A proposta deste estudo foi desenvolver ferramentas que permitam um exame de palpação completo utilizando o algômetro e verificar a validade e confiabilidade intra e interexaminadores. Neste estudo foram examinados 80 indivíduos, sendo 40 pacientes sintomáticos que freqüentavam a clínica de prótese da Faculdade de Odontologia da Universidade de São Paulo, divididos em 20 mulheres e 20 homens com idade média de 43 anos e 40 voluntários assintomáticos divididos em 20 mulheres e 20 homens com idade média de 40 anos. Os pacientes foram examinados com um algômetro digital, ferramenta de palpação intra-oral e em forma de pinçamento em três sessões diferentes de exames com intervalo de uma semana entre si. Na primeira sessão os pacientes sintomáticos foram avaliados por um examinador, e este grupo foi denominado F1. Após uma semana, na segunda sessão, os mesmos pacientes foram reavaliados pelo mesmo examinador, e foram denominados grupoF2, após 30 minutos um segundo examinador avaliou os mesmos pacientes, com os resultados formou-se o grupoJ. Após uma semana, na terceira sessão, os 40 voluntários assintomáticos (controle) foram avaliados pelo examinador F, grupo denominado C. A validade do algômetro foi avaliada comparando-se grupoF2 x grupoC (sintomáticos x assintomáticos). A confiabilidade intra-examinador foi avaliada comparando-se grupoF1 x grupoF2 e a confiabilidade interexaminadores comparando-se grupoF2xgrupoJ. Após a aplicação de testes estatísticos a validade do algômetro foi comprovada, a confiabilidade intraexaminador foi considerada boa, porém a confiabilidade interexaminadores foi de aproximadamente 50%, mostrando que para se atingir altos níveis de confiabilidade é necessário um programa de calibragem e uma padronização da taxa de aplicação da força. / The purpose of this study was to develop tools that allow a complete palpation examination using an algometer to evaluate validity and reliability. This study examined 80 subjects, 40 symptomatics patients from the school of Dentistry, University of São Paulo, divided in 20 women and 20 men, mean age 40 years, were examined using an eletronic algometer, intra-oral tool and pincer ? type pressure tool. The symptomatics patients were examinated in tree different sessions with intervals of one week. In the first session, an examiner (F1 group) evaluated the simptomatics patients. After one week, in the second session, the same examiner (F2 group) evaluated the same patients, 30 minutes later a second examiner evaluated the same patients (J group). One week later, in the third session, the first examiner (C group) evaluated 40 healthy volunteers. The validity of pressure digital algometer was obtained comparing F2 group x C group. The reliability intra examiner was obtained comparing F1 group x F2 group and the reliability inter examiners comparing F1 group x J group. After a statistic study, validity of the pressure digital algometer was obteined, good intra-examiner reliability was found but low interexaminer reliability was found, sugesting that to achieve hight levels of reliability a calibrating program and a padronization of pressure rate is necessary.

Algometers are devices that can be used to identify the pressure and/or force eliciting a pressure-pain threshold. It has been noted in pressure-pain threshold studies that the rate at which manual force is applied should be consistent to provide the greatest reliability. This study tested the reliability and construct validity of an algometer (1000-Hz sampling rate) by manually applying pressure on a force plate (500-Hz sampling rate): 10 sets of 5 applications to 80 N and 1 set of 5 applications to each force level: 20, 30, 40, 50, 60, 70, 80, 90, 100, and 110 N. The investigator had previously become familiar with and practiced with the algometer. The handheld algometer had a 1-cm2 round rubber application surface, and the maximum force reading was compared with maximum force readings by the force plate using SEM and t-tests. Force-time curves were analyzed for average slope representing rate of force application. Average Pearson (r) correlations between the maximum force reading of the algometer and force plate were excellent in both trials to 80 N (r = 0.990) and the incremental trials (r = 0.999). The application of force was reasonably constant, with slopes averaging 6.8 ± 0.932 N·s−1. The SEE was 0.323 N. In conclusion, with previous familiarization and practice, an investigator may have high reliability in the rate of force application. The device itself was also highly correlated with readings from a force plate and, therefore, may be considered valid.

