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Dressler D and Benecke R (2005) Diagnosis and management of acute movement disorders arrhythmia practice tests 5 mg zestril buy fast delivery. Barany was a keen observer and a gifted theoretician, who was able to synthesize diverse clinical observations and investigations into a cogent theoretical framework. He is considered the founder of modern clinical neuro-otology, because he led the way to the modern understanding of labyrinthine function and established and developed important components of the modern neurootologic examination. He then spent 2 years studying internal medicine, neurology, and psychiatry at clinics in Germany, where he attended the lectures of internist Carl H. From these observations, Barany devised a variety of new tests for detecting vestibular disease. His research was rapidly adopted, and caloric and rotational testing quickly became essential elements of neuro-otologic evaluation. Pastpointing after turning or douching is not due to the misplaced position of the eyes or to the disturbance of vision, but is due to the stimulation of the ears. As he summarized in 1910, when testing for rotation-induced Encyclopedia of the Neurological Sciences, Volume 1 doi:10. The patient is then rotated 10 times at a uniform speed, while wearing spectacles fitted with opaque lenses to eliminate physiological optokinetic nystagmus. Caloric Test Around 1868, Schmiedekam discovered that cold water poured into the external auditory canal caused vertigo and vomiting. Barany, though, first observed that the direction of the accompanying nystagmus was dependent on the temperature of the water. Barany immediately recognized that the presence and direction of nystagmus were dependent on the temperature of the water used to irrigate the external auditory canal. He believed that vestibular nystagmus was produced by a reflex involving the semicircular canals, and then hypothesized that such reflex action could be abolished by destruction of the labyrinth. He sought supporting case material and, as he recounted in his Nobel lecture, soon identified a patient with suppurative otitis media who did not develop nystagmus with continuous syringing of the external auditory canal with cold water. He therefore diagnosed destruction of the labyrinth and subsequently proved this at operation. Because each horizontal semicircular duct could be selectively stimulated, a malfunctioning duct on one side could be identified by a shorter duration or intensity of caloric nystagmus. He was subsequently able to prove this theory through clever clinical experiments. Specifically, he deduced that, if his theory was correct, the direction of endolymph flow within the canal would change with the same caloric stimulus if the patient was moved 1801 from a supine to a prone position. Serviceman being examined after rotation at the School of Aviation Medicine (of the United States Army Air Corps) at Randolph Field, Texas. Barany nevertheless attempted to continue writing scientific articles, although he was then able to use only one finger on a typewriter.
Although almost invariably this disorder is discussed with brachial plexopathies arrhythmia what to do buy 2.5 mg zestril free shipping, in most instances the lesion actually appears to involve one or more peripheral nerves, with the majority derived from the upper or upper and middle plexuses, rather than the brachial plexus itself. Both familial and sporadic forms of neuralgic amyotrophy are seen, although the latter is far more common. It affects persons of either sex, with a slight Traumatic Shoulder Injuries Causing Brachial Plexopathy Injury to various bony structures near the shoulder, particularly humeral head fractures and dislocations, may damage elements of the infraclavicular brachial plexus. The pathology is variable, ranging from total axon loss to near total demyelination conduction block. Brachial Plexopathies 461 male predominance, and it tends to be restricted to adolescents and adults. The best article on the subject was authored by Parsonage and Turner in 1948 and concerned 136 patients. It has acquired several other names, including idiopathic brachial plexitis and cryptogenic brachial neuropathy. Typically, a latent period of several hours to 3 or 4 weeks follows the triggering event, and then forequarter pain abruptly occurs. This is usually unilateral, often awakens the patient from sleep, reaches maximal intensity quite rapidly, and is very severe. Often, it is experienced along the lateral deltoid muscle (in the sensory distribution of the axillary nerve), but it may be situated interscapularly, in the antecubital fossa, or along the lateral thorax, depending on the particular peripheral nerve affected. Because the nerve damage is often severe, wasting frequently appears soon thereafter. Neuralgic amyotrophy has a marked tendency to involve solely or predominantly motor nerves The prognosis is variable, particularly when total denervation is present in the distribution of one or more peripheral nerves. There is no effective treatment for neuralgic amyotrophy, although the pain may respond to high doses of steroids. Proper recognition of this disorder can prevent two undesired results: unnecessary surgical decompression of the affected nerves, which are mistakenly thought to be entrapped (this is particularly true for the suprascapular and anterior interosseous nerves), and erroneously considering the nerve lesions to be iatrogenic in nature, resulting in legal action being taken against various medical personnel. Transverse process fractures particularly are associated with nerve root avulsion at C7. Imaging of the brachial plexus requires the capability for high resolution, multiplanar imaging and the ability to achieve clear soft tissue contrast. It is also the preferred modality for the assessment of nontraumatic brachial plexopathy, including neoplasia. Surgical Repair of the Brachial Plexus In extensive plexus injuries, reconstructive priority should be given to restoration of elbow flexion, and then to shoulder function. Although surgeons have traditionally used nerve graphs or muscle and tendon transfers, nerve transfer procedures are now being used with increasing frequency and success. The double fascicular transfer for elbow flexion and transfers to the suprascapular and axillary nerves have consistently yielded excellent results and now offer a better potential for recovery than previously possible with nerve graft or muscle and tendon transfer. Most disorders that affect it tend to damage its elements in a predictable fashion and produce predictable pathology. It is important that the clinician is familiar with the anatomical components of the brachial plexus and able to identify the various entities that affect the brachial plexus.
