目的:评估华蟾素注射液肝动脉给药联合碘油栓塞对中晚期原发性肝癌患者中医证候特点的影响.方法:80例中晚期原发性肝癌患者随机分为华蟾素组和表阿霉素组.于介入治疗前及治疗后第6周,采用"中医肝病证候调查表"对两组患者的中医证候进行调查,并观察其单一症状出现频次及程度.结果:治疗前,两组气虚证、血瘀证、气滞证等评分及中医乏力、胁痛、大便干及小便黄等症状比较均无统计学差异.治疗后第6周,与表阿霉素组比较,华蟾素组气虚证、血瘀证、气滞证评分及乏力、胁痛、大便干、小便黄等显著变化(P＜0.05,P＜0.01).结论:华蟾素注射液肝动脉给药联合碘油栓塞治疗方案可改善中晚期原发性肝癌患者中医单证证候.

目的 探讨原发性肝癌的中医证候分布规律.方法 对559例原发性肝癌患者使用“中医肝癌证候调查表”采集患者四诊信息,将患者分为气滞证、血瘀证、实热证、水湿证、气虚证、血虚证、阴虚证、阳虚证8种基本证候,比较各证型患者在不同临床分期(Ⅰ、Ⅱ、Ⅲ期)的分布及证候量化积分,并结合聚类分析初步探讨其证候组合规律.结果559例原发性肝癌患者的证候按出现频次由高到低依次为血瘀证380例、气虚证330例、水湿证264例、气滞证250例、实热证236例、阴虚证136例、血虚证与阳虚证各57例.气滞证在Ⅱ、Ⅲ期中分布较Ⅰ期明显减少,水湿证、阴虚证和阳虚证则在Ⅲ期的分布较Ⅰ、Ⅱ期明显增高(P＜0.01);血瘀证、气虚证、实热证和血虚证在各期分布的差异无统计学意义(P＞0.05).气滞证、水湿证、气虚证和阳虚证的证候量化积分在各临床分期的差异具有统计学意义(P＜0.01),血瘀证、实热证、血虚证和阴虚证的证候量化积分差异无统计学意义(P＞0.05).聚类分析结果显示,血瘀证和气虚证一类,气滞证、水湿证和实热证一类,阳虚证、阴虚证和血虚证一类.结论原发性肝癌的基本证候以血瘀证和气虚证最常见,随着分期进展,气滞证减少,而水湿证、阴虚证和阳虚证明显增多.

OBJECTIVE: To explore the characteristics of primary liver cancer in terms of Traditional Chinese Medicine(TCM) by analyzing the variations of the patterns along with the clinical stages.METHODS: The patients who were hospitalized in the Changhai Hospital of Traditional Chinese Medicine dated from March 1999 to December 2008 were included in this retrospective study. The patients were grouped according to their cancer stages, and their patterns were judged and quantified according to the 'Standard diagnosis and quantitative criteria of the common patterns in primary liv-er cancer' formulated by the Changhai Hospital of Traditional Chinese Medicine. Statistics methods included ANOVA and nonparametric test, among others.RESULTS: The data of the 398 newly diagnosed patients showed that Qi Stagnation, Blood Stasis, and Dampness patterns were more frequent than the other basic patterns with relatively high scores; patterns of Liver Qi Stagnation, Liver Blood Stasis, and Dampness Heat were more than the other complex patterns and scored relatively high. Scores of Dampness and Liver Qi Stagnation patterns varied among the groups at different stages and the differences were statistically significant(PDampness= 0.002,PLiver Qi Stagnation= 0.020). The highest scores of Dampness pattern and Liver Qi Stagnation pattern corresponded with Stage Ⅲb, and Stage equency wⅢ a, respectively. Dampness pattern fras higher(P =0.001) in the Stage Ⅲb group than in other groups.CONCLUSION: Pattern characteristics in patients with primary liver cancer of different clinical stages might manifest in the variations of the Dampness pattern along the process of the disease and the major pathogenic factor of primary liver cancer might be Dampness.

