Establishment and verification of a surgical prognostic model for cervical spinal cord injury without radiological abnormality
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摘要
Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) =-25.4545 + 21.2576 VALUE + 1.2160SCORE-3.4224 TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score(0–17) after the operation, and TIME refers to the disease duration(from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941(95% confidence interval, 0.7930–0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥-2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China(approval number: 2018063) on May 8, 2018.
Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) =-25.4545 + 21.2576 VALUE + 1.2160SCORE-3.4224 TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score(0–17) after the operation, and TIME refers to the disease duration(from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941(95% confidence interval, 0.7930–0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥-2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China(approval number: 2018063) on May 8, 2018.
Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) =-25.4545 + 21.2576 VALUE + 1.2160SCORE-3.4224 TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score(0–17) after the operation, and TIME refers to the disease duration(from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941(95% confidence interval, 0.7930–0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥-2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China(approval number: 2018063) on May 8, 2018.
引文
Aarabi B,Hadley MN,Dhall SS,Gelb DE,Hurlbert RJ,Rozzelle CJ,Ryken TC,Theodore N,Walters BC(2013)Management of acute traumatic central cord syndrome(ATCCS).Neurosurgery 72 Suppl 2:195-204.
Aebli N,Wicki AG,Ruegg TB,Petrou N,Eisenlohr H,Krebs J(2013)The Torg-Pavlov ratio for the prediction of acute spinal cord injury after a minor trauma to the cervical spine.Spine J 13:605-612.
Alexander M,Aslam H,Marino RJ(2017)Pulse article:How do you do the international standards for neurological classification of SCI anorectal exam?Spinal Cord Ser Cases 3:17078.
Altman DG,Vergouwe Y,Royston P,Moons KG(2009)Prognosis and prognostic research:validating a prognostic model.BMJ338:b605.
Armstrong AJ,Clark JM,Ho DT,Payne CJ,Nolan S,Goodes LM,Harvey LA,Marshall R,Galea MP,Dunlop SA(2017)Achieving assessor accuracy on the international standards for neurological classification of spinal cord injury.Spinal Cord 55:994-1001.
Chen IH,Liao KK,Shen WY(1994)Measurement of cervical canal sagittal diameter in Chinese males with cervical spondylotic myelopathy.Zhonghua Yi Xue Za Zhi(Taipei)54:105-110.
Chen TY,Dickman CA,Eleraky M,Sonntag VK(1998)The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis.Spine(Phila Pa 1976)23:2398-2403.
Chen X,Liu Z,Sun T,Ren J,Wang X(2014)Relationship between nutritional status and mortality during the first 2 weeks following treatment for cervical spinal cord injury.J Spinal Cord Med 37:72-78.
Dang GD,Sun Y,Liu ZJ(2003)Cervical spinal cord injury without radiological abnormality and the surgical treatment of it.Zhongguo Jizhu Jisui Zazhi 13:581-582.
Diaz JJ,Jr.,Aulino JM,Collier B,Roman C,May AK,Miller RS,Guillamondegui O,Morris JA,Jr.(2005)The early work-up for isolated ligamentous injury of the cervical spine:does computed tomography scan have a role?J Trauma 59:897-904.
Franz S,Kirshblum SC,Weidner N,Rupp R,Schuld C,EMSCI study group(2016)Motor levels in high cervical spinal cord injuries:Implications for the International Standards for Neurological Classification of Spinal Cord Injury.J Spinal Cord Med 39:513-517.
Fukui M,Chiba K,Kawakami M,Kikuchi S,Konno S,Miyamoto M,Seichi A,Shimamura T,Shirado O,Taguchi T,Takahashi K,Takeshita K,Tani T,Toyama Y,Wada E,Yonenobu K,Tanaka T,Hirota Y;Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association(2007)An outcome measure for patients with cervical myelopathy:Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire(JOACMEQ):Part 1.J Orthop Sci 12:227-240.
Furlan JC,Catharine Craven B(2016)Psychometric analysis and critical appraisal of the original,revised,and modified versions of the Japanese Orthopaedic Association score in the assessment of patients with cervical spondylotic myelopathy.Neurosurg Focus40:E6.
Grosso MJ,Hwang R,Mroz T,Benzel E,Steinmetz MP(2013)Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery.J Neurosurg Spine 18:537-544.
Gu J,Ghosal S,Roy A(2008)Bayesian bootstrap estimation of ROCcurve.Stat Med 27:5407-5420.
Gupta SK,Rajeev K,Khosla VK,Sharma BS,Paramjit,Mathuriya SN,Pathak A,Tewari MK,Kumar A(1999)Spinal cord injury without radiographic abnormality in adults.Spinal Cord 37:726-729.
Herzog RJ,Wiens JJ,Dillingham MF,Sontag MJ(1991)Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players.Plain film radiography,multiplanar computed tomography,and magnetic resonance imaging.Spine(Phila Pa 1976)16:S178-186.
Hong Y,Zhang QM,Li X,Guan H(2005)Expansive laminoplasty as a method for managing cervical spinal cord injury coincident with no fracture and dislocation.Zhongguo Jizhu Jisui Zazhi 15:19-22.
