Evaluation of: Bangalore S, Steg PG, Deedwania P et al. β-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 308(13), 1340–1349 (2012). The number of myocardial infarctions (MIs) in population remains high and this event is a significant predictor of mortality. Information in the literature points to a reduction in mortality, reinfarction and sudden death in first year, especially in patients with high risk, if β-blockers (BBs) are used after MI. In a perspective study, Zuckerman et al. have determined outcome following pharmacotherapy after acute MI in older adults. It is apparent that a number of matters require consideration in evaluation of the effectiveness of BBs. It seems that not all patients benefit equally from treatment with BBs but such an intervention reduces mortality. It is also important to recognize that the beneficial effects of BBs should not be considered in isolation since the biological system is too complex to manipulate with the use of a single class of drugs.

A pretest-posttest experimental study was conducted on 35 music majors at Taylor University, using questionnaires to measure musical performance anxiety and musical performance quality. The study compared the effectiveness of two different treatments: 1) informal practice performance and 2) a coping skills seminar. Though the students attending the seminar averaged less anxiety after treatment, neither treatment was proven statistically to be effective in reducing the level of anxiety or enhancing musical performance quality. / Ed. D.

Controversy exists regarding the effects of beta-blocker medications on functional capacity in cardiac patients and in the effects of disease-related impairments on cardiorespiratory dynamics during exercise testing. Therefore, this study was conducted to examine the exercise responses of 26 subjects (ages 37-66 years) to a graded exercise test. Subjects were divided into three groups based on clinical status: apparently healthy (AH; N=8); cardiacs receiving beta-blockers (C-BB; N=8); cardiacs not receiving beta-blockers (Câ NBB; N=lO). / Master of Science

The sympathetic nervous system plays a key role in the regulation of cardiovascular and ventilatory responses during exercise. The regulation of the heart and peripheral circulation by the autonomic nervous system is accomplished by control centers that receive input from mechanical and chemical receptors through the body. Therefore, the changes in sympathetic and parasympathetic activity allow for rapid responses. <p><p>Exercise is associated with increases of ventilation, heart rate and blood pressure. Ventilation increases adaptedly to increased oxygen uptake (VO2) and carbon dioxide output (VCO2) and eventually to limit metabolic acidosis occurring above the ventilatory threshold. Cardiac output increases to meet the contracting muscles’ requirement for flow. The increase in cardiac output occurs through increases in both heart rate and stroke volume and is regulated by feed-forward mechanisms: central command and exercise pressor reflex. <p><p>Skeletal muscle contraction elicits a reflex increase in sympathetic outflow which causes vasoconstriction contributing to the exercise induced rise in blood pressure. This reflex is triggered by stimulation of metabo- and chemoreceptors. Although the precise stimulus is not known, adrenergic receptor signaling is involved in the cardiovascular and respiratory alterations in response to exercise. <p><p>This thesis has been devoted to a better understanding of the functional aspects of sympathetic nervous system activation during dynamic and resistive exercise, with use of β blocker and β2 stimulant interventions The hypotheses were: 1) that β blocker interventions would decrease aerobic exercise capacity by a limitation of maximal cardiac output, but more so the ventilatory responses to exercise because of a decreased chemosensitivity, thereby decreasing dyspnea, and 2) β2 stimulant interventions would slightly increase aerobic exercise capacity by an increase in maximal cardiac output, but also the ventilatory responses because of an increased chemosensitivity, with possible decrease of the ventilatory reserve at exercise and increased dyspnea. Both interventions could affect maximal muscle strength through central effects.