70 Measuring Itch Intensity in Young Children with Burns: What We Learnt from Parents. A Mixed-Methods Study

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S49-S49
Author(s):  
Yuting Lin
Keyword(s):  
Young Children ◽  
Future Development ◽  
Rating Scale ◽  
Burn Injury ◽  
Numerical Rating Scale ◽  
Average Length ◽  
Time Frame ◽  
Mosquito Bite ◽  
Intensity Rating ◽  
Numerical Rating

Abstract Introduction Despite the persistence and debilitating symptoms among inflicted children and their families, little is known about children’s itching behavior as perceived and described by parents. This study examined the parental description of young children’s itching behavior corresponding to the itch intensity rating, which can inform the future development of itch measurements for young children. Methods This analysis was part of a larger descriptive study that examined parental behavioral and psychological responses to children’s itch following the child’s unintentional burn injury. Parents of young children with deep second or third-degree burns were recruited. Parents were asked to rate the child’s itching intensity under four situations during the 7-day time frame using a 0–10 numerical rating scale (0 indicates no itch, and 10 indicates the worst itch possible). Parents were subsequently interviewed to describe the child’s observed behavior that reflected the itch intensity rating. The four itch situations were the current itch, the worst intense itch, the least intense itch, and the itch by a mosquito bite. Qualitative data were analyzed using inductive content analysis methods. Results Twenty parents of children 34 (±11.5) months old participated in the study. The average length of time since the child’s burn accident was 6.4 (±3.1) months. The mean ratings of the current itch, the worst intense itch, the least intense itch, and the itch by a mosquito bite were 3.45 (±2.4), 8.35 (±2.3), 1.5 (±1.7), and 4 (±1.2), respectively. Two themes that described a child’s itching behavior were identified: the level of a child’s needs for parental comfort and the frequency and disturbance (to activity and sleep) of scratching behavior. Conclusions Results suggest that the parent’s description of a child’s needs for parental comfort and scratching behaviors may serve as objective indicators of itching intensity. Interpreting inching intensive based on a child’s needs for parental comfort offered a creative way to evaluate itch considering the developmental perspective in young children. Future development of itch measures for children under 5 years of age shall consider these two important aspects.

Comparing the efficacy of nebulized morphine with intravenous morphine in traumatic musculoskeletal pain management

2020 ◽  
Vol 8 (1) ◽  
pp. 21-21
Author(s):  
Mani Mofidi ◽  
Ali Dashti ◽  
Mahdi Rezai ◽  
Niloufar Ghodrati ◽  
Hoorolnesa Ameli ◽  
...  
Keyword(s):  
Pain Management ◽  
Pain Relief ◽  
Musculoskeletal Pain ◽  
Normal Saline ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Vital Signs ◽  
Categorical Variables ◽  
Intravenous Morphine ◽  
Numerical Rating

Introduction: This study was designed to compare the effectiveness of intravenous morphine with nebulized morphine in pain relief of patients referring to the emergency setting with traumatic musculoskeletal pain. Methods: This randomized, placebo-controlled and double-blind clinical study evaluated 160 patients 18 to 65 years of age with acute traumatic pain, who attended the emergency department during 2019. Subjects were assessed with Numerical Rating Scale based on inclusion and exclusion criteria and randomly divided into two groups. In one group, 80 patients received IV morphine (0.1 mg/kg+5 mL normal saline) plus an equivalent volume of IV placebo. In the second group, 80 patients received nebulized morphine (0.2 mg/kg+5 mL normal saline) plus nebulized placebo. Pain score was monitored in all patients with Numerical Rating Scale before and after intervention at baseline, 15, 30, 45, and 60-minute intervals. Patients’ vital signs and possible adverse events were evaluated in each observation time points. Finally, all participants were assessed for their satisfaction with pain management. Data were analyzed using repeated measure analysis for continuous variables and Binomial test for categorical variables Results: There was no significant difference between the demographic characteristics of patients in study groups. Pain relief between the two groups was similar during the observation (0, 15, 30, 45, 60 min) (P>0.05). There were no changes in vital signs between two groups, although the nebulized group had lower systolic blood pressure at the time-point of 15 minutes after the treatment initiation (P=0.03). Conclusion: Although Nebulized morphine has similar efficacy in comparison with IV route, nebulization might be considered as the clinically efficacious route of morphine administration with minimal side effects, providing optimal pain relief in patients.