目的:初步评估华蟾素注射液肝动脉给药联合碘油栓塞治疗中晚期肝癌的安全性.方法:将住院治疗的中晚期原发性肝癌患者80例分为华蟾素组和表阿霉素组.两组患者均予肝动脉栓塞术(HAE)治疗,华蟾素组患者同时给予华蟾素注射液肝动脉注射,表阿霉素组给予表阿霉素肝动脉注射.分别于纳入时及3个月时进行介入,治疗方案结束后第6周进行疗效评价.检测患者血常规、肝肾功能、凝血功能指标并观察患者介入术后不良反应等,评价华蟾素治疗的安全性.结果:治疗前两组患者的血常规、肝肾功能、凝血指标等差异均无统计学差异(P＞0.05).介入术后两组患者均出现骨髓抑制现象,WBC、PLT和HGB下降,但华蟾素组轻于表阿霉素组.两组患者血TB、ALT、AST水平均显著升高(P＜0.05,P＜0.01),第6天开始恢复,在治疗后第6周华蟾素组TB、ALT、AST、ALP、γ-GGT值低于表阿霉素组(P＜0.05).两种治疗方法对肾功能及凝血指标无明显影响.华蟾素组患者出现厌食、恶心呕吐、发热、疼痛等症状的程度及例数明显低于表阿霉素组.结论:华蟾素注射液肝动脉栓塞治疗方案较表阿霉素肝动脉栓塞治疗方案具有较高的安全性.

笔者在临床中应用加味四黄汤治疗各种难愈性皮肤溃疡,每有获效,报道如下:加味四黄汤组成:生大黄、黄连、黄柏、黄芩、蛇床子、紫草、千里光各50g、花椒15g,久煎浓缩,先熏洗后浸泡或浸透无菌纱布湿敷. 1 临床资料 例1:姚某,男性,65岁,患右下肢静脉曲张30余年,右下肢外侧皮肤溃烂1年余,于2010年就诊我院.

Primary liver cancer (PLC) is one of the most common malignant tumors because of its high incidence and high mortality. Traditional Chinese medicine (TCM) plays an active role in the treatment of PLC. As the most important part in the TCM system, syndrome differentiation based on the clinical manifestations from traditional four diagnostic methods has met great challenges and questions with the lack of statistical validation support. In this study, we provided evidences for TCM syndrome differentiation of PLC using the method of analysis of latent structural model from clinic data, thus providing basis for establishing TCM syndrome criteria. And also we obtain the common syndromes of PLC as well as their typical clinical manifestations, respectively.

目的 探讨脑出血临床路径实施的可行性以及对住院日和医疗费用的控制效果.方法 通过同期队列研究,对实施与未实施临床路径的脑出血患者的住院天数、住院总费用、各种住院费用、患者满意度等指标进行综合比较分析.结果 路径组住院总费用下降[(12520.1±922.5) vs(22757.5±21282.5)元]、药费下降[(6772.6±6388.0) vs(12578.8±10546.1)元]、化验费下降[(1649.3±948.4) vs(2337.1±1745.6)元]与对照组比较差异有统计学意义(p＜0.05).路径组住院天数缩短[(16.0±6.9)vs(18.1±9.9)天]、检查费下降[(770.7±1064.8) vs(1331.1±2086.2)元]、治疗费下降[(592.5±1108.7)vs(1218.9±2896.1)元],与对照组比较均有下降,但差异无统计学意义(p＞0.05).路径组患者满意度提高.结论 脑出血临床路径实施后在降低医疗费用和平均住院日、优化诊疗护理工作流程上效果显著.

Objective To investigate the effects of cognitive behavior therapy on self-efficacy,hope level of patients with primary liver cancer(PLC).Methods By convenience sampling,a total of 202 patients with PLC were recruited from Changhai Hospital.The patients were equally divided into treatment group and control group based on their admission time.Patients in the treatment group were intervened with cognitive behavior therapy and patients in control group received routine care.After 10 or 15 days intervention, patients were evaluated using General Self-Efficacy Scale(GSES),and hope index.Results There were no significant differences between treatment group and control group in scores of self-efficacy and hope levels before health education(P>0.05).Both routine care and cognitive behavior therapy can increase the scores of GSES and hope index,especially in treatment group(P<0.01).Conclusion Cognitive behavior therapy is effective in improving quality of life of patients with PLC by easing pressure,and promoting hope and recovery.

