5-ASA不同药物制剂在溃疡性结肠炎患者肠黏膜中浓度的对比研究

目的比较5-ASA不同药物制剂治疗溃疡性结肠炎(ulcerative colitis,UC)患者肠黏膜中浓度的差异。方法纳入我院133例UC患者,按治疗分为四组:A组(pH依赖的5-ASA)68例,B组(时间依赖的5-ASA)14例,C组(5-ASA前体)30例,D组(pH依赖的5-ASA,口服联合局部用药)21例,常规行肠镜检查并于乙状结肠区取组织活检,采用高压液相色谱法分析比较肠黏膜中5-ASA药物浓度。结果①A组肠黏膜5-ASA浓度明显高于B组及C组(P0.05);②内镜下缓解期的UC患者肠黏膜5-ASA浓度明显高于活动期患者[(61.02±7.11)ng/mg vs(36.16±6.28)ng/mg,P=0.03],组织学炎症缓解的UC患者肠黏膜5-ASA浓度明显高于炎症活动的患者[(66.68±8.95)ng/mg vs(34.98±5.61)ng/mg,P0.001];③口服联合局部用药(灌肠)的UC患者肠黏膜5-ASA浓度明显高于单独口服用药的患者[(72.55±10.89)ng/mg vs(52.21±6.78)ng/mg,P=0.03]。结论 5-ASA治疗UC患者,pH依赖性的5-ASA易获得较高的药物浓度,且口服联合局部用药效果更佳。     

益生菌对溃疡性结肠炎维持缓解的作用

溃疡性结肠炎(ulcerative colitis,UC)是炎症性肠病在我国的主要发病形式,临床最常见的是复发和缓解交替.由于其发病机制不明,目前无明确根治措施,临床治疗以诱导和维持缓解为主[1],然而对于急性期患者,即使标准的维持治疗方案,疗效也不能令人满意,仅能将1年内复发率降为50%[2,3],且有部分患者不能接受长期应用5-氨基水杨酸(5-ASA)类药物的不良反应.     

沙利度胺治疗成人难治性溃疡性结肠炎11例疗效分析

目的评价沙利度胺对成人难治性溃疡性结肠炎(UC)的有效性和安全性。方法对2009年11月至2017年11月间北京协和医院消化内科接受沙利度胺治疗的所有成人UC患者进行回顾性分析,对患者的临床特点,沙利度胺的使用剂量、疗程、合并用药、临床疗效及不良反应进行评估。结果 11例难治性UC患者中,2例为重度活动,3例为中度活动,5例为轻度活动,1例为缓解期。10例活动期患者经沙利度胺治疗后,5例临床缓解,1例临床有效,3例无效,1例因不良反应停药。7例缓解期的患者中,6例为沙利度胺诱导缓解,1例为前期其他方案诱导缓解,除1例失访、1例维持缓解失败,其余5例均能维持缓解,且内镜评估均达到黏膜愈合。8例患者出现不良反应,包括手足麻木、便秘、嗜睡、头晕、皮疹、肝功能异常及多汗。1例患者因无法耐受嗜睡和头晕症状而停药。结论沙利度胺对难治性UC具有一定疗效,可用于诱导和维持临床缓解和黏膜愈合,但治疗时应密切监测和随访不良反应。     

复方谷氨酰胺肠溶胶囊对缓解期UC维持缓解的作用

目的观察复方谷氨酰胺肠溶胶囊对缓解期UC维持缓解的作用,比较奥沙拉秦钠与复方谷氨酰胺肠溶胶囊对维持缓解期UC的疗效.方法采用随机对照方法观察70例活动期溃疡性结肠炎经治疗后处于缓解期的患者,给予奥沙拉秦钠或复方谷氨酰胺肠溶胶囊口服,疗程为1年.结果治疗1年末复方谷氨酰胺肠溶胶囊组的复发率为33.3%,奥沙拉秦钠组的复发率为36.7%,两组复发率相比无统计学差异(P＞0.05).结论复方谷氨酰胺肠溶胶囊对缓解期UC维持缓解有较好的疗效,与奥沙拉秦钠组比无明显差异.     

