Comparative Effectiveness of Supervised and Home-Based Rehabilitation after Anterior Cruciate Ligament Reconstruction in Competitive Athletes.

Background: After the increasingly common anterior cruciate ligament reconstruction (ACLR) procedure in competitive athletes, rehabilitation is crucial for facilitating a timely return to sports (RTS) and preventing re-injury. This pilot study investigates the patient-reported outcomes of postoperative rehabilitation in competitive athletes, comparing supervised rehabilitation (SVR) and home-based rehabilitation (HBR). Methods: After ACLR, 60 (out of 74 screened) athletes were recruited and equally divided into HBR and SVR groups using non-probability convenience sampling, with each group comprising 15 males and 15 females. The rehabilitation outcomes in the respective groups were evaluated at 8 months using measures (Tegner Activity Scale [TAS], International Knee Documentation Committee subjective knee form [IKDC-SKF], ACL Return to Sport after Injury [ACL-RSI]) and objective parameters (isometric muscle strength, hamstring/quadricep asymmetry). RTS was evaluated at 9 months, with ACL re-injury rates recorded approximately 6 months post-RTS. Results: Both groups exhibited decreased TAS scores (HBR: 8 to 6, SVR: 8 to 7), with the SVR group demonstrating superior postoperative IKDC-SKF scores (81.82 vs. 68.43) and lower ACL-RSI scores (49.46 vs. 55.25). Isometric and isokinetic muscle strength, along with asymmetry values, was higher in the SVR group 8 months post-ACLR (p < 0.05). The SVR group showed a higher RTS rate to the same level (76.6% vs. 53.3%), while the re-injury rate was the same in both the rehabilitation groups (3.3%). Conclusions: Although both rehabilitation approaches yielded comparable outcomes, SVR may demonstrate some superior biomechanical improvements in athletes, resulting in a higher RTS rate. However, the psychological outcomes and re-injury rates did not significantly differ between the groups, emphasizing the need to address individual psychological needs during rehabilitation. Further investigation is recommended with a larger sample size to address the differences of gender among competitive athletes.

Some Optimal Conditions for the ASCLT.

Let X1,X2,… be independent random variables with EXk=0 and σk2:=EXk2<∞ (k≥1). Set Sk=X1+⋯+Xk and assume that sk2:=ESk2→∞. We prove that under the Kolmogorov condition |Xn|≤Ln,Ln=o(sn/(loglogsn)1/2)we have 1logsn2∑k=1nσk+12sk2fSksk→12π∫Rf(x)e-x2/2dxa.s.for any almost everywhere continuous function f:R→R satisfying |f(x)|≤eγx2, γ<1/2. We also show that replacing the o in (1) by O, relation (2) becomes generally false. Finally, in the case when (1) is not assumed, we give an optimal condition for (2) in terms of the remainder term in the Wiener approximation of the partial sum process {Sn,n≥1} by a Wiener process.

Random walks on the circle and Diophantine approximation.

Random walks on the circle group R/Z whose elementary steps are lattice variables with span α∉Q or p/q∈Q taken mod Z exhibit delicate behavior. In the rational case, we have a random walk on the finite cyclic subgroup Zq, and the central limit theorem and the law of the iterated logarithm follow from classical results on finite state space Markov chains. In this paper, we extend these results to random walks with irrational span α, and explicitly describe the transition of these Markov chains from finite to general state space as p/q→α along the sequence of best rational approximations. We also consider the rate of weak convergence to the stationary distribution in the Kolmogorov metric, and in the rational case observe a phase transition from polynomial to exponential decay after ≈q2 steps. This seems to be a new phenomenon in the theory of random walks on compact groups. In contrast, the rate of weak convergence to the stationary distribution in the total variation metric is purely exponential.

Significantly Delayed Medium-Latency Response of the Stretch Reflex in Delayed-Onset Muscle Soreness of the Quadriceps Femoris Muscles Is Indicative of Sensory Neuronal Microdamage.

