 32 percent occurred in chat rooms. Harassment was most common with instant messaging, which accounted for 55 percent, the researchers found.
Ybarra thinks that rather than focusing on the technology, the focus should be placed on the children themselves. “We need to stop worrying about social networking sites and pay more attention to what young people are doing online generally,” she said.
Parents have mistakenly thought that if their children aren’t on a social networking site they are safe, and if they are on one, they are at risk, Ybarra said. “We need to stop trying to scare our kids. We need to start having real conversations,” she said.
“We need to help parents understand it’s not about social networking sites, it’s about monitoring what’s going on,” Ybarra said. “Just as you should know where your child is after school, you should know where they go online.”
One expert isn’t sure that social networking sites are as safe as Ybarra’s team found.
“I am most concerned that they have surveyed kids who are younger than I would have expected, with only half of the survey population in the 13 to 15 age range,” said Kimberly M. Thompson, director of the Kids Risk Project at the Harvard School of Public Health.
MySpace and Facebook have age restrictions to prevent youths under ages 14 and 13 from using the sites,, Thompson said. “This means that many of the kids in the survey are theoretically prevented from exposure, and one interpretation of the author’s findings is that setting an entry age is keeping many kids out of these sites,” she said.
“The authors downplay the role of social networking sites instead of recognizing that these are the newest form of online media opportunities, and hence, their use and uses are still growing as people adopt the technology,” Thompson added. “I wonder what they would have found if they surveyed a slightly older population.”
The fear of social networking sites has lead one state to propose a law that would attempt to bar sex offenders from these sites.
Recently, New York State Attorney General Andrew Cuomo drafted a bill mandating that e-mail addresses and screen names of registered sex offenders be reported to social networking sites.
The bill would make it easier to stop sex offenders from using popular teen-oriented sites. It would also bar paroled sex offenders from social networking sites and ban online communication with minors.
More information
For more on teens and the Internet, visit the SafeTeens.com.
SOURCES: Michele Ybarra, Ph.D., M.P.H., founder, Internet Solutions for Kids Inc., Irvine, Calif.; Kimberly M. Thompson, Sc.D., associate professor, and director, Kids Risk Project, Harvard School of Public Health, Boston; February 2008, Pediatrics
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2008.02.01 — Quit-Smoking Drug May Raise Suicide Risk
February 01, 2008
Quit-Smoking Drug May Raise Suicide Risk
FRIDAY, Feb. 1 (HealthDay News) — There’s increasing evidence that the smoking-cessation drug Chantix is linked to serious “neuropsychiatric” side effects, including agitation, depressed mood and even suicide, U.S. health officials said Friday.
The U.S. Food and Drug Administration has asked Chantix’s manufacturer, Pfizer Inc., to make the warning about these potential problems more prominent on prescribing information and on the drug’s label. The agency is also working with Pfizer to produce a Medication Guide for patients, officials said.
“We have become increasingly concerned as we have seen a number of compelling cases that truly look as if they are the result of exposure to the drug and not to other causes,” Dr. Bob Rappaport, director of the FDA’s Division of Anesthesia, Analgesia and Rheumatology Products, said during an afternoon teleconference.
“These cases involve abnormal behaviors, changes in mood, and suicidal ideation and suicide,” Rappaport said.
The FDA knows of 491 cases of suicidal behavior associated with Chantix, said Dr. Celia Winchell, a team leader in the FDA’s Division of Anesthesia, Analgesia and Rheumatology Products.
“Of these, 420 are from the United States,” Winchell said. “There are 39 that involve completed suicides, 34 in the United States.”
According to Pfizer, 5 million patients have taken Chantix, whose generic name is varenicline.
Friday’s warning follows a Nov. 20 FDA statement that the agency was “evaluating post-marketing adverse event reports on Chantix related to changes in behavior, agitation, depressed mood, suicidal ideation, and actual suicidal behavior.”
At that time, Pfizer said there had never been a cause-and-effect relationship shown between Chantix and these symptoms. The company also said that part of the problem may be due to nicotine withdrawal.