<p><p>Ventilatory responses to hyperoxic hypercapnia (central chemoreflex) and to isocapnic hypoxia (peripheral chemoreflex) were confronted to measurements of ventilatory equivalents for oxygen (O2) and carbon dioxide (CO2) during standard cardiopulmonary exercise test (CPET). Resting 5 measurements of muscle sympathetic nervous activity (MSNA) were obtained in different conditions with and without pharmacological interventions. Muscle metaboreflex and muscle stength measurements were also considered. Drugs with β blocker or β2 stimulant properties were administered in range of doses used in clinical practice for the teatment of cardiovascular or rerspiratory conditions. The results show that β blockade with bisoprolol slightly reduced maximal exercise capacity as assessed by a maximal oxygen uptake (VO2max) or maximal workload (Wmax), with a decreased maximal heart rate, without significant effect on ventilation (VE) or MSNA responses to hypercapnia, hyperoxia or to isometric muscle contraction or ischemia. Both VE/VO2 and VE/VCO2 slopes were decreased during CPET, which was attributable to β blockade-related hemodynamic changes. On the other hand, stimulation of β2 receptors with salbutamol did not affect exercise capacity as assessed by VO2max or Wmax in spite of increased peripheral chemosensitivity with increased VE/VCO2 slopes and early lactic acidosis. MSNA burst frequency, muscle metaboreflex and maximal isokinetic muscle strength were not affected by salbutamol. <p><p>Thus, aerobic exercise capacity in healthy subjects is sensitive to sympathetic nervous system modulation by β blocker or β2 stimulant interventions with drugs at doses prescribed in clinical practice. B blocker intervention has a slight limitation of aerobic exercise capacity and a hemodynamic decrease in ventilation, while β2 stimulant intervention has no change in exercise capacity with associated increased ventilatory responses because of increased chemosensitivity, partly related to early lactic acidosis. None of the studied phamacologic interventions affected MSNA or muscle strength measurements. <p><p>We hope that these results might be useful for the understanding of the effects of revalidation to exercise of patients treated with β blocker or β2 stimulant drugs, document the limited ergogenic properties and also side effects of the intake of these substances in healthy exercising subjects.<p> / Doctorat en Sciences de la motricité / info:eu-repo/semantics/nonPublished

OBJECTIVES: To determine the pattern and predictors of use of antiplatelet agents and beta-blockers given in the emergency department (ED) to older adults with acute myocardial infarction (AMI) and its effects on in-hospital mortality and length of hospital stay (LOS) and to determine the effect of computerized ED guideline reminders on their utilization. METHODS: A cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data for years 1992 to 2010 was conducted. Patients were included if they had an admission diagnosis of AMI (ICD-9-CM code 410.xx) and were ≥55 years. Survey logistic regression was used to examine whether there was a trend in the use of antiplatelet agents and beta-blockers across the years and to explore the association between various predictor variables, including ED computerized guideline reminders, and their utilization rates. The chi-square test was used to see whether users of these drugs were different from non-users in their rates of in-hospital mortality. Survey linear regression was used to explore the effect of utilization of these drugs on LOS. All the visits were weighted to get national estimates. All of the analyses were carried out with SAS 9.3 statistical package. RESULTS: A total of 1,771 visits (weighted frequency = 6.1 million) were eligible for this study. Both antiplatelet agents and beta-blockers were shown to have a positive trend across the years. Age, sex, chest pain, triage, using an ambulance, and metropolitan region were all found to be significant predictors of either antiplatelet agent or beta-blocker utilization. Use of beta-blockers was associated with lower in-hospital mortality. Neither drug class had an effect on LOS. Finally, patients who were treated in EDs with computerized guideline reminders were twice as likely to get an antiplatelet agent, but this was not seen with beta-blockers. CONCLUSION: This study displayed a positive pattern across the years in the use of antiplatelet agents and beta-blockers given to older AMI patients. It also showed that age, sex, and other important variables were significant predictors of their utilization. The use of beta-blockers yielded lower in-hospital mortality. Finally, the use of ED reminders increased antiplatelet agent utilization.

