Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium at pharyngeal and anorectal sites in patients presenting to an STI outpatient ward.

BACKGROUND: The incidence of sexually transmitted infections (STIs) is unbridled and on the rise. Extragenital STIs (anal and pharyngeal infections) are commonly asymptomatic, resulting in delayed diagnosis and treatment and consequently higher chances of onward transmission. OBJECTIVE: The aim of this observational single-centre study was to determine the prevalence of STIs at extragenital sites in symptomatic and asymptomatic patients presenting at an STI outpatient clinic. METHODS: We conducted a retrospective analysis of patients who presented between October 2019 and February 2021 at the STI outpatient clinic of a tertiary centre in Central Europe. Patients were included in the study if they received at least one pharyngeal and/or anorectal swab in addition to a genital swab for multiplex-PCR STI diagnostics. Demographic data, symptoms and serological results were collected and analysed. RESULTS: Data collected from 440 patients were analysed (mean age: 33.9 years, male: n = 345, 78.4%, female: n = 95, 21.6%). Ninety-seven males reported having sex with men (MSM); 174 patients identified as heterosexual (132 males, 42 females), and 10 females as bisexual. The sexual orientation was not reported in 159 cases. An STI was confirmed in 195 patients (44.3%) and, among those, 109 patients (55.9%) tested positive for an STI at extragenital sites. Seventy-one patients had a pharyngeal STI whereas 61 were infected in the anorectal region. Of those suffering from an extragenital STI, 64.2% (70 out of 109) tested negative for relevant pathogens at genital sites. The most frequently detected extragenital pathogen was Neisseria gonorrhoeae (71.8% of all pharyngeal STIs [51 out of 71], 55.7% of anorectal STIs [34 out of 61]), followed by Chlamydia trachomatis (41.0% of all anal infections [25 out of 61], 5.6% of pharyngeal infections [4 out of 71]). Pharyngeal and anorectal infections were asymptomatic in 88.7% [63 out of 71] and 65.6% [40 out of 61] of the cases, respectively. CONCLUSION: These results underline the need to perform multisite testing, regardless of the presence of symptoms.

Concomitant bihemispheric cerebral ganglioglioma and hemangioma in an 18-month-old child: case report.

This is a rare case of concomitant bihemispheric cerebral ganglioglioma and hemangioma in an 18-month-old child. There were two identical processes; a combination of ganglioglioma and hemangioma was located in the parieto-occipital region of both cerebral hemispheres. The child underwent diagnostic computed tomographic and magnetic resonance imaging examinations for seizures and right-sided facial palsy, which showed the bilateral presence of parieto-occipital, oval, well-demarcated, subcortically located processes. A biparieto-occipital craniotomy was carried out and two well-demarcated abnormalities were observed and both were removed in toto. Two years after the operation, the boy had normal psychomotor development and remained free from seizures with no therapy required. Repeat magnetic resonance imaging showed no tumor recurrence. Gangliogliomas are relatively uncommon tumors in childhood, located in the supratentorial compartment and usually associated with seizures. Histopathologic and immunohistochemical analysis of the two processes found in our patient showed them to be a ganglioglioma and a hemangioma, confirming the dysontogenetic origin of these alterations and the association between malformations and tumor growth. The combination of ganglioglioma and hemangioma, especially bilateral presentation of two such identical processes in a young child, is very rare and was not found in the recent literature.

Postural stability using different neck positions in normal subjects and patients with neck trauma.