Diseases
Lesions in related parietotemporal somatosensory association areas are most strongly implicated to underlie tactile Agnosia 83 agnosia lower blood pressure quickly for test discount zestril 5 mg buy. Autotopagnosia (somatotopagnosia) refers to impaired ability to localize or orient body parts and is most commonly associated with left parietal lesions. Although this syndrome has been historically associated with focal left parietal lesions, recent evidence suggests an alternative mechanism involving subcortical disconnection of disparate white matter tracts that lie in proximity to each other, thereby disrupting multiple discrete neural networks. Duchaine B and Nakayama K (2005) Dissociations of face and object recognition in developmental prosopagnosia. Developmental forms of prosopagnosia extend the spectrum of agnosia from purely acquired disorders reflecting brain lesions to disorders that may be genetically influenced. Overview Agrammatism refers to the misuse of grammatical elements in a spoken or written sentence. It manifests as telegraphic speech output that typically preserves the canonical order of the English language. However, vascular lesions are not the only neurological insult that may result in agrammatism. As the disease spreads, it is likely that speech output will become less fluent and grammatical. Motor speech disorders, such as apraxia of speech or dysarthria, may often be comorbid symptoms in nonfluent aphasias. However, it is important to point out that agrammatism is a linguistic deficit and therefore is a separate entity than motor speech impairments. A patient may be agrammatic without the presence of a motor speech impairment and similarly a patient with a motor speech impairment may have good grammatical output. However, this does not go without saying that motor speech deficits have no effect on the linguistic production of speech output. Therefore, grammatical competency will be sacrificed secondary to the increased effort of speech production. This is to say that a motor speech deficit may confound grammatical speech output, but it is not the neurological cause of agrammatism. However, the term paragrammatism is often used to refer to the specific pattern of speech output that is seen in patients with damage to this region. Paragrammatism is qualitatively distinct from agrammatism in that paragrammatism often manifests as an abundance of grammar. Briefly mentioned above, agrammatism, like many symptom classifications, presents as a gradient.