Objective To evaluate the effect of transhepatic arterial embolization(TAE)with Cinobufotalin Injection on the quality of life(QOL)in patients with advanced primary liver cancer.Methods Eighty patients with advanced primary liver cancer were randomly divided into treatment group(n=40)and control group(n=40).The treatment group received TAE with Cinobufotalin Injection,while the control group received TAE with Epirubicin Injection.Before and 6weeks after TAE,the QOL was evaluated by Zubrod-ECOG-WHO(ZPS)score and Functional Assessment of Cancer Therapy-Hepatobiliary(FACTHep)questionnaire(Chinese version).Results Before treatment,there were no significant differences in ZPS score,FACT-Hep subscale scores,and total FACT-Hep score between the two groups(P0.05).At 6days after TAE,the treatment group showed a significant improvement in ZPS score(P0.01).At 6weeks after TAE,the treatment group had significantly higher FACT-Hep subscale scores and total FACT-Hep score than the control group(P0.05or P0.01).Conclusion Administration of Cinobufotalin Injection via the hepatic artery combined with lipiodol embolization can improve the QOL in patients with advanced primary liver cancer.

Objective:In this study,we try to investigate the serum metabolic variations in Yang deficiency syndrome of patients with primary liver cancer(PLC),and try to provide evidence for objectification and standardization in TCM syndromes diagnosis of PLC.Methods:Basic syndrome types of 42 patients with PLC were classified by PLC TCM syndrome qualitative diagnosis criteria and quantitative diagnosis model into two groups,including Yang deficiency syndrome group(21 cases) and non-Yang deficiency syndrome group(21 cases).Serum samples were analyzed to acquire metabolic profiles using the metabonomics technology based on nuclear magnetic resonance(NMR).Partial least squares discriminant analysis(PLS-DA) was applied to visualize the variation patterns in metabolic profiles of sera from different groups,then to identify the differential metabolites and analyze the biological characteristics.Results:The difference of serum metabolite profiling was differentiated by PLS-DA model between Yang deficiency syndrome group and non-Yang deficiency syndrome group.We found and identified 6 kinds of significant differential metabolites(P0.05))between PLC Yang deficiency syndrome group and non-Yang deficiency syndrome group: VLDL/LDL,isoleucine,lactate,lipids,choline,glucose/sugars.The concentration of these differential metabolites in serum of Yang deficient patients with PLC were decreased than non-Yang deficient patients.Conclusions: Multiple metabolisms,including amino acid metabolism,lipid metabolism,glycometabolism,energy metabolism,and so on,are unbalanced or weak in Yang deficient patients with PLC.The decreased concentration of metabolites,including VLDL/LDL,isoleucine,lactate,lipids,choline and glucose/sugars in serum may be the distinctive metabolic variations of Yang deficient patients with PLC.And these metabolites may be potential biomarkers for diagnosis of Yang deficiency syndrome in PLC patients.

目的:探讨慢性乙肝病毒携带者不同中医证型与HBV基因型及HBV DNA载量的关系。方法:对95例慢性乙肝病毒携带者进行临床流行病学调查,组织专家组对其进行中医辨证,同时检测HBV基因型及HBV DNA载量,进行统计学分析。结果:慢性乙肝病毒携带者的中医证型以肝胃不和、肝气郁结、肝阴虚、肾阴虚证为主。4个主要证型间的HBV DNA载量比较,肝阴虚证>肝气郁结证>肝胃不和证>肾阴虚证。不同HBV基因型中HBV DNA载量比较,C型>B型。结论:不同中医证型与HBV基因型及HBV DNA载量间有一定的规律性,但无明显的相关性。