Subjects with neck problems, such as whiplash injuries, often complain of disturbed equilibrium and, in some instances, provocation of the neck position can elicit such problems. The importance of neck proprioceptors for maintaining balance is gaining increased interest, moreover the function or malfunction of the otoliths may disturb equilibrium in certain head positions. The aim of the study was to create a reference material for postural control and its dependence on head position in healthy subjects and to compare this with a set of patients with known neck problems and associated vertiginous problems. A total of 32 healthy subjects (16 men, 16 women, age range 21-58 years) as well as 10 patients age range 27-62 years (mean 44 years) with neck problems and associated balance problems since a whiplash injury were tested for postural control using the EquiTest dynamic posturographic model. The normal subjects were initially split into four age groups in order to estimate the effects of age on performance. The postural stability was evaluated for dependence of support surface conditions (stable or sway-referenced), visual input (eyes open or closed) and head position (neutral, left rotated, right rotated, extended backwards or flexed forward) using analysis of variance (ANOVA) with Tukey's post hoc test in case of a significant factor effect. As expected, visual cues as well as stable support surface improve postural stability (p < 0.001). Postural stability is statistically different in the head extended backwards condition compared with the other four head positions (p < 0.001 in all cases) in both patients and controls. Eliminating this test condition from the analysis, only a slight (p < 0.05) difference between head forwards and head turned left remained. This pattern of results remained if the normal subjects were only split into two age groups instead of four. Finally, the patient group exhibited significantly lower postural performance than all the groups of normal subjects (p <0.01), but none of the normal groups differed significantly from each other. It is concluded that the postural control system is significantly challenged in the head extended backwards condition in both normal subjects and patients with previous whiplash injury and persistent neck problems. The patient group differed statistically from all groups of normal subjects. This suggests that neck problems impair postural control, and that the head extended position is a more challenging task for the postural system to adapt to. Whether this is due to utricular malpositioning, central integrative functions or cervical proprioceptive afferents is not within the scope of this study to answer.

Intramedullary lipoma of dorsocervicothoracic spinal cord with intracranial extension and hydrocephalus.

An intradural, intramedullary lipoma originating within the cervicothoracic cord with significant extension into the posterior fossa is reported. The lipoma was found incidentally by CT scan at the infant's age of 2 days. Follow-up studies by CT and MRI were performed on several occasions. Because of hydrocephalus, VP shunting was performed. After shunting and shunt revisions, surgery of lipoma was performed at the age of 2 years. Posterior fossa craniectomy and laminectomy from C1 to T4 revealed a lipoma, which was maximally reduced. Six months after surgery, the child was well and showed good recovery.

Cardiac phase-synchronized myocardial thallium-201 single-photon emission tomography using list mode data acquisition and iterative tomographic reconstruction.

The purpose of this study was to determine whether data acquisition in the list mode and iterative tomographic reconstruction would render feasible cardiac phase-synchronized thallium-201 single-photon emission tomography (SPET) of the myocardium under routine conditions without modifications in tracer dose, acquisition time, or number of steps of the a gamma camera. Seventy non-selected patients underwent 201T1 SPET imaging according to a routine protocol (74 MBq/2 mCi 201T1, 180 degrees rotation of the gamma camera, 32 steps, 30 min). Gamma camera data, ECG, and a time signal were recorded in list mode. The cardiac cycle was divided into eight phases, the end-diastolic phase encompassing the QRS complex, and the end-systolic phase the T wave. Both phase- and non-phase-synchronized tomograms based on the same list mode data were reconstructed iteratively. Phase-synchronized and non-synchronized images were compared. Patients were divided into two groups depending on whether or not coronary artery disease had been definitely diagnosed prior to SPET imaging. The numbers of patients in both groups demonstrating defects visible on the phase-synchronized but not on the non-synchronized images were compared. It was found that both postexercise and redistribution phase tomograms were suited for interpretation. The changes from end-diastolic to end-systolic images allowed a comparative assessment of regional wall motility and tracer uptake. End-diastolic tomograms provided the best definition of defects. Additional defects not apparent on non-synchronized images were visible in 40 patients, six of whom did not show any defect on the non-synchronized images. Of 42 patients in whom coronary artery disease had been definitely diagnosed, 19 had additional defects not visible on the non-synchronized images, in comparison to 21 of 28 in whom coronary artery disease was suspected (P < 0.02; chi 2). It is concluded that cardiac phase-synchronized 201T1 SPET of the myocardium was made feasible by list mode data acquisition and iterative reconstruction. The additional findings on the phase-synchronized tomograms, not visible on the non-synchronized ones, represented genuine defects. Cardiac phase-synchronized 201T1 SPET is advantageous in allowing simultaneous assessment of regional wall motion and tracer uptake, and in visualizing smaller defects.

[Right ventricular function and pulmonary hypertension]. / Rechtsventrikuläre Funktion und pulmonale Hypertonie.