多靶点治疗Ⅳ+Ⅴ型狼疮性肾炎的长期随访

目的:既往研究证实多靶点疗法(MT)治疗Ⅳ+Ⅴ型狼疮性肾炎(LN)较传统静脉环磷酰胺冲击疗法(IVCY)能获得更高的诱导缓解率,本研究进一步探讨MT治疗Ⅳ+Ⅴ型LN的长期疗效和安全性。方法:将80例经肾活检证实的Ⅳ+Ⅴ型LN患者随机分为MT组(MT诱导缓解后MT维持,40例),和IVCY-硫唑嘌呤(AZA)组(IVCY诱导缓解后AZA维持,40例)。两组均同时予口服激素,总随访时间24月。主要疗效指标为完全缓解率,次要指标包括部分缓解、复发和不良反应发生率。结果:MT组和IVCY-AZA组分别有36例(90%)和24例(60%)获得诱导缓解(P0.01),MT组6月(45%vs12.5%,P0.01)和24月完全缓解率(80%vs47.5%,P0.01)显著高于IVCY-AZA组。MT组和IVCY-AZA组分别有36例、21例进入维持期观察,两组24月内肾脏复发率(8.3%vs4.8%,P0.05)及肾脏无复发生存率无明显差异。诱导期MT组和IVCY-AZA组感染发生率均为22.5%,IVCY-AZA组脱发、胃肠道症状发生率高于MT组(17.5%vs2.5%,22.5%vs5%,P0.05),新发高血压仅出现在MT组。维持期MT组和IVCY-AZA组分别有11.1%和28.6%患者出现白细胞减低(P0.05)。结论:采用多靶点疗法诱导,并维持治疗Ⅳ+Ⅴ型LN能获得较高缓解率、安全性好。     

美沙拉秦缓释片维持治疗缓解期溃疡性结肠炎患者的有效性和安全性

目的探讨美沙拉嗪缓释片维持治疗缓解期溃疡性结肠炎(Ulcerative colitis,UC)的疗效及安全性。方法选取在我院接受治疗的缓解期溃疡性结肠炎患者126例,按数字表法随机分为试验组和对照组,每组均63例。对照组采用传统保守治疗方式维持治疗,试验组则在传统维持治疗基础上给予美沙拉嗪缓释片治疗。对比两组维持治疗后临床总有效率、疾病活动指数(DAI)、IL-6、IL-8及TNF-α水平变化、服药不良反应发生情况以及UC复发情况。结果试验组临床治疗总有效率(98.41%)、DAI(3.55±1.20)分、IL-6(100.18±25.14)ng/L、IL-8(159.88±34.85)ng/L、TNF-α(80.11±21.41)ng/L水平,以及UC复发率(1.59%)均明显优于对照组临床总有效率(52.38%)、DAI(4.29±1.33)分、IL-6(121.21±26.01)ng/L、IL-8(187.68±37.08)ng/L、TNF-α水平以及UC复发率(23.81%),统计学上有意义(P0.05);治疗后,两组不良反应发生率差异比较,无统计学意义(P0.05)。结论采用美沙拉嗪缓释片治疗缓解期UC患者,可进一步抑制UC患者炎症反应,患者各项指标均有明显改善,临床不适症状消失,对疾病维持治疗效果较显著,减少缓解期UC复发率,且药物副作用少,有助于患者恢复,安全性较好。     

英夫利西治疗重度溃疡性结肠炎2例

目的:探讨英夫利西治疗重度溃疡性结肠炎(UC)的安全性和有效性.方法:报道2例重度UC治疗中英夫利西的用法、疗效及安全性,并复习近年国内外相关文献,结果:1例患者在接受3次英夫利西5 mg/kg诱导缓解后并以相同剂量每8wk 1次维持治疗,输注5次后达到黏膜愈合.另l例患者应用英夫利西5 mg/kg效果欠佳,加量至10...     

