Research Article
BibTex RIS Cite

Vücut Kitle İndeksi ve Mononöropatiler Arasındaki İlişki

Year 2022, , 269 - 275, 30.12.2022

Ayşe Begüm Büyüksural , Halit Fidancı , Şencan Buturak , İlker Öztürk , Mehmet Yıldız , İzzet Fidancı , Zülfikar Arlıer

https://doi.org/10.18678/dtfd.1141743

Abstract

Amaç: Bu çalışmada medyan, ulnar, radyal, peroneal ve siyatik sinirlerin mononöropatileri ile vücut kitle indeksi (VKİ) arasında bir ilişki olup olmadığının araştırılması amaçlandı.
Gereç ve Yöntemler: Klinik ve elektrodiagnostik bulguları karpal tünel sendromu (KTS), dirsekte ulnar nöropati (DUN), spiral olukta radiyal nöropati (RNS), fibula başında peroneal nöropati (PNFB) ve intramüsküler enjeksiyona bağlı siyatik yaralanması (İMESY) ile uyumlu olan hastalar bu geriye dönük kohort çalışmasına dahil edildi. Ayrıca klinik ve elektrodiagnostik özellikleri mononöropati ile uyumlu olmayan kontroller çalışmaya dahil edildi. Tüm katılımcıların VKİ değerleri analiz edildi.
Bulgular: Yüz otuz bir KTS hastası, 53 DUN hastası, 6 RNS hastası, 25 PNFB hastası, 72 İMESY hastası ve 53 kontrol bu çalışmaya dahil edildi. KTS hastalarının VKİ değeri kontrollerin (p<0,001), PNFB hastalarının (p<0,001) ve İMESY hastalarının (p<0,001) VKİ değerinden daha yüksekti. İMESY hastalarının VKİ değeri kontrollerin (p<0,001), KTS hastalarının (p<0,001) ve DUN hastalarının (p<0,001) VKİ değerinden daha düşüktü. PNFB hastalarının VKİ değeri KTS hastalarından (p<0,001) ve DUN hastalarından (p=0,004) daha düşüktü. Gruplarda VKİ değerleri ile mononöropatilerin elektrodiagnostik sınıflandırması arasında anlamlı bir korelasyon bulunmadı.
Sonuç: Bu çalışma, yüksek VKİ değerinin KTS için bir risk faktörü olduğunu ve düşük VKİ değerinin ise İMESY için bir risk faktörü olduğunu göstermiştir. VKİ ve PNFB arasında da bir ilişki olabilir, ancak bu daha ileri çalışmalarla doğrulanmalıdır.

Keywords

Vücut kitle indeksi karpal tünel sendromu tuzak nöropati mononöropati siyatik sinir hasarı