Objective: To investigate the therapeutic effects of Jiedu Granules ((sic)), a Chinese medicine (CM) compound, plus Cinobufacini Injection ((sic)), which was extracted from skin of Bufo bufo gargarizans Cantor, to prevent the recurrence of hepatocellular carcinoma (HCC) after surgical resection. Methods: In this case-control trial, a total of 120 patients who stayed in Changhai Hospital were enrolled from December 2001 to December 2006. Sixty patients were treated with Jiedu Granules plus Cinobufacini Injection to prevent tumor recurrence after operation (CM group) and 60 patients were treated with transcatheter arterial chemoembolization (TACE) after operation (TACE group). Progression-free survival (PFS) and overall survival (OS) rates were determined to evaluate the therapeutic effects of post-operative management of patients with HCC. Results: PFS in the CM group was 18.07 months [95% confidence interval (CI): 12.49-23.65] and the 1-, 2-, 3-, 4- and 5-year PFS rates were 61%, 39%, 26%, 22% and 12%, respectively. PFS in the TACE group was 8.03 months (95% CI: 6.63-9.44) and the 1-, 2-, 3-, 4- and 5-year PFS rates were 34%, 11%, 7%, 2% and 0%, respectively. There was significant difference in survival rate between the two groups (P<0.01). The mean survival time (MST) of patients in the CM group was 49.53 months versus 39.90 months of the TACE group. The 1-, 2-, 3-, 4- and 5-year survival rates were 90%, 82%, 80%, 70% and 63%, respectively, in the CM group, and 79%, 70%, 60%, 60% and 36%, respectively, in the TACE group. There was significant difference in survival time between the two groups (P=0.045). Conclusions: Jiedu Granules plus Cinobufacini Injection, a combination that is commonly used for post-operation management of HCC, can postpone tumor recurrence and metastasis, prolong the survival time and increase the survival rate of post-surgical patients with HCC. However, these findings need to be confirmed in a prospective, randomized controlled trial.

OBJECTIVE:To study the traditional Chinese medicine (TCM) syndrome distribution in patients with hepatitis B virus (HBV) infection in Qidong region of Jiangsu Province, China.METHODS:A cross-sectional survey was performed. Subjects from Qidong of Jiangsu Province of China were screened among the locally enrolled residents by detecting hepatitis B surface antigen (HBsAg) from May 2007 to May 2011 and were assigned to HBsAg-negative cohort or HBsAg-positive cohort. Then, the subjects were diagnosed according to alanine aminotransferase, alpha-fetoprotein and B ultrasound. The syndrome of the subjects was determined using a TCM questionnaire consisting of signs and symptoms.RESULTS:A total of 5 908 subjects were enrolled in this survey, among whom, 4 718 were diagnosed with HbsAg infection (positive result of HbsAg detection) and 1 147 were negative. 143 subjects were excluded for not receiving the blood examination. The final diagnoses of the subjects were non-HBV infection (n=1128), HBV carrier (n=4019), chronic hepatitis B (n=225), posthepatitic cirrhosis (n=263) or liver cancer (n=111). The TCM syndrome differentiation results showed that there were differences in syndrome distribution between HBV-infected and non-HBV-infected patients. The main syndromes of the HBV-infected patients were qi deficiency, qi stagnation, blood stasis and dampness heat, related to the Zang of liver and spleen. The distribution principles of TCM syndrome among patients of HBV carrier, chronic hepatitis B and cirrhosis were similar. Moreover, with the progression of the patients' condition, the scores of syndromes increased, and the number of accompanying syndromes increased as well. The main syndromes of patients with liver cancer were blood stasis and excess heat, which was slightly different from that of the other HBV-infected patients.CONCLUSION:The TCM syndrome distribution in patients of HBV infection in Qidong region of Jiangsu Province shows regularity. The disorder is mainly due to qi stagnation and blood stasis and is also related to deficiency of healthy qi, especially deficiency of spleen qi.

AIM:To investigate and evaluate the change in health-related quality of life (HRQoL) by tumor node metastasis (TNM) staging system in patients with hepatocellular carcinoma (HCC).METHODS:A total of 140 patients diagnosed with HCC between June 2008 and April 2009 in our department were enrolled to this study. One hundred and thirty-five (96.5%) patients had liver cirrhosis secondary to hepatitis B virus (HBV) infection, 73 (54.07%) of them being HBV DNA positive; the other etiologies of liver cirrhosis were alcoholic liver disease (1.4%), hepatitis C (1.4%) or cryptogenic (0.7%). All subjects were fully aware of their diagnosis and provided informed consent. HRQoL was assessed before treatment using the functional assessment of cancer therapy-hepatobiliary (FACT-Hep) questionnaire. Descriptive statistics were used to evaluate demographics and disease-specific characteristics of the patients. One-way analysis of variance and independent samples t tests were used to compare the overall FACT-Hep scores and clinically distinct TNM stages. Scores for all FACT-Hep items were analyzed by frequency analyses. The mean scores obtained from the FACT-Hep in different Child-Pugh classes were also evaluated.RESULTS:The mean FACT-Hep scores were reduced significantly from TNM Stage I to Stage II, Stage IIIA, Stage IIIB group (687 ± 39.69 vs 547 ± 42.57 vs 387 ± 51.24 vs 177 ± 71.44, P = 0.001). Regarding the physical and emotional well-being subscales, scores decreased gradually from Stage I to Stage IIIB (P = 0.002 vs Stage I; P = 0.032 vs Stage II; P = 0.033 vs Stage IIIA). Mean FACT-Hep scores varied by Child-Pugh class, especially in the subscales of physical well-being, functional well-being and the hepatobiliary cancer (P = 0.001 vs Stage I; P = 0.036 vs Stage II; P = 0.032 vs Stage IIIA). For the social and family well-being subscale, only Stage IIIB scores were significantly lower as compared with Stage I scores (P = 0.035). For the subscales of functional well-being and hepatobiliary cancer, there were significant differences for Stages IIΙ, IIIA and IIIB (P = 0.002 vs Stage I).CONCLUSION:HRQoL of patients with HCC worsens gradually with progression of TNM stages. The most impaired subscales of HRQoL, as measured by FACT-Hep, were physical and emotional well-being.

