Weak association between urea-creatinine ratio and c-reactive protein with nutritional risk in hospitalized patients with COVID-19: A cross-sectional study.

BACKGROUND: COVID-19 is a systemic infection with a significant impact on nutrition risk and the hematopoietic system. The neutrophil-lymphocyte ratio (NLR) may have prognostic value in determining severe cases of COVID-19 and the urea-creatinine ratio (UCR) is currently being studied as a potential biomarker of catabolism associated with critical illness. The aim was to assess the association between the NLR, UCR and C-reactive protein (CRP) with nutritional risk in hospitalized patients with COVID-19. METHODS: This is a retrospective cross-sectional study that assessed 589 hospitalized patients with COVID-19, 18 years of age or older, of both sexes. Nutritional risk was assessed by Nutritional Risk Screening (NRS, 2002) and NLR by neutrophils divided by lymphocyte count. The UCR was calculated by the ratio between urea and creatinine and quantified by the calorimetric biochemical method and CRP by the immunoturbidimetric method. Differences between groups were applied by the Mann-Whitney U test and the automated binary regression test. RESULTS: Of the 589 patients, 87.4% were at nutritional risk. When evaluating patients admitted to the ICU, 91.9% were at nutritional risk. Patients with NRS ≥3 are older, with lower body mass and BMI, higher NLR and UCR and lower CRP values. However, 73% of patients admitted to the ward were at nutritional risk, and only age differed between groups, being higher in patients with NRS ≥3. Logistic regression showed a weak association between nutritional risk in NRS and UCR (Model 1) (OR = 0.96, 95%CI: 0.94-0.99, p = 0.003) and NRS with CRP (Model 1) (OR = 1.01, 95%CI: 1.00-1.02, p < 0.001) in patients in the ICU. On the other hand, the logistic regression in ward patients found association only for CRP in both models (Model 1, OR = 1.01, 95%CI: 1.00-1.01, p = 0.041) and (Model 2, OR = 1.01, 95%CI: 1.00-1.01, p = 0.031). CONCLUSION: We found a weak association between nutritional risk and UCR and CRP levels in patients admitted to the ICU, while in the ward patients the nutritional risk also had weak association with CRP.

A Randomized Controlled Trial on the Effects of Leucine-Supplement Combined with Nutritional Counseling on Body Composition in Mix Cancer Older Men.

BACKGROUND: Malnutrition and metabolic alterations of cancer cachexia are often associated with negative weight loss and muscle mass wasting. In this sense, protein supplementation can be a strategy to help counteract the loss and/or maintenance of mass in these patients. The aim of this study was to evaluate the effect of leucine supplementation on body composition in outpatients with gastrointestinal tract cancer. METHODS: It was a randomized, blinded, controlled, parallel trial, performed in male patients with a cancer diagnosis of the gastrointestinal tract and appendix organs undergoing chemotherapy. All the patients were allocated to one of the protocol groups: L-leucine supplement or the control group, during 8 weeks of intervention. We evaluated the body composition through bioelectrical impedance analysis, the cancer cachexia classification, and the diet intake before and after the intervention protocol. The intention-to-treat approach was performed to predict the missing values for all patients who provide any observation data. RESULTS: The patients were an average age of 65.11 ± 7.50 years old. In the body composition analysis with patients who finished all the supplementation, we observed a significant gain in body weight (61.79.9 ± 9.02 versus 64.06 ± 9.45, p = 0.01), ASMM (7.64 ± 1.24 versus 7.81 ± 1.20, p = 0.02) in the Leucine group, whereas patients in the control did not present significant variation in these parameters. There was no significant intergroup difference. While in the analysis included the patients with intention-to-treat, we found a significant increase in body weight (p = 0.01), BMI (p = 0.01), FFM (p = 0.03), and ASMM (p = 0.01) in the Leucine group. No significant intergroup differences. These results also similar among cachectic patients. CONCLUSION: A balanced diet enriched with free-Leucine supplementation was able to promotes gains in body weight and lean mass in older men diagnosticated with gastrointestinal and appendix organs of digestion cancer after 8 weeks. However, the fact that most men are non-cachectic or pre-cachectic is not clear if the increase in muscle mass was due to a high intake of leucine, since no difference between groups was detected. Moreover, we know that benefits on body composition are due to adequate calorie and macronutrients consumption and that balanced feeding according to nutrition Guidelines seems crucial and must be advised during the oncological treatment.