A proposta deste estudo foi desenvolver ferramentas que permitam um exame de palpação completo utilizando o algômetro e verificar a validade e confiabilidade intra e interexaminadores. Neste estudo foram examinados 80 indivíduos, sendo 40 pacientes sintomáticos que freqüentavam a clínica de prótese da Faculdade de Odontologia da Universidade de São Paulo, divididos em 20 mulheres e 20 homens com idade média de 43 anos e 40 voluntários assintomáticos divididos em 20 mulheres e 20 homens com idade média de 40 anos. Os pacientes foram examinados com um algômetro digital, ferramenta de palpação intra-oral e em forma de pinçamento em três sessões diferentes de exames com intervalo de uma semana entre si. Na primeira sessão os pacientes sintomáticos foram avaliados por um examinador, e este grupo foi denominado F1. Após uma semana, na segunda sessão, os mesmos pacientes foram reavaliados pelo mesmo examinador, e foram denominados grupoF2, após 30 minutos um segundo examinador avaliou os mesmos pacientes, com os resultados formou-se o grupoJ. Após uma semana, na terceira sessão, os 40 voluntários assintomáticos (controle) foram avaliados pelo examinador F, grupo denominado C. A validade do algômetro foi avaliada comparando-se grupoF2 x grupoC (sintomáticos x assintomáticos). A confiabilidade intra-examinador foi avaliada comparando-se grupoF1 x grupoF2 e a confiabilidade interexaminadores comparando-se grupoF2xgrupoJ. Após a aplicação de testes estatísticos a validade do algômetro foi comprovada, a confiabilidade intraexaminador foi considerada boa, porém a confiabilidade interexaminadores foi de aproximadamente 50%, mostrando que para se atingir altos níveis de confiabilidade é necessário um programa de calibragem e uma padronização da taxa de aplicação da força. / The purpose of this study was to develop tools that allow a complete palpation examination using an algometer to evaluate validity and reliability. This study examined 80 subjects, 40 symptomatics patients from the school of Dentistry, University of São Paulo, divided in 20 women and 20 men, mean age 40 years, were examined using an eletronic algometer, intra-oral tool and pincer ? type pressure tool. The symptomatics patients were examinated in tree different sessions with intervals of one week. In the first session, an examiner (F1 group) evaluated the simptomatics patients. After one week, in the second session, the same examiner (F2 group) evaluated the same patients, 30 minutes later a second examiner evaluated the same patients (J group). One week later, in the third session, the first examiner (C group) evaluated 40 healthy volunteers. The validity of pressure digital algometer was obtained comparing F2 group x C group. The reliability intra examiner was obtained comparing F1 group x F2 group and the reliability inter examiners comparing F1 group x J group. After a statistic study, validity of the pressure digital algometer was obteined, good intra-examiner reliability was found but low interexaminer reliability was found, sugesting that to achieve hight levels of reliability a calibrating program and a padronization of pressure rate is necessary.

This study assessed the effect of an eight-minute cycling intervention using varying intensities on exercise-induced hypoalgesia (EIH). Generally, current research examines EIH using protocols that last for more than 10 minutes and reach 75% of an individual's VO2 peak. The main objective of this study was to examine the effect of varying intensities on pressure pain threshold (PPT) and heat pain threshold (HPT) at the thigh and forearm, tested pre- and post-cycling intervention. Healthy male participants (n=16) performed a graded exercise test on a cycle ergometer to establish their peak power output (PPO). In subsequent visits, participants completed five different 8-minute cycling interventions, with intensities randomly assigned to one of three counterbalanced orders. HPT and PPT were applied to the thigh and forearm two times before and after each cycling intervention. Additionally, there was a notable effect of intensity on PPT in the thigh, with significant changes at intensities of 90% (p = 0.024) and 100% (p = 0.003). In the forearm, repeated measures ANOVA indicated that there was no significant interaction or main effect for intensity and time. Similarly, for HPT, the analysis did not show significant interaction or main effects for both intensity and location. This study was the first to examine EIH using an 8-minute cycling intervention on a cycling ergometer at individualized intensities. Higher intensity cycling sessions generated EIH locally in the thigh using PPT. This intervention appeared to target the nociceptors activated by mechanical, rather than thermal stimuli, further highlighting the multi-faceted nature of EIH. A short but high intensity cycling intervention may have clinical relevance, as it can provide an intervention to reduce localized pain immediately after exercise using a pressure pain stimulus.