Unaccustomed or strenuous eccentric exercise is known to cause delayed-onset muscle soreness. A recent hypothesis postulated that mechano-energetic microinjury of the primary afferent sensory neuron terminals in the muscle spindles, namely a transient Piezo2 channelopathy, could be the critical cause of delayed-onset muscle soreness in the form of a bi-phasic non-contact injury mechanism. This theory includes that this microlesion could delay the medium-latency response of the stretch reflex. Our aim with this study was to investigate this hypothesis. According to our knowledge, no study has examined the effect of delayed-onset muscle soreness on the medium-latency response of the stretch reflex. Our findings demonstrated that a significant delay in the medium-latency stretch reflex could be observed right after a multi-stage fitness test in the quadriceps femoris muscles of Hungarian professional handball players who consequently experienced delayed-onset muscle soreness. The long-latency stretch reflex and most likely short-latency stretch reflex were unaffected by delayed-onset muscle soreness in our study, which is in line with earlier findings. We translate these findings as indicative of proprioceptive Type Ia terminal microdamage in the muscle spindle in line with the aforementioned new acute non-contact compression axonopathy theory of delayed-onset muscles soreness.

Finishing stationary cycling too early after anterior cruciate ligament reconstruction is likely to lead to higher failure.

BACKGROUND: Anterior cruciate ligament injury arises when the knee anterior ligament fibers are stretched, partially torn, or completely torn. Operated patients either end up re-injuring their reconstructed anterior cruciate ligament or majority develop early osteoarthritis regardless of the remarkable improvements of surgical techniques and the widely available rehabilitation best practices. New mechanism theories of non-contact anterior cruciate ligament injury and delayed onset muscle soreness could provide a novel perspective how to respond to this clinical challenge. MAIN BODY: A tri-phasic injury model is proposed for these non-contact injuries. Mechano-energetic microdamage of the proprioceptive sensory nerve terminals is suggested to be the first-phase injury that is followed by a harsher tissue damage in the second phase. The longitudinal dimension is the third phase and that is the equivalent of the repeated bout effect of delayed onset muscle soreness. Current paper puts this longitudinal injury phase into perspective as the phase when the long-term memory consolidation and reconsolidation of this learning related neuronal injury evolves and the phase when the extent of the neuronal regeneration is determined. Reinstating the mitochondrial energy supply and 'breathing capacity' of the injured proprioceptive sensory neurons during this period is emphasized, as avoiding fatigue, overuse, overload and re-injury. CONCLUSIONS: Extended use, minimum up to a year or even longer, of a current rehabilitation technique, namely moderate intensity low resistance stationary cycling, is recommended preferably at the end of the day. This exercise therapeutic strategy should be a supplementation to the currently used rehabilitation best practices as a knee anti-aging maintenance effort.

Does Compression Sensory Axonopathy in the Proximal Tibia Contribute to Noncontact Anterior Cruciate Ligament Injury in a Causative Way?-A New Theory for the Injury Mechanism.

Anterior cruciate ligament injury occurs when the ligament fibers are stretched, partially torn, or completely torn. The authors propose a new injury mechanism for non-contact anterior cruciate ligament injury of the knee. Accordingly, non-contact anterior cruciate ligament injury could not happen without the acute compression microinjury of the entrapped peripheral proprioceptive sensory axons of the proximal tibia. This would occur under an acute stress response when concomitant microcracks-fractures in the proximal tibia evolve due to the same excessive and repetitive compression forces. The primary damage may occur during eccentric contractions of the acceleration and deceleration moments of strenuous or unaccustomed fatiguing exercise bouts. This primary damage is suggested to be an acute compression/crush axonopathy of the proprioceptive sensory neurons in the proximal tibia. As a result, impaired proprioception could lead to injury of the anterior cruciate ligament as a secondary damage, which is suggested to occur during the deceleration phase. Elevated prostaglandin E2, nitric oxide and glutamate may have a critical neuro-modulatory role in the damage signaling in this dichotomous neuronal injury hypothesis that could lead to mechano-energetic failure, lesion and a cascade of inflammatory events. The presynaptic modulation of the primary sensory axons by the fatigued and microdamaged proprioceptive sensory fibers in the proximal tibia induces the activation of N-methyl-D-aspartate receptors in the dorsal horn of the spinal cord, through a process that could have long term relevance due to its contribution to synaptic plasticity. Luteinizing hormone, through interleukin-1ß, stimulates the nerve growth factor-tropomyosin receptor kinase A axis in the ovarian cells and promotes tropomyosin receptor kinase A and nerve growth factor gene expression and prostaglandin E2 release. This luteinizing hormone induced mechanism could further elevate prostaglandin E2 in excess of the levels generated by osteocytes, due to mechanical stress during strenuous athletic moments in the pre-ovulatory phase. This may explain why non-contact anterior cruciate ligament injury is at least three-times more prevalent among female athletes.