This may be spontaneous (manifest as overt tetany prehypertension cdc 2.5 mg zestril sale, as exemplified by carpal or pedal spasm) or induced (latent tetany). Each of these subunits exists in a variety of forms, and it is the specific type of a1 subunit present that confers specific functional and pharmacological properties on a channel. The a1 subunits present and the drug sensitivity of the various calcium channel subtypes are shown in Table 1. Disturbances in the function of voltage-gated calcium channels have been implicated in clinical disease. These patients have limb weakness, depressed tendon reflexes and ptosis, and repetitive nerve stimulation yields a potentiated posttetanic contractile response of skeletal muscle. Several mutations in calcium channel subunits have also been identified as the underlying defect in neurological disorders. They result from missense mutations associated with single-nucleotide substitutions, frame-shift and splicesite mutations leading to premature stops and truncated proteins, and expanded trinucleotide repeats that code for polyglutamine tracts. These include neuromuscular disorders like hypokalemic periodic paralysis and malignant hyperthermia, as well as cerebral disorders such as familial hemiplegic migraine, episodic ataxia, and spinocerebellar ataxia. Calcium can also enter neurons through ligand-gated channels, such as N-methyl-D-aspartate-preferring glutamate Table 1 Calcium channel subunits: subtypes and blockers Channel subtype L Channel blockers Dihydropyridines Once inside the cell, calcium triggers a host of biochemical events that culminate in critical physiological events such as neurotransmitter release and muscle contraction. This disorder is sometimes associated with a neoplasm and may respond to tumor resection and immunotherapy. Corpus callosotomy is a salvage procedure for patients with medically refractory generalized epilepsy. The goal of corpus callosotomy is to disrupt the pathways involved in the generalization or spread of seizures. It is reserved for patients who experience generalized seizures without a focus amenable to resection and who experience seizures despite optimal anticonvulsant medications. In 1940, Van Wagenen and Herren first reported sectioning the corpus callosum as a treatment for epilepsy in 10 patients. Their rationale for the technique was based on the observation that tumors involving the corpus callosum were associated with seizures. However, as more of the corpus callosum was destroyed by tumor, the seizures diminished or became focal. The procedure was seldom used until the 1960s, when more extensive reports were published. In subsequent studies, two separate craniotomies were used to section the anterior and posterior portions of the callosum individually. Sectioning other structures, including the massa intermedia, anterior commissure, hippocampal commissure, and unilateral fornix, was also described. Over time, the procedure has evolved and sectioning the corpus callosum has been refined. The current technique can be performed through a relatively small opening through an interhemispheric approach with the patient in the lateral decubitus or supine position.
A wart paint or gel is then applied carefully just to the warts arteria tibialis posterior buy 10 mg zestril with visa, left to dry and then covered with a plaster overnight. In the morning the plaster is removed to allow the wart to harden up again before the wart is pared down the next night. Whichever paint (or gel) is chosen, it should be used each night before the patient goes to bed. A fair trial of a treatment is to use it for 12 weeks before giving up and changing to something else. One of the reasons why the treatment does not work is that the patient stops using it if the foot becomes sore. Freezing with liquid nitrogen this is not a good treatment for plantar warts, because you need to freeze for quite a long time to produce a blister (because of the thick layer of keratin on the sole of the foot) and this will be too painful for the patient. The most likely outcome is recurrence of the wart, and there is always the risk that scarring will lead to the formation of permanent callosities, especially over pressure points. First apply a thickish layer of white soft paraffin (Vaseline) around the warts, so that the formalin does not make the normal skin sore. Then pour the formalin into a saucer or shallow bowl and soak the warts in it for 10 minutes each day. The next day, rub down any hard skin with a pumice stone or foot scraper before repeating the treatment. These are stuck onto the warts shiny side down, taped securely in place with Hypafix (or something similar), and left for a week at a time. When they are removed the soggy keratin is removed with a sharp scalpel blade before putting on a new plaster. Nails protect the end of the digits and on the fingers they are useful for picking up small objects and for scratching. A single wide groove may be due to myxoid cyst or fibroma over the posterior nail fold that presses on the underlying matrix (see p. Splinter haemorrhages are small, red, longitudinal streaks classically seen in subacute bacterial endocarditis. With time, if the blood is not released immediately by puncturing the nail, the area is discoloured black or brown. It can be distinguished from a subungual malignant melanoma by making a small horizontal nick on the nail plate at the distal end of the discolouration and watching for a week. Pink, mauve A glomus tumour is a rare benign tumour that presents as a mauve area under the nail that is tender, particularly on pressure or in the cold.