Title: Algometric analysis of influence of crimp grip on soft tissues of hand and forearm. Objectives: The main aim of this thesis is comparison and evaluation of changes of nociceptors sensitivity treshold in chosen points of upper extremities area before and after defined strain using pressure algometer. Methods: Data for the experiment was obtained using pressure algometr. Pain threshold was measured in defined 42 points in the order given at each subject firstly before strain and again immediately after defined strain of upper extremities (one minute hangig by the both hands in crimp grip on a campus board in this way: 10 sec strain plus 10 sec break, all six times). Then were measured values statisticaly analysed. Sources for processing of theoretical part of this work were obtained from expert articles and literature which follow up the given task. Results: Statisticaly important results show, that decreasing of pain threshold (on average by 100 - 160 kPa) comes about in tissues of upper extremity immediately after its loading in crimp grip, which means increasing of nociceptors sensitivity. At the same time it has been proved that nociceptors sensitivity in the area of tendon pulleys correlates with frequency of their injury quoted in a literature (that is the highest sensitivity in the...

Este trabalho objetivou avaliar a prevalência de subgrupos da Disfunção Temporomandibular (DTM) e hábitos parafuncionais orais em indivíduos portadores de zumbido subjetivo, sendo comparados com indivíduos sem zumbido. Duzentos indivíduos, de ambos os gêneros, com idade entre 18 a 60 anos, participaram do estudo. Inicialmente, foram subdivididos, com auxílio do exame otorrinolaringológico, em grupo experimental (n=100), indivíduos portadores de zumbido subjetivo, e grupo controle (n=100), voluntários sem qualquer queixa de zumbido. A análise da prevalência de DTM, bem como o estudo dos seus sinais e sintomas, foi feita segundo os critérios de diagnóstico Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). O Limiar de Dor à Pressão (LDP) dos músculos masseter e temporais (anterior, médio e posterior) foram medidos bilateralmente, por meio de um algômetro KRATOS®, e a dor subjetiva pela Escala de Análise Visual (EAV). O estudo da presença dos hábitos parafuncionais orais, apertamento dentário diurno e bruxismo do sono, foi feito através do auto-relato e da aplicação de exame clínico de bruxismo, respectivamente. Os dados obtidos foram submetidos à análise estatística (Testes Qui-Quadrado, t de Student e Mann-Whitney e Coeficiente de Correlação de Spearman), em um nível de significância de 5%. Foi encontrada uma maior prevalência de DTM no grupo experimental quando comparado ao grupo controle (p<0,05). De uma maneira geral, os sinais e sintomas de DTM avaliados foram mais prevalentes no grupo experimental em comparação ao grupo controle, como a presença de dor à palpação na ATM e de ruídos articulares na abertura bucal, maior tempo de dor e maior grau de severidade de dor crônica. O resultado médio da EAV encontrado foi estatisticamente maior no grupo experimental (p<0,05), contudo os LDPs não apresentaram diferença significativa entre os grupos. A análise dos hábitos parafuncionais mostrou diferença estatisticamentente significativa da presença de bruxismo noturno entre os grupos, sendo mais prevalente no grupo experimental (p<0,05). Houve uma correlação positiva estatisticamente significativa entre a severidade do zumbido e a severidade da dor crônica (p<0,05) e entre o tempo de zumbido e o tempo de dor (p<0,05). Conclui-se que parece existir uma forte correlação entre os sinais e sintomas da DTM e o zumbido de caráter subjetivo. / The aim of this study was to study the prevalence of Temporomandibular Disorders (TMD) subgroups and oral parafunctional habits, daytime clenching and sleep bruxism, in patients with subjective tinnitus when compared to a group of asymptomatic volunteers. Two hundred patients (ages between 18-60 years-old) participated in this study, divided into two groups, according to the presence (experimental) or not (comparison) of subjective tinnitus. According to the RDC/TMD criteria, the subgroups were determined. The Pain Pressure Threshold (PPT) values of masseter and temporalis (anterior, middle, and posterior regions) muscles were recorded bilaterally with an algometer and a visual analog scale (VAS) was used to address subjective pain. The severity of the TMD was determined by using an anamnestic questionnaire while a self-reported questionnaire detected parafuncional habits. Data were submitted to statistical analysis (Chi-square, t Student, Mann-Whitney and Spearmans Correlation), at a 5% significance level. The prevalence of signs and symptoms of TMD was significantly associated with the presence of tinnitus (p.001). The three most prevalent TMD subgroups in tinnitus patients (p<.05) were myofascial pain with temporomandibular joint (TMJ) internal derangement (39%), disc displacement with reduction (44,33%) and arthralgy (53,54%). The PPT values were lower (p>.05) while VAS was statistically higher (p<.05) for tinnitus patients. The severity of TMD was associated with tinnitus (p0.001). Both, the report of sleep bruxism (58%), as well as of daytime clenching (60%) were found more frequently in tinnitus patients. Significant difference, however, was detected only for the report of bruxism (p<.05). These results suggest that an association exists between TMD and subjective tinnitus.