The roles of microRNA in redox metabolism and exercise-mediated adaptation.

MicroRNAs (miRs) are small regulatory RNA transcripts capable of post-transcriptional silencing of mRNA messages by entering a cellular bimolecular apparatus called RNA-induced silencing complex. miRs are involved in the regulation of cellular processes producing, eliminating or repairing the damage caused by reactive oxygen species, and they are active players in redox homeostasis. Increased mitochondrial biogenesis, function and hypertrophy of skeletal muscle are important adaptive responses to regular exercise. In the present review, we highlight some of the redox-sensitive regulatory roles of miRs.

Have We Looked in the Wrong Direction for More Than 100 Years? Delayed Onset Muscle Soreness Is, in Fact, Neural Microdamage Rather Than Muscle Damage.

According to our hypothesis, delayed onset muscle soreness (DOMS) is an acute compression axonopathy of the nerve endings in the muscle spindle. It is caused by the superposition of compression when repetitive eccentric contractions are executed under cognitive demand. The acute compression axonopathy could coincide with microinjury of the surrounding tissues and is enhanced by immune-mediated inflammation. DOMS is masked by sympathetic nervous system activity at initiation, but once it subsides, a safety mode comes into play to prevent further injury. DOMS becomes manifest when the microinjured non-nociceptive sensory fibers of the muscle spindle stop inhibiting the effects of the microinjured, hyperexcited nociceptive sensory fibers, therefore providing the 'open gate' in the dorsal horn to hyperalgesia. Reactive oxygen species and nitric oxide play a cross-talking role in the parallel, interlinked degeneration-regeneration mechanisms of these injured tissues. We propose that the mitochondrial electron transport chain generated free radical involvement in the acute compression axonopathy. 'Closed gate exercises' could be of nonpharmacological therapeutic importance, because they reduce neuropathic pain in addition to having an anti-inflammatory effect. Finally, DOMS could have an important ontogenetical role by not just enhancing ability to escape danger to survive in the wild, but also triggering muscle growth.

Exercise, redox system and neurodegenerative diseases.

Regular exercise induces a wide range of redox system-associated molecular adaptive responses to the nervous system. The intermittent induction of reactive oxygen species (ROS) during acute exercise sessions and the related upregulation of antioxidant/repair and housekeeping systems are associated with improved physiological function. Exercise-induced proliferation and differentiation of neuronal stem cells are ROS dependent processes. The increased production of brain derived neurotrophic factor (BDNF) and the regulation by regular exercise are dependent upon redox sensitive pathways. ROS are causative and associative factors of neurodegenerative diseases and regular exercise provides significant neuroprotective effects against Alzheimer's disease, Parkinson's disease, and hypoxia/reperfusion related disorders. Regular exercise regulates redox homeostasis in the brain with complex multi-level molecular pathways.

The COVID-19 pandemic and physical activity.

The SARS-CoV-2-caused COVID-19 pandemic has resulted in a devastating threat to human society in terms of health, economy, and lifestyle. Although the virus usually first invades and infects the lung and respiratory track tissue, in extreme cases, almost all major organs in the body are now known to be negatively impacted often leading to severe systemic failure in some people. Unfortunately, there is currently no effective treatment for this disease. Pre-existing pathological conditions or comorbidities such as age are a major reason for premature death and increased morbidity and mortality. The immobilization due to hospitalization and bed rest and the physical inactivity due to sustained quarantine and social distancing can downregulate the ability of organs systems to resist to viral infection and increase the risk of damage to the immune, respiratory, cardiovascular, musculoskeletal systems and the brain. The cellular mechanisms and danger of this "second wave" effect of COVID-19 to the human body, along with the effects of aging, proper nutrition, and regular physical activity, are reviewed in this article.

Exercise effects on physiological function during aging.