References

  • Wahab KW, Sanya EO, Adebayo PB, Babaola MO, Ibraheem HG. Carpal tunnel syndrome and other entrapment neuropathies. Oman Med J. 2017;32(6):449-54.
  • Lundborg G, Dahlin LB. Anatomy, function, and pathophysiology of peripheral nerves and nerve compression. Hand Clin. 1996;12(2):185-93.
  • Nakano KK. The entrapment neuropathies. Muscle Nerve. 1978;1(4):264-79.
  • Shiri R, Pourmemari MH, Falah-Hassani K, Viikari-Juntura E. The effect of excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies. Obes Rev. 2015;16(12):1094-104.
  • Werner RA, Franzblau A, Albers JW, Armstrong TJ. Influence of body mass index and work activity on the prevalence of median mononeuropathy at the wrist. Occup Environ Med. 1997;54(4):268-71.
  • Kouyoumdjian JA, Morita MD, Rocha PR, Miranda RC, Gouveia GM. Body mass index and carpal tunnel syndrome. Arq Neuropsiquiatr. 2000;58(2A):252-6.
  • Bland JD. The relationship of obesity, age, and carpal tunnel syndrome: more complex than was thought? Muscle Nerve. 2005;32(4):527-32.
  • Harris-Adamson C, Eisen EA, Kapellusch J, Garg A, Hegmann KT, Thiese MS, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med. 2015;72(1):33-41.
  • Cazares-Manríquez MA, Wilson CC, Vardasca R, García-Alcaraz JL, Olguín-Tiznado JE, López-Barreras JA, et al. A review of carpal tunnel syndrome and its association with age, body mass index, cardiovascular risk factors, hand dominance, and sex. Appl Sci. 2020;10(10):3488.
  • Richardson JK, Green DF, Jamieson SC, Valentin FC. Gender, body mass and age risk factors for ulnar mononeuropathy at the elbow. Muscle Nerve. 2001;24(4):551-4.
  • Landau ME, Barner KC, Campbell WW. Effect of body mass index on ulnar nerve conduction velocity, ulnar neuropathy at the elbow, and carpal tunnel syndrome. Muscle Nerve. 2005;32(3):360-3.
  • Uzunkulaoğlu A, Ikbali Afsar S, Karataş M. Association between gender, body mass index, and ulnar nerve entrapment at the elbow: a retrospective study. J Clin Neurophysiol. 2016;33(6):545-8.
  • Yeremeyeva E, Kline DG, Kim DH. Iatrogenic sciatic nerve injuries at buttock and thigh levels: the Louisiana State University experience review. Neurosurgery. 2009;65(4 Suppl):A63-6.
  • Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg. 1998;89(1):13-23.
  • Jung Kim H, Hyun Park S. Sciatic nerve injection injury. J Int Med Res. 2014;42(4):887-97.
  • NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 milion paticipants. Lancet. 2006;387(10026):1377-96.
  • Chen S, Andary M, Buschbacher R, Del Toro D, Smith B, So Y, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve. 2016;54(3):371-7.
  • Fidanci H, Öztürk I, Köylüoğlu AC, Yildiz M, Buturak Ş, Arlier Z. The needle electromyography findings in the neurophysiological classification of ulnar neuropathy at the elbow. Turk J Med Sci. 2020;50(4):804-10.
  • Fidanci H, Öztürk I, Köylüoğlu AC, Yıldız M, Arlıer Z. Bilateral nerve conduction studies must be considered in the diagnosis of sciatic nerve injury due to intramuscular injection. Neurol Sci Neurophysiol. 2020;37(2):94-9.
  • Oh SJ, editor. Nerve conduction in focal neuropathies. In: Clinical electromyography: nerve conduction studies. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p.231-4.
  • Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-84.
  • Padua L, Lo Monaco M, Padua R, Gregori B, Tonali P. Neurophysiological classification of carpal tunnel syndrome: assessment of 600 symptomatic hands. Ital J Neurol Sci. 1997;18(3):145-50.
  • Omejec G, Podnar S. Normative values for short-segment nerve conduction studies and ultrasonography of the ulnar nerve at the elbow. Muscle Nerve. 2015;51(3):370-7.
  • Beekman R, Van Der Plas JP, Uitdehaag BM, Schellens RL, Visser LH. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve. 2004;30(2):202-8.
  • Padua L, Aprile I, Mazza O, Padua R, Pietracci E, Caliandro P, et al. Neurophysiological classification of ulnar entrapment across the elbow. Neurol Sci. 2001;22(1):11-6.
  • Landau ME, Campbell WW. Clinical and electrodiagnosis of ulnar neuropathies. Phys Med Rehabil Clin N Am. 2013;24(1):49-66.
  • Seror P. Electrophysiological pattern of 53 cases of ulnar nerve lesion at the wrist. Neurophysiol Clin. 2013;43(2):95-103.
  • Wang LH, Weiss MD. Anatomical, clinical, and electrodiagnostic features of radial neuropathies. Phys Med Rehabil Clin N Am. 2013;24(1):33-47.
  • Carlson N, Logigian EL. Radial neuropathy. Neurol Clin. 1999;17(3):499-523.
  • Katirji B. Peroneal neuropathy. Neurol Clin. 1999;17:567-92.
  • Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Curr Rev Musculoskelet Med. 2008;1(2):147-53.
  • Katirji MB, Wilbourn AJ. Common peroneal mononeuropathy: a clinical and electrophysiologic study of 116 lesions. Neurology. 1988;38(11):1723-8.
  • Masakado Y, Kawakami M, Suzuki K, Abe L, Ota T, Kimura A. Clinical neurophysiology in the diagnosis of peroneal nerve palsy. Keio J Med. 2008;57(2):84-9.
  • Yuen EC, So YT, Olney RK. The electrophysiologic features of sciatic neuropathy in 100 patients. Muscle Nerve. 1995;18(4):414-20.
  • Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am. 1999;81(11):1600-10.
  • Sprofkin BE. Peroneal paralysis; a hazard of weight reduction. AMA Arch Intern Med. 1958;102(1):82-7.
  • Sotaniemi KA. Slimmer’s paralysis--peroneal neuropathy during weight reduction. J Neurol Neurosurg Psychiatry. 1984;47(5):564-6.
  • Lawlor T, Wells DG. Metabolic hazards of fasting. Am J Clin Nutr. 1969;22(8):1142-9.
  • Park CW, Cho WC, Son BC. Iatrogenic injury to the sciatic nerve due to intramuscular injection: a case report. Korean J Neurotrauma. 2019;15(1):61-6.
  • Small SP. Preventing sciatic nerve injury from intramuscular injections: literature review. J Adv Nurs. 2004;47(3):287-96.
  • Komurcu HF, Kilic S, Anlar O. Relationship of age, body mass index, wrist and waist circumferences to carpal tunnel syndrome severity. Neurol Med Chir (Tokyo). 2014;54(5):395-400.
  • Genova A, Dix O, Saefan A, Thakur M, Hassan A. Carpal tunnel syndrome: a review of literature. Cureus. 2020;12(3):e7333.
  • Anderson A, Woods B, Abubakar T, Koontz C, Li N, Hasoon J, et al. A comprehensive review of cubital tunnel syndrome. Othop Rev (Pavia). 2022;14(3):38239.
  • Hidayati HB, Subadi I, Fidiana F, Puspamaniar VA. Current diagnosis and management of carpal tunnel syndrome: A review. Anaesth Pain Intensive Care. 2022;26(3):394-404.