Orientador: Aparecido Antonio Camacho / Resumo: O uso de betabloqueadores tem mostrado implicações significativas na terapia de neoplasias através do bloqueio de adrenoreceptores em tecidos tumorais. O sistema nervoso autônomo simpático apresenta um perfil pró-inflamatório e por estímulo das catecolaminas ocorre à ativação de macrófagos teciduais com liberação de citocinas inflamatórias. Estudos recentes sugerem que estímulos inflamatórios crônicos podem acelerar a progressão do câncer, fato este relacionado à ativação do sistema beta adrenérgico. Assim, o objetivo do presente estudo foi avaliar a influência do emprego do propranolol sobre a evolução macroscópica dos nódulos mamários assim como a monitoração da função cardíaca. O estudo foi prospectivo, randomizado e longitudinal. Para tanto, 06 cadelas portadoras de tumores de mama (G1) receberam cloridrato de propranolol (0.2 mg/kg/BID, VO, 30 dias) e, outras 08 cadelas também com neoplasia mamária (G0) receberam apenas medicação placebo (BID, VO, 30 dias). Foram realizados exames ecocardiográfico, eletrocardiográficos convencional e Holter, paquimetria tumoral e exame histopatológico. A análise estatística foi baseada em um estudo experimental, cujos resultados foram submetidos à análise de variância (ANOVA) com medidas repetidas no tempo e em seguida Teste de Tukey. O uso do fármaco mostrou segurança sobre os parâmetros cardíacos avaliados e controle sobre o crescimento tumoral quando comparado com o grupo placebo. / Abstract: The use of beta-blockers has shown significant implications in the therapy of neoplasias through the blockade of adrenoreceptors in tumor tissues. The autonomic sympathetic nervous system presents a pro-inflammatory profile and by stimulating the catecholamines occurs to the activation of tissue macrophages with the release of inflammatory cytokines. Recent studies suggest that chronic inflammatory stimuli may accelerate the progression of cancer, a fact related to activation of the beta adrenergic system. Thus, the objective of the present study was to evaluate the influence of the use of propranolol on the macroscopic evolution of the mammary nodes as well as the monitoring of the cardiac function. The study was prospective, randomized, and longitudinal. For this, 06 bitches bearing breast tumors (G1) received propranolol hydrochloride (0.2 mg / kg / BID, VO, 30 days) and another 08 female mammary glanders (G0) received only placebo medication (BID, VO , 30 days). Echocardiographic, conventional electrocardiographic and Holter tests, tumor pachymetry and histopathological examination were performed. The statistical analysis was based on an experimental study, whose results were submitted to analysis of variance (ANOVA) with measures repeated in time and then Tukey's test. The use of the drug showed safety over the evaluated cardiac parameters and control over tumor growth when compared to the placebo group. / Mestre

Les thérapies ciblées telles que les inhibiteurs de la tyrosine kinase ont permis d'améliorer le traitement du cancer du sein en ciblant HER2. Cependant, il a été observé que le lapatinib était moins efficace chez les patients obèses ou en surpoids que chez les patients de poids normal.Nous avons d'abord reproduit l'effet de résistance des cellules de cancer du sein au lapatinib en présence de tissu adipeux tel qu’il a été observé pour d’autres thérapies. Les cellules tumorales qui surexpriment HER2 étaient partiellement résistantes au lapatinib mais également à d'autres inhibiteurs de la tyrosine kinase lorsqu'elles étaient en contact avec le milieu conditionné d’adipocytes. En implantant du tissu adipeux humain et des tumeurs humaines chez la souris, nous avons pu étudier la résistance du cancer du sein au lapatinib in vivo.Pour comprendre le mécanisme de cette résistance, nous avons exposé les adipocytes à plusieurs modulateurs du métabolisme. La cytotoxicité cellulaire induite par le lapatinib était plus faible pour les cellules tumorales exposées à un milieu conditionné d'adipocytes préalablement incubés avec les alpha-bloquants qu'à un milieu conditionné à partir d'adipocytes seuls. De la même manière, cette toxicité était inférieure pour les agonistes des récepteurs alpha adrénergiques, pour les bêtabloquants et pour les inhibiteurs de lipolyse. Au contraire, la cytotoxicité a été augmentée pour les cellules tumorales en contact avec le milieu conditionné d’adipocytes exposés aux agonistes du récepteur