BACKGROUND: Hypothetically the right ventricular function measured by Equilibrium Radionuclide Ventriculography (RNV) is determined by the right ventricular ejection fraction and depends on the afterload. We investigated the possibility to evaluate the increased pulmonary artery pressure (PAP) by using this method. PATIENTS AND METHOD: We examined 109 patients (54.6 +/- 11 years) with chronic obstructive pulmonary disease (COPD). Lung function test, analysis of blood gases, pulmonary artery catheterisation and RNV were done within one week. RESULTS: There are 52 patients with non. 37 with labile and 20 with fixed pulmonary hypertension. Patients with normal PAP and nearly normal RVEF (49.2 +/- 8) were used as control group. Patients with pulmonary hypertension have had a lower mean RVEF, but there was no significant difference to the control group. Furthermore there was no significant correlation between mean PAP and RVEF detectable. By using RNV we diagnosed fixed pulmonary hypertension with a sensitivity of 95% and a specificity of 33% reduced RVEF and partial respiratory failure as a second noninvasive parameter achieved a more precise but not sufficient prediction of pulmonary hypertension, tested in Chi Square-Test. Obviously the RVEF depends not only on the afterload but also on the preload and contractility. However, influences on contractility are multidimensional and difficult to assess and to determine. CONCLUSION: Eventually it is not possible to use the RNV for measuring RVEF to diagnose pulmonary hypertension in COPD.

Assessment of myocardial viability in persistent defects on thallium-201 SPECT after reinjection using gradient-echo MRI.

This prospective study assessed myocardial viability in 30 patients with coronary heart disease and persistent defects despite reinjection on TI-201 single-photon computed tomography (SPECT). In each patient, three observers graded TI-201 uptake in 7 left ventricular wall segments. Gradient-echo magnetic resonance imaging in the region of the persistent defect generated 12 to 16 short axis views representing a cardiac cycle. A total of 120 segments were analyzed. Mean end-diastolic wall thickness and systolic wall thickening (+/-SD) was 11.5 +/- 2.7 mm and 5.8 +/- 3.9 mm in 48 segments with normal TI-201 uptake, 10.1 +/- 3.4 mm and 3.7 +/- 3.1 mm in 31 with reversible lesions, 11.3 +/- 2.8 mm and 3.3 +/- 1.9 mm in 10 with mild persistent defects, 9.2 +/- 2.9 mm and 3.2 +/- 2.2 mm in 15 with moderate persistent defects, 5.8 +/- 1.7 mm and 1.3 +/- 1.4 mm in 16 with severe persistent defects, respectively. Significant differences in mean end-diastolic wall thickness (p < 0.0005) and systolic wall thickening (p < 0.005) were found only between segments with severe persistent defects and all other groups, but not among the other groups. On follow-up in 11 patients after revascularization, 6 segments with mild-to-moderate persistent defects showed improvement in mean systolic wall thickening that was not seen in 6 other segments with severe persistent defects. These data indicate that most myocardial segments with mild and moderate persistent TI-201 defects after reinjection still contain viable tissue. Segments with severe persistent defects, however, represent predominantly nonviable myocardium without contractile function.

[123I]IBZM SPET analysis of dopamine D2 receptor occupancy in narcoleptic patients in the course of treatment.

Elevated levels of central D2 dopamine receptors were found on postmortem examination in cases of human narcolepsy. In vivo investigations using positron emission tomography (PET) and single photon emission tomography (SPET) found no changes of D2 binding in the striatal structures. To investigate whether the elevated D2 receptors in postmortem investigations are due to long-term treatment effects, we applied 123I-labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) ([123I]IBZM, a highly selective CNS D2 dopamine receptor ligand) and SPET in narcoleptic patients in the course of treatment with stimulants and/or antidepressants. Before treatment we found no changes in D2 binding in 10 patients (in comparison to 10 normal controls). After treatment (performed in five patients for 3 months) we found changes in D2 binding in four of them, indicating that the results of the postmortem studies could have been influenced by long-term medications. Human narcolepsy seems not to be related to a striatal D2 dopaminergic disturbance.

Changes of central benzodiazepine receptor density in the course of anticonvulsant treatment in temporal lobe epilepsy.