Greater trochanteric pain (GTP) is a regional pain syndrome characterized by lateral hip pain and tenderness. Its incidence after total hip arthroplasty (THA) is variable. Bursal inflammation, degenerative changes of the attachment of the gluteal muscles, direct operative trauma and biomechanical disturbance of the operated hip have been discussed as being related to GTP. The diagnosis is purely clinical because radiological and laboratory investigations show no definite pathology. Although most treatment modalities are conservative, some patients may develop refractory complaints leading to surgical intervention. In study I we studied the incidence of GTP in 172 consecutive patients who underwent THA during 2002 at Sundsvall Hospital. Patients with GTP (n=21, incidence 12%) were matched with controls from the same cohort. The THA outcome was assessed using the Western Ontario and McMaster Universities Arthrosis (WOMAC) Index. Trochanteric tenderness was studied using an electronic pressure algometer. We found an association between the occurrence of GTP and postoperative uncorrected lengthening of the operated limb of ≥ one centimetre. The WOMAC index revealed a reduction of the clinical outcome in the GTP group. In Study II we tested the value of using an algometer in the diagnosis of GTP after THA. We measured the pressure-pain threshold (PPT) over the greater trochanter and ilio-tibial band in 18 patients and 18 matched controls. Both groups were evaluated using the visual analogue scale (VAS). We found the algometer to have a good predictive validity and reproducibility. However, there was large inter-individual variability across subjects. The PPT ratio of 0.8 (affected vs. unaffected side) can be used as a cutoff ratio to establish GTP. There was no correlation between PPT measurements and VAS. Because of a low positive predictive value and large inter-individual variability, the pressure algometer has a limited value as a screening tool. In study III we proposed a new surgical treatment for refractory GTP after THA consisting of distal lengthening of the ilio-tibial band (ITB) by Z-plasty under local anaesthesia. This method was used in 12 women between March 2004 and June 2006. The patients were followed up by phone interview 3-4 months postoperatively and by an EQ-5D questionnaire and clinical examination including evaluation with the algometer at 1-3 years postoperatively. We found that the patients‘ quality of life was markedly improved following the operation (EQ-5D = 0.26 preoperatively vs. 0.67 postoperatively; p &lt;0.005). There were no postoperative complications. In study IV we evaluated the accuracy of a commonly used clinical method of LLD measurement (anterior superior iliac spine-medial malleolus) by comparing it to a reliable radiological method (tear drop-lesser trochanter) in 139 patients before and after THA. We found the correlation between the clinical and radiological methods to be weak preoperatively (r=0.21, ICC= 0.33) while the correlation was moderate postoperatively (r= 0.45, ICC=0.62). It is therefore recommended that the radiological method be used to measure leg length discrepancy in patients who undergo THA.

