RESUMO
OBJECTIVE: Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1-4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. DESIGN: Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. SETTING: Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. INTERVENTIONS: Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. CONCLUSION: The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.
Assuntos
Endometriose/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Plexo Hipogástrico/cirurgia , Enteropatias/cirurgia , Laparoscopia/métodos , Doenças Peritoneais/cirurgia , Dissecação/educação , Dissecação/métodos , Endometriose/patologia , Feminino , Procedimentos Cirúrgicos em Ginecologia/educação , Humanos , Plexo Hipogástrico/diagnóstico por imagem , Plexo Hipogástrico/patologia , Enteropatias/patologia , Itália , Laparoscopia/educação , Ontário , Órgãos em Risco/diagnóstico por imagem , Órgãos em Risco/patologia , Órgãos em Risco/cirurgia , Pelve/diagnóstico por imagem , Pelve/inervação , Pelve/patologia , Pelve/cirurgia , Doenças Peritoneais/patologiaRESUMO
INTRODUCTION: Adequate liver retraction is an essential step in bariatric surgery, with technical challenges due to an enlarged, fatty liver. Traditional methods utilize externally fixed, rigid retractors with inherent drawbacks including an extra incision, pain, scarring, and liver injury. Advancement of laparoscopic techniques for liver retraction methods has focused on simplicity, reproducibility, safety, and effective use to avoid patient comorbidity. Our study is a retrospective evaluation of the safety and efficacy of a totally internal, atraumatic bulldog liver retractor versus standard retraction in a large series of patients undergoing laparoscopic bariatric surgery. METHODS: A retrospective chart review was performed on all patients undergoing bariatric surgery from April 2010 to December 2017. Standard retraction was used in 108 subjects and a bulldog retractor system attached to the pars flaccida, and anterior abdominal wall was used in 483 subjects. Any operations with additional procedures, re-do operations, or missing data were excluded. RESULTS: Five hundred fifty-one procedures were included between 2010 and 2017. In unadjusted analysis, no significant differences were found in AST/ALT elevation, need for additional retraction, length of stay (LOS), or operative times between the bulldog and standard retraction. Adjustment for demographics and Roux-en-Y gastric bypass versus sleeve gastrectomy in a multivariable logistic regression model, the standard retractor showed higher odds of AST/ALT elevation post-op and higher odds of needing additional retraction compared with those of the bulldog retractor. DISCUSSIONS/CONCLUSION: The bulldog retractor system can be used safely and effectively to expose the gastroesophageal junction in morbidly obese patients with advancements on the customary approach.
Assuntos
Cirurgia Bariátrica/instrumentação , Cuidados Intraoperatórios , Fígado/patologia , Fígado/cirurgia , Obesidade Mórbida/cirurgia , Instrumentos Cirúrgicos , Parede Abdominal/cirurgia , Adulto , Cirurgia Bariátrica/métodos , Desenho de Equipamento , Fígado Gorduroso/complicações , Fígado Gorduroso/patologia , Fígado Gorduroso/cirurgia , Feminino , Gastrectomia/instrumentação , Gastrectomia/métodos , Derivação Gástrica/instrumentação , Derivação Gástrica/métodos , Humanos , Cuidados Intraoperatórios/instrumentação , Cuidados Intraoperatórios/métodos , Laparoscopia/instrumentação , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/patologia , Duração da Cirurgia , Tamanho do Órgão , Órgãos em Risco/patologia , Órgãos em Risco/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Instrumentos Cirúrgicos/efeitos adversos , Instrumentos Cirúrgicos/normas , Ferida Cirúrgica/etiologiaRESUMO
The purpose of this study was to analyze transposed ovarian movement. Data from 27 patients who underwent ovarian transposition after surgical treatment for uterine cancer were retrospectively analyzed. Computed tomography (CT) images including transposed ovaries were superimposed on other CT images acquired at different times, and were matched on bony structures. Differences in ovarian position between the CT images were measured. The planning organ at risk volume (PRV) margins were calculated from the formula of the 90% reference intervals (RIs) and the 95% RI, which were defined as mean ± 1.65 standard deviation (SD) and mean ± 1.96 SD, respectively. The 90% RI in the cranial, caudal, anterior, posterior, left and right directions were 1.5, 1.5, 1.4, 1.0, 1.7 and 0.9 cm, respectively. The 95% RI in the corresponding directions were 1.5, 2.0, 1.7, 1.2, 1.9 and 1.2 cm, respectively. These data suggest that bilateral ovaries need a PRV margin of â¼2 cm in all directions. The present study suggests that a transposed ovary needs the same PRV margin as a normal ovary (â¼2 cm). Even after transposition, ovaries should be kept away from the radiation field to take into consideration the degree of ovarian movement.