bêta-adrénergiques. Au niveau des cellules cancéreuses, l'arrêt du cycle cellulaire induit par le lapatinib était réduit pour les cellules tumorales exposées au milieu conditionné d’adipocytes en ce qui concerne le pourcentage de cellules dans la phase G0/G1. Ceci s’est vérifié en étudiant l'expression des gènes codant pour plusieurs protéines impliquées dans la progression du cycle cellulaire / Targeted therapies as tyrosine kinase inhibitors permitted an improvement of breast cancer therapies by targeting HER2. However, resistance has been observed in obèse patients for lapatinib treatment.We reproduced the effect of resistance of breast cancer cells to laaptinib in presence of adipose tissue as observed for other therapies. Tumor cells overexpressing HER2 was partly resistant to lapatinib but also for other tyrosine kinase inhibitors when in contact with adipocyte-conditioned medium. By impnating human adipose tissue nad human tumors in mice, we were able to study rhe resistance of breast tumor cells in vivo.In order to elucidate the mechanism of such resistance, we exposed the adipocytes to several metabolism modulators. The lapatinib-induced cell cytotoxicity was lower for the tumor cells exposed to the conditioned medium from adipocytes earlier exposed to alpha blockers than to the conditioned medium from adipocytes alone. In the same manner, the toxicity was lower for the agonists of alpha-adrenergic receptors , for beta-blockers and for the lipolysis inhibitors. At the opposite, the cytotoxicity was enhanced for tumor cells in contact with the conditioned medium of adipocytes exposed to the agonists of beta adrenergic receptors.At the tumor cell level, the laaptinib-induced cell cycle arrest was reduced for the tumor cells exposed to the conditioned medium regarding the G0/G1 phase. That was verified by the study of the expression of genes involved in the cell cycle progression

Made available in DSpace on 2016-06-02T20:18:14Z (GMT). No. of bitstreams: 1 3660.pdf: 12159654 bytes, checksum: e4bf1704d730c95175def3dbe81e9d83 (MD5) Previous issue date: 2011-03-18 / Financiadora de Estudos e Projetos / Myocardial infarction (MI) and chronic heart failure (CHF) are among the cardiovascular diseases with high morbidity and mortality and both conditions are characterized by reduced ability to perform dynamic exercise. In CHF, the mechanisms responsible for exercise intolerance has been most widely investigated. There is a complex interaction between central and peripheral factors, including changes in lung function, reduced respiratory muscle strength and impaired autonomic modulation. However, little is known about their capacity to exercise at high altitude. The responsible factors to the functional capacity reduction in IM are unclear, especially in the early phase of recovery after hospital discharge. In this sense, two studies were developed with the purpose of assessing ventilatory limitation and cardiorespiratory efficiency in subjects with recent myocardial infarction and chronic heart failure. The first was developed in two stages and involved eight men (49 ± 8 years) with uncomplicated recent MI (RMI) and ten men (48 ± 9 years) apparently healthy subjects (CG). All patients underwent pulmonary function (PF), cardiopulmonary exercise testing on a ramp (CPX) and constant load (TECC) protocol. TECC was applied at three intensities, identified in CPET, corresponding to ventilatory anaerobic threshold, plus 25% and minus 25%. At the initial step we investigated the ventilatory limitation, with exercise tidal flow-volume loop, the breathing strategy and ventilatory efficiency during exercise (VE/VCO2 slope and OUES). The RMI group presented lower expiratory reserve volume (0.9±0.3 vs. 1.8±0.5 L; p<0.05) and OUES (1836±470 vs. 2695±258; p<0.01) when compared to the CG. RMI group also demonstrated EFL during all three CWETs, whereas the CG presented EFL only during the higher intensity. In the second step we evaluated the heart rate (HR) and oxygen uptake (VO2) responses at the beginning of dynamic exercise at three intensities, through the kinetics analysis. The RMI time constants (_) of HR (_HR) and VO2 (_VO2) showed different response, because the _VO2 was slower than _HR. When compared to the CG, RMI presented slower _VO2 at moderate workload. In conclusion, recent uncomplicated MI is associated with reduction in oxygen uptake ventilatory efficiency, slowing of _VO2 and ventilatory limitation at dynamic