The decrease in cognitive/motor functions and physical abilities severely affects the aging population in carrying out daily activities. These disabilities become a burden on individuals, families and society in general. It is known that aging conditions are ameliorated with regular exercise, which attenuates the age-associated decline in maximal oxygen uptake (VO2max), production of reactive oxygen species (ROS), decreases in oxidative damage to molecules, and functional impairment in various organs. While benefits of physical exercise are well-documented, the molecular mechanisms responsible for functional improvement and increases in health span are not well understood. Recent findings imply that exercise training attenuates the age-related deterioration in the cellular housekeeping system, which includes the proteasome, Lon protease, autophagy, mitophagy, and DNA repair systems, which beneficially impacts multiple organ functions. Accumulating evidence suggests that exercise lessens the deleterious effects of aging. However, it seems unlikely that systemic effects are mediated through a specific biomarker. Rather, complex multifactorial mechanisms are involved to maintain homeostatic functions that tend to decline with age.

High altitude exposure alters gene expression levels of DNA repair enzymes, and modulates fatty acid metabolism by SIRT4 induction in human skeletal muscle.

We hypothesized that high altitude exposure and physical activity associated with the attack to Mt Everest could alter mRNA levels of DNA repair and metabolic enzymes and cause oxidative stress-related challenges in human skeletal muscle. Therefore, we have tested eight male mountaineers (25-40 years old) before and after five weeks of exposure to high altitude, which included attacks to peaks above 8000m. Data gained from biopsy samples from vastus lateralis revealed increased mRNA levels of both cytosolic and mitochondrial superoxide dismutase. On the other hand 8-oxoguanine DNA glycosylase (OGG1) mRNA levels tended to decrease while Ku70 mRNA levels and SIRT6 decreased with altitude exposure. The levels of SIRT1 and SIRT3 mRNA did not change significantly. However, SIRT4 mRNA level increased significantly, which could indicate decreases in fatty acid metabolism, since SIRT4 is one of the important regulators of this process. Within the limitations of this human study, data suggest that combined effects of high altitude exposure and physical activity climbing to Mt. Everest, could jeopardize the integrity of the particular chromosome.

Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study.

BACKGROUND: Several methods are used to treat focal chondral and osteochondral defects on the weightbearing surfaces of synovial joints. Autologous osteochondral grafting is 1 option used to replace hyaline cartilage in the defect. HYPOTHESIS: Mosaicplasty is effective in returning elite athletes to participation in sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In 3 institutes, 354 of 383 patients were followed from 2 to 17 years (average, 9.6 years). The results of mosaicplasty were prospectively evaluated at 6 weeks, 3 months, 6 months, and yearly with patient-reported outcomes measures and radiographs. RESULTS: Slight or moderate degenerative changes (Fairbank grade I or II) were detected preoperatively in 27% of the cases and in 36% of the cases at follow-up. Fairbank grade III changes were observed in 5 cases. An average radiographic deterioration of 0.32 on the Fairbank scale was detected (preoperative, 0.34; postoperative, 0.66). Good to excellent results were found in 91% of femoral mosaicplasties, 86% of tibial, and 74% of patellofemoral; 92% of talar mosaicplasties had similar results (Hannover ankle scoring system). Patellofemoral pain related to graft harvest was observed in 5% of cases. Second-look arthroscopies revealed good, congruent, gliding surfaces of the transplants and acceptable fibrocartilage coverage of donor sites in 16 patients and degenerative changes of the transplants in 5 cases. Histological evaluation revealed good graft incorporation in all 11 cases. Two infections and 3 deep venous thromboses occurred. CONCLUSION: Despite a higher rate of preoperative osteoarthritic changes in the athletic patients, clinical outcomes of mosaicplasty in this group demonstrated a success rate similar to that of less athletic patients. Higher motivation resulted in better subjective evaluation. Slight deterioration in results occurred during the 9.6-year follow-up; thus, autologous osteochondral mosaicplasty may be a useful alternative for the treatment of 1.0- to 4.0-cm(2) focal chondral and osteochondral lesions in competitive athletes.

Femoral press-fit fixation technique in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft: a prospective clinical evaluation of 285 patients.