Assuntos
Ovário/diagnóstico por imagem , Ovário/cirurgia , Proteção Radiológica/métodos , Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias Uterinas/diagnóstico por imagem , Neoplasias Uterinas/radioterapia , Adulto , Relação Dose-Resposta à Radiação , Feminino , Humanos , Movimento (Física) , Órgãos em Risco/efeitos da radiação , Órgãos em Risco/cirurgia , Pelve/efeitos da radiação , Radiografia , Dosagem Radioterapêutica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
In recent years, a definite change towards organ-sparing, reconstructive local treatment of penile cancer has been observed. Surgical treatment aims to achieve margin-free resections with risk-adapted much smaller safety margins. Thus, the penile structures are preserved as far as possible or reconstructed in order to achieve a functionally and cosmetically satisfactory result. The oncological safety concerning tumor-free survival is not compromised. However, a higher rate of local recurrences has to be accepted.
Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Neoplasias Penianas/cirurgia , Transplante de Pele/métodos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Humanos , Masculino , Neoplasias Penianas/diagnóstico , Recuperação de Função FisiológicaRESUMO
BACKGROUND: Curative treatment for prostate cancer is associated with risks which may adversely influence quality of life. Furthermore, there is a considerable rate of overdiagnosis of tumors which would be non-life-threatening if left untreated. Efforts have been made to reduce overtreatment. DISCUSSION: Beside the traditional conservative symptomatic management especially in elderly patients with meaningful comorbidity, several prostate-sparing or deferred treatment options are currently discussed. For all of them, insufficient data on efficacy and safety are available. RESULTS: Because of the required long-term follow-up of large sample sizes, conclusive data will not become available in the near future. Therefore, these treatment options have to be considered experimental to a large degree. This applies both to focally ablative techniques and to active surveillance of prostate cancer in patients with a long further life expectancy. Only in carefully selected patients with favorable tumor-associated risk profiles and high risk of medium-term competing mortality may active surveillance be considered a valid and relatively safe treatment option.
Assuntos
Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/radioterapia , Neoplasias da Próstata/cirurgia , Conduta Expectante/métodos , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Órgãos em Risco/efeitos da radiação , Neoplasias da Próstata/diagnóstico , Recuperação de Função FisiológicaRESUMO
Primary urethral carcinomas are rare tumors that can occur both in men and women. Histological patterns of these tumors are mixed, urothelial tumors occur as well as squamous cell tumors or adenocarcinomas.There are different clinical factors that define clinical prognosis, and the 1- and 5-year cancer-free survival is 75% and 54%. Therapy of locally limited disease is surgical resection, and organ-preserving treatment is possible if negative frozen sections prove complete surgical resection. However, in men a perineal urethrostomy might be necessary, and in women there is a high risk of urinary incontinence if more than 2 cm of the distal urethra is resected.In case of locally advanced tumors or tumors of the proximal urethra, a radical urethrectomy with supravesical urinrary diversion is necessary. In some cases neoadjuvant (radio-)chemotherapy may be an option.