exercise, even when there is no reduction in PF and respiratory muscle strength. In the second study, thirty CHF patients (NYHA I-III, 25M/5F; 59±10 years, LVEF=39.6±7.1%) treated with carvedilol were underwent to CPET and CWET. CWET was applied at 50% of the peak workload reached at CPET, in normoxia and hypoxia, to simulate a 2000 meters altitude. To identify the effect of carvedilol on the response to moderate exercise in hypoxia, we evaluated the kinetics of HR and VO2 at the initial stage of dynamic exercise and the response of these variables during the CWET. The VO2 was 20% higher in hypoxia, the _VO2 was faster in hypoxia and the _HR was faster in normoxia. Ten patients, who lowered _VO2 in hypoxia had greater HR increase during maximal CPET, suggesting lower functional betablockade. The faster _VO2 in hypoxia is likely due to a peripheral effect of carvedilol mediated either by _- or _-receptor. / O infarto do miocárdio (IM) e a insuficiência cardíaca (IC) crônica estão entre as doenças cardiovasculares com maior morbidade e mortalidade e caracterizam-se por redução da capacidade de realização de exercício dinâmico. Na IC crônica, os mecanismos responsáveis pela intolerância ao exercício têm sido mais amplamente investigados e apresentam complexa interação entre fatores centrais e periféricos, incluindo alterações da função pulmonar, redução da força dos músculos respiratórios e comprometimento da modulação autonômica. Contudo, pouco se sabe em relação à capacidade de exercício em altitude elevada. No IM, principalmente na fase precoce da recuperação pós-alta hospitalar, os fatores responsáveis pela redução da capacidade funcional são pouco conhecidos. Com o propósito de avaliar a limitação ventilatória e a eficiência cardiorrespiratória de indivíduos com IM recente e IC crônica, foram desenvolvidos dois estudos. O primeiro foi realizado em duas etapas e contou com oito homens (49±8 anos) com IM recente (RMI) não complicado e dez homens (48±9 anos) aparentemente saudáveis (CG). Todos realizaram prova de função pulmonar (FP), teste de exercício cardiopulmonar em rampa (TECP) e em carga constante (TECC). O TECC foi aplicado em três intensidades, identificadas no TECP, correspondentes ao limiar de anaerobiose ventilatório, 25% acima e 25% abaixo. Inicialmente investigou-se a limitação ventilatória, com emprego da alça fluxo-volume corrente durante o exercício, a estratégia ventilatória e a eficiência ventilatória durante o exercício (VE/VCO2 slope e OUES). O grupo RMI apresentou menor volume de reserva expiratório em repouso (0,9±0,3 vs. 1,8±0,5 L; p<0,05) e OUES (1836±470 vs. 2695±258; p<0,01). Além disso, o RMI apresentou limitação ao fluxo expiratório nas três intensidades estudadas, enquanto no CG esteve presente apenas na maior intensidade. Na segunda etapa avaliou-se o comportamento da frequência cardíaca (FC) e do consumo de oxigênio (VO2) no início do exercício dinâmico, em três intensidades, por meio da análise da cinética da resposta destas variáveis. As constantes de tempo (_) da FC (_FC) e do VO2 (_VO2) apresentaram comportamento distinto no RMI, sendo que a _VO2 foi mais lenta nas três intensidades. Além disso, a _VO2 do RMI foi mais lenta que a do CG na intensidade moderada. Em conclusão, IM recente não complicado está associado com redução da eficiência ventilatória para o consumo de oxigênio, lentificação do consumo de oxigênio e limitação ao fluxo expiratório durante exercício dinâmico, mesmo quando não há redução da FP e da força dos músculos respiratórios. No segundo estudo foram realizados TECP e TECC em trinta pacientes com IC crônica (NYHA I-III, 25M/5F; 59±10 anos; FEVE=39,6±7,1%) em uso de carvedilol. O TECC foi aplicado em intensidade equivalente a 50% da máxima do TECP em condições de normóxia e hipóxia, a fim de simular altitude de 2000 metros. Com o propósito de identificar o efeito do carvedilol sobre a resposta da FC e do VO2 ao exercício moderado em normóxia e hipóxia, avaliou-se a cinética destas variáveis na fase inicial do exercício dinâmico, bem como a resposta das mesmas durante o TECC. O VO2 foi 20% maior em hipóxia, a _VO2 foi mais rápida em hipóxia e a _FC foi mais rápida em normóxia. Dez pacientes que apresentaram _VO2 mais lenta em hipóxia mostraram maior incremento da FC no TECP, o que sugere menor bloqueio funcional dos receptores beta. A _VO2 mais rápida em hipóxia pode estar relacionada ao efeito periférico do carvedilol, mediado pelos receptores alfa e beta.