Last month, Pfizer agreed, after consulting with the FDA, to update packages of Chantix sold in the United States to more prominently display a warning that users should be monitored for suicidal behavior, depressed mood, and other mental health symptoms.
The FDA approved Chantix in May 2006 as a smoking-cessation drug. It acts in areas of the brain affected by nicotine and may ease withdrawal symptoms and block the effects of nicotine if users resume smoking.
On Friday, FDA officials advised patients to tell their doctor about any history of psychiatric illness before starting Chantix. The drug can cause current psychiatric illness to get worse even if it is under control. Chantix may also cause the recurrence of an old psychiatric illness, the officials warned.
Patients should also report changes in mood and behavior to their doctor. Symptoms to look out for include anxiety, nervousness, tension, depressed mood, unusual behaviors and thinking about or attempting suicide, the FDA officials said.
In most cases, these symptoms developed while taking Chantix, but they can also appear after stopping the drug, the officials noted.
“We are continuing with the review process over the next several months as we try to pin down to what extent these problems are being seen with Chantix,” Rappaport said.
Vivid, unusual, or strange dreams may occur while taking the drug. Patients may also experience impaired ability to drive or operate heavy machinery, the officials said.
More information
For more on quitting smoking, visit Smokefree.gov.
SOURCES: Feb. 1, 2008, teleconference with Bob Rappaport, M.D., director, and Celia Winchell, M.D., team leader, Division of Anesthesia, Analgesia and Rheumatology Products, Office of Drug Evaluation II, Center for Drug Evaluation and Research, U.S. Food and Drug Administration
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2008.02.01 — Pregnant Women With Asthma Should Stay on Low Dose of Meds
February 01, 2008
Pregnant Women With Asthma Should Stay on Low Dose of Meds
FRIDAY, Feb. 1 (HealthDay News) — During pregnancy, asthmatic women should continue to use their asthma medication in the lowest dose possible to manage symptoms.
So recommends a new Practice Bulletin just released by the American College of Obstetricians and Gynecologists (ACOG).
The bulletin says women with moderate or severe asthma should also be monitored throughout pregnancy for fetal growth restriction and signs of possible preterm birth.
During pregnancy, asthma attacks may deprive the fetus of oxygen and may be associated with premature birth, growth restriction and other fetal complications, as well as illness and death in women, the ACOG said.
The new recommendations are based on a review of existing studies and support the position of the U.S. National Asthma Education Prevention Program that “it is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.”
“Previously, there was limited guidance regarding the management of asthma during pregnancy,” Dr. Andrew J. Satin, chairman of the ACOG’s Committee on Practice Bulletins-Obstetrics, said in a prepared statement. “With the growing number of asthmatics in the U.S., it became a priority to formalize recommendations for ob-gyns, who will likely see an increasing number of asthmatic patients.”
“Research consistently shows that women with well-controlled asthma can have healthy pregnancies with excellent maternal and perinatal outcomes,” Dr. Mitchell P. Dombrowski, an ACOG Fellow who contributed to the new Practice Bulletin, said in a prepared statement. “The ultimate goal of controlling asthma during pregnancy is to ensure that the fetus continues to get adequate oxygen by preventing asthma attacks.”
The bulletin is published in the February issue of Obstetrics & Gynecology.
More information
The American Academy of Allergy, Asthma and Immunology has more about asthma and pregnancy.
– Robert Preidt
SOURCE: American College of Obstetricians and Gynecologists, news release, Jan. 31, 2008
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2008.02.01 — Key Risk Factors for Suicide Consistent Across Globe
February 01, 2008
Key Risk Factors for Suicide Consistent Across Globe
FRIDAY, Feb. 1 (HealthDay News) — Risk factors for suicidal thoughts, plans and attempts are similar in many countries, new research suggests.
The study, which used data collected by the World Health Organization World Mental Health Survey Initiative, looked at people in 17 nations and found that an overall average of 9.2 percent reported having seriously thought about suicide and 2.7 percent attempted suicide. It also found that suicide risk factors are associated with having a mental disorder, being female, younger, less educated, and unmarried.
“Our research suggests that suicidal thoughts and behaviors are more common than one might think, and also that key risk factors for these behaviors are quite consistent across many different countries around the world,” study leader Matthew Nock, associate professor of psychology at Harvard University, said in a prepared statement.