Assuntos
Antineoplásicos/uso terapêutico , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Neoplasias Uretrais/terapia , Procedimentos Cirúrgicos Urológicos/métodos , Quimioterapia Adjuvante/métodos , Feminino , Humanos , Masculino , Recuperação de Função FisiológicaRESUMO
BACKGROUND: The therapy of malignant testicular neoplasms has always been characterized by a high degree of radicality. Thanks to a number of medical achievements the cure rate of testicular cancer has notably increased through the last decades. In the meanwhile the main focus is on reducing therapy load, scrutinizing radical orchiectomy as the only adequate therapy for the primary tumour. OBJECTIVES: This article discusses the question, if and under which conditions an organ-sparing approach can be used appropriately in clinical practice. MATERIALS AND METHODS: A selective literature search was performed in PubMed. RESULTS: A set of data suggest that endocrine and exocrine function of the testis can be preserved using an organ-sparing approach and many patients could benefit regarding their quality of life, e.g., preserving the ability to father a child at least temporarily and avoiding the need for hormone substitution. Different from kidney tumors, precancerous lesions (testicular intraepithelia neoplasia, TIN) can almost inevitably be found in the surrounding tissue of testicular tumors. This has to be considered when making a decision in favor of an organ-sparing approach, because radiation therapy on the affected testis has to be performed after tumor resection. Despite the absence of prospective data, organ-sparing surgical tumor resection can be recommended in carefully selected patients. CONCLUSION: After careful selection of patients, particularly young men can profit from an organ-sparing therapy regimen. Therefore, organ preservation should always be considered in the surgical treatment of testicular masses.
Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Recuperação de Função Fisiológica , Neoplasias Testiculares/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Humanos , Masculino , Neoplasias Testiculares/diagnósticoRESUMO
Transitional cell carcinoma of the bladder can - in the majority of cases - be safely treated by transurethral resection and bladder preservation. In case of more aggressive and genetically instable tumors, the effect of radical cystectomy depends on tumor volume. If complete resection of invasive tumors is also possible, the additional effect of radical cystectomy seems to be marginal. In patients with favorable tumor location and acceptable prostate parameters, prostate-sparing surgery seems to be oncologically safe with good quality of life.
Assuntos
Carcinoma de Células de Transição/cirurgia , Cistectomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Carcinoma de Células de Transição/diagnóstico , Humanos , Recuperação de Função Fisiológica , Neoplasias da Bexiga Urinária/diagnósticoRESUMO
With the technical innovations of smaller, flexible ureteroscopes, color-filtered imaging, and endoscopic laser technology, organ-preserving treatment for upper urinary tract transitional cell carcinoma has become feasible. While in the past, radical nephroureterectomy was the sole gold standard approach for the treatment of upper urinary tract tumors, the endoscopic approach is no longer restricted to only patients with the imperative indication of kidney preservation. Initial clinical results have demonstrated oncologic efficacy of endoscopic management or segmental ureteral resection. However, careful preoperative risk-assessment and close endoscopic follow-up are mandatory.
Assuntos
Neoplasias Renais/cirurgia , Nefrectomia/métodos , Tratamentos com Preservação do Órgão/métodos , Órgãos em Risco/cirurgia , Neoplasias Ureterais/cirurgia , Ureteroscopia/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Humanos , Neoplasias Renais/patologia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Recuperação de Função Fisiológica , Neoplasias Ureterais/patologiaRESUMO
BACKGROUND: The aim of this study was to evaluate the clinical efficacy of submandibular gland transfer for the prevention of xerostomia after radiotherapy for nasopharyngeal carcinoma. METHODS: Using the randomized controlled clinical research method, 65 patients with nasopharyngeal carcinoma were randomly divided into an experimental group consisting of 32 patients and a control group consisting of 33 patients. The submandibular glands were averted to the submental region in 32 patients with nasopharyngeal carcinoma before they received conventional radiotherapy; a lead block was used to shield the submental region during therapy. Prior to radiotherapy, the function of the submandibular glands was assessed using imaging. Submandibular gland function was measured using 99mTc radionuclide scanning at 60 months after radiotherapy. The data in the questionnaire regarding the degree of xerostomia were investigated and saliva secretion was measured at 3, 6, 12, and 60 months after radiotherapy. In addition, the 5-year survival rate was calculated. RESULTS: After follow-up for 3, 6, and 12 months, the incidence of moderate to severe xerostomia was significantly lower in the experimental group than in the control group. The average amount of saliva produced by the experimental and control groups was 1.60 g and 0.68 g, respectively (P<0.001). After follow-up for 60 months, the uptake and secretion functions of the submandibular glands in the experimental group were found to be significantly higher than in the control group (P<0.001 and P<0.001, respectively). The incidence of moderate or severe xerostomia was significantly lower than in the control group (15.4% and 76.9%, respectively; P<0.001). The 5-year survival rates of the experimental group and the control group were 81.3% and 78.8%, respectively, and there was no significant difference between the two groups (P=0.806). CONCLUSIONS: After a 5 year follow-up period involving 32 patients who had their submandibular glands transferred for the prevention of xerostomia after radiotherapy for nasopharyngeal carcinoma, we found that clinical efficacy was good. This approach could improve the quality of life of nasopharyngeal carcinoma patients after radiotherapy and would not affect long-term treatment efficacy.