低氧诱导因子-1α在溃疡性结肠炎患者血清和结肠黏膜中的表达及意义

目的检测溃疡性结肠炎(UC)患者血清和结肠黏膜中低氧诱导因子-1α(HIF-1α)的含量,探讨其在UC发病机制中的调控作用及其与患者病情活动性和严重性的关系。方法采用酶联免疫吸附试验(ELISA)定量检测10名健康对照者、13例缓解期UC及47例活动期UC患者血清中HIF-1α含量,同时采用枸橼酸-微波-SP-免疫组织化学方法检测结肠黏膜中HIF-1α的表达情况,并评价其与活动期患者病情相关性。结果活动期UC患者血清HIF-1α含量(73.21±28.65)ng/L显著高于缓解期(44.54±14.75)ng/L和对照组(42.83±15.49)ng/L(P0.05),且缓解期与对照组比较,差异无统计学意义(P0.05),血清HIF-1α的表达与病情活动性、病情分型及内镜表现分级呈正相关;活动期UC结肠黏膜中HIF-1α表达阳性率(58.05±13.83)%显著高于缓解期(3.00±2.72)%和对照组(3.04±2.69)%(P0.05),且缓解期与对照组相比,差异无统计学意义(P0.05),结肠黏膜中HIF-1α的表达与病情活动性、病情分型及内镜表现分级也呈正相关。结论 HIF-1α作为一种转录因子可能在UC发病机制中有重要作用,并可能作为评价UC患者病情活动性及严重程度的良好指标。     

溃疡性结肠炎和克罗恩病的英夫利西(类克)治疗效果比较

目的分析、比较7例CD和7例UC的英夫利西(类克)治疗效果。方法按5 mg/kg,0、2、6周诱导,每8周巩固一次的方法应用类克。根据国内共识意见评定疗效,分别计算进入缓解期和仍处于活动期患者治疗前后ESR和CRP数据。结果7例CD患者中,4例达到症状缓解,3例好转。仅1例达到黏膜愈合。7例UC患者中,3例达到症状缓解,4例好转,2例黏膜愈合。14例CD和UC患者中,治疗后症状消失较快者提示临床和内镜下病变明显好转。无合并症CD或UC患者类克治疗效果最好。手术后用药可防止CD复发。1例发生过敏反应。结论类克治疗难治性CD和UC有相同的治疗效果。     

不同剂量美常安对溃疡性结肠炎患者维持治疗的临床对比研究

目的比较小剂量和标准剂量美常安对溃疡性结肠炎(ulcerative colitis,UC)患者维持治疗的疗效及安全性。方法选取2012年6月-2013年12月于湖北省襄阳市中心医院就诊的UC缓解期患者98例,随机分为3组:美沙拉嗪组,口服美沙拉嗪缓释颗粒1.5 g/d;小剂量美常安组,口服美常安750 mg/d;标准剂量美常安组,口服美常安1 500 mg/d。所有患者随访6个月,观察并记录维持缓解时间、不良反应情况,所有患者复查肠镜并记录UC活动度积分和病理组织学积分。结果三组患者UC复发率、维持缓解时间、肠镜活动度积分及病理组织学积分差异均无统计学意义(P0.05)。结论小剂量美常安在UC患者维持治疗中是安全、有效的。     

Effect of weekend 5-aminosalicylic acid (mesalazine) enema as maintenance therapy for ulcerative colitis: results from a randomized controlled study

BACKGROUND: 5-aminosalicylic acid (5-ASA) is known to be effective in the treatment of active ulcerative colitis (UC). The aim of the current study was to investigate the effect of 5-ASA enemas, as a maintenance therapy for UC, when administered twice weekly as a weekend treatment regimen, compared to daily oral 5-ASA alone. We hypothesized that the weekend enema therapy would be better tolerated by patients who worked or attended school. METHODS: Between January 2004 and August 2005, patients with UC, in whom remission of the condition had just been induced, were randomly assigned to either: the weekend 5-ASA enema group (n=11), who received 1 g 5-ASA enemas twice a week on Saturday and Sunday plus oral 5-ASA 3 g/day for 7 days, or to the daily oral 5-ASA use only group (n=13), who received only oral 5-ASA 3 g/day for 7 days. The primary endpoint of the study was defined as the incidence of relapse. The study was stopped after 24 patients had been enrolled because an interim analysis showed a significant benefit of the weekend 5-ASA enema group. RESULTS: In the weekend enema group, 2 patients (18.2%) had relapses compared with 10 (76.9%) in the oral 5-ASA only group. The multivariate hazard ratio of relapse associated with weekend 5-ASA enema, relative to the oral alone group, was 0.19 (95% confidence interval, 0.04-0.94). CONCLUSIONS: This study demonstrated the beneficial effects of adding weekend 1 g 5-ASA enema to daily 3 g oral 5-ASA as maintenance therapy for UC.     

