Heart rate, respiratory rate, apnoeas and peripheral arterial oxygen saturation in healthy term neonates during quiet sleep.

AIM: This study compiled percentiles for cardiorespiratory parameters in healthy term neonates during quiet sleep. METHODS: We enrolled 215 healthy term neonates born at Hannover Medical School, Germany, between October 2011 and March 2013. They were prospectively observed on the maternity ward at a median age of two days using six-hour recordings of pulse oximeter plethysmography, oxygen saturation, thoracic breathing movements and electrocardiogram during sleep in a supine position. We examined their heart rate, respiratory rate and oxygen saturation during quiet sleep, plus bradycardias, apnoeas lasting at least four-seconds and desaturations below 85%. RESULTS: The 3rd, 50th and 97th percentiles were calculated as follows: heart rate 87, 112 and 133 beats per minute, respiratory rate 32, 44 and 57 per minute and oxygen saturation 94, 98 and 100%. Desaturations, apnoeas and bradycardias below 80 beats per minute were common and recorded in 54%, 98% and 30% of participants. In contrast, only 7% experienced bradycardias of less than two-thirds of the baseline heart rate and 5% experienced apnoeas exceeding 15 seconds. CONCLUSION: Our results will facilitate the evidence-based valuation of cardiorespiratory parameters in term neonates and help validate the significance of cardiorespiratory events in preterm infants at discharge.

Pregnancy risk factors for very premature delivery: what role do hypertension, obesity and diabetes play?

PURPOSE: Very premature delivery is a major cause of infant morbidity and mortality. Obesity, diabetes and pregnancy hypertension are known risk factors for pregnancy complications. The study aimed to scrutinize differences of pregnancy complications in a cohort of very premature deliveries compared to a national group. METHODS: In a multicenter study performed between January 2009 and December 2010 including 1,577 very low birth weight (VLBW) infants, we compared parental reported pregnancy problems of VLBW infants with a national cohort (KIGGS). We compared reported pregnancy complications to reasons for premature delivery and neonatal outcome within the group of VLBW infants. RESULTS: While parents of the national cohort reported pregnancy-induced hypertension in 8 %, parents of VLBW infants reported this complication more frequently (27 %). Mothers of the national cohort were significantly younger (1 year), suffered less from obesity, anaemia, diabetes. Regression analysis showed that hypertension (OR = 5.11) and advanced maternal age (OR = 1.03) increased the risk for premature birth. Women with hypertension were likely to experience a clinically indicated premature delivery, had more VLBW infants with a moderate growth restriction, but less multiples and their infants had less intraventricular haemorrhages grade 3 or 4. Otherwise, neonatal outcome was correlated with gestational age but not with the pregnancy complications diabetes, hypertension or obesity. CONCLUSION: Premature birth seems to be correlated to gestational hypertension and associated problems in about » of VLBW infants. Further studies should focus on preventing and treating gestational hypertension to avoid premature delivery and associated neonatal morbidity.

Major contributors to hospital mortality in very-low-birth-weight infants: data of the birth year 2010 cohort of the German Neonatal Network.

The German Neonatal Network (GNN) is a prospective cohort study with the focus on long term development of very-low-birth-weight infants. It was the aim of this study to determine detailed information on causes of mortality in the GNN birth cohort 2010.Major contributors to hospital mortality were recorded by the attending neonatologists for the cohort of very-low-birth-weight (VLBW) infants born in centres of the German Neonatal Network (GNN) in 2010. The data quality was approved by on-site monitoring.2 221 VLBW infants were born in GNN centres in 2010, and death occurred in 221 infants. Male infants carried a higher risk than females (58.8% males among non-survivors vs. 51.7% among survivors, p=0.047). In 11 infants, the major contributor to death was not determined by the attending neonatologist. In 25 infants born at the limit of viability, comfort palliative care was primarily initiated and 14 infants had lethal malformations. The majority of non-survivors suffered from inflammatory diseases including sepsis- or necrotizing enterocolitis (NEC)-associated death (n=56). Respiratory pathology was a major contributor to death in 65 infants including 11 infants who died from pulmonary haemorrhage.Potentially preventable complications of preterm birth such as sepsis, NEC and pulmonary haemorrhage predominate the major contributors to mortality in the GNN 2010 cohort. In order to decrease the rate of these associated deaths, future trials should focus on prophylaxis and therapy optimization strategies for these outcomes.