Assuntos
Neoplasias Nasofaríngeas/radioterapia , Lesões por Radiação/prevenção & controle , Glândula Submandibular/transplante , Xerostomia/prevenção & controle , Adulto , Carcinoma , Carcinoma de Células Escamosas/diagnóstico por imagem , Carcinoma de Células Escamosas/radioterapia , Feminino , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/radioterapia , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma Nasofaríngeo , Neoplasias Nasofaríngeas/diagnóstico por imagem , Órgãos em Risco/diagnóstico por imagem , Órgãos em Risco/cirurgia , Cintilografia , Carcinoma de Células Escamosas de Cabeça e Pescoço , Glândula Submandibular/diagnóstico por imagem , Glândula Submandibular/efeitos da radiação , Resultado do Tratamento , Xerostomia/etiologia , Adulto JovemRESUMO
We present the case of a 69-year-old patient with a history of gynecological neoplasia and a pulmonary metastasis, who in 1996 underwent chemotherapy and mediastinal radiotherapy followed by cancer remission. Ten years later she presented with heart failure and her Doppler echocardiogram showed severe mitral regurgitation with pulmonary hypertension. In 2011, she underwent a mitral valve replacement with a biological prosthesis and the pathology exam revealed valve damage consistent with radiotherapy-induced changes. This unusual mechanism of mitral regurgitation can be demonstrated clearly by echocardiography and should be disseminated among cardiology physicians and in patients who have survived for long periods after radiotherapy, it is important to remember that cardiac complications may indeed occur, and the treating physician is responsible for detecting them.
Assuntos
Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Lesões por Radiação/diagnóstico por imagem , Lesões por Radiação/etiologia , Radioterapia/efeitos adversos , Idoso , Ecocardiografia/métodos , Feminino , Insuficiência Cardíaca/cirurgia , Humanos , Insuficiência da Valva Mitral/cirurgia , Órgãos em Risco/efeitos da radiação , Órgãos em Risco/cirurgia , Lesões por Radiação/cirurgia , Resultado do TratamentoRESUMO
Clinical resulting risks of the abdominal organs trauma in the injured persons, as a consequence of a traffic accident, constitute an important component of multicomponent polysystem trauma for the sign of taking part in a traffic.
Assuntos
Acidentes de Trânsito/mortalidade , Órgãos em Risco/lesões , Pâncreas/lesões , Cavidade Abdominal/cirurgia , Traumatismos Abdominais/cirurgia , Condução de Veículo , Automóveis , Humanos , Motocicletas , Órgãos em Risco/cirurgia , Pâncreas/cirurgia , Projetos de Pesquisa , Medição de Risco , Baço/lesões , Baço/cirurgia , Taxa de SobrevidaRESUMO
INTRODUCTION: The decision on thrombolytics administration is usually based on a generalized, rigid time-based rule rather than an individualized evaluation of the "tissue at risk of infarction" which is the target of the recanalization therapies. The goals of our article are to assess whether there is tissue at risk of infarction in a group of acute stroke patients treated beyond 8 h after symptom onset and to investigate the baseline imaging and clinical features that predict the fate of this tissue at risk. METHODS: We retrospectively reviewed a series of patients with acute ischemic stroke treated with endovascular recanalization therapies beyond 8 h after symptom onset. The tissue at risk was calculated as the difference between the infarct volumes on baseline and follow-up imaging (infarct growth). We analyzed the epidemiological distribution of infarct growth, and we performed a multivariate regression analysis to identify the baseline variables that predict infarct growth. RESULTS: Our study group included 75 patients (65 ± 13.8 years, baseline National Institutes of Health Stroke Scale 14 ± 4.9, time to treatment 15.2 ± 8.7 h). The mean infarct growth was 78.6 ± 95.0 cc (p < 0.001), and, overall, the infarct growth was greater when the baseline volume of infarct tissue was small (p < 0.001) and in the case of a unsuccessful arterial recanalization (p = 0.001). CONCLUSIONS: There is potentially salvageable ischemic tissue at risk in acute stroke patients treated beyond 8 h after symptom onset.