Amino acids and cancer: potential for therapies?

PURPOSE OF REVIEW: Cancer patients may have a variety of disorders associated with systemic inflammation caused by disease progression. Consequently, we have protein hypercatabolism. In view of this, protein and amino acid adequacy should be considered in relation to nutritional behavior. Therefore, this review aims to evaluate the influence of protein and amino acids in the nutritional therapy of cancer. RECENT FINDINGS: Diets with adequate protein levels appear to be beneficial in the treatment of cancer; guidelines suggest consumption of greater than 1.0-1.5 g/kg body weight/day. In patients diagnosed with malnutrition, sarcopenia, or cachexia, it is recommended to use the maximum amount of protein (1.5 g/kg of weight/day) to adapt the diet. In addition, based on the evidence found, there is no consensus on the dose and effects in cancer patients of amino acids such as branched-chain amino acids, glutamine, arginine, and creatine. SUMMARY: When evaluating the components of the diet of cancer patients, the protein recommendation should be greater than 1.0-1.5 g/kg of weight/day, with a distribution between animal and vegetable proteins. We found little evidence demonstrating clinical benefits regarding individual or combined amino acid supplementation. Still, it is unclear how the use, dose, and specificity for different types of cancer should be prescribed or at what stage of treatment amino acids should be prescribed.

Effects of Juçara (Euterpe edulis Martius) on Health: An Overview of Clinical and Experimental Studies and Call for Action.

BACKGROUND AND AIMS: Juçara is a fruit of ecological and nutritional importance. Its fruits represent an option for the sustainable use of the plant due to its vulnerability to extinction. Thus, the aim of this review was to analyze clinical and experimental studies and highlight the literature gaps regarding the effects of supplementation with Juçara on health. METHODS: For this scoping review, we consulted the Medline (PubMed), Science Direct, and Scopus databases in March, April, and May 2022. Experimental studies and clinical trials published in the last ten years (2012-2022) were analyzed. Data were synthesized and reported. RESULTS: A total of 27 studies were included, 18 of which were experimental studies. Of these, 33% evaluated inflammatory markers associated with fat accumulation. Most of these studies (83%) used pulp in lyophilized form, and the others (17%) involved juçara extract mixed in water. In addition, 78% of the studies showed positive results with respect to the lipid profile, reduction of oncological lesions, inflammation, microbiota modulation, and improvement in obesity and glycemia-related metabolic complications. Nine clinical trials with results similar to those of experimental trials were found. The majority (56%) were chronic (four to six weeks into the intervention), and 44% were acute. Three offered juçara supplementation in the form of juice, four used freeze-dried pulp, two used fresh pulp, and one used a 9% dilution. The dose was fixed at 5 g, but the dilution ranged from 200 to 450 mL. These trials assessed mainly healthy, physically active, and obese individual adults (19-56 years old), and cardioprotective and anti-inflammatory effects, as well as improvement in the lipid profile and prebiotic potential, were observed. CONCLUSION: Juçara supplementation showed promising results with respect to its effect on health. However, further studies are needed to clarify these possible effects on health and their mechanisms of action.

MSRA has low concordance with skeletal muscle mass index in mixed cancer patients: A preliminary and feasibility study.

BACKGROUND AND AIMS: Currently, there are no studies evaluating the agreement between the Mini Sarcopenia Risk Assessment (MSRA) questionnaire and skeletal muscle mass index (SMI) in cancer patients. Thus, this study aimed to evaluate the agreement of the MSRA questionnaire with SMI in cancer patients. METHODS: Cross-sectional study with 132 unselected cancer patients. The risk of sarcopenia was determined using the MSRA of 5 and 7 questions. Men and women were divided into subgroups with and without risk of sarcopenia, according to MSRA. SMI was assessed by the muscle mass divided by heigh using the Lee's formula. The ROC curve was used to estimate sensitivity, specificity, and area under the curve between MSRA 5 and 7 versus SMI. The Kappa index was used to assess the agreement between them. RESULTS: MSRA 5 and 7 showed better sensitivity values in women when compared to men. However, better specificity values were obtained in men when compared to women. Although, there was better agreement between MSRA 5/7 and SMI in women, kappa values indicated low agreement in both sexes (MSRA 5: women: 0.36 vs. men: 0.07 and MSRA 7: women: 0.22 vs. men: - 0.07). CONCLUSION: MSRA 5 and 7 questionnaires has low agreement with SMI to identify risk of sarcopenia in unselected cancer patients.