Comparison of Analgesic Effect of Levobupivacaine with Dexmedetomidine and Levobupivacaine for Scalp Block before Supratentorial Craniotomy: A Randomized Controlled Trial

2020 ◽  
Vol 103 (10) ◽  
pp. 1028-1035
Keyword(s):  
Postoperative Pain ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Control Group ◽  
Study Group ◽  
Analgesic Requirement ◽  
Supratentorial Craniotomy ◽  
Numerical Rating ◽  
Fentanyl Consumption ◽  
Scalp Block

Background: Craniotomy causes acute and chronic pain. Uncontrolled postoperative pain may lead to adverse events. Perioperative scalp nerves block is not only effective in reducing intraoperative hemodynamic response, but it also reduces postoperative pain and postoperative analgesia requirement. Objective: To compare the benefits of adding dexmedetomidine to levobupivacaine in scalp nerves block before craniotomy for the duration of analgesia in supratentorial craniotomy. Materials and Methods: After approval by the Committee for Research, 50 supratentorial craniotomy patients were randomized into two groups. The control group received 30 mL scalp nerves block with 0.25% levobupivacaine with adrenaline 1:200,000, whereas the study group received 30 mL scalp nerves block with 0.25% levobupivacaine with adrenaline 1:200,000 plus dexmedetomidine 1 mcg/kg. The primary outcome was the time to first analgesic requirement postoperatively. The secondary outcomes included intraoperative fentanyl consumption, verbal numerical rating scale, tramadol consumption, and complications during the first 24 hours postoperatively. Results: Patients in the study group had significantly increase time to the first analgesic requirement in postoperative period and reduced intraoperative fentanyl consumption. The median time to first analgesic requirement was 555 (360 to 1,035) minutes in the study group versus 405 (300 to 520) minutes in the control group (p=0.023). Intraoperative fentanyl consumption 125 (75 to 175) mcg in the study group was significantly lower than 200 (150 to 250) mcg in the control group (p=0.02). The verbal numerical rating scale at 1, 4, 8, 12 and 24 hours postoperatively, tramadol consumption, and complications during the first 24 hours postoperatively were not statistically significant different. Conclusion: Preoperative scalp nerves block with 0.25% levobupivacaine with adrenaline (1:200,000) with dexmedetomidine 1 mcg/kg significantly increased the time to first analgesic requirement and reduced intraoperative fentanyl consumption compared to 0.25% levobupivacaine with adrenaline (1:200,000) without perioperative complications. Keywords: Scalp block, Dexmedetomidine, Post-craniotomy analgesia, Supratentorial tumor, Levobupivacaine

scholarly journals P188 Secukinumab provides significant improvement of spinal pain and lowers disease activity in patients with axial spondyloarthritis: 24-week results from a randomised controlled Phase 3b trial

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Helena Marzo-Ortega ◽  
Chiara Perella ◽  
Denis Poddubnyy ◽  
Effie Pournara ◽  
Agnieszka Zielińska ◽  
...  
Keyword(s):  
Disease Activity ◽  
Primary Endpoint ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Spinal Pain ◽  
Stock Ownership ◽  
Double Blind ◽  
Low Disease Activity ◽  
Numerical Rating ◽  
Randomised Controlled