Assuntos
Angiografia Cerebral/estatística & dados numéricos , Procedimentos Endovasculares/mortalidade , Fibrinolíticos/uso terapêutico , Órgãos em Risco/diagnóstico por imagem , Órgãos em Risco/patologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Órgãos em Risco/cirurgia , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Acidente Vascular Cerebral/mortalidade , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES/HYPOTHESIS: To evaluate the effect of larynx and esophageal inlet sparing on dysphagia recovery after intensity-modulated radiotherapy (IMRT) for stage III-IV oropharyngeal squamous cell carcinoma. STUDY DESIGN: Retrospective study. METHODS: Of 88 patients treated with IMRT, 38 were planned with a larynx + esophageal inlet mean dose <50 Gy constraint, 27 with a larynx alone mean dose constraint of <50 Gy, and 23 without a larynx/esophagus constraint. All had a percutaneous endoscopic gastrostomy (PEG) tube placed before IMRT, which was removed when the patient could swallow and maintain weight. All IMRT plans were retrieved, and the larynx; esophageal inlet; and superior, middle, and inferior constrictors were contoured. Dosimetric data were correlated with PEG tube dependence duration. RESULTS: The PEG tube was removed within 3, 6, 9, and 12 months after IMRT in 24%, 61%, 71%, and 83% of patients, respectively. Median times to PEG tube removal were 3.7 and 8.6 months (P = .0029) in patients planned with or without a larynx/larynx + esophageal inlet dose constraint. A mean dose to the larynx + esophageal inlet of ≤60 Gy reduced the median PEG tube duration from 10.8 to 6.1 months (P = .02), compared to >60 Gy. Mean pharyngeal constrictor doses in patients receiving a mean dose to the larynx + esophageal inlet of ≤50 Gy versus >50 Gy were: 60 Gy and 69 Gy, 55 Gy and 67 Gy, and 47 Gy and 57 Gy, for the superior, middle, and inferior constrictors, respectively (P < .0001). CONCLUSIONS: A dose constraint on the larynx and esophageal inlet during IMRT planning reduces dose to pharyngeal constrictors and expedites PEG tube removal.
Assuntos
Carcinoma de Células Escamosas/radioterapia , Transtornos de Deglutição/prevenção & controle , Remoção de Dispositivo/métodos , Esôfago/cirurgia , Laringe/cirurgia , Neoplasias Orofaríngeas/radioterapia , Radioterapia de Intensidade Modulada/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/complicações , Carcinoma de Células Escamosas/diagnóstico , Transtornos de Deglutição/etiologia , Esôfago/efeitos da radiação , Feminino , Seguimentos , Humanos , Laringe/efeitos da radiação , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Órgãos em Risco/efeitos da radiação , Órgãos em Risco/cirurgia , Neoplasias Orofaríngeas/complicações , Neoplasias Orofaríngeas/diagnóstico , Estudos RetrospectivosRESUMO
In the management of muscle-invasive bladder cancer, prostate-sparing cystectomy represents a surgical alternative to radical cystoprostatectomy with equivalent oncological and improved functional results. Patient selection for prostate-sparing cystectomy is very critical and men with pT1 high-grade or solitary pT2 urothelial cancer without multifocal CIS and bladder neck involvement appear to be the most appropriate candidates. Stromal invasion of the prostate and accompanying clinically significant prostate cancer must be ruled out by appropriate diagnostic maneuvers. Considering the above-mentioned selection criteria, local and systemic relapse rates are around 3 and 13%, respectively, and do not differ from radical cystoprostatectomy. Daytime and nighttime continence is around 90-95% and erectile function can be preserved in 80-90% of the patients. Therefore, the functional results are much better than those achieved for nerve-sparing radical cystoprostatectomy. Especially young men might benefit from prostate-sparing cystectomy.