The findings were published in the February issue of the British Journal of Psychiatry.
While the overall averages were 9.2 percent for suicidal thoughts and 2.7 percent for attempted suicide, there were variations from country to country. For example, rates of suicidal thoughts ranged from 3.1 percent in China to 15.9 percent in New Zealand. But the researchers noted that people in some countries wouldn’t report having suicidal thoughts because it’s culturally unacceptable, meaning those countries would have much lower rates.
In high-income countries, the strongest risk factor associated with suicidal thoughts and behaviors was mood disorders; in low- and middle-income countries, it was impulse control disorders.
“We often think of suicidal thoughts and behaviors as occurring among people who are depressed, but across all of these countries, we found that it is not just depression that increases the risk of suicidal behaviors — impulse control disorders, substance abuse disorders and anxiety disorders are all associated with a significantly higher risk of suicidal thoughts and attempts,” Nock said.
Among people with suicidal thoughts, the risk of making a suicide attempt was strongest among those with substance abuse and impulse control disorders, which suggests these disorders are most strongly associated with acting on suicidal thoughts.
The study also found that among people with suicidal thoughts, 29 percent later made a suicide attempt, and these attempts were most common within the first year after the onset of suicidal thoughts.
Among people with both suicidal thoughts and a plan, there was a 56 percent probability of a suicide attempt, compared with 15.4 percent among those without a plan.
The study looked at 84,850 adults in Nigeria, South Africa, Colombia, Mexico, the United States, Japan, New Zealand, China, Belgium, France, Germany, Italy, the Netherlands, Spain, Ukraine, Israel and Lebanon.
Suicide is a leading cause of death worldwide. This is the first study to examine the suicidal thoughts and behaviors of people in numerous and diverse countries.
More information
Mental Health America has more about suicide.
– Robert Preidt
SOURCE: Harvard University, news release, Jan. 31, 2008
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2008.02.01 — IPods Don’t Interfere With Heart Pacemakers
February 01, 2008
IPods Don’t Interfere With Heart Pacemakers
FRIDAY, Feb. 1 (HealthDay News) — Portable music players such as the iPod don’t cause electronic interference in implanted cardiac pacemakers, a new study claims.
Government researchers reported in the current issue of BioMedical Engineering OnLine that they measured the magnetic fields produced by four different iPod models — a fourth-generation iPod; iPod with video; iPod shuffle; and iPod nano — and measured the voltages delivered inside a pacemaker by the magnetic fields from the iPods.
They determined the music devices would have no impact on people with cardiac pacemakers.
“Based on the observations of our in-vitro study, we conclude that no interference can occur in pacemakers exposed to the iPods we tested,” wrote U.S. Food and Drug Administration researcher Howard Bassen and his colleagues.
Over the past year, there have been a number of media reports about iPod interference with cardiac pacemakers. But those stories were based on a single incident where a person with a pacemaker experienced dizziness while using an iPod. During an examination, doctors conducted a test with an iPod and found it interfered with the patient’s pacemaker.
The case was published in the journal Heart Rhythm and prompted discussions about the use of warning labels for portable music and video players, according to background information in a news release about this new study.
More information
The U.S. Food and Drug Administration has more about implanted cardiac pacemakers.
– Robert Preidt
SOURCE: BioMed Central, news release, Jan. 31, 2008
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2008.02.01 — Health Tip: Soothing Engorged Breasts
February 01, 2008
Health Tip: Soothing Engorged Breasts
(HealthDay News) – After giving birth, a woman’s breasts can become large and swollen — called engorged. This is caused by congestion of the blood vessels in the breast. When this happens, the nipples may not protrude to allow the baby to nurse.
The U.S. National Library of Medicine lists these suggested remedies:
- Try to feed often throughout the day — at least eight times in a 24-hour period.
- Feed for at least 15 minutes at each sitting.
- If your breasts feel uncomfortable and you are unable to feed your baby, express your milk with a breast pump.
- Take a warm shower to soothe soreness.
- Apply a cool compress to reduce swelling and ease pain.