BACKGROUND: The security of the graft fixation is an important factor of anterior cruciate ligament reconstruction, especially in the early postoperative period. HYPOTHESIS: The femoral press-fit fixation technique is a safe, alternative technique for the fixation of the bone-patellar tendon-bone graft. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 1, 1998, and June 30, 2002, 285 patients, with a mean age of 29.1 years, underwent operation and observation in our department. All patients had arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft with femoral press-fit and tibial interference screw fixation. The mean follow-up period was 35.8 months (range, 24-77 months). During each patient's evaluation, a physical examination, a subjective evaluation, the International Knee Documentation Committee and Lysholm scores, KT-1000 arthrometer testing, and radiological evaluation were performed. The paired Student t test or chi(2) test was used for statistical analysis. RESULTS: According to the International Knee Documentation Committee score, 241 patients (85%) had good (46 normal and 195 nearly normal) results, whereas 39 patients had abnormal and 5 patients had severely abnormal overall results. The preoperative mean Lysholm score was 63.5 +/- 12.7 points. At the final examination, the mean value was 93.5 +/- 7.8 points (P < .01). One hundred ninety-seven athletes could return to their previous sports activity level, whereas 13 patients gave up their sports career. The KT-1000 arthrometer results showed a side-to-side difference of 1.91 +/- 2.1 mm at the maximum manual strength tests. CONCLUSION: The femoral press-fit fixation is an alternative fixation method for the bone-patellar tendon-bone graft and provides good stability for the anterior cruciate ligament reconstruction. The use of press-fit fixation technique avoids most interference screw or other hardware-induced complications at the femoral side.

The effects of moderate, strenuous, and overtraining on oxidative stress markers and DNA repair in rat liver.

Physical exercise above a certain load has been suggested as being a cause of oxidative stress. We have tested whether training with moderate (MT), strenuous (ST), or over (OT) load can cause alterations in the activities of antioxidant enzymes, lipid peroxidation, protein oxidation, DNA damage, or activity of 8-oxoG-DNA glycosylase (OGG1) in rat liver. The levels of corticosterone decreased in all exercising groups but the differences were not significant. Adrenocorticotrophin hormone (ACTH) levels decreased, not significantly, in MT and OT compared to C. Activity levels of antioxidant enzymes did not change significantly in the liver. The levels of reactive carbonyl derivative (RCD) content decreased in the liver of exercising animals, and the differences reached significance between control and moderately trained groups. The changes in the levels of lipid peroxidation (LIPOX) were not significant, but were lower in the exercised groups. The 8-hydroxydeoxyguanosine (8-OHdG) levels increased in the OT group, and the activity of OGG1 measured from crude cell extracts tended to increase in MT and ST. The findings of this study imply that overtraining induces oxidative damage to nuclear DNA, but not to liver lipids and proteins.

The effect of exercise and nettle supplementation on oxidative stress markers in the rat brain.

Chronic swimming training and phytotherapeutic supplementation are assumed to alleviate oxidative damage, and support cell survival in the brain. The effect of forced, chronic swimming training, and enriched lab chow containing 1% (w/w) dried nettle (Urtica dioica) leaf were investigated for oxidative stress, inflammation and neurotrophic markers in Wistar rat brains. The rats were divided into groups subjected to swimming training (6 weeks) or to nettle supplementation (8 weeks) or to a combination of these two treatments. The level of oxidative stress was measured by electron spin resonance (EPR), and by the concentration of carbonylated proteins. Nettle supplementation resulted in a decreased concentration of free radicals in both cerebellum and frontal lobe. Swimming, however, did not influence significantly the oxidative damage nor was it reflected in the carbonyl content. The protein content of nerve growth factor (NGF), and brain-derived neurotrophic factors (BDNF) was evaluated by E-Max ImmunoAssay in the cerebellum. No changes occurred either with exercise or nettle diet treatments. On the other hand, nuclear factor kappa B (NF-kappaB) binding activity to DNA increased with the combined effect of swimming training and nettle diet, while the activator protein1 (AP-1) DNA binding activity showed a more profound elevation in the nettle treated animals. The amount of c-Jun decreased by swimming training. In conclusion, the results suggest that both exercise and nettle influenced physiological brain functions. Nettle supplementation reduces the free radical concentration and increases the DNA binding of AP-1 in the brain. Nettle was found to be an effective antioxidant and possible antiapoptotic supplement promoting cell survival in the brain. Exercise, as a downregulator of c-Jun and in combined group as an upregulator of NF-kappaB, may play also a role in antiapoptotic processes, which is important after brain injury.