Developmental changes of oxalate excretion in enterally fed preterm infants.

To further substantiate gestational age-related changes in oxalate excretion, we studied urinary oxalate excretion in 66 preterm infants born at 23.4-34.7 weeks of gestation. Spot urine of 66 preterm infants was analysed by ion chromatography as soon as they were completely orally fed with enriched breast milk and/or special preterm milk formula (days 7 to 57 of postnatal life). Infants with evidence of renal, gastrointestinal, muscular or metabolic disease were not included. Newborns on parenteral nutrition were excluded. Oxalate/creatinine ratios (Ox/Cr) decreased with gestational age (three age groups: group 1, 23 0/7-28 0/7; group 2, 28 1/7-32 0/7; and group 3, 32 1/7-35 0/7 weeks of gestation). The mean Ox/Cr was highest in group 1 (398.2 mmol/mol +/- 116.8; n = 21). Differences between groups 1 + 3 were statistically significant; p = 0.001; those between groups 1 + 2 and between groups 2 + 3 were not. Ox/Cr correlated inversely with gestational and maturational age (r = -0.41, p = 0.001; r = -0.33, p = 0.007) and positively with postnatal age (r = 0.32, p = 0.008). It correlated inversely with birth weight as well as actual weight at sample collection (r = -0.46 and -0.44, p < 0.001). Ox/Cr was significantly linked to energy and carbohydrate intake (r = 0.3 and 0.4, p = 0.03 and 0.001). These results were independent of sex. In the present study we show that urinary oxalate excretion in preterm infants depends on gestational age.

Prospective surveillance of bacterial colonization and primary sepsis: findings of a tertiary neonatal intensive and intermediate care unit.

BACKGROUND: Preterm infants and critically ill neonates are predisposed to nosocomial infections as sepsis. Moreover, these infants acquire commensal bacteria, which might become potentially harmful. On-ward transmission of these bacteria can cause outbreaks. AIM: To report the findings of a prospective surveillance of bacterial colonization and primary sepsis in preterm infants and neonates. METHODS: The results of the surveillance of bacterial colonization of the gut and the respiratory tract, targeting meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Gram-negative bacteria from November 2016 to March 2018 were analysed. Bacterial colonization was compared to surveillance of sepsis. FINDINGS: Six-hundred and seventy-one patients were admitted and 87.0 % (N=584) of the patients were screened; 48.3% (N=282) of the patients screened were colonized with at least one of the bacteria included in the screening; 26.2% of them (N=74) had multi-drug-resistant strains. A total of 534 bacterial isolates were found. The most frequently found species were Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca and Klebsiella pneumoniae. Three MRSA but no VRE were detected. The surveillance detected a K. pneumoniae cluster involving nine patients. There were 23 blood-culture-confirmed sepsis episodes; 60.9% (N=14) were caused by staphylococci. Gram-negative bacteria (one Klebsiella aerogenes and two E. cloacae) caused three sepsis episodes which were preceded by colonization with the respective isolates. CONCLUSIONS: Surveillance of colonization provided a comprehensive overview of species and antibiotic resistance patterns. It allowed early detection of a colonization cluster. Knowledge of colonization and surveillance of sepsis is useful for guiding infection control measures and antibiotic treatment.

Therapeutic lung puncture for diffuse unilateral pulmonary interstitial emphysema in preterm infants.

BACKGROUND: Pulmonary interstitial emphysema (PIE) represents a severe complication of respiratory distress syndrome and can dramatically impair the ventilation of premature infants. OBJECTIVES: We report three mechanically ventilated premature infants with severe diffuse, unilateral PIE not responding to conventional treatment, whose clinical condition improved dramatically following an ipsilateral pneumothorax. RESULTS: In the first two patients, the pneumothoraces occurred spontaneously. In the third patient, the ipsilateral lung was punctured with a pigtail catheter to create and - subsequently drain - a pneumothorax. Thereafter, mechanical ventilation could be discontinued within 3 days in all infants. CONCLUSIONS: Lung puncture with consecutive tension release of the overinflated lung by drainage is a therapeutic option for premature infants suffering from diffuse PIE in whom other conservative measures fail. It may be considered before proceeding to surgical measures in order to preserve potentially functional lung tissue.