Abstract Background/Aims  SKIPPAIN (NCT03136861) is the first randomised controlled study involving a biological disease-modifying anti-rheumatic drug, with a primary endpoint of spinal pain at Week 8 in patients with axial spondyloarthritis (axSpA; ankylosing spondylitis [AS] and non-radiographic [nr]-axSpA). We present the 24-week results of secukinumab in reducing spinal pain and disease activity following step-up dosing. Methods  This double-blind, placebo-controlled Phase 3b study enrolled patients (aged ≥18 years) with active disease (BASDAI ≥4; average spinal pain numerical rating scale [NRS] score >4 at baseline; inadequate response to ≥ 2 non-steroidal anti-inflammatory drugs ≥4 weeks). Patients were randomised (3:1) to subcutaneous secukinumab 150 mg or placebo weekly followed by every 4 weeks (Q4W) from Week 4. At Week 8, placebo patients were re-randomised to secukinumab 150 or 300 mg Q4W. Patients originally randomised to secukinumab 150 mg were classified as responders or non-responders (spinal pain NRS score <4 or ≥ 4, respectively) at Week 8. Responders were re-assigned to continue doubleblind secukinumab 150 mg Q4W (Arm A1). Non-responders were re-randomised to double-blind secukinumab 150 mg (Arm A2) or a step-up dose of 300 mg (Arm A3) Q4W. Treatment was up to Week 24. Primary endpoint: proportion of patients achieving an average spinal pain score <4 on a 0-10 NRS with secukinumab vs placebo at Week 8. Results  380 axSpA patients (269/380 [70.8%] AS; 111/380 [29.2%] nr-axSpA) were randomised to secukinumab 150 mg (N = 285) or placebo (N = 95). The primary endpoint was met (proportion of spinal pain NRS [average] score responders: 32% vs 20%; odds ratio [95% confidence interval] 1.9 [1.1-3.3] favouring secukinumab vs placebo; P < 0.05). Further reductions in spinal pain occurred at Week 24, especially in those initially randomised to placebo and switched to active drug. Pronounced improvements were observed in other disease activity measurements (Table 1). Numerically, more patients achieved ASDAS low disease activity at Week 24 post-secukinumab dose escalation (Arm A3) vs those remaining on the same dose (Arm A2). Conclusion  Secukinumab provided rapid, significant improvement in spinal pain and led to low disease activity in axSpA patients. Secukinumab dose escalation might be beneficial for patients not responding fully to the starting dose. P188 Table 1:Spinal pain and ASDAS-CRP scores at Weeks 8 and 24Week 8SEC 150 mg (N = 285)PBO (N = 95)Change from baseline in spinal pain NRS score (total), mean (SD) [n]-2.6 (2.5) [279]-1.5 (2.2) [92]Change from baseline in ASDAS-CRP score, mean (SD) [n]-1.2 (1.0) [271]-0.5 (0.8) [89]Week 24Active treatment group (SEC treatment starting at baseline)PBO switchers group (SEC treatment starting at Week 8)Arm A1 (SEC 150 R-150) N = 90Arm A2 (SEC 150 NR-150) N = 94Arm A3 (SEC 150 NR-300) N = 94Arm B1 (PBO-SEC 150) N = 45Arm B2 (PBO-SEC 300) N = 44Change from Week 8 in spinal pain NRS score (total), mean (SD) [n]-0.4 (1.5) [88]-2.1 (2.2) [93]-1.9 (2.2) [91]-2.5 (2.6) [45]-2.9 (2.6) [43]Change from baseline in ASDAS-CRP score, mean (SD) [n]-2.2 (1.0) [86]-1.2 (1.0) [93]-1.5 (1.0) [92]-1.5 (1.1) [44]-1.8 (0.9) [43]Arm A1=SEC responder to SEC 150 mg at Week 8 (SEC 150 R-150); Arm A2=SEC non-responder to SEC 150 mg at Week 8 (SEC 150 NR-150); Arm A3=SEC non-responder to SEC 300 mg at Week 8 (SEC 150 NR-300); Arm B1=Placebo patients to SEC 150 mg (PBO-SEC 150); Arm B2=Placebo patients to SEC 300 mg (PBO-SEC 300). ASDAS-CRP, Ankylosing Spondylitis Disease Activity Score using C-reactive protein; N, total number of patients randomised; n, number of evaluable patients; NR, non-responders; NRS, numerical rating scale; PBO, placebo; R, responders; SD, standard deviation; SEC, secukinumab. Disclosure  H. Marzo-Ortega: Consultancies; AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, UCB. Member of speakers’ bureau; AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda, UCB. Grants/research support; Janssen, Novartis. C. Perella: Corporate appointments; Employee of Novartis. Shareholder/stock ownership; Novartis Stock. D. Poddubnyy: Consultancies; Consultant/speaker for: AbbVie, BMS, Lilly, MSD, Novartis, Pfizer, Roche, UCB. Grants/research support; AbbVie, MSD, Novartis, Pfizer. E. Pournara: Corporate appointments; Employee of Novartis. Shareholder/stock ownership; Novartis Stock. A. Zielińska: Consultancies; Novartis, Pfizer. A. Baranauskaite: Consultancies; AbbVie. Member of speakers’ bureau; Novartis, AbbVie, Amgen, Roche, KRKA. S. Sadhu: Corporate appointments; Employee of Novartis. B. Schulz: Corporate appointments; Employee of Novartis. M. Rissler: Corporate appointments; Employee of Novartis. Shareholder/stock ownership; Novartis Stock.