Probiotic Escherichia coli Nissle 1917 (EcN) for successful remission maintenance of ulcerative colitis in children and adolescents: an open-label pilot study

Since about 20 % of patients with ulcerative colitis (UC) are children and adolescents there is a need for therapeutic options custom-tailored to the children's needs. E. coli Nissle 1917 (EcN) as an evidence-based probiotic alternative to mesalazine (5-ASA) in adult UC remission maintenance is a promising agent for such a therapy. The present open-labelled pilot study was undertaken to investigate the clinical benefit of EcN for maintenance therapy in young UC patients. 34 patients with UC in remission aged between 11 and 18 years were allocated either to EcN (2 capsules o. d., n = 24) or 5-ASA (median 1.5 g/d, n = 10) and observed over one year. As a result, the relapse rate was 25 % (6 / 24) in the EcN group and 30 % (3 / 10) in the 5-ASA group. Data on the patients' global health and development were favourable and no serious adverse events were reported. In conclusion, maintenance therapy for UC with the probiotic EcN is effective also in young patients.     

Long-term intermittent treatment with low-dose 5-aminosalicylic enemas is efficacious for remission maintenance in ulcerative colitis

BACKGROUND: The standard remission maintenance treatment for ulcerative colitis (UC) is 5-amino-salicylic acid (5-ASA), given orally and topically and in different doses, with various frequencies and duration of administration. Both the efficacy of long-term intermittent therapy with low-dose 5-ASA enemas in preventing UC relapses and its economic implications were evaluated. METHODS: In accordance with a prospective case control study, 42 adult UC outpatients (29 M and 13 F) were treated with 5-ASA tablets (1.6 g/day) and 5-ASA enemas (2 g/50 mL) twice weekly, and 42 concurrent UC outpatients, matched for sex, age, extension and duration of disease, received only the oral therapy; the median treatment period was 6 years. RESULTS: There was a significant reduction in the number (42%: P = 0.034) and incidence of relapses (43%: P = 0.022) in the patients receiving combined oral + topical 5-ASA, who also had a significantly higher cumulative probability of not experiencing a first relapse (P = 0.001). There were no dropouts or side effects. Local therapy increased drug costs, but decreased the costs of relapses by 48% and completely precluded hospitalization costs. CONCLUSIONS: The scheduled oral + topical 5-ASA treatment, at the lowest cumulative topical dosage tested over the longest known observation period, is efficacious in improving clinical outcome and decreasing overall costs in UC patients.     

Recent advances in the management of distal ulcerative colitis

The most frequent localization of ulcerative colitis (UC) is the distal colon. In treating patients with active distal UC, efficacy and targeting of the drug to the distal colon are key priorities. Oral and rectal 5-aminosalicylic acid (5-ASA) preparations represent the first line therapy of mild-to-moderate distal UC for both induction and maintenance treatment. It has been reported that many UC patients are not adherent to therapy and that non-compliant patients had a 5-fold risk of experiencing a relapse. These findings led to the introduction of once-daily oral regimens of 5-ASA as better therapeutic options in clinical practice due to improved adherence. New formulations of mesalazine, including the multi-matrix delivery system, and mesalazine granules, which allow once-daily administration, have been developed. They have been demonstrated to be efficacious in inducing and maintaining remission in mild-to-moderate distal UC in large clinical trials. However, existing data for distal UC are rather insufficient to make a comparison between new and classical 5-ASA formulations. It seems that the new formulations are at least as effective as classical oral 5-ASA formulations. Other treatment options, in the case that 5-ASA therapy is not effective, include systemic corticosteroids, thiopurines (azathioprine or 6-mercaptopurine), cyclosporine, infliximab and surgery. The combination of a prompt diagnostic work-up, a correct therapeutic approach and an appropriate follow-up schedule is important in the management of patients with distal UC. This approach can shorten the duration of symptoms, induce a prolonged remission, improve patient's quality of life, and optimize the use of health resources.     