Patient with trisomy 6 mosaicism.

Trisomy 6 and trisomy 6 mosaicism were found in chorionic villi cell culture and short term incubation in a prenatal diagnosis at 12 weeks of gestation in a pregnancy with a growth retarded fetus showing nuchal translucency. The child was born in the 25th gestational week with a number of malformations including heart defects, deep-set ears, cleft right hand, cutaneous syndactylies, and overlapping toes of irregular shape and length. Trisomy 6 was not found in peripheral blood lymphocytes but was confirmed in umbilical cord fibroblasts. Currently, at the age of 2-3/4 years, the development of the child is relatively normal despite considerable growth delay. At the age of two years, she developed a papular erythema clinically suggestive of epidermal nevi. Cytogenetic analysis of fibroblast cultures derived from skin from a right hand finger and the inguinal area confirmed the presence of a trisomy 6 mosaicism. This is the first observation of a liveborn with trisomy 6 mosaicism.

Detection of hyperoxaemia in neonates: data from three new pulse oximeters.

AIM: To determine the sensitivity and specificity of three newly developed pulse oximeters in the detection of hyperoxaemia, defined as an arterial partial pressure of oxygen (PaO(2)) of > 80 mm Hg. METHODS: SpO(2) readings from three oximeters (Agilent Viridia (AgV), Masimo SET (MaS), Nellcor Oxismart (NeO)) were documented in 56 infants (median gestational age at birth 35.5 weeks, range 24-41) whenever an arterial blood gas was taken for clinical purposes. Blood samples were analysed within one minute in a Radiometer ABL 505 blood gas analyser and OSM3 co-oximeter. RESULTS: Between 280 and 291 blood gases were analysed for each instrument; 105-112 showed a PaO(2) > 80 mm Hg. At an upper alarm limit of 95%, the three instruments detected hyperoxaemia with 93-95% sensitivity. Specificity at this alarm level ranged from 26 to 45%. The mean (SD) difference between arterial oxygen saturation and SpO(2) (bias) was -0.25 (2.5)% for AgV, -0.06 (2.5)% for MaS, and -0.91 (2.6)% for NeO (p < 0.01, NeO v AgV and MaS). CONCLUSION: These instruments detected hyperoxaemia with sufficient sensitivity at an upper alarm limit of 95%, but showed differences in their specificity, which was probably related to differences in measurement bias.

Portal venous gas detected by ultrasound differentiates surgical NEC from other acquired neonatal intestinal diseases.

BACKGROUND: The definite clinical diagnosis of acquired neonatal intestinal diseases (ANID) is a challenge, usually met by applying Bell's or, more recently, Gordon's classification. Both classifications incorporate radiological pneumatosis intestinalis (PI) as a cornerstone of the NEC diagnosis. However, PI may be absent or difficult to identify by abdominal X-ray. Portal venous gas detected by ultrasound (PVG-US) has been proposed as another characteristic of NEC, but its incidence in other entities of ANID remains unknown. OBJECTIVE: To determine whether PVG-US and Gordon's classification can help to differentiate between NEC and other ANID, especially SIP. METHODS: Retrospective analysis of the data of 83 infants, who underwent laparotomy for a clinical diagnosis of ANID was performed. The results of PVG-US and other markers of ANID were compared with the operative result, defined as the gold standard for diagnosis. RESULTS: The NEC diagnosis was confirmed in 28/83 infants and PVG-US was present in 23 (82%) of those patients prior to operation. PVG-US was detected in 2 patients without NEC (one volvulus, one SIP), resulting in an 82% sensitivity and a 96% specificity. The sensitivity and specificity of radiological PI for patients with NEC was lower (75 and 91%), but the combination of PVG-US and radiological PI increased the sensitivity for NEC detection to 89%. Gordon's classification had a sensitivity of 93% and a specificity of 92% for NEC diagnosis. CONCLUSION: Screening for PVG-US and Gordon's classification are valid tools to differentiate between NEC and other ANID including SIP. Although an effect of these proposed diagnostic tools on treatment regimen and operative management has yet to be verified, the improvement in diagnosing ANID is certainly valuable.

Prenatal benzoate treatment in urea cycle defects.