Krill Oil Supplementation Does Not Change Waist Circumference and Sagittal Abdominal Diameter in Overweight Women: A Pilot Balanced, Double-Blind, and Placebo-Controlled Clinical Trial.

An excess of body fat is one of the biggest public health concerns in the world, due to its relationship with the emergence of other health problems. Evidence suggests that supplementation with long-chain polyunsaturated fatty acids (omega-3) promotes increased lipolysis and the reduction of body mass. Likewise, this clinical trial aimed to evaluate the effects of supplementation with krill oil on waist circumference and sagittal abdominal diameter in overweight women. This pilot, balanced, double-blind, and placebo-controlled study was carried out with 26 women between 20 and 59 years old, with a body mass index >25 kg/m2. The participants were divided into the control (CG) (n = 15, 3 g/daily of mineral oil) and krill oil (GK) (n = 16, 3 g/daily of krill oil) groups, and received the supplementation for eight weeks. Food intake variables were obtained using a 24 h food recall. Anthropometric measurements (body mass, body mass index, waist circumference, and sagittal abdominal diameter) and handgrip strength were obtained. After the intervention, no changes were found for the anthropometric and handgrip strength variables (p > 0.05). Regarding food intake, differences were found for carbohydrate (p = 0.040) and polyunsaturated (p = 0.006) fatty acids, with a reduction in the control group and an increase in krill oil. In conclusion, supplementation with krill oil did not reduce the waist circumference and sagittal abdominal diameter. Therefore, more long-term studies with a larger sample size are necessary to evaluate the possible benefits of krill oil supplementation in overweight women.

Acute Supplementation of Yerba Mate Extract Did Not Change Muscle Strength in Physically Active Men Following the Strength Muscle Test: A Pilot Clinical Trial.

Polyphenol supplementation may be useful during exercise. However, there is no evidence indicating yerba mate (YM) increases muscle strength. Thus, this study sought to evaluate the effect of acute YM supplementation on muscle strength following the strength test. In a crossover and pilot clinical trial, ten men were divided into two groups, receiving either supplementation with YM or a placebo. One hour after consumption of beverages, the participants were submitted to tests of one-repetition maximum (1 RM) on the bench press and leg press. The average age of the participants was 25.5 ± 4.1 years, and the average body mass index was 24.4 ± 2.9 kg/m². YM was not able to increase muscle strength when compared to the placebo in either the 1RM leg press exercise (YM: 225 ± 56.2 kg, vs. placebo: 223 ± 64.3 kg, p = 0.743, Cohen's d = 0.03) or in the 1 RM bench press exercise (YM: 59.5 ± 20.7 kg vs. placebo: 59.5 ± 21.5 kg, p = 1.000, Cohen's d = 0.) In conclusion, acute intake of YM did not change muscle strength in physically active men.

High Charlson comorbidity index value is not associated with muscle strength in unselected cancer patients.

BACKGROUND AND AIMS: Cancer patients usually lose muscle mass and strength during progression of tumor or treatment. One of the simplest, easiest, and cheapest methods to assess muscle strength is by handgrip strength (HGS), which has been widely used during clinical practice. However, it is not established whether the presence of comorbidities, when assessed by the Charlson Comorbidities Index (CCI), is associated with lower HGS in cancer patients. Thus, this study sought to verify if low HGS is associated with highest CCI in cancer patients. METHODS: Cross-sectional study enrolled 167 cancer patients of both sexes diagnosed with cancer. The sample was divided into two groups, CCI <5: low comorbidity or CCI ≥5: high comorbidity number. Muscle strength was assessed by digital dynamometer. Student t and Chi-square tests were performed to analyze the differences between groups and logistic regression was used to verify the association between CCI and HGS, in the crude (model 1) and adjusted for confounding variables (model 2). RESULTS: Patients from the CCI ≥5 group were older (65.0 ± 11.3 vs. 55.3 ± 13.1; p < 0.05), hospitalized (p < 0.05), and the gastrointestinal and accessory organs of digestion tumors were more prevalent when compared to the CCI <5 group. The logistic regression in the crude model showed a negative association between CCI and HGS (OR: 0.94 [95%CI: 0.90-0.98], p = 0.006), however, after adjusting for confounders variables this association was lost (OR: 0.98 [95%CI: 0.94-1.03], p = 0.58). CONCLUSION: In patients with cancer, there is no independent association between HGS and CCI.