NAT1 genotypes do not predict response to mesalamine in patients with ulcerative colitis

BACKGROUND: 5- Aminosalicylic acid (5-ASA) is metabolised in colonic mucosa by N-acetyltransferase 1 (NAT1). Common genetic polymorphisms in this enzyme result in rapid or slow acetylation. 5-ASA treatment causes side effects in up to 10 % of patients with ulcerative colitis (UC). We therefore determined genetic variations of NAT1 in patients with UC and looked for a possible association with the clinical response to 5-ASA. METHODS: DNA was obtained from 78 patients with UC. 77 % of the patients were in remission during 5-ASA treatment, whereas 23 % suffered from active disease. NAT1 genotyping was performed for 23 known alleles using RFLP and sequence analysis. Clinical response to 5-ASA was determined by medical record review and associated with NAT1 genotypes. RESULTS: Utilising PCR we amplified a 570-bp coding region of the human NAT1 gene in addition to 240 bp in the 3'-untranslated region (UTR). 4 NAT1 alleles previously known as NAT1*3, *4, *10 and *11 were recovered. 31 % of the patients were heterozygous and 4 % homozygous for the NAT1*10 allele. 6 % were heterozygous for the NAT1*3 allele. 6 % were heterozygous for the NAT1*11 allele. No association was found between NAT1 genotype and clinical response as well as side effects to 5-ASA in patients with UC. CONCLUSIONS: NAT1 genotypes do not predict response or side effects to mesalamine in patients with UC. Variations caused by non-genomic effects may be associated with the clinical response to 5-ASA.     

Algorithms to facilitate shared decision-making for the management of mild-to-moderate ulcerative colitis

ABSTRACT

Introduction: Nonadherence has been a key barrier to the efficacy of medical treatments in ulcerative colitis (UC). Engaging patients in their IBD care via shared decision-making (SDM) to facilitate self-management may improve adherence to therapy.

Areas covered: This review aims to summarize the most recent trial evidence from 2012 to 2017 for mild-to-moderate UC in order to develop clinical algorithms that guide SDM to facilitate self-management. A structured literature search via multiple electronic databases was performed using the search terms ‘ulcerative colitis,’ ‘treatment,’ ‘management,’ ‘medication,’ ‘maintenance,’ ‘remission,’ ‘5-ASA,’ and ‘inflammatory bowel disease.

Expert commentary: Novel formulations of existing oral and topical medications have expanded the treatment options available for the induction and maintenance therapy for mild-to-moderate UC. Daily dosing of 5-ASA therapy is equivalent to twice daily dosing. The combination therapies of oral plus topical 5-ASA therapy and 5-ASA plus corticosteroid therapy are more effective than monotherapy. Budesonide MMX now plays a role in the management of mild-to-moderate UC. This review collates the evidence on drug efficacy and safety, adherence and tolerability, and noninvasive monitoring of mild-to-moderate UC into SDM-orientated algorithms to facilitate self-management.     

Aminosalicylates and steroids in the treatment ot chronic inflammatory bowel diseases--consensus paper of the Working Group for Chronic Inflammatory Bowel Diseases of the OGGH

5-aminosalicylates (5-ASA) and steroids constitute a cornerstone of medical therapy in patients with inflammatory bowel diseases (IBD). Whereas the efficacy of 5-ASA in Crohn's disease (CD) is equivocal, ulcerative colitis (UC) is the main indication for this drug. In UC, 5-ASA is effective in the treatment of mild to moderate acute disease and in maintenance of remission. Furthermore, 5-ASA topical therapy is an important treatment option in patients with mild to moderate proctitis and/or left-sided UC and shows additive efficacy to oral therapy. From retrospective data a chemo-preventative activity of long-term 5-ASA therapy in UC is delineated. Steroids are treatment of first choice for moderate to severe cases of CD and UC. Budesonide, a modified steroid with less side effects, plays a major role in the treatment of ileocolonic CD +/- involvement of the right colon and is used as treatment of choice in mild-to-moderate cases. In case of acute, severe disease conventional steroids are superior compared to budesonide and therefore budesonide should only be used after considerable improvement of disease activity. The necessity to apply steroids in a given patient represents a negative prognostic indicator for the course of disease and should incite the early introduction of immunosuppressive therapy in this case. Steroids are only effective as short term therapy of IBD and are to be avoided for maintenance treatment. In all cases of steroid therapy an osteoporosis prophylaxis with calcium and vitamin D is recommended. Topical steroid treatment is less effective in left-sided UC compared to 5-ASA.     