The clinical presentation of a brain abscess is influenced by the size and location of the abscess blood pressure medication compliance zestril 10 mg discount, severity of the cerebral edema, and degree of increased intracranial pressure. As cerebral edema develops, there may be signs of increased intracranial pressure, including an altered level of consciousness, nausea, vomiting, and papilledema. Meningismus is not present unless the abscess has ruptured into the ventricle or infection has spread to the subarachnoid space. On T2-weighted images, cerebritis is evident as an area of increased signal intensity. On gadolinium-enhanced T1-weighted images, the central cavity of a mature brain abscess is hypointense, and the capsule is hyperintense. On T2-weighted images, the central area of pus is hyperintense and surrounded by a well-defined hypointense capsule. With development of the abscess, the abscess center appears as an area of hypointense signal surrounded by a contrast-enhancing ring that represents the abscess capsule. Lumbar puncture should not be performed in patients with focal intracranial infections, such as abscess or empyema, because cerebrospinal fluid analysis contributes nothing to diagnosis or therapy, and lumbar puncture increases the risk of herniation. Blood cultures can be expected to be positive in patients with brain abscess due to hematogenous spread of infection from an extracranial site of infection. The predisposing conditions associated with a brain abscess help to predict the etiological organism and can be used in decisions regarding initial empirical therapy (Table 1). A brain abscess that arises from sinusitis is usually due to streptococci, staphylococci, and anaerobic organisms. Empirical therapy of a sinusitis-associated brain abscess should include a combination of penicillin G or a third- or fourthgeneration cephalosporin and metronidazole. Most anaerobes in brain abscesses are also susceptible to penicillin, with the exception of B. The most common organisms isolated in a brain abscess from an otitic source are Streptococcus spp. Empirical therapy of an otogenic abscess should include a combination of penicillin G, metronidazole, and ceftazidime. The central area of pus is hyperintense, surrounded by a well-defined hypointense capsule. Empirical therapy should be a combination of penicillin G or a third- or fourth-generation cephalosporin plus vancomycin. Nocardia asteroides Anaerobic and microaerophilic streptococci (viridans streptococci) Haemophilus spp. Staphylococcus aureus and microaerophilic streptococci Staphylococci Enterobacteriaceae Clostridium spp. Staphylococci Gram-negative bacilli Antibiotics Penicillin G or a third- or fourth-generation cephalosporin plus metronidazole Predisposing condition Paranasal sinusitis Dental infections Penicillin G or a third- or fourth-generation cephalsporin plus metronidazole Penicillin G plus metronidazole plus ceftazidime Otitis media or mastoiditis Pyogenic lung infection (lung abscess and empyema) Penicillin G plus metronidazole plus ceftazidime7trimethoprim sulfamethoxazole Cyanotic congenital heart disease Penicillin G or a third- or fourth-generation cephalosporin plus metronidazole Nafcillin or vancomycin plus a third- or fourth-generation cephalosporin Vancomycin plus meropenem Endocarditis Penetrating head trauma Neurosurgical procedure Vancomycin plus meropenem Enterobacteriaceae. Empirical therapy should include a combination of a third- or fourth-generation cephalopsorin plus vancomycin.
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Neurological examination may reveal signs of mechanical tension hypertension 2012 10 mg zestril sale, weakness, sensory deficits, reflex changes, spasticity, and gait disturbance. Most patients describe a history of spinal surgery, myelography with oil-based or ionic contrast agents, or both. The latency between the inciting event and appearance of symptoms varies, but most patients are affected within the first year. Patients with syringomyelia can develop myelopathic signs or symptoms including progressive spasticity and pain syndromes. Advanced forms of arachnoiditis may be associated with incapacitating pain, disability, and even death. Incidence Arachnoiditis is widespread and its debilitating effect cannot be overstated. The incidence of radiographic arachnoiditis is higher than that of clinically significant arachnoiditis. Etiology Arachnoiditis is the result of any injury that causes an inflammatory response leading to fibrosis in the delicate arachnoid membrane. Infection, nonsurgical and surgical trauma, and retained irritants are important causes. Tuberculosis and syphilis are the most common infectious agents and were the most common overall causes before the 1940s. Spinal cord injuries, cerebral or subarachnoid hemorrhage, and intrathecally injected agents such as steroids, anesthetics, and radiologic contrast material also have been implicated. Since the introduction of water-soluble and newer nonionic contrast agents, the incidence of postmyelographic arachnoiditis has diminished significantly. The clinical syndrome of arachnoiditis is now most often associated with repeated surgical trauma. In particular, lumbosacral arachnoiditis most often is associated with myelography and spinal surgical procedures. Radiographic Characteristics Classically, myelography has been used to confirm the diagnosis of arachnoiditis. Findings can range from a filling defect of a single nerve root to complete obliteration of the thecal sac. High-resolution computed tomography demonstrates arachnoiditis effectively, particularly the calcific variety. The collagenous adhesions 258 Encyclopedia of the Neurological Sciences, Volume 1 doi:10. Minimally invasive techniques such as myeloscopy are promising modalities for verifying the diagnosis of arachnoiditis.