Charlson comorbidity index is not associated with neutrophil-lymphocytes ratio in unselected hospitalized cancer patients: A cross-sectional study.

This study sought to evaluate the association between Charlson Comorbidity Index (CCI) and neutrophil lymphocyte ratio (NLR). Cross-sectional study evaluated 134 patients of both sexes diagnosed with several types of cancer. NLR was calculated by dividing the absolute value of neutrophils by lymphocytes count, and the CCI questionnaire was used to assess the risk of comorbidities and mortality. The sample was dichotomized in CCI < 5 or ≥5. Student's t-test and Chi-square test were calculated to analyze the differences. The association between CCI and NLR was investigated by logistic regression analysis, performed with model 1 (crude) and model 2 (adjusted). The patients in the CCI ≥ 5 group were older, with higher neutrophil levels and prevalence of solid tumor type. There was no difference between groups regarding type of treatment, body weight, body mass index, performance status, lymphocyte count and NLR. There was no association between CCI and NLR, in both crude model (OR: 1.04 [95% CI: 0.99-1.09], p = 0.09), as well as adjusted for sex, age, physical activity, alcohol consumption, smoking habit, type of treatment, and performance status (OR: 1.04 [95% CI:0.97-1.12], p = 0.19). In hospitalized unselected cancer patients, despite of small sample size and design of study, we showed the presence of comorbidities is not related to the NLR.

Absence of risk of sarcopenia protects cancer patients from fatigue.

BACKGROUND: Cancer and its treatments often lead to sarcopenia and fatigue. However, whether these factors are associated remains unproven. OBJECTIVE: To evaluate whether the risk of sarcopenia predicts the presence of fatigue. METHODS: A cross-sectional study was completed and included 198 cancer patients of both sexes, undergoing in- and outpatient treatment. The Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) and the Functional Assessment of Cancer Therapy Fatigue (FACT-F) were used to assess the risk of sarcopenia and the presence of fatigue, respectively. The cut-off values used to identify the risk of sarcopenia and the severity of fatigue scale were SARC-F ≥ 4 and Fatigue <34, respectively. Logistic regression analysis was performed to evaluate the association between SARC-F and the FACT-F. RESULTS: Out of 198 patients, 35% were at risk of sarcopenia and of these 87% had fatigue. Patients at risk of sarcopenia had lower scores in the FACT-F subscales, lower handgrip strength, lower performance status, were mostly hospitalized and were sedentary. Logistic regression analysis revealed that patients with SARC-F < 4 had a lower risk of fatigue in both models, crude (OR: 0.83; CI 95% [0.79-0.88], p < 0.0001) as well as adjusted for age, gender, BMI, physical activity, current use of alcoholic beverages, smoking, performance status, cancer type, clinical setting and use of supplements (OR: 0.87; CI 95% [0.81-0.92], p < 0.0001). CONCLUSION: In patients with cancer, 35% presented risk of sarcopenia and of these 87% had fatigue. In addition, the absence of sarcopenia was considered protective against fatigue.

High neutrophil to lymphocytes ratio is associated with nutritional risk in hospitalised, unselected cancer patients: a cross-sectional study.