OBJECTIVE: In patients with severe urea cycle defects (UCD) metabolic decompensation with hyperammonaemia typically occurs during the first days of life resulting in severe neurological damage or death. Benzoate can eliminate nitrogen independent of the urea cycle. Usually, benzoate is started soon after birth, but prenatal administration might improve metabolic stability. DESIGN: Two fetuses with a prenatal diagnosis of UCD (female: citrullinaemia; male: ornithine transcarbamylase deficiency) were loaded with benzoate prenatally via the placenta by infusing their mothers with benzoate. Benzoate concentrations were measured in umbilical cord blood and the blood of the mothers and their newborns. RESULTS: Therapeutic concentrations of benzoate were found in umbilical cord blood and in the children's blood. Thus, benzoate transfer across the placenta was demonstrated. Plasma ammonia and glutamine levels in the postnatal period were within the normal range. CONCLUSIONS: Benzoate infusion of the mother shortly before birth is safe and results in therapeutic levels of benzoate in umbilical cord blood.

Evaluation of portal venous gas detected by ultrasound examination for diagnosis of necrotising enterocolitis.

BACKGROUND: Early diagnosis of necrotising enterocolitis (NEC) is difficult but essential for timely therapy. The diagnostic hallmarks and specific radiological signs for NEC are pneumatosis intestinalis (PI) and portal venous gas (PVG), but PVG in abdominal ultrasound (PVG-US) has been proposed as an effective tool in the diagnosis of NEC as well. OBJECTIVE: To prospectively assess the value of PVG-US for the diagnosis of NEC. METHODS: The study screened 352 neonates for PVG-US (n = 796 routine examinations) and performed 48 additional screenings in 34/352 neonates with suspected (stage I, n = 28) or definite NEC (stage > or =II, n = 20). Sensitivity and specificity of PVG-US for detection of NEC were computed by using NEC stage > or =II as the reference standard. RESULTS: PVG-US was only present in cases of suspected or definite NEC. The study observed PVG-US in 4/28 NEC stage I and in 9/20 NEC stage > or =II episodes corresponding to a 86% specificity and a 45% sensitivity for diagnosis of NEC stage > or =II. However, 7/20 patients with NEC stage > or =II showed intraoperative findings other than NEC and another 3/20 infants presented with radiologically unspecific intestinal dilatation. None of these 10 infants had detectable PVG-US. Thus, with application of specific radiological signs the sensitivity of PVG-US for diagnosis of NEC stage > or =II increased to 90%. CONCLUSION: Screening for PVG-US is a useful, easy and quick bedside test with a high specificity for NEC. Moreover, these results question the value of the Walsh criteria in the diagnosis of NEC.

[Paroxysmal cold hemoglobinuria in a 2-year-old boy]. / Paroxysmale Kältehämoglobinurie bei einem 2jährigen Jungen.

We report the case of a two-year-old boy, who presented with two episodes of severe abdominal pain and consecutive macrohematuria after he had been outside the house at very low temperatures. The cause of this was found to be acute hemolytic anemia with hemoglobinuria, induced by a cold reacting Donath-Landsteiner autoantibody. After a few days parameters of hemolysis had normalized, hemoglobin levels were within the normal range after 4 weeks. Eight months later the Donath-Landsteiner autoantibody could not be detected any more, the boy is healthy since then.

Effects of bottle feeding and two different methods of gavage feeding on oxygenation and breathing patterns in preterm infants.

OBJECTIVE: To determine the effect of bottle feeding, as compared to two methods of gavage feeding, on apnoea, bradycardia and oxygen desaturation frequency. PATIENTS: Thirty preterm infants breathing room air; gestational age 28.6 +/- 2.1 weeks at birth and 34 +/- 1.4 weeks at study (mean +/- SD). METHODS: Nine-hour recordings of pulse oximeter saturation (SpO2), pulse waveforms, electrocardiogram, breathing movements and nasal airflow. Administration of 21 +/- 1.5 ml/kg of milk/feed in 3-h intervals using three different feeding techniques in random order: bottle feeding, bolus gavage feeding, and slow gavage feeding (1 h). Analysis of recordings for apnoeas (> or =4s, bradycardias (heart rate < 2/3 of baseline), and episodic desaturation (SpO2 < or = 80%). RESULTS: There were three times more desaturations with bottle feeding than with bolus gavage feeding (p < 0.001), but no further reduction with slow gavage feeding. With all three feeding techniques, there were significantly more desaturations in the hour when the feeds were given than during the following 2 h. The deleterious effects of bottle feeding were most evident during the hour of feeding, but desaturation frequency remained significantly higher than with gavage feeding during the following 2 h. There was no significant effect of feeding technique on the frequency of apnoea or bradycardia. CONCLUSIONS: Preterm infants who are normally oxygenated in room air may have significant desaturation during bottle feeding. Such desaturation can be effectively reduced by gavage feeding. Slow gavage feeding offers no advantage over bolus gavage feeding with respect to the avoidance of hypoxaemia.