The Relationship Between Body Mass Index and Mononeuropathies

Year 2022, , 269 - 275, 30.12.2022

Ayşe Begüm Büyüksural , Halit Fidancı , Şencan Buturak , İlker Öztürk , Mehmet Yıldız , İzzet Fidancı , Zülfikar Arlıer

https://doi.org/10.18678/dtfd.1141743

Abstract

Aim: The study aimed to find out whether there is a relationship between the mononeuropathies of the median, ulnar, radial, peroneal, and sciatic nerves and body mass index (BMI).
Material and Methods: Patients whose clinical and electrodiagnostic findings were compatible with carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy at the spiral groove (RNS), peroneal neuropathy at the fibular head (PNFH), and sciatic injury due to intramuscular injection (SNIII) were included in this retrospective cohort study. In addition, controls whose clinical and electrodiagnostic features were not compatible with mononeuropathy were included in the study. The BMI values of all participants were analyzed.
Results: One hundred thirty-one CTS patients, 53 UNE patients, 6 RNS patients, 25 PNFH patients, 72 SNIII patients, and 53 controls were included in the study. The BMI of CTS patients was higher than the BMI of controls (p<0.001), PNFH patients (p<0.001), and SNIII patients (p<0.001). The BMI of SNIII patients was lower than the BMI of controls (p<0.001), CTS patients (p<0.001), and UNE patients (p<0.001). The BMI of PNFH patients was lower than that of CTS patients (p<0.001) and UNE patients (p=0.004). No significant correlation was found between BMI values and electrodiagnostic classification of mononeuropathies in the groups.
Conclusion: This study showed that high BMI is a risk factor for CTS and low BMI is a risk factor for SNIII. There may also be a relationship between BMI and PNFH, but this should be confirmed by further studies.

Keywords

Body mass index carpal tunnel syndrome entrapment neuropathy mononeuropathy sciatic nerve injury