Les estrogènes et les bêtabloquants transitent quotidiennement par les réseaux d’assainissement et les stations d’épuration des eaux résiduaires urbaines. Une première partie de ce travail a consisté à développer des méthodes pour analyser ces micropolluants émergents dans les boues de station d’épuration et les matières en suspension. L’efficacité des traitements épuratoires a ensuite été évaluée vis-à-vis de l’élimination de ces molécules. En règle générale, les 5 estrogènes étudiés (estrone, 17α- et 17β-estradiol, estriol, 17α-éthinylestradiol) sont plutôt bien éliminés par les stations d’épuration avec des efficacités d’élimination généralement supérieures à 90%. Pour les 10bêtabloquants analysés (acébutolol, aténolol, bêtaxolol, bisoprolol, métoprolol, nadolol, oxprénolol,propranolol, sotalol et timolol), des comportements différents ont été observés. Alors que l’acébutololet le nadolol sont éliminés (abattements moyens supérieurs à 80%), d’autres molécules comme lesotalol et le propranolol ne sont que peu impactées par les traitements épuratoires (abattements moyens inférieurs à 20%). Pour les autres bêtabloquants étudiés, des abattements intermédiaires (entre 40 et 70%) sont observés. Excepté le propranolol, qui est le plus hydrophobe des bêtabloquants étudiés, les molécules ciblées dans cette étude s’adsorbent peu sur les matières en suspension (en moyenne 90% des molécules se trouvent dans la phase dissoute) et ne sont pas concentrées dans les boues ; les abattements mesurés correspondent donc, sauf pour le propranolol,à une biodégradation et pas à un transfert des micropolluants vers les boues. Les molécules résiduelles non éliminées par le traitement épuratoire rejoignent le milieu aquatique récepteur. Les rejets de station d’épuration représentent en effet une source de contamination pour les milieux aquatiques et l’impact de ces rejets est visible, notamment en termes d’augmentation des concentrations de micropolluants mesurées dans le milieu. Néanmoins, les faibles concentrations mesurées ne semblent pas individuellement représenter de risque environnemental majeur ; seul le propranolol a présenté sur 4 des 15 sites étudiés un quotient de risque supérieur à 1 ce qui indique un risque environnemental probable. Cependant, même si le risque associé à une molécule est faible,chaque molécule présente dans l’environnement contribue au potentiel toxique global des substances présentes dans l’environnement. / Estrogens and beta blockers are daily excreted by human beings and wastewater treatmentplants are recognised as the main pathway of these emerging micropollutants to the aquaticenvironment. This study aims at analyzing 5 estrogens (estrone, 17α- and 17β-estradiol, estriol, 17α-ethynylestradiol) and 10 beta blockers (acebutolol, atenolol, betaxolol, bisoprolol, metoprolol, nadolol, oxprenolol, propranolol, sotalol et timolol) in urban wastewater treatment plants and surface waters.First of all, methods were developed for the analysis of target molecules in sewage sludge and suspended particulate matters. Then, estrogens and beta blockers were studied in urban wastewater treatment plants. Generally, wastewater treatments are efficients to remove estrogens fromwastewater with mean removal rates above 90%. For beta blockers, acebutolol and nadolol areefficiently removed (mean removal rates of about 80%), while sotalol and propranolol are hardlyimpacted by wastewater treatment (mean removal rates below 20%). Other studied beta blockerspresent intermediate removal rates (between 40 and 70%). Except propranolol which is the lesshydrophilic molecule among the different studied beta blockers, target molecules are not adsorbed onsuspended particulate matters (mean proportion of 90% of the target molecules are present in the dissolved phase) and are not concentrated into sludge. So, calculated removal rates correspond,except for propranolol, to biodegradation and not to transfer into sludge. Residual molecules which are not removed by wastewater treatment reach the aquatic environment. The impact of wastewater treatment plants on the receiving rivers was studied showing a clear increase of target molecules concentrations near the wastewater treatment plants outfall. However, only propranolol presented an environmental risk ratio in the range or above 1 showing a possible environmental risk in 4 studied receiving waters out of 15. Never the less, even if no specific toxic effects are pointed out, each molecule contributes to the overall toxic potential of the substances present in the aquatic environment.

Beta adrenergic antagonists and antianginal drugs are used with the aim to ultimately decrease mortality and enable patients to lead an improved quality of life by avoidance of anginal episodes. Each class of medications used for this purpose has a variety of actual or potential side effects associated with their use. Side effects and drug interactions involving these medications are discussed in the following chapter. Evidence presented should be used in the context of the patient populations described and may aid clinical decision making through avoidance or identification of actual or potential side effects. This review includes literature published from January 2019 to January 2020 written in English.