Cancer patients possess metabolic and pathophysiological changes and an inflammatory environment that leads to malnutrition. This study aimed to (i) determine whether there is an association between neutrophil-to-lymphocyte ratio (NLR) and nutritional risk, and (ii) identify the cut-off value of NLR that best predicts malnutrition by screening for nutritional risk (NRS 2002). This cross-sectional study included 119 patients with unselected cancer undergoing chemotherapy and/or surgery. The NRS 2002 was applied within 24 h of hospitalisation to determine the nutritional risk. Systemic inflammation was assessed by blood collection, and data on C-reactive protein (CRP), neutrophils, and lymphocytes were collected for later calculation of NLR. A receiver operating characteristic (ROC) curve was used to identify the best cut-point for NLR value that predicted nutritional risk. Differences between the groups were tested using the Student's t-, Mann-Whitney U and Chi-Square tests. Logistic regression analyses were performed to assess the association between NLR and nutritional risk. The ROC curve showed the best cut-point for predicting nutritional risk was NLR > 5.0 (sensitivity, 60.9%; specificity, 76.4%). The NLR ≥ 5.0 group had a higher prevalence of nutritional risk than the NLR < 5.0 group (NLR ≥ 5.0: 73.6% vs. NLR < 5.0: 37.9%, p = 0.001). The NLR group ≥ 5.0 showed higher values of CRP and NLR than the NLR < 5.0 group. In addition, patients with NLR ≥ 5.0 also had higher NRS 2002 values when compared to the NLR < 5.0 group (NLR ≥ 5.0: 3.0 ± 1.1 vs. NLR < 5.0: 2.3 ± 1.2, p = 0.0004). Logistic regression revealed an association between NRS and NLR values. In hospitalised unselected cancer patients, systemic inflammation measured by NLR was associated with nutritional risk. Therefore, we highlight the importance of measuring the NLR in clinical practice, with the aim to detect nutritional risk.

Cross-Cultural Adaptation of the Brazilian Portuguese-Translated Version of the Mini Sarcopenia Risk Assessment (MSRA) Questionnaire in Cancer Patients.

BACKGROUND AND AIMS: This study sought (i) to adapt cross-culturally the Brazilian Portuguese-translated version of the MSRA questionnaire, (ii) to estimate the prevalence of risk of sarcopenia, and (iii) to correlate the MSRA Portuguese version with CC in hospitalized cancer patients. METHODS: This was a cross-sectional study developed at the hospital in the year 2018. After being translated and adapted to the Portuguese language, the questionnaire was applied and associated with the measurement of calf circumference (CC) to verify its validity. RESULTS: Of the 45 patients, 71.1% presented significant or severe body weight loss, and 55.5% indicated muscle mass loss (CC < 31 cm). From the MSRA of seven and five items, 91.1 and 84.5% of the patients, respectively, presented risk for sarcopenia. Among those at risk for sarcopenia, more than 60% were aged <70 years, >80% were hospitalized in the last year, more than 40% could not walk > 1000 m, >40% did not eat regularly, and >80% lost >2 kg in the last year. CC was correlated with MSRA of five items (r = 0.46, p = 0.001) and seven items (r = 0.53, p = 0.0002). Furthermore, both versions of the MSRA (seven and five items) presented strong agreement and high reliability. CONCLUSIONS: The MSRA full and short version was adapted for a Brazilian Portuguese-translated version and showed strong agreement and high reliability to identify the risk for sarcopenia in hospitalized cancer patients. Therefore, this questionnaire can be used as part of nutritional assessment protocols in order to enable early screening of the risk for sarcopenia.

The Effect of Baru (Dypterix alata Vog.) Almond Oil on Markers of Bowel Habits in Hemodialysis Patients.

Gastrointestinal symptoms are common in patients in hemodialysis treatment and were frequently associated with low intake of dietary fibers and liquids, oral iron supplementation, phosphate binders, and low level of physical activity. Thus, the aim of this study was to evaluate the effect of baru almond oil in comparison with mineral oil supplementation on bowel habits of hemodialysis patients. Thirty-five patients on hemodialysis (57% men, 49.9 ± 12.4 years) were enrolled in a 12-week single-blind clinical trial. Patients were allocated (1 : 2) by sex and age into (1) the mineral group: 10 capsules per day of mineral oil (500 mg each) or (2) the baru almond oil group: 10 capsules per day of baru almond oil (500 mg each). Bowel habits were assessed by the Rome IV criteria, Bristol scale, and self-perception of constipation. Food consumption, physical activity level, and time spent sitting were also evaluated at the baseline and at the end of the study. After 12 weeks of supplementation, the baru almond oil group showed reduced Rome IV score (6.1 ± 5.5 vs 2.8 ± 4.3, p=0.04) and the straining on the evacuation score (1.2 ± 1.4 vs 0.4 ± 0.7; p=0.04), while the mineral group did not show any change in the parameters. The frequency of self-perception of constipation was lower in the baru almond oil group after intervention (45.0% vs 15.0%, p=0.04). Baru almond oil improved bowel habit and the straining on evacuation in hemodialysis patients.