Este trabalho objetivou avaliar a prevalência de subgrupos da Disfunção Temporomandibular (DTM) e hábitos parafuncionais orais em indivíduos portadores de zumbido subjetivo, sendo comparados com indivíduos sem zumbido. Duzentos indivíduos, de ambos os gêneros, com idade entre 18 a 60 anos, participaram do estudo. Inicialmente, foram subdivididos, com auxílio do exame otorrinolaringológico, em grupo experimental (n=100), indivíduos portadores de zumbido subjetivo, e grupo controle (n=100), voluntários sem qualquer queixa de zumbido. A análise da prevalência de DTM, bem como o estudo dos seus sinais e sintomas, foi feita segundo os critérios de diagnóstico Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). O Limiar de Dor à Pressão (LDP) dos músculos masseter e temporais (anterior, médio e posterior) foram medidos bilateralmente, por meio de um algômetro KRATOS®, e a dor subjetiva pela Escala de Análise Visual (EAV). O estudo da presença dos hábitos parafuncionais orais, apertamento dentário diurno e bruxismo do sono, foi feito através do auto-relato e da aplicação de exame clínico de bruxismo, respectivamente. Os dados obtidos foram submetidos à análise estatística (Testes Qui-Quadrado, t de Student e Mann-Whitney e Coeficiente de Correlação de Spearman), em um nível de significância de 5%. Foi encontrada uma maior prevalência de DTM no grupo experimental quando comparado ao grupo controle (p<0,05). De uma maneira geral, os sinais e sintomas de DTM avaliados foram mais prevalentes no grupo experimental em comparação ao grupo controle, como a presença de dor à palpação na ATM e de ruídos articulares na abertura bucal, maior tempo de dor e maior grau de severidade de dor crônica. O resultado médio da EAV encontrado foi estatisticamente maior no grupo experimental (p<0,05), contudo os LDPs não apresentaram diferença significativa entre os grupos. A análise dos hábitos parafuncionais mostrou diferença estatisticamentente significativa da presença de bruxismo noturno entre os grupos, sendo mais prevalente no grupo experimental (p<0,05). Houve uma correlação positiva estatisticamente significativa entre a severidade do zumbido e a severidade da dor crônica (p<0,05) e entre o tempo de zumbido e o tempo de dor (p<0,05). Conclui-se que parece existir uma forte correlação entre os sinais e sintomas da DTM e o zumbido de caráter subjetivo. / The aim of this study was to study the prevalence of Temporomandibular Disorders (TMD) subgroups and oral parafunctional habits, daytime clenching and sleep bruxism, in patients with subjective tinnitus when compared to a group of asymptomatic volunteers. Two hundred patients (ages between 18-60 years-old) participated in this study, divided into two groups, according to the presence (experimental) or not (comparison) of subjective tinnitus. According to the RDC/TMD criteria, the subgroups were determined. The Pain Pressure Threshold (PPT) values of masseter and temporalis (anterior, middle, and posterior regions) muscles were recorded bilaterally with an algometer and a visual analog scale (VAS) was used to address subjective pain. The severity of the TMD was determined by using an anamnestic questionnaire while a self-reported questionnaire detected parafuncional habits. Data were submitted to statistical analysis (Chi-square, t Student, Mann-Whitney and Spearmans Correlation), at a 5% significance level. The prevalence of signs and symptoms of TMD was significantly associated with the presence of tinnitus (p.001). The three most prevalent TMD subgroups in tinnitus patients (p<.05) were myofascial pain with temporomandibular joint (TMJ) internal derangement (39%), disc displacement with reduction (44,33%) and arthralgy (53,54%). The PPT values were lower (p>.05) while VAS was statistically higher (p<.05) for tinnitus patients. The severity of TMD was associated with tinnitus (p0.001). Both, the report of sleep bruxism (58%), as well as of daytime clenching (60%) were found more frequently in tinnitus patients. Significant difference, however, was detected only for the report of bruxism (p<.05). These results suggest that an association exists between TMD and subjective tinnitus.

Pain and movement are intimately connected and nearly universal human experiences. However, our understanding of the extent, significance, and mechanisms of pain-movement relationships is limited. While pain is a normal, protective response to injury and potentially harmful stimuli, prolonged or dysfunctional neuromuscular adaptions in response to pain can contribute to a variety of pain conditions. Alternatively, movement (in the form of global physical activity, individual exercise programs, and/or specific motor learning/functional tasks) is often prescribed to help decrease pain and improve function. While attempts have been made to show an effect of movement on pain or to better understand altered movement strategies in response to pain, much of the research has been limited to animal models or to those with specific persistent or chronic pain conditions limiting generalizability and interpretability. Therefore, this research sought to advance current understanding of the relationships between physical activity and normal variability in centrally- and peripherally-mediated pain in healthy adults. Additionally, we sought to characterize changes in reflexive motor responses in the upper extremity to an endogenous, naturally-occurring, long-lasting acute muscle pain. The results of these investigations indicate that greater, self-reported intense (i.e. vigorous) and leisure activity are more strongly associated with decreased pain sensitivity than is pain modulation or measured activity (via accelerometry). Future research is needed to determine directionality of these relationships. Further, reflexive motor responses to endogenous, acute muscle pain in the upper extremity were not significantly altered indicating that changes in pain-related, movement strategies may be more strongly influenced by supraspinal adaptations. These results may have value in improving understanding of pain-related, movement sequelae and directing future research in this area.