– Diana Kohnle
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2008.02.01 — Health Tip: Exercise Routines for Arthritis Patients
February 01, 2008
Health Tip: Exercise Routines for Arthritis Patients
(HealthDay News) – Exercise can be a great way to deal with the aches and pains of arthritis. But it’s important to perform the right exercises under a doctor’s supervision.
Here are suggestions about exercising if you have arthritis, courtesy of the University of Washington School of Medicine:
- If you have a physical or occupational therapist, he or she should participate in creating your exercise plan.
- Your exercises should put minimal stress on your joints, especially when you first start out. Don’t overdo it.
- Try a combination of both therapeutic (designed to help ease symptoms and improve joint function) and recreational (just for fun) exercises.
- Use other methods to ease symptoms, such as using heating pads and ice packs, eating a healthy diet, taking medication as prescribed, and maintaining a healthy body weight.
– Diana Kohnle
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2008.02.01 — Health Highlights: Feb. 1, 2008
February 01, 2008
Health Highlights: Feb. 1, 2008
Here are some of the latest health and medical news developments, compiled by editors of HealthDay:
FDA Approves 1st New Drug-Eluting Stent Since 2004
The U.S. Food and Drug Administration gave approval Friday to a new drug-eluting stent for use in treating patients with narrowed coronary arteries.
The Endeavor Zotarolimus-Eluting Coronary Stent, manufactured by Medtronic Inc., of Minneapolis, is the first such stent OK’d since 2004 and the first since an agency panel convened in 2006 to examine the risk of blood clots occurring in patients who receive drug-eluting stents.
Stents are tiny mesh tubes positioned in an artery to act as a scaffold that keeps a clogged artery open. Stents can be bare-metal or drug-eluting — coated with drugs — to ensure that the artery doesn’t re-close in a process call restenosis.
According to the FDA, Medtronic provided data from seven clinical trials in its application showing that the Endeavor significantly reduced the number of major coronary events such as heart attack or cardiac death. The company said use of its product cut the restenosis rate by about half.
“The Endeavor drug-eluting stent provides cardiologists with another option for treating the one million patients who undergo an angioplasty procedure every year to open their clogged coronary arteries,” said Dr. Daniel Schultz, director of the FDA’s Center for Devices and Radiological Health.
U.S. Women’s Heart Disease Deaths Continue to Decline
Heart disease deaths among American women declined again in 2005, marking the sixth consecutive year of decreases, according to a new analysis announced Friday by the U.S. National Heart, Lung, and Blood Institute.
It’s the first time there’s been a six-year consecutive decline.
The preliminary data analysis for 2005, the most recent year for which statistics are available, shows that women are living longer and healthier lives, and dying at much older ages than in the past.
“Considerable progress continues to be made in the fight against heart disease in women,” NHLBI Director Dr. Elizabeth G. Nabel said in a prepared statement.
However, she noted there are still serious challenges. One in four women dies from heart disease and women of color have higher rates of some risk factors for heart disease and are more likely to die of the disease.
“Unfortunately, many women still do not take heart disease seriously and personally,” Nabel said. “Millions of women still have one or more risk factors for heart disease, dramatically increasing their risk of developing heart disease. In fact, having just one risk factor increases a woman’s chance of developing heart disease two-fold.”
An NHLBI-sponsored campaign called “The Heart Truth” is striving to educate people that heart disease is largely preventable. As part of that campaign, Friday is National Wear Red Day, when thousands of people across the country wear red to give women a personal and urgent reminder about their risk for heart disease.
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Marigold Therapies May Help Treat Stubborn Warts
Marigold-based therapies show promise in helping people with hard-to-treat warts, according to preliminary research by an assistant professor at Temple University School of Podiatric Medicine.
Tracey Vlahovic offers Marigold therapy — creams, ointments, tinctures and oils — to her patients and has investigated it as an alternative treatment for three HIV-infected patients with warts that hadn’t responded to other treatments.
Plantar warts are common among healthy adults. In HIV patients, these warts are often more difficult to treat, more numerous and less receptive to common treatments such as cryotherapy or surgical removal.