References

  • Wahab KW, Sanya EO, Adebayo PB, Babaola MO, Ibraheem HG. Carpal tunnel syndrome and other entrapment neuropathies. Oman Med J. 2017;32(6):449-54.
  • Lundborg G, Dahlin LB. Anatomy, function, and pathophysiology of peripheral nerves and nerve compression. Hand Clin. 1996;12(2):185-93.
  • Nakano KK. The entrapment neuropathies. Muscle Nerve. 1978;1(4):264-79.
  • Shiri R, Pourmemari MH, Falah-Hassani K, Viikari-Juntura E. The effect of excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies. Obes Rev. 2015;16(12):1094-104.
  • Werner RA, Franzblau A, Albers JW, Armstrong TJ. Influence of body mass index and work activity on the prevalence of median mononeuropathy at the wrist. Occup Environ Med. 1997;54(4):268-71.
  • Kouyoumdjian JA, Morita MD, Rocha PR, Miranda RC, Gouveia GM. Body mass index and carpal tunnel syndrome. Arq Neuropsiquiatr. 2000;58(2A):252-6.
  • Bland JD. The relationship of obesity, age, and carpal tunnel syndrome: more complex than was thought? Muscle Nerve. 2005;32(4):527-32.
  • Harris-Adamson C, Eisen EA, Kapellusch J, Garg A, Hegmann KT, Thiese MS, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med. 2015;72(1):33-41.
  • Cazares-Manríquez MA, Wilson CC, Vardasca R, García-Alcaraz JL, Olguín-Tiznado JE, López-Barreras JA, et al. A review of carpal tunnel syndrome and its association with age, body mass index, cardiovascular risk factors, hand dominance, and sex. Appl Sci. 2020;10(10):3488.
  • Richardson JK, Green DF, Jamieson SC, Valentin FC. Gender, body mass and age risk factors for ulnar mononeuropathy at the elbow. Muscle Nerve. 2001;24(4):551-4.
  • Landau ME, Barner KC, Campbell WW. Effect of body mass index on ulnar nerve conduction velocity, ulnar neuropathy at the elbow, and carpal tunnel syndrome. Muscle Nerve. 2005;32(3):360-3.
  • Uzunkulaoğlu A, Ikbali Afsar S, Karataş M. Association between gender, body mass index, and ulnar nerve entrapment at the elbow: a retrospective study. J Clin Neurophysiol. 2016;33(6):545-8.
  • Yeremeyeva E, Kline DG, Kim DH. Iatrogenic sciatic nerve injuries at buttock and thigh levels: the Louisiana State University experience review. Neurosurgery. 2009;65(4 Suppl):A63-6.
  • Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg. 1998;89(1):13-23.
  • Jung Kim H, Hyun Park S. Sciatic nerve injection injury. J Int Med Res. 2014;42(4):887-97.
  • NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 milion paticipants. Lancet. 2006;387(10026):1377-96.
  • Chen S, Andary M, Buschbacher R, Del Toro D, Smith B, So Y, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve. 2016;54(3):371-7.
  • Fidanci H, Öztürk I, Köylüoğlu AC, Yildiz M, Buturak Ş, Arlier Z. The needle electromyography findings in the neurophysiological classification of ulnar neuropathy at the elbow. Turk J Med Sci. 2020;50(4):804-10.
  • Fidanci H, Öztürk I, Köylüoğlu AC, Yıldız M, Arlıer Z. Bilateral nerve conduction studies must be considered in the diagnosis of sciatic nerve injury due to intramuscular injection. Neurol Sci Neurophysiol. 2020;37(2):94-9.
  • Oh SJ, editor. Nerve conduction in focal neuropathies. In: Clinical electromyography: nerve conduction studies. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p.231-4.
  • Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-84.
  • Padua L, Lo Monaco M, Padua R, Gregori B, Tonali P. Neurophysiological classification of carpal tunnel syndrome: assessment of 600 symptomatic hands. Ital J Neurol Sci. 1997;18(3):145-50.
  • Omejec G, Podnar S. Normative values for short-segment nerve conduction studies and ultrasonography of the ulnar nerve at the elbow. Muscle Nerve. 2015;51(3):370-7.
  • Beekman R, Van Der Plas JP, Uitdehaag BM, Schellens RL, Visser LH. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve. 2004;30(2):202-8.
  • Padua L, Aprile I, Mazza O, Padua R, Pietracci E, Caliandro P, et al. Neurophysiological classification of ulnar entrapment across the elbow. Neurol Sci. 2001;22(1):11-6.
  • Landau ME, Campbell WW. Clinical and electrodiagnosis of ulnar neuropathies. Phys Med Rehabil Clin N Am. 2013;24(1):49-66.
  • Seror P. Electrophysiological pattern of 53 cases of ulnar nerve lesion at the wrist. Neurophysiol Clin. 2013;43(2):95-103.
  • Wang LH, Weiss MD. Anatomical, clinical, and electrodiagnostic features of radial neuropathies. Phys Med Rehabil Clin N Am. 2013;24(1):33-47.
  • Carlson N, Logigian EL. Radial neuropathy. Neurol Clin. 1999;17(3):499-523.
  • Katirji B. Peroneal neuropathy. Neurol Clin. 1999;17:567-92.
  • Baima J, Krivickas L. Evaluation and treatment of peroneal neuropathy. Curr Rev Musculoskelet Med. 2008;1(2):147-53.
  • Katirji MB, Wilbourn AJ. Common peroneal mononeuropathy: a clinical and electrophysiologic study of 116 lesions. Neurology. 1988;38(11):1723-8.
  • Masakado Y, Kawakami M, Suzuki K, Abe L, Ota T, Kimura A. Clinical neurophysiology in the diagnosis of peroneal nerve palsy. Keio J Med. 2008;57(2):84-9.
  • Yuen EC, So YT, Olney RK. The electrophysiologic features of sciatic neuropathy in 100 patients. Muscle Nerve. 1995;18(4):414-20.
  • Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am. 1999;81(11):1600-10.
  • Sprofkin BE. Peroneal paralysis; a hazard of weight reduction. AMA Arch Intern Med. 1958;102(1):82-7.
  • Sotaniemi KA. Slimmer’s paralysis--peroneal neuropathy during weight reduction. J Neurol Neurosurg Psychiatry. 1984;47(5):564-6.
  • Lawlor T, Wells DG. Metabolic hazards of fasting. Am J Clin Nutr. 1969;22(8):1142-9.
  • Park CW, Cho WC, Son BC. Iatrogenic injury to the sciatic nerve due to intramuscular injection: a case report. Korean J Neurotrauma. 2019;15(1):61-6.
  • Small SP. Preventing sciatic nerve injury from intramuscular injections: literature review. J Adv Nurs. 2004;47(3):287-96.
  • Komurcu HF, Kilic S, Anlar O. Relationship of age, body mass index, wrist and waist circumferences to carpal tunnel syndrome severity. Neurol Med Chir (Tokyo). 2014;54(5):395-400.
  • Genova A, Dix O, Saefan A, Thakur M, Hassan A. Carpal tunnel syndrome: a review of literature. Cureus. 2020;12(3):e7333.
  • Anderson A, Woods B, Abubakar T, Koontz C, Li N, Hasoon J, et al. A comprehensive review of cubital tunnel syndrome. Othop Rev (Pavia). 2022;14(3):38239.
  • Hidayati HB, Subadi I, Fidiana F, Puspamaniar VA. Current diagnosis and management of carpal tunnel syndrome: A review. Anaesth Pain Intensive Care. 2022;26(3):394-404.
There are 44 citations in total.