scholarly journals Individual Differences and Similarities in the Judgement of Facial Pain: A Mixed Method Study

2020 ◽  
Vol 10 (4) ◽  
pp. 1186-1194
Author(s):  
Sheila Glenn ◽  
Helen Poole ◽  
Paula Oulton
Keyword(s):  
Individual Differences ◽  
Undergraduate Students ◽  
Pain Assessment ◽  
Health Care Professionals ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Pain Catastrophizing ◽  
Sensory Sensitivity ◽  
Facial Cues ◽  
Numerical Rating

Accurate assessment of pain by health-care professionals is essential to ensure optimal management of pain. An under-researched area is whether personality characteristics affect perception of pain in others. The aims were (a) to determine whether individual differences are associated with participants’ ability to assess pain, and (b) to determine facial cues used in the assessment of pain. One hundred and twenty-eight undergraduate students participated. They completed questionnaire assessments of empathy, pain catastrophizing, sensory sensitivity and emotional intelligence. They then viewed and rated four adult facial images (no, medium, and high pain—12 images total) using a 0–10 numerical rating scale, and noted the reasons for their ratings. (a) Empathy was the only characteristic associated with accuracy of pain assessment. (b) Descriptions of eyes and mouth, and eyes alone were most commonly associated with assessment accuracy. This was the case despite variations in the expression of pain in the four faces. Future studies could evaluate the effect on accuracy of pain assessment of (a) training empathic skills for pain assessment, and (b) emphasizing attention to the eyes, and eyes and mouth.

scholarly journals Rhomboid intercostal block combined with sub-serratus plane block versus rhomboid intercostal block for postoperative analgesia after video-assisted thoracoscopic surgery: a prospective randomized-controlled trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Wei Deng ◽  
Xiao-min Hou ◽  
Xu-yan Zhou ◽  
Qing-he Zhou
Keyword(s):  
Rating Scale ◽  
Numerical Rating Scale ◽  
Thoracoscopic Surgery ◽  
Controlled Trial ◽  
Ultrasound Guided ◽  
Video Assisted ◽  
Prospective Randomized Controlled Trial ◽  
Numerical Rating ◽  
Intercostal Block ◽  
Video Assisted Thoracoscopic Surgery

Abstract Background Rhomboid intercostal block (RIB) and Rhomboid intercostal block with sub-serratus plane block (RISS) are the two types of plane blocks used for postoperative analgesia after video-assisted thoracoscopic surgery (VATS). This prospective randomized controlled trial was performed to analyze the postoperative analgesic effects of ultrasound-guided RIB block and RISS block after video-assisted thoracoscopic surgery. Methods Ninety patients aged between 18 and 80 years, with American Society of Anesthesiologists physical status Classes I–II and scheduled for elective unilateral VATS were randomly allocated into three groups. In group C, no block intervention was performed. Patients in group RIB received ultrasound-guided RIB with 20-mL 0.375% ropivacaine and those in group RISS received ultrasound-guided RIB and serratus plane block using a total of 40-mL 0.375% ropivacaine. All patients received intravenous sufentanil patient-controlled analgesia upon arrival in the recovery room. Postoperative sufentanil consumption and pain scores were compared among the groups. Results The dosages of sufentanil consumption at 24 h after the surgery in the RIB and RISS groups were significantly lower than that in group C (p < 0.001 and p < 0.001 for all comparisons, respectively), the postoperative Numerical Rating Scale (NRS) scores in the RIB and RISS groups at 0.5, 1, 3, 6, 12, 18, and 24 h after surgery when patients were at rest or active were significantly lower than that in group C (p < 0.05 for all comparisons). The required dosage of sufentanil and time to first postoperative analgesic request in groupRISS were less than those in the group RIB at 24 h after the surgery (p < 0.001 and p < 0.001 for all comparisons, respectively). Similarly, the Numerical Rating Scale scores for group RISS at 12, 18, and 24 h after the surgery when the patients were active were significantly lower than those for group RIB (p < 0.05 for all comparisons). Conclusion Both ultrasound-guided RIB block and RISS block can effectively reduce the demand for sufentanil within 24 h after VATS, and less sufentanil dosage is needed in patient with RISS block. Ultrasound-guided RIB block and RISS block can effectively relieve pain within 24 h after VATS, and RISS block is more effective.