Objective To investigate the therapeutic effects of Jiedu Granules (解毒颗粒), a Chinese medicine (CM) compound, plus Cinobufacini Injection (华蟾素注射液), which was extracted from skin of Bufo bufo gargarizans Cantor , to prevent the recurrence of hepatocellular carcinoma (HCC) after surgical resection. Methods In this case-control trial, a total of 120 patients who stayed in Changhai Hospital were enrolled from December 2001 to December 2006. Sixty patients were treated with Jiedu Granules plus Cinobufacini Injection to prevent tumor recurrence after operation (CM group) and 60 patients were treated with transcatheter arterial chemoembolization (TACE) after operation (TACE group). Progression-free survival (PFS) and overall survival (OS) rates were determined to evaluate the therapeutic effects of post-operative management of patients with HCC. Results PFS in the CM group was 18.07 months [95% confidence interval (CI): 12.49–23.65] and the 1-, 2-, 3-, 4- and 5-year PFS rates were 61%, 39%, 26%, 22% and 12%, respectively. PFS in the TACE group was 8.03 months (95% CI: 6.63–9.44) and the 1-, 2-, 3-, 4- and 5-year PFS rates were 34%, 11%, 7%, 2% and 0%, respectively. There was significant difference in survival rate between the two groups ( P <0.01). The mean survival time (MST) of patients in the CM group was 49.53 months versus 39.90 months of the TACE group. The 1-, 2-, 3-, 4- and 5-year survival rates were 90%, 82%, 80%, 70% and 63%, respectively, in the CM group, and 79%, 70%, 60%, 60% and 36%, respectively, in the TACE group. There was significant difference in survival time between the two groups ( P =0.045). Conclusions Jiedu Granules plus Cinobufacini Injection, a combination that is commonly used for post-operation management of HCC, can postpone tumor recurrence and metastasis, prolong the survival time and increase the survival rate of post-surgical patients with HCC. However, these findings need to be confirmed in a prospective, randomized controlled trial.

Objective:To explore the distributive regularity of TCM syndromes of chronic HBV carriers.Methods:Organize experts to make clinical epidemiology survey,analyse the TCM syndromes and conduct the statistics frequency of TCM syndromes to the chronic HBV carriers.Results:The main syndrome types were Disharmony betueen liver and stomach syndrome,Liver-qi stagnation syndrome,Deficiency of liver-yin syndrome,Deficiency of kidney-yin syndrome.Conclusion:The distribution of TCM syndromes of chronic HBV carriers was regular.