Details

Primary Language English
Subjects Clinical Sciences
Journal Section Research Article
Authors

Ayşe Begüm Büyüksural 0000-0001-7164-7360

Halit Fidancı 0000-0001-6573-9090

Şencan Buturak 0000-0002-7496-5628

İlker Öztürk 0000-0002-2333-9360

Mehmet Yıldız 0000-0002-0411-6794

İzzet Fidancı 0000-0001-9848-8697

Zülfikar Arlıer 0000-0003-2645-648X

Publication Date December 30, 2022
Submission Date July 6, 2022
Published in Issue Year 2022

Cite

APA Büyüksural, A. B., Fidancı, H., Buturak, Ş., Öztürk, İ., et al. (2022). The Relationship Between Body Mass Index and Mononeuropathies. Duzce Medical Journal, 24(3), 269-275. https://doi.org/10.18678/dtfd.1141743
AMA Büyüksural AB, Fidancı H, Buturak Ş, Öztürk İ, Yıldız M, Fidancı İ, Arlıer Z. The Relationship Between Body Mass Index and Mononeuropathies. Duzce Med J. December 2022;24(3):269-275. doi:10.18678/dtfd.1141743
Chicago Büyüksural, Ayşe Begüm, Halit Fidancı, Şencan Buturak, İlker Öztürk, Mehmet Yıldız, İzzet Fidancı, and Zülfikar Arlıer. “The Relationship Between Body Mass Index and Mononeuropathies”. Duzce Medical Journal 24, no. 3 (December 2022): 269-75. https://doi.org/10.18678/dtfd.1141743.
EndNote Büyüksural AB, Fidancı H, Buturak Ş, Öztürk İ, Yıldız M, Fidancı İ, Arlıer Z (December 1, 2022) The Relationship Between Body Mass Index and Mononeuropathies. Duzce Medical Journal 24 3 269–275.
IEEE A. B. Büyüksural, H. Fidancı, Ş. Buturak, İ. Öztürk, M. Yıldız, İ. Fidancı, and Z. Arlıer, “The Relationship Between Body Mass Index and Mononeuropathies”, Duzce Med J, vol. 24, no. 3, pp. 269–275, 2022, doi: 10.18678/dtfd.1141743.
ISNAD Büyüksural, Ayşe Begüm et al. “The Relationship Between Body Mass Index and Mononeuropathies”. Duzce Medical Journal 24/3 (December 2022), 269-275. https://doi.org/10.18678/dtfd.1141743.
JAMA Büyüksural AB, Fidancı H, Buturak Ş, Öztürk İ, Yıldız M, Fidancı İ, Arlıer Z. The Relationship Between Body Mass Index and Mononeuropathies. Duzce Med J. 2022;24:269–275.
MLA Büyüksural, Ayşe Begüm et al. “The Relationship Between Body Mass Index and Mononeuropathies”. Duzce Medical Journal, vol. 24, no. 3, 2022, pp. 269-75, doi:10.18678/dtfd.1141743.
Vancouver Büyüksural AB, Fidancı H, Buturak Ş, Öztürk İ, Yıldız M, Fidancı İ, Arlıer Z. The Relationship Between Body Mass Index and Mononeuropathies. Duzce Med J. 2022;24(3):269-75.
Creative Commons License
Duzce Medical Journal is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.