scholarly journals Differential response to scrambler therapy by neuropathic pain phenotypes

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Young Gi Min ◽  
Hyun Seok Baek ◽  
Kyoung-Min Lee ◽  
Yoon-Ho Hong
Keyword(s):  
Neuropathic Pain ◽  
Treatment Outcome ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Brief Pain Inventory ◽  
Differential Response ◽  
Open Label ◽  
Numerical Rating ◽  
Scrambler Therapy ◽  
Post Hoc

AbstractScrambler therapy is a noninvasive electroanalgesia technique designed to remodulate the pain system. Despite growing evidence of its efficacy in patients with neuropathic pain, little is known about the clinical factors associated with treatment outcome. We conducted a prospective, open-label, single-arm trial to assess the efficacy and safety of scrambler therapy in patients with chronic neuropathic pain of various etiologies. A post-hoc analysis was performed to investigate whether cluster analysis of the Neuropathic Pain Symptom Inventory (NPSI) profiles could identify a subgroup of patients regarding neuropathic pain phenotype and treatment outcome. Scrambler therapy resulted in a significant decrease in the pain numerical rating scale (NRS) score over 2 weeks of treatment (least squares mean of percentage change from baseline, − 15%; 95% CI − 28% to − 2.4%; p < 0.001). The mean score of Brief Pain Inventory (BPI) interference subdimension was also significantly improved (p = 0.022), while the BPI pain composite score was not. Hierarchical clustering based on the NPSI profiles partitioned the patients into 3 clusters with distinct neuropathic pain phenotypes. Linear mixed-effects model analyses revealed differential response to scrambler therapy across clusters (p = 0.003, pain NRS; p = 0.072, BPI interference subdimension). Treatment response to scrambler therapy appears different depending on the neuropathic pain phenotypes, with more favorable outcomes in patients with preferentially paroxysmal pain rather than persistent pain. Further studies are warranted to confirm that capturing neuropathic pain phenotypes can optimize the use of scrambler therapy.

scholarly journals NUMERICAL RATING SCALE AS A PREDICTOR OF AN UNDERLYING PATHOLOGY IN PEDIATRIC BACK PAIN USING MAGNETIC RESONANCE IMAGE AS DIAGNOSTIC TOOL

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0004
Author(s):  
Eduardo A. Lindsay ◽  
Gerardo Olivella ◽  
Manuel Rodríguez ◽  
Edwin Burgos-Rossy ◽  
Natalia Torres-Acevedo ◽  
...  
Keyword(s):  
Back Pain ◽  
Magnetic Resonance Image ◽  
Rating Scale ◽  
Chronic Back Pain ◽  
Numerical Rating Scale ◽  
Children And Adolescent ◽  
Constant Pain ◽  
Neurological Exam ◽  
Numerical Rating ◽  
Underlying Pathology