With disease onset and progression blood pressure healthy vs unhealthy effective zestril 2.5 mg, blood pressure begins to decrease, which is possibly related to vessel stiffening, weight loss, and changes in the autonomic regulation of blood flow. In addition, impaired glucose tolerance and diabetes lead to advanced glycosylation products, which in turn bind to amyloid plaques and neurofibrillary tangles enhancing their aggregation in vitro. They are involved in metabolism and inflammation and correlate with insulin resistance and hyperinsulinemia. Traumatic brain injury Postmortem and experimental studies support a link between traumatic brain injury and risk of dementia. This notion is supported by retrospective studies suggesting that individuals with a history of traumatic brain injury had a higher risk of dementia than those without. There is evidence for reverse causation in the years preceding dementia onset, and the relation seems to be driven in particular by central obesity. Protective Factors Physical activity the results of cross-sectional and longitudinal observational studies relating exercise with cognitive decline or dementia are inconsistent, although epidemiological and experimental data suggest that physical exercise may promote brain health. Better aerobic fitness increases cerebral blood flow, oxygen extraction and glucose utilization, and activates growth factors mediating structural changes such as capillary density. Intellectual activity Persons with higher education have a lower incidence of dementia, and several prospective studies have found that people who engage in cognitively stimulating activities such as learning, reading, or playing games at younger or older ages are less likely to develop dementia compared with those who do not engage in these activities. Although cognitive training can improve memory, reasoning, and mental processing speed in older adults, cognitive training does not seem to generalize across domains and does not affect everyday functioning. However, subsequent prospective studies have either shown an increased risk or no association. Smoking may increase the risk of dementia through increasing cerebrovascular disease, oxidative stress, a lower dietary intake of antioxidants, or augmentation of cholinergic metabolism by upregulation of cholinergic nicotinic receptors in the brain. Ab deposition, which occurs early in the disease, leads to a decrease in cerebral iron and copper concentrations, resulting in oxidative stress and neuronal damage. However, there is evidence from in vitro studies that vitamin E, vitamin C, and carotenes reduce Ab-induced lipid peroxidation and cell death. These effects were independent of the levels of physical activity and vascular comorbidity. However, several important medical and behavioral factors can modify the baseline risk of the disease. Clearly, more genes will be identified that influence the risk of disease, but it is uncertain whether these different genes act together or as independent factors and whether they interact with environmental factors. Also the specific disease-causing mutations in the identified genes need to be clarified. Nonetheless, studies currently in progress should provide important clues toward the etiology, pathogenesis, and eventual prevention of this disease. Introduction There are an estimated 10 million people living mainly in rural areas of Latin America infected by American trypanosomiasis, a parasitic disease caused by Trypanosoma cruzi. American trypanosomiasis is endemic in the Western Hemisphere between 251 N and 381 S latitudes and is independent of climate, temperature, and altitude.
Surgical treatment of tumors in the region of the dominant medial temporal lobe risks profound memory impairment hypertension essential benign 5 mg zestril order free shipping. Although most right-handed patients maintain dominance for language and memory in the left hemisphere, long-standing lesions (low-grade gliomas) as well as prior cortical injury (during childhood) can result in reorganization of function that is shifted to , or shared with, the right hemisphere. Preoperative functional studies can assist with the determination of localization of language and memory. Relatively slowgrowing tumors may manifest with a history of generalized seizures. Rapidly growing lesions are more likely to produce complex partial motor or sensory seizures, although grand mal seizures are also common. This agent does not induce hepatic cytochrome P450 enzymes, thus limiting interaction with many chemotherapeutic agents. Reported adverse reactions include psychiatric symptoms (depression) and cognitive slowing. Hypersensitivity reactions include cutaneous eruptions, lymphadenopathy, and fever. Carbamazepine, another commonly used agent, is administered with a gradual increase in dosage. Pain at the infusion site, ataxia, nausea, or bradycardia may require a slower rate of infusion. However, the drug requires metabolic activation, and the risk of bradyarrhythmias is not reduced. Tumor patients can start a low dose of subcutaneous heparin the day after surgery. Furthermore, sequential compression devices are used on the lower extremities when the patient is restricted to bed. Surveillance Doppler ultrasonography of the deep leg veins is performed on all patients who have been immobilized due to restricted mobility or monitoring that requires bed rest. The timing of safe anticoagulation remains controversial, but usually it can be instituted 48 h after surgery with little increased risk of hemorrhagic intracranial complications. Anticoagulation is preferable over filter placement because thrombotic complications (inferior vena cava thrombosis) associated with the latter are frequent and disabling. Depression Depression is common in brain tumor patients and underrecognized by most physicians. Although most neurosurgeons are not trained in the management of depression, this problem can degrade the quality of life in this population. Few neurosurgeons prescribe antidepressants for their patients because they are not familiar with the use of these medications and their side effects.