The first investigation of the central-type benzodiazepine (BZ) receptor density before and following 2 months successful treatment with carbamazepine (CBZ) in a patient with temporal lobe epilepsy (TLE) using 123I-labelled Iomazenil (a specific lipophile central BZ receptor compound) and single photon emission tomography (SPET) is reported. First, a focal slowing of the EEG in the left temporal area was noted and a corresponding reduction of the central BZ density of the left temporal lobe was found. After 2 months of treatment the patient was symptom-free, and a normal BZ receptor density and no pathological EEG signs were found. The increase in central BZ receptor binding sites might be related to the anticonvulsant effects of CBZ mediated by the so-called peripheral BZ receptor sites.

Cerebrovascular reactivity to acetazolamide in (senile) dementia of Alzheimer's type: relationship to disease severity.

Neuropathological reports about denervation and amyloid angiopathy in dementia of Alzheimer's type (DAT) as well as signs of selective incomplete white matter infarctions point to a vascular involvement within the degenerative process. In order to investigate potential alterations of cerebrovascular function we performed cerebral blood flow measurements before and after intravenous injection of 1 g acetazolamide using technetium-99m hexamethylpropyleneamine oxime and single photon emission tomography in 12 patients (6 female, 6 male; mean age 70.8 +/- 9.6 years) with probable (senile) dementia of Alzheimer's type (SDAT) and 9 controls (7 female, 2 male; mean age 71.2 +/- 8.6 years). SDAT patients revealed significantly reduced cerebrovascular reactivity with lower values with increasing cognitive impairment. We discuss possible underlying mechanisms.

Nocturnal myoclonus syndrome (periodic movements in sleep) related to central dopamine D2-receptor alteration.

The nocturnal myoclonus syndrome (NMS) consists of stereotyped, repetitive jerks of the lower limbs that occur during sleep or wakefulness. NMS is often related with restless-legs syndrome (RLS) and can cause severe sleep disturbances and daytime sleepiness. The efficacy of dopamine agonists in the treatment points to a dopaminergic dysfunction in NMS. We investigated the central dopamine D2-receptor occupancy with [123I] labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) ([123I]IBZM) and single photon emission tomography (SPET) in 20 patients with NMS and in 10 healthy controls. In most of the patients with NMS there was a lower [123I]IBZM binding in the striatal structures compared to controls. The results indicate that NMS is related to a decrease of central D2-receptor occupancy.

Single photon emission tomography (SPET) imaging of dopamine D2 receptors in the course of dopamine replacement therapy in patients with nocturnal myoclonus syndrome (NMS).

Single photon emission tomography (SPET) permits the in vivo measurements of regional cerebral radioactivity in the human brain following the administration of compounds labeled with photon-emitting isotopes. According to our SPET findings of a reduced binding of [123I]labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) to D2 dopamine receptors in striatal structures in untreated patients with nocturnal myoclonus syndrome (NMS) it seemed to be of interest to investigate whether there are changes in D2 receptor binding under dopamine replacement therapy or not. We studied the uptake and distribution of [123I]IBZM before and in the course of dopamine replacement therapy in four patients with severe insomnia caused by a nocturnal myoclonus syndrome (NMS). We found an increase of the IBZM binding to D2 receptors in the course of treatment, which was associated with an improvement of sleep quality. Reasons for this are discussed. The [123I]IBZM SPET technique in conclusion offers an intersting tool for in vivo investigations of functional changes in the dopaminergic neurotransmitter system in longitudinal studies.

99mTc-HMPAO-SPECT in the diagnosis of senile dementia of Alzheimer's type--a study under clinical routine conditions.