Vlahovic found that four to six sessions of marigold-based therapy either cleared or greatly reduced the number and size of the warts. The findings were presented Friday at the American Academy of Dermatology’s annual meeting.
“Mainstream treatments are sometimes not an option for HIV-positive patients because they have weakened immune systems and invasive procedures can further compromise them,” Vlahovic said in a prepared statement. “But alternative therapies like Marigold therapy don’t pose that threat.”
She plans further research with more patients and a standardized treatment regimen.
Marigold plants have been used as a treatment for a variety of health problems as far back as ancient Greece and Rome, when marigold tea was used to combat sleep disorders and calm nerves. During the Renaissance, the yellow plant was used to treat everything from headache, red eyes and toothaches to jaundice and skin problems, the statement said.
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Eye Drops and Eye/Ear Wash Recalled
Possible contamination with bacteria and particulate matter has prompted a voluntary recall of NuCel-brand eye drops and eye/ear wash, the U.S. Food and Drug Administration announced this week.
The problem was detected after an FDA inspection of the products made by NuCel Labs of Idaho Falls, Idaho, United Press International reported. The company then initiated a nationwide recall of the potentially non-sterile eye drops and eye/ear wash in 1/4-ounce bottles.
About 500 units of the products, which have no lot numbers or expiration dates, were distributed across the United States, the FDA said. Consumers should stop using these products and return them to the company. For further information, contact NuCel at 208-542-0325.
Non-sterile eye drops could cause infections which, in rare cases, could lead to blindness, the FDA warned. So far, there have been no reports of illness or injury caused by the recalled eye drops and eye/ear wash.
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More Tamiflu-Resistant Flu Viruses Found in Europe
Tamiflu-resistant seasonal flu viruses have now been found in nine European countries, indicating the resistant strains are more widespread than previously believed, Bloomberg news reported.
The European Centre for Disease Prevention and Control (ECDC) said Thursday that tests on 437 H1N1 flu strain specimens from patients in 18 countries found that 59 specimens from nine countries showed resistance to Tamiflu (oseltamivir). Nearly half the resistant specimens were from Norway.
The viruses have a gene mutation that gives them “high-level” resistance to Tamiflu, Bloomberg reported.
Experts are still analyzing data and will release an interim assessment of the situation in the coming days, the ECDC said.
“At this stage, it is impossible to say what the level of resistance is in influenza across Europe,” the health agency said. “However, from the limited data, the proportion of influenza viruses exhibiting resistance to oseltamivir must be significant, but not as high as in Norway.”
This emerging resistance to Tamiflu has led doctors in Europe to consider other anti-flu drugs such as Relenza, Bloomberg reported.
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Well-Fed Babies Earn More as Adults: Study
Feeding nutritious food to babies could boost the amount of money they earn as adults, suggests a three-decade study that followed Guatemalan males from birth, BBC News reported.
The study found that babies who were given a very nutritious food supplement up to age 3 went on to earn an average of almost 50 percent more as adults than babies who didn’t receive the supplement. The findings are published in The Lancet medical journal.
Experts said the study results could influence how aid is managed in developing nations and could also affect social policy toward the poor in more developed nations, BBC News reported.
The study provides the first direct evidence of a link between nutrition early in life and adult wages, and that well-fed infants could boost economic growth, according to The Lancet.
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U.S. Army Suicides Increased in 2007
In 2007, as many as 121 U.S. Army soldiers committed suicide, compared to 102 suicides in 2006 and 87 in 2005, according to the Associated Press, which cited internal briefing papers prepared by the Army’s psychiatry consultant early this month.
The papers showed there were 89 confirmed suicides last year and 32 suspected suicides that are still under investigation, the AP reported.
Last year, more than a quarter of the confirmed and suspected suicides occurred during deployments in Iraq.
The number of attempted suicides and self injuries also increased from fewer than 1,500 in 2006 to about 2,100 in 2007. There were fewer than 500 such incidents in 2002.
The 2007 rate of suicides per 100,000 active duty soldiers has not yet been calculated, Army officials said. The 2006 suicide rate of 17.5 per 100,000 was the highest since the Army started counting in 1980, the AP reported.
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