Current State and Future of Apraxia Research Recent research on limb apraxia has greatly benefitted from the application of paradigms from cognitive science and modern techniques blood pressure 152 over 90 zestril 5 mg order amex, such as functional neuroimaging, lesionfunction mapping, and methods to record and quantify different movement parameters. These varied approaches have allowed us to gain a deeper mechanistic understanding of deficits seen in limb apraxia. For example, functional imaging studies in healthy individuals have demonstrated that when shown pictures of tools, increased blood flow, which reflects neural activation, occurs not only in the inferior temporal lobe associated with tool recognition but also parietal, premotor, and motor cortical regions associated with use of the tool. In mature humans, it measures approximately 1 mm2 in crosssectional area and slightly more than 1 cm in length. Although they did not originally describe the structure of the aqueduct, they both were great anatomists and teachers. In 1523, Barengarius Carpensis specifically identified and described the aqueduct. The neural tube cranial to the mesencephalon expands and curls to form the third and lateral ventricles of the forebrain. The neural tube caudal to the mesencephalon expands to form the fourth ventricle of the hindbrain. Immediately surrounding the aqueduct is the periaqueductal gray matter, which plays an important role in modulating pain. Dorsal to the aqueduct is the tectal plate of the midbrain and ventral to the aqueduct is the midbrain tegmentum. The aqueduct does not contain any vessels or choroid plexus but does have a cluster of specially formed cells at its junction with the third ventricle located just ventral to the posterior commissure, called the subcommissural organ. Similar to the rest of the ventricular system, the configuration of the aqueduct is determined by the intraventricular pressure and the surrounding neural structures. Increases in intraventricular pressure, such as those occurring in communicating hydrocephalus, can result in dilation of the aqueduct to greater than 3 mm. Fetal stretching can occur with spinal bifida aperta and result in doubling the length of the aqueduct. The second segment is the first constriction, as the aqueduct is indented dorsally by the superior colliculi. Next is the ampulla, a dilated portion between the superior and inferior colliculi. The narrowest portion is typically the fourth portion or the second constriction, associated with the inferior colliculi. A tracer injected into the spinal subarachnoid space preferentially flows over the convexities of the brain and only in old age or in the presence of a communicating hydrocephalus does it flow up through the aqueduct into the third and lateral ventricles. Communicating hydrocephalus is associated with an increase flow through the aqueduct and inserting a shunt can return the flow to normal. Triventricular hydrocephalus refers to dilatation of the third and both lateral ventricles with a normal appearing fourth ventricle, and it is the classic imaging appearance for aqueductal stenosis.
Rhobar, 60 years: Summary Other analgesics (sometimes also referred to as adjuvant analgesics or coanalgesics) are agents that generally have other indications or uses but also possess inherent analgesic properties for certain painful conditions. Approximately two-thirds of the head injured could be classified as having a good outcome on the Glasgow Outcome Scale. Once the decision has been made, Q-switched or picosecond laser therapy is the treatment of choice. Since the introduction of water-soluble and newer nonionic contrast agents, the incidence of postmyelographic arachnoiditis has diminished significantly.
Roland, 64 years: Brain Tumors and Inherited Tumor Syndromes Brain tumors may occur as part of known inherited cancer syndromes. The presence of b-gal in second-order sensory neurons (trigeminal spinal nucleus and nucleus solitarius) suggested that transsynaptic spread had occurred following inoculation (and after passage through the neuromuscular junction and into the peripheral nerve). The patient should then change his or her underwear, pyjamas and the sheets on his or her bed. Damage to the juxtarestiform body, which carries signals from the fastigial nucleus to the brainstem reticular formation, may account for a saccadic abnormality referred to as lateropulsion of saccadic eye movements.
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