Background & Objectives: Recently, constant and night pain has been discarded as adequate clinical markers to predict the presence of an underlying pathology in pediatric back pain. The pain intensity has been recognized as an important domain in the pain assessment. Numerical Rating Scale (NRS) is one of the most common validated tools to assess pediatric pain intensity in children above 8 years of age. The aim of this study is to assess NRS as a predictor of underlying pathologies found by magnetic resonance image (MRI) in pediatric back pain. We hypothesize that a higher NRS score is associated with a high sensitivity, specificity and likelihood ratio to identify the present of organic pathology in pediatric chronic back pain. Methodology: After obtaining Institutional Review Board approval, a retrospective electronical medical record review was conducted. All pediatric patients who reported back pain lasting > 4 weeks between 2009 to 2018 were enrolled in the study. As per regular protocol, a pediatric orthopedic surgeon evaluated all patients who presented with back pain. After a non-diagnostic history, physical examination and spinal x-ray; spine MRI was order. Pain was graded with the use of NRS from 0 to 10. Patients were divided in two groups: NRS (1-5) & NRS (6-10). Variables such as gender, age, pain frequency, night pain, neurological exam, and the presence of an underlying pathology were compared between both groups. Patients that presented with injury due to trauma, previous diagnosis of back pain or cervical pain were excluded. Results: A total of 467 patients were evaluated in the study. Mean age of subjects was 15 years; 69% being female. An underlying pathology was identified in 131/315 (41.6%) patients with NRS (6-10), and 55/152 (36.2%) patients with NRS (1-5) (P=0.27). Patients with NRS (6-10) had two times more probability of suffering constant pain (P<0.03) and three times more likely of having an abnormal neurological examination (P<0.05). See table 1. Conclusion: Evaluation and treatment of children and adolescent with chronic back pain is challenging. Our study shows a strong association between NRS high (6-10) and constant pain and/or abnormal neurological exam. However, the use of NRS of (6-10) was not found as adequate predictor for the presence of an underlying organic pathology in children and adolescent patients. Therefore, physicians should not rely only high NRS score to recommend advance imaging study to assess chronic back pain in children and adolescent patients. Summary [Table: see text]

scholarly journals Content validity of a sleep numerical rating scale and a sleep diary in adults and adolescents with moderate-to-severe atopic dermatitis

2020 ◽  
Vol 4 (1) ◽  
Author(s):  
Carla Dias-Barbosa ◽  
Rodolfo Matos ◽  
Margaret Vernon ◽  
Colleen E. Carney ◽  
Andrew Krystal ◽  
...  
Keyword(s):  
Atopic Dermatitis ◽  
Phase I ◽  
Sleep Disturbance ◽  
Content Validity ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Sleep Diary ◽  
Convenience Sample ◽  
Concept Elicitation ◽  
Numerical Rating

Abstract Background The intense itching associated with atopic dermatitis (AD) often causes patients to experience severe sleep disturbance. Here, we describe the results of a two-phase concept elicitation and cognitive interview study to establish the content validity of a sleep disturbance numerical rating scale (SD NRS) and a Consensus Sleep Diary adapted for adults and adolescents with moderate-to-severe AD (CSD-AD©). Results In phase I, a concept elicitation conducted in 20 adults and 10 adolescents with moderate-to-severe AD revealed that the following sleep-related issues were important and relevant: nighttime awakening (87%), trouble falling asleep (73%), feeling unrested (53%), daytime fatigue or sleepiness (53%), and feeling as if they did not get enough sleep (33%). The frequency and extent of sleep disturbance varied substantially from day to day due to varying degrees of itching and flares, medication use, and changes in the weather. All participants understood the SD NRS question, with most finding it easy or very easy to understand (100% of adults and 90% of adolescents) and most understanding the anchors as intended (95% of adults, and 100% of adolescents). Most participants (94% of adults, and 90% of adolescents) indicated that they would consider a one- or two-point change meaningful on the SD NRS. The CSD-AD© was revised based on participant feedback, and tested during phase II in a convenience sample of six adults and four adolescents from phase I. The changes made to the CSD-AD© were confirmed to be relevant and understandable. All patients were able to provide an answer to each item in the CSD-AD©, and most were able to estimate the duration of nighttime awakenings, daytime naps, and dozing. Conclusions The study supported the content validity of the SD NRS and CSD-AD© in adults and adolescents with moderate-to-severe AD. It also emphasized the importance of using these instruments daily when assessing the benefit of a new treatment on sleep quality in this population.

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