Pulse oximeters' reliability in detecting hypoxemia and bradycardia: comparison between a conventional and two new generation oximeters.

OBJECTIVE: Pulse oximeters are increasingly used for patient monitoring; however, they are traditionally very prone to motion artifact. Newly developed instruments have lower false alarm rates. We wanted to know whether this is achieved at the expense of an increased proportion of false negative alarms such as missed or delayed identification of hypoxemia and/or bradycardia. DESIGN: Observational study. SETTING: Neonatal intensive care unit. PATIENTS: A total of 17 unsedated preterm infants (median gestational age at birth, 25 wks; range, 24-30 wks). INTERVENTION: Long-term recordings of transcutaneous partial pressure of oxygen (P(Tc)O2), heart rate, pulse oximeter saturation (SpO2), and pulse rate from a conventional oximeter and two new generation oximeters. MEASUREMENTS: Recordings were analyzed for episodes with P(Tc)O2 <40 torr or with heart rate <80 beats/min for >5 secs. Hypoxemia was considered identified if SpO2 had fallen to <85% within 2 mins of P(Tc)O2 reaching 40 torr, and bradycardia was considered identified if pulse rate had fallen to <80 beats/min within 2 mins of the heart rate reaching this threshold. MAIN RESULTS: A total of 202 falls in P(Tc)O2 to <40 torr occurred; 174 (86%) were identified by all three oximeters. Of the remaining episodes, manual analysis of red and infrared absorption signals confirmed that SpO2 had indeed been <85% for > or =10 secs in 11 episodes; therefore, these episodes should have been identified by all three oximeters. None of these had been missed by the conventional oximeter, but 10 (5.4% of the total) were missed by one of the new generation instruments (Nellcor), and one (0.5%) was missed by the other (Masimo). Of 54 bradycardias, only 14 were identified by all three oximeters; 17 (32%) were missed by the conventional, 37 (69%) by the Nellcor, and 4 (7%) by the Masimo instrument. CONCLUSION: One of the two new generation instruments investigated in this study missed 5.4% of hypoxemic episodes and 69% of bradycardias. It thus appears that this instrument's reduced false alarm rate is achieved at the expense of an unreliable and/or delayed identification of hypoxemia and bradycardia. The other instrument identified both conditions equally as or more reliably than a conventional pulse oximeter.

Effect of doxapram on episodes of apnoea, bradycardia and hypoxaemia in preterm infants.

AIM: To study the effect of doxapram on the frequency of apnoea, bradycardia and hypoxaemia. METHODS: Fifteen infants, median gestational age at birth 27 weeks (range 24-30), age at study 27 days (12-60), with >/=6 episodes of bradycardia or hypoxaemia/6 h despite serum caffeine levels in the therapeutic range, received doxapram either intravenously (0.5-2 mg/kg/h) or orally (2-8 mg/kg every 2 h). Six-hour recordings of pulse oximeter saturation (S(P)O(2)), pulse waveforms, ECG, breathing movements and nasal airflow were performed immediately before as well as 1, 3 and 6 days after onset of treatment. Recordings were analysed for apnoea (>/=4 s), bradycardia (heart rate < 2/3 of baseline) and hypoxaemia (S(P)O(2)

Effect of blood transfusion on apnoea, bradycardia and hypoxaemia in preterm infants.