This study was designed to evaluate, whether investigations of cerebral blood flow can be a helpful diagnostic tool in the differential diagnosis between (senile) dementia of Alzheimer's type [(S)DAT] and geriatric depression with cognitive impairment. Under clinical routine conditions we performed Single Photon Emission Computed Tomography (SPECT) using 99mTc-Hexamethylpropyleneamine Oxime (HMPAO) in 23 patients with (S)DAT (14f, 9m; mean age 68.9 y), 17 patients with geriatric depression (9 f, 8 m; mean age 66.4 y) and 12 age-matched controls (9 f, 3 m; mean age 69.2 y). Semiquantitative analysis (corticocerebellar ratios) of eight different regions of interest (ROI) revealed a significantly (p < 0.05) reduced perfusion in the (S)DAT patients compared to the control group. The depression group exhibited perfusion values between the (S)DAT and control group. The difference between the depression and (S)DAT group was most prominent in the left parieto-occipital ROI (p = 0.008). We discuss the data with extensive regard to the literature and conclude that 99mTc-HMPAO SPECT is a valuable additional tool in the differential diagnosis of depression and dementia in the elderly.

[Nightly myoclonus syndrome (NMS) and restless legs syndrome (RLS)--review and case report]. / Nächtliches Myoklonie-Syndrom (NMS) und Restless-Legs-Syndrom (RLS)--Ubersicht und Fallbeschreibung.

The paper gives a brief review of the existing literature concerning the nocturnal myoclonus syndrome (NMS). The clinical symptomatology, criteria for differential diagnosis and the relation to the restless legs syndrome (RLS) are discussed. Recently we investigated central dopamine receptor density with 123I-labeled 3'-iodo-6-methoxybenzamide (IBZM) (a highly selective CNS D2 dopamine receptor ligand) and single photon emission tomography (SPECT) in patients with NMS and found a reduced density of dopamine D2-receptors in the striatal structures, indicating a dopaminergic dysfunction in NMS and RLS. We present a report concerning a 58-year old female with NMS-associated insomnia and present IBZM SPECTs and hypnograms before and after a 3-month treatment with L-dopa and discuss the results with regard to pathophysiological theories.

Dopamine D2 receptor alteration in patients with periodic movements in sleep (nocturnal myoclonus).

Periodic movements in sleep (PMS) can cause severe sleep disturbances. We investigated the central dopamine D2 receptor density in patients with PMS with 123I-IBZM and single photon emission tomography (SPET). In PMS there was a lower 123I-IBZM binding in the basal ganglia compared to the control group. The results indicate a loss of central D2 receptors in PMS.

[Neurosurgical treatment of children with spina bifida associated with congenital spinal lipoma in the lumbosacral region]. / Neurokirursko lijecenje djece sa spinom bifidom udruzenom sa spinalnim kongenitalnim lipomom u lumbosakralnom podrucju.

This paper presents twelve neurosurgically treated children with spina bifida associated with congenital spinal lumbosacral lipoma over a 3-year period. The introduction deals with various types of lipoma, their development, clinical presentation, local findings in children with spinal lipoma, as well as with the significance of neurosurgical treatment. The age span of children with occult spina bifida and spinal lumbosacral lipoma was from 3 months to 2 years, and there were seven girls and five boys. In all the twelve children, a smaller or bigger fatty mass in the lumbosacral area was noticed immediately after birth, gradually increasing in size. Neurologic examination revealed weakness of lower extremities, with somewhat atonic sphincters, in only two of the children. Spinal dysraphism was demonstrated by plain roentgenograms in all the twelve children, while CT-scans, CT-myelography and recently MR-scans, confirmed the diagnosis of spinal lipoma. In all the twelve children the spinal lipoma and the adherences between the lipoma and the low-lying conus or an enlarged filum terminale were removed by the neurosurgical excision. Follow-up of children 6 and more months following the surgery showed improvement of their condition. Spina bifida associated with congenital spinal lumbosacral lipoma is a condition that although benign in histology, can have devastating effects if not surgically corrected early. Children who are asymptomatic at the time of repair will tend to remain asymptomatic. Those who are not repaired early will develop and show subsequent deterioration as time progresses.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaplastic ependymoma in children--increasing incidence?