Topical treatment of distal active ulcerative colitis with beclomethasone dipropionate or mesalamine: a single-blind randomized controlled trial

GOALS: Therapy for active ulcerative colitis (UC) usually involves rectal formulations of corticosteroids (CS), which are characterized by the risk of systemic steroid-related adverse effects. BACKGROUND: To compare the efficacy and safety of the topically acting CS beclomethasone dipropionate (BDP) versus mesalamine (5-ASA) in the treatment of active UC. STUDY: Patients with mild to moderate distal active UC were randomized to a 6-week treatment with BDP 3 mg enema o.d. or 5-ASA 1 g enema daily in a single-blind, multicenter, parallel-group, controlled study. The primary efficacy variable was the decrease in Disease Activity Index (DAI) score. Safety variables were adrenal function, monitoring of adverse events, vital signs, and laboratory parameters. RESULTS: A total of 217 patients were enrolled and treated with BDP (n = 111) or 5-ASA (n = 106). A significant decrease in the DAI score (P < 0.05) was observed in both treatment groups, with a clinical remission rate of 36.7% in the BDP group and of 29.2% in the 5-ASA group. Both treatments were well tolerated. No changes from baseline in morning cortisol levels were observed in the BDP group. CONCLUSIONS: BDP administered as a rectal enema over a 6-week treatment period was efficacious and safe in patients with active UC, without interference with pituitary adrenal axis.     

Does colonoscopy cause increased ulcerative colitis symptoms?

BACKGROUND: Ulcerative colitis (UC) patients often report symptom flares after colonoscopy. However, this has not been documented in the literature. OBJECTIVES: 1. Determine whether colonoscopy is associated with increased UC symptoms. 2. Determine whether there is a need for escalation of UC medications after colonoscopy. 3. Identify baseline variables associated with increased symptoms after colonoscopy. METHODS: Fifty-five outpatients with a history of UC, intact colon, and quiescent disease were enrolled in a prospective case-crossover study. Subjects were evaluated with the Simple Clinical Colitis Activity Index (SCCAI) before colonoscopy, 1 week and 4 weeks after colonoscopy. A mixed model analysis was used to accommodate nonindependence of repeated measurements on the same patients. RESULTS: Fifty-one (91%) subjects completed the study. Six subjects had clinical relapse defined by a score of 5 or greater on the SCCAI during the week after colonoscopy. Five subjects increased their 5-aminosalicylic acid (5-ASA) medications immediately postcolonoscopy, two of whom had a SCCAI 5 or greater. Multivariate modeling demonstrated a clear association between the week immediately after colonoscopy preparation and increased disease activity, with the time period being predictive of increased SCCAI (week 1 vs. week 4, P = 0.0127). The baseline SCCAI (P value < 0.0001) and prednisone use (P = 0.0120) were predictive of increased SCCAI postcolonoscopy. Thiopurines (P < 0.001) were protective against increased symptoms. CONCLUSIONS: In our study, 1 in 8 subjects had UC relapse by SCCAI immediately postcolonoscopy, and 1 in 10 subjects required an increase in their 5-ASA medications. Clinicians should be cognizant of this effect of colonoscopy in patients with UC.     

5-ASA in ulcerative colitis： Improving treatment compliance

5-aminosalicylic acid （5-ASA） compounds are a highly effective treatment for ulcerative colitis （UC）. While UC patient compliance in clinical studies is over 90%, only 40% of patients in every day life take their prescribed therapy. Adherence to medication has been emphasized recently by a Cochrane meta-analysis that has suggested that future trials of 5-ASA in UC should look at patient compliance rather than drug efficacy. Better compliance can be obtained by reducing the number of tablets and times of administration. Given that the 5-ASA formulations have different delivery systems that split the active moiety in various regions of the intestine, it is particularly important that an adequate dose of the drug arrives at the inflamed part of the colon. 5-ASA Multi matrix （MMx） is a novel, high strength （1.2 g）, oral formulation designed for oncedaily dosing. It releases the active moiety throughout the colon. Different studies with this compound have shown that it is as effective as 5-ASA enema in the treatment of mild-to-moderate, left-sided UC, and is comparable to a pH-dependent, delayed release 5-ASA （Asacol）, even if given once daily. Recently, the effectiveness in the acute phase of UC has been confirmed also in maintenance. In conclusion, at present, 5-ASA MMx seems theoretically the best agent for maintaining patient compliance, and consequently, treatment effectiveness.