The effects of moderate-, strenuous- and over-training on oxidative stress markers, DNA repair, and memory, in rat brain.

We have tested the hypothesis that training with moderate- (MT), strenuous- (ST), or over- (OT) load can cause alterations in memory, lipid peroxidation, protein oxidation, DNA damage, activity of 8-oxoG-DNA glycosylase (OGG1) and brain-derived neurotrophic factor (BDNF), in rat brain. Rat memory was assessed by a passive avoidance test and the ST and OT group demonstrated improved memory. The content of BDNF was increased only in the OT group. The oxidative damage of lipids and DNA, as measured by thiobarbituric acid reactive substances (TBARS), and 8-hydroxydeoxyguanosine (8-OHdG), did not change significantly with exercise. Similarly, the activity of DNA repair enzyme, 8-oxoguanine DNA glycosylase (OGG1), was not altered with exercise training. On the other hand, the content of reactive carbonyl derivatives (RCDs) decreased in all groups and the decrease reached significance levels in the ST and OT groups. The activity of the proteasome complex increased in the brain of OT. The findings of this study imply that over-training does not induce oxidative stress in the brain and does not cause loss of memory. The improved memory was associated with enhanced BDNF content.

[Femoral press-fit fixation in anterior cruciate ligament reconstruction: postoperative histological examination of bone block incorporation in pigs]. / Femoralis press-fit rögzítés elülso keresztszalag pótlás során. A csontblokk beépülésének posztoperatív szövettani vizsgálata sertéseken.

INTRODUCTION: The histological properties of the femoral press-fit fixation in anterior cruciate ligament reconstruction have not been extensively examined. The purpose of the study was to analyse the histological properties of the bone-patellar tendon graft in the bone tunnel area during the early stages of healing in an animal model. Furthermore the authors wanted to draw conclusions for the postoperative rehabilitation program on the basis of their data. MATERIAL AND METHODS: ACL reconstruction was performed in pigs using femoral press-fit fixation. After 3 and 6 weeks the incorporation of the bone block in the femur in 2 pigs was histological and radiological evaluated. RESULTS: After 3 and 6 weeks the examination showed almost similar histology on the bony side the grafts except (1) a higher amount of fibrotic tissue in-between the lamellae of the inserted patellar bone after 6 weeks, (2) the presence of direct osseous unions between the two lamellar systems and (3) thicker lamellae at the base than toward the condylar tissue. CONCLUSIONS: Concerning the progression of graft healing by histological findings our study showed, that after 6 weeks the femoral press-fit fixation appear to have good incorporation after ACL reconstruction.

[Prevalence of patellofemoral pain syndrome. Evaluation of the role of biomechanical malalignments and the role of sport activity]. / A patellofemoralis fájdalom szindróma prevalenciája. A biomechanikai tengelyeltérések es a sportaktivitás szerepének elemzése.

INTRODUCTION: Disorders around the patella are the most frequent knee complaints seen in adolescents. In the literature many intrinsic and extrinsic risk factors have been linked to Patellofemoral Pain Syndrome (PFPS), but the role of these risk factors is controversial. AIM: The goal of this study was to evaluate the prevalence of PFPS in a group of adolescents aged 12-20 years in Hungary, and to gain more information on the relationship between the biomechanical anomalies of the lower extremity and the PFPS. MATERIAL AND METHODS: In this epidemiological study the authors investigated the effect of sporting activity in the maturation of symptoms among 586 randomly selected students. Different physical examinations, anthropometric measurements, stability tests, footscan analysis were performed. RESULTS: Concerning the prevalence of this syndrome they could not find any differences between males (n = 60, 20.41%) and females (n = 61, 20.89%). The authors could not identify any statistically significant intrinsic risk factors, although changes in the Q angle may be linked to increased prevalence of PFPS. The study supports the theory of the importance of "overload", for there was a significant correlation between the prevalence of PFPS and the different levels of sporting activities (competitive, recreational and non-athletes). CONCLUSION: The authors concluded that the prevalence of PFPS among Hungarian students is 20.65%.