UNLABELLED: We studied the effect of blood transfusion on the frequency of apnoea, bradycardia and hypoxaemia in 21 spontaneously breathing preterm infants with a median gestational age at birth of 28 (range 23-31) weeks. Age at time of study was 22 days (3-84), weight 925 g (640-2120). The patients exhibited frequent episodes of bradycardia and/or hypoxaemia and were anaemic (median haemoglobin level 109 (82-120) g/l). One infant received two transfusions and was thus studied twice. Four-hour recordings of pulse oximeter saturation (SpO2), pulse waveforms, transcutaneous oxygen pressure, electrocardiogram, breathing movements and nasal airflow were performed immediately before and after transfusion, and again after a further interval of 12 h. Recordings were analysed for isolated and periodic apnoeas (> 4 s), bradycardias (heart rate < 2/3 of baseline), and episodic desaturation (SpO2 < or = 80%). There were no significant changes in the frequency, severity and/or duration of apnoea, bradycardia or desaturation following transfusion. The average SpO2 nadir reached during each desaturation, however, increased by 3% following transfusion (P < 0.05), and there was a trend towards shorter desaturations. CONCLUSION: The occurrence of frequent episodes of apnoea, bradycardia and/or hypoxaemia does not, on its own, justify a blood transfusion in moderately anaemic preterm infants.

Skin-to-skin (kangaroo) care, respiratory control, and thermoregulation.

AIM: To demonstrate that skin-to-skin care (SSC) has no detrimental effects on the frequency of episodes of bradycardia and/or hypoxemia. METHODS: Twenty-two spontaneously breathing preterm infants (median gestational age at birth, 29 weeks [range, 24-31 weeks]; age at study, 26 days [range, 7-72 days]; weight at study, 1310 g [range, 725-1890 g]) had three 2-hour recordings of breathing movements, nasal airflow, heart rate, and oxygen saturation as measured by pulse oximetry (SpO(2)) before, during, and after SSC. Rectal temperature was obtained every 2 hours. Recordings were analyzed for baseline heart and respiratory rates, bradycardia (heart rate < two thirds of baseline), and hypoxemia (SpO(2) < or =80%), as well as for breathing pattern (regular vs non-regular). RESULTS: Baseline heart rate and respiratory rate increased during SSC (P <.01), as did the combined frequency of bradycardia and hypoxemia (from 1.5/h [0-8] before to 2.8/h [0-15] during SSC; P<.05). Rectal temperature increased from 36.9 degrees C (36.2 degrees -37.4 degrees C) to 37.3 degrees C (36.6 degrees -38.6 degrees C; P <.01). The proportion of regular breathing pattern decreased from 14% (2%-28%) to 7% (3%-26%) with SSC (P<.01). CONCLUSION: SSC was associated with a significant increase in the combined frequency of bradycardia and hypoxemia and with less regular breathing. These changes were unexpected and may have been related to heat stress. Body temperature, heart rate, and oxygenation should be monitored during SSC.

[Intraoperative thrombosis of the inferior vena cava]. / Intraoperative Thrombose der V. cava inferior.

A pre-term infant weighing 900 g, gestational age 25 weeks, developed an acute abdomen. Intravenous lines had been inserted previously in the left (silastic catheter) and right (24 G cannula) saphenous veins in the neonatal intensive care unit. During surgical exploration, a perforation of the terminal ileum was found. The operation consisted in partial resection of the perforated ileum with an end-to-end anastomosis and a double-lumen colostomy. Major blood loss during the procedure caused serious haemodynamic problems. Despite transfusion of erythrocyte (100 ml), thrombocytes (75 ml), and albumin (50 ml), the patient developed bradycardia and hypotension. Administration of atropine, adrenaline, and calcium i.v. had no effect. The operation could be finished only with extrathoracic resuscitation. When the drapes were removed, livid, swollen lower limbs raised the suspicion of an acute thrombosis of the inferior vena cava. After insertion of a 24 G i.v. cannula into a vein of the right upper arm, the circulation stabilised after rapid transfusion of 40 ml blood and 25 ml thrombocytes and resuscitation was successful. Paediatricians and anaesthesiologists must consider the risk of thrombosis of the vena cava. If venous lines in the lower limbs are not visible to the anaesthesiologist during the operation, venipuncture of veins of an upper limb is recommended before starting the surgical procedure. Due to the high incidence of vena cava thrombosis caused by central venous lines and the difficulty of peripheral venipuncture in pre-termintanty, a safe venous line should be inserted if necessary by pre-operative venesection.