O objetivo deste trabalho foi analisar a influência da ansiedade e do estresse no limiar de dor à pressão (LDP) de músculos mastigatórios, numa amostra de estudantes universitários em diferentes períodos do ano letivo. Para este propósito, foram selecionados 45 indivíduos, sendo 29 estudantes, que apresentavam DTM de origem miogênica seguindo critérios de inclusão propostos pelo Research Diagnostic Criteria (RDC) e 16 que não apresentavam características de DTM, do gênero feminino, equilibrados em relação à idade. Utilizando um algômetro (KRATOS®) foram realizadas tomadas bilaterais dos limiares de dor à pressão (LDP) dos indivíduos da amostra nos músculos masseter, temporal anterior, médio e posterior. Além disso, os participantes foram solicitados a responder questionários multidimensionais, através do Inventário de Ansiedade de Beck (BAI) e o Inventário de Sintomas de Stress de Lipp (ISSL), para mensurar reações emocionais ou afetivas em situações que causem estresse e/ou ansiedade. Também, o nível de dor foi registrado pela Escala de Análise Visual (EAV). Todos os exames foram realizados em quatro momentos distintos (T1, T2, T3 e T4) tendo como parâmetro o período de avaliações acadêmicas da Faculdade de Odontologia de Bauru. Os dados obtidos foram submetidos à análise estatística (ANOVA, Teste de Tukey, Teste de Friedman e Mann-Whitney), em um nível de significância de 5%. A comparação entre os diferentes tempos do estudo nos 2 grupos mostrou diferença estatisticamente significativa (p<0,05), sendo que o período das avaliações mostrou maiores níveis de estresse e ansiedade e menores valores de LDP. Sob o ponto de vista do músculo nos diferentes grupos e nos diferentes tempos, foram encontradas diferenças estatisticamente significativas (p<0,05). Os resultados da Escala de Análise Visual mostraram diferenças estatisticamente significantes entre o grupo sintomático e o grupo assintomático em T1, T2, T3 e T4. Com relação ao estresse e ansiedade, não houve diferenças estatisticamente significante entre os grupos. Houve, no entanto, uma associação entre o aumento do estresse e da ansiedade e diminuição dos valores de LDP em cada tempo. Concluiu-se que existe relação entre estresse e ansiedade e LDP tanto para indivíduos assintomáticos quanto para sintomáticos com DTM de origem miogênica. / The aim of this research was to evaluate the influence of stress and anxiety on the Pressure Pain Threshold (PPT) of the masticatory muscles and on the subjective pain report of dental students of the Bauru School of Dentistry (University of São Paulo, Brazil) at different situations. Forty-five females, matched for age, were divided into two groups: 29 presenting with myofascial pain, according to the RDC/TMD criteria, and 16 with no TMD signs or symptoms. PPT measurements were taken bilaterally at the masseter, anterior, middle and posterior temporalis muscles in four different occasions throughout the academic year. The Achilles tendon was used as control. In order to quantify emotional or affective reactions under stress/anxiety situations, the sample were requested to fill out multidimensional questionnaires, such as the Beck Anxiety Inventory (BAI) and the Lipp Inventory for Stress Symptoms (LISS). In addition, pain levels were registered with a Visual Analog Scale (VAS). Data obtained were submitted to statistical analysis (ANOVA, Tukey, Friedman, and Mann-Whitney tests), at a 5% significance level. The VAS and PPT had a negative correlation, regardless the period, and group studied (p<.05). Higher levels of stress and anxiety were detected at the time of school examinations for both groups, with a strong association with decreased PPT figures (p<.05). Stress and anxiety, however, were not statistically different between groups. It can be concluded that external stressors as academic examinations have a potential impact on the masticatory muscle tenderness, regardless the presence of a previous condition, such as the masticatory myofascial pain.