During 1988 and 1989, 16 cases of ependymomas were diagnosed at the Department of Pathology, University Hospital "Sestre milosrdnice", Zagreb. The specimens were obtained from the Department of Neurosurgery of the same hospital. Seven tumors out of these 16 were supratentorial, four of them being diagnosed as anaplastic ependymomas. At the time of the first operation, patients with anaplastic ependymoma were aged 2 to 18 years, and there were three man and one woman. The criteria for this diagnosis were cellular pleomorphism and anaplasia, vascular hyperplasia with marked endothelial proliferation, and the most important of all, the presence of numerous mitoses. Necroses, cystic degenerations and bleeding were found in all four tumors. The aim of this study is the survey of morphology, tumor localisation and patient's age at the moment of diagnosis as relevant factors for the prognosis of these tumors. It seems significant to indicate a relatively great number of these tumors in only a two-year period in one hospital, while statistical data reported in the literature have been taken from several institutions in various towns or states for much longer period of even several decades. Hence, this study could be in favour of the idea presented in the recent literature data, that this tumor type is increasing.

Diastematomyelia--case report.

An eight-month-old infant with diastematomyelia, as a very rare variety of spinal dysraphism is presented in this article. The introduction deals with a detailed description of diastematomyelia, its development, local, neurological, and orthopedic signs in affected patients, diagnostic procedures and significance of neurosurgical treatment in patients with diastematomyelia. In the particular child, immediately upon birth, a thornlike bulging was noticed in the L2-L3 region. Neurological deficit, established at the time of surgery, was due to the perinatal brain damage and corresponded to the spastic syndrome of the central origin with the right-hand side predomination, and there was no predomination in the lower extremities, which could be expected in regard to the spinal dysraphism. Plain X-ray film revealed a thornlike bulging at the L2-L3 level. Lumbar myelography showed a distinctly enlarged dural sac at the level of L2 to S1 with a well pronounced contrast medium passage defect at the L3 level. The spinal canal CT-findings revealed a bony bulging between L1 and L2, starting from the posterior arches towards the spinal canal. Besides a markedly broadened lumbar spinal canal, MR-findings also showed a well pronounced bony septum from the L2 posterior edge, and a low-lying conus medullaris with an accompanying spinal lipoma. By the neurosurgical operation bony septum and extradural lipoma were radically removed, and the spinal cord was set free from adhesions. In that way a later onset of neurological signs, due to the "tethered cord syndrome", was prevented. Six months following surgery the child's condition was still unchanged.

[Myocardial tomography with single photon emission computerized tomography (SPECT) technique in X syndrome]. / Myokardtomographie mit der Single-Photon-Emissions-Computertomographie (SPECT)-Technik beim Syndrom X.

Compared with the usual planar scintigraphy of the myocardium the single photon emission computer tomography (SPECT) has essential advantages. By means of the SPECT a three-dimensional reconstruction of the intersection image is possible which allows a judgement of the myocardium in the transversal, sagittal and coronary planes of section. The scans of the SPECT are richer in contrast and freer from overshadowings of normally of disturbedly perfused areas of the myocardium. 43 patients with angina pectoris complaints in angiographically normal coronary arteries (syndrome X) were examined by means of the SPECT under bicycle ergometer load and at rest. As radionuclide thallium-201 was used. 28 out of 43 patients (65%) showed disturbances of the perfusion, in which cases 21 patients with reversible ischaemias and 7 ones with cicatrised changes and an ischaemia of the marginal zone were conspicuous. Previous own investigations with the planar Tl-201 scintigraphy of the myocardium showed pathological findings in 66% of the cases with a syndrome X. The nearly identical results speak for the high reliability of the scintigraphy of the myocardium, but against the increase sensitivity of the SPECT in contrast to the planar scintigraphy of the myocardium.

Cranial ultrasonography in the evaluation of macrocrania in infancy.

Cranial ultrasonography was used in the initial evaluation of 40 infants with macrocrania. Three of the infants had normal findings. The other 37 had evidence of various types of abnormality: intraventricular obstructive hydrocephalus, external hydrocephalus, arrested hydrocephalus with atrophy, or mild ventriculomegaly. All the infants were given neurological and developmental examinations at the time of presentation and were followed up for one year. Sonograms and head-circumference and intracranial pressure measurements were done at intervals, according to the initial ultrasound findings and the clinical status of the children. Neurodevelopmental outcome was related to the type of abnormality. The majority of children with external hydrocephalus were neurodevelopmentally normal at follow-up. In contrast, those with obstructive or arrested hydrocephalus had unfavourable outcomes, which may be related to the significant perinatal insult causing the hydrocephalus. CT confirmation was available for 16 of the infants.