Objective To primarily analyze the efficacy of Chinese medicine therapeutic program for the liver cancer patients after operation.Methods The liver cancer patients after resection were selected from Changhai Hospital and Dongfang Liver and Gallbladder Hospital.According to the post-operative treatment situations,the patients were divided into a western medicine group and a cinobufotalin group.The cases were staged in light of the findings in operation and image examination.The recurrence and survival situation were investigated in follow-up visit.The complication of hepatitis B,AFP level,liver cancer TNM staging and the others were analyzed.Additionally,the different factors of recurrence were analyzed for the patients.Results The survival analysis for the liver cancer patients at Ia-IIb stages suggested that the life span for the patients in the cinobufotalin group was longer than that in the western medicine group,in which the disease-free median life span was 18.43,11.97,11.53 and 5.7 months in the cinobufotalin group,and was 14.81,7.73,6.00 and 4.53 months in the western medicine group separately in each cancer stage.The life span of 1,2 and 3 years for the patients with AFP mRNA negative as well as the disease-free median life span were higher than those for the patients with AFP mRNA positive(P0.05).In the cinobufotalin group,the disease-free media life span was 13.00,11.97 and 11.93 months separately for the patients with AFP positive of different levels.In the western medicine group,that was 8.10,71 and 5.83 months separately.Conclusion Cinobufotalin is probably effective in the treatment of the recurrence of primary liver cancer after the operation.But,a further verification is required as for this conclusion is based on the retrospective study.

MicroRNAs (miRNAs) have crucial roles in the development and progression of human cancers, including hepatocellular carcinoma (HCC). Recent studies have shown that microRNA-124 (miR-124) was downregulated in HCC; however, the underlying mechanisms by which miR-124 suppresses tumorigenesis in HCC are largely unknown. In this study, we report that phosphoinositide 3-kinase catalytic subunit alpha (PIK3CA) is a novel target of miR-124 in HepG2 cells. Overexpression of miR-124 resulted in decreased expression of PIK3CA at both mRNA and protein levels. We found that miR-124 overexpression markedly suppressed cell proliferation by inducing G1-phase cell-cycle arrest in vitro. Consistent with the restoring miR-124 expression, PIK3CA knockdown suppressed cell proliferation, whereas overexpression of PIK3CA abolished the suppressive effect of miR-124. Mechanistic studies showed that miR-124-mediated reduction of PIK3CA resulted in suppression of PI3K/Akt pathway. The expressions of Akt and mTOR, key components of the PI3K/Akt pathway, were all downregulated. Moreover, we found overexpressed miR-124 effectively repressed tumor growth in xenograft animal experiments. Taken together, our results demonstrate that miR-124 functions as a growth-suppressive miRNA and plays an important role in inhibiting the tumorigenesis through targeting PIK3CA.

[目的]初步探讨经动脉化疗栓塞(TACE)治疗对肝癌患者证候的影响.[方法]收集2005年3月至2008年12月长海医院中医科收治的274例次仅行TACE治疗的肝癌患者,采用配对检验等统计学方法对患者治疗前后证候的变化进行统计分析,并将有无癌栓作为分组因素,对患者TACE治疗前后证候的变化进行对比分析.[结果]274例次肝癌患者行肝脏TACE术后基本证候中气虚证程度加重(P＜0.05),血瘀证有减轻趋势,水湿证有加重趋势；复合证候中肝气郁结证程度减轻(P＜0.05),肝血瘀阻证有减轻趋势,湿热内蕴证有加重趋势.有癌栓者治疗后水湿证及脾肾阳虚证加重程度较无癌栓者大(P＜0 05).[结论]TACE治疗对证候的影响体现了肿瘤病情的好转及机能的损耗.

This study proposes a 1H NMR-based metabonomic approach to explore the biochemical characteristics of Yang deficiency syndrome in hepatocellular carcinoma (HCC) based on serum metabolic profiling. Serum samples from 21 cases of Yang deficiency syndrome HCC patients (YDS-HCC) and 21 cases of non-Yang deficiency syndrome HCC patients (NYDS-HCC) were analyzed using 1H NMR spectroscopy and partial least squares discriminant analysis (PLS-DA) was applied to visualize the variation patterns in metabolic profiling of sera from different groups. The differential metabolites were identified and the biochemical characteristics were analyzed. We found that the intensities of six metabolites (LDL/VLDL, isoleucine, lactate, lipids, choline, and glucose/sugars) in serum of Yang deficiency syndrome patients were lower than those of non-Yang deficiency syndrome patients. It implies that multiple metabolisms, mainly including lipid, amino acid, and energy metabolisms, are unbalanced or weakened in Yang deficiency syndrome patients with HCC. The decreased intensities of metabolites including LDL/VLDL, isoleucine, lactate, lipids, choline, and glucose/sugars in serum may be the distinctive metabolic variations of Yang deficiency syndrome patients with HCC. And these metabolites may be potential biomarkers for diagnosis of Yang deficiency syndrome in HCC.