Acute caffeine mouth rinsing does not improve 10-km running performance in CYP1A2 C-allele carriers.

PURPOSE: This study assessed whether caffeine mouth rinsing affects 10-km run performance and vertical jump in recreational runners. METHODS: A double-blind, placebo-controlled, crossover study was conducted. Ten well-trained volunteers performed two trials, following caffeine or placebo mouth rinse, separated by seven days. Immediately before the 10-km run, a 10-second mouth rinse with either 300 mg of caffeine (1.2%) or microcrystalline cellulose (placebo) diluted in 25 mL of water was performed. Pre- and post-exercise, participants performed a vertical jump test. A Garmin Forerunner® GPS, was used to measure 10-km running time and an 11-point Borg scale was used post-exercise to measure ratings of perceived exertion. Blood samples were also collected during the visit in the laboratory in the afternoon period to classify individuals according to their CYP1A2 genotype. Vertical jump performance was evaluated using a force plate. RESULTS: Nine runners (90%) were CC homozygotes and one (10%) was an AC heterozygote for CYP1A2. There was no difference in 10-km time-trial performance (Placebo: 47.07 ± 5.18 vs. CAF: 47.45 ± 6.34 min, p = 0.89), ratings of perceived exertion (Placebo: 17 ± 1 vs. CAF: 16 ± 2, p = 0.34) or vertical jump power (Placebo, Pre: 4.5 ± 0.6 W•kg-1 and Post: 4.5 ± 0.7 W•kg-1; CAF: Pre: 4.4 ± 0.7 W•kg-1 and Post: 4.4 ± 0.8 W•kg-1, d = 0.21, p = 0.66) between trials. CONCLUSION: Acute caffeine mouth rinsing (1.2%) did not improve 10-km performance and showed similar null effects on vertical jump performance in CYP1A2 C-allele carriers.

Association of SARC-F and dissociation of SARC-F + calf circumference with comorbidities in older hospitalized cancer patients.

The Strength, Assistance for walking, Rise from a chair, Climb stairs and Falls (SARC-F) score is a tool recommended for screening the risk of sarcopenia in older patients. However, the association between SARC-F or SARC-F + calf circumference (SARC-F + CC) and the Charlson Comorbidity Index (CCI) in hospitalized older cancer patients is not fully understood. Thus, our aim is to evaluate the association between the SARC-F or SARC-F + CC and the presence of comorbidities and risk of death in older hospitalized cancer patients. A cross-sectional study involving 90 (42 M/48F) hospitalized cancer patients over 60 years old with ongoing chemotherapy or surgical treatment is carried out. The SARC-F is performed to assess the muscle function loss (MFL if SARC-F ≥ 4), sarcopenia (SARC-F ≥ 6) and sarcopenia using the calf circumference (SARC-F + CC ≥11). CC is assessed using an inelastic tape. The CCI is used to assess the presence of comorbidities. Logistic regression is used to evaluate the association between the SARC-F and Charlson Comorbidity Index. Mean of age is 67.8 years and half (49%) of the patients present MFL (SARC-F ≥ 4), 31% present sarcopenia using the SARC-F ≥ 6 and 60% using the SARC-F + calf circumference ≥ 11. Although no association in the crude model, there is association after adjusting by age, sex, alcohol use, smoking habit, physical activity, use of oral nutritional supplementation, body mass index, performance status, tumor, and treatment type between SARC-F ≥ 4 or ≥ 6 and CCI (SARC-F ≥ 4 × CCI: OR: 2.31 [95%CI: 1.02-5.23], p = 0.04) and (SARC-F ≥ 6 × CCI: OR: 3.24 [95%CI: 1.21-8.65], p = 0.01), respectively. However, this association is lost when using the SARC-F + calf circumference (SARC-F + CC ≥11 × CCI: OR: 1.12 [95%CI: 0.63-1.90], p = 0.68). In conclusion, screening for the risk of sarcopenia in older cancer patients is highly recommended as sarcopenia is tightly associated with the clinical outcome. The use of the SARC-F score using a cut-off ≥4 or ≥ 6 is more relevant for clinical practice to detect comorbidities and risk of death than the use of SARC-F with the calf circumference.