Janssens AC,Deng Y,Borsboom GJ,Eijkemans MJ,Habbema JD,Steyerberg EW(2005)A new logistic regression approach for the evaluation of diagnostic test results.Med Decis Making 25:168-177.
Kawano O,Ueta T,Shiba K,Iwamoto Y(2010)Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression:a multicenter prospective study.Spinal Cord 48:548-553.
Kawano O,Maeda T,Mori E,Yugue I,Takao T,Sakai H,Ueta T,Shiba K(2014)Influence of spinal cord compression and traumatic force on the severity of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament.Spine(Phila Pa 1976)39:1108-1112.
Knottnerus JA(1992)Application of logistic regression to the analysis of diagnostic data:exact modeling of a probability tree of multiple binary variables.Med Decis Making 12:93-108.
Koyanagi I,Iwasaki Y,Hida K,Akino M,Imamura H,Abe H(2000)Acute cervical cord injury without fracture or dislocation of the spinal column.J Neurosurg 93:15-20.
La Rosa G,Conti A,Cardali S,Cacciola F,Tomasello F(2004)Does early decompression improve neurological outcome of spinal cord injured patients?Appraisal of the literature using a meta-analytical approach.Spinal Cord 42:503-512.
Maeda T,Ueta T,Mori E,Yugue I,Kawano O,Takao T,Sakai H,Okada S,Shiba K(2012)Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury.Spine(Phila Pa 1976)37:E1560-1566.
Pang D,Wilberger JE,Jr.(1982)Spinal cord injury without radiographic abnormalities in children.J Neurosurg 57:114-129.
Royston P,Moons KG,Altman DG,Vergouwe Y(2009)Prognosis and prognostic research:developing a prognostic model.BMJ338:b604.
Saruhashi Y,Hukuda S,Katsuura A,Asajima S,Omura K(1998)Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma.Spinal Cord 36:567-573.
Schuld C,Franz S,Brüggemann K,Heutehaus L,Weidner N,Kirshblum SC,Rupp R,EMSCI study group(2016)International standards for neurological classification of spinal cord injury:impact of the revised worksheet(revision 02/13)on classification performance.J Spinal Cord Med 39:504-512.
Song KJ,Choi BW,Kim SJ,Kim GH,Kim YS,Song JH(2009)The relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury:an analysis using Pavlov’s ratio,spinal cord area,and spinal canal area.Clin Orthop Surg 1:11-18.
Suk KS,Kim KT,Lee JH,Lee SH,Kim JS,Kim JY(2009)Reevaluation of the Pavlov ratio in patients with cervical myelopathy.Clin Orthop Surg 1:6-10.
Takao T,Morishita Y,Okada S,Maeda T,Katoh F,Ueta T,Mori E,Yugue I,Kawano O,Shiba K(2013)Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation.Eur Spine J 22:2228-2231.
Tanaka N,Konno S,Takeshita K,Fukui M,Takahashi K,Chiba K,Miyamoto M,Matsumoto M,Kasai Y,Kanamori M,Matsunaga S,Hosono N,Kanchiku T,Taneichi H,Hashizume H,Kanayama M,Shimizu T,Kawakami M(2014)An outcome measure for patients with cervical myelopathy:the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire(JOACMEQ):an average score of healthy volunteers.J Orthop Sci 19:33-48.
Tanaka Y(2018)“The Power of Yamato”:The 33rd annual research meeting of the Japanese orthopedic association.J Orthop Sci23:715-716.
Tetreault LA,Cote P,Kopjar B,Arnold P,Fehlings MG;AOSpine North America and International Clinical Trial Research Network(2015)A clinical prediction model to assess surgical outcome in patients with cervical spondylotic myelopathy:internal and external validations using the prospective multicenter AOSpine North American and international datasets of 743 patients.Spine J 15:388-397.
Tewari MK,Gifti DS,Singh P,Khosla VK,Mathuriya SN,Gupta SK,Pathak A(2005)Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging:analysis of 40 patients.Surg Neurol 63:204-209.
Wang Z,Leng J,Liu J,Liu Y(2015)Morphological study of the posterior osseous structures of subaxial cervical spine in a population from northeastern China.J Orthop Surg Res 10:53.
Wenger M,Adam PJ,Alarcón F,Markwalder TM(2003)Traumatic cervical instability associated with cord oedema and temporary quadriparesis.Spinal Cord 41:521-526.
Yamazaki T,Yanaka K,Fujita K,Kamezaki T,Uemura K,Nose T(2005)Traumatic central cord syndrome:analysis of factors affecting the outcome.Surg Neurol 63:95-100.
Yue WM,Tan SB,Tan MH,Koh DC,Tan CT(2001)The Torg--Pavlov ratio in cervical spondylotic myelopathy:a comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic,nonmyelopathic population.Spine(Phila Pa1976)26:1760-1764.
Zheng CF,Liu YC,Hu YC,Xia Q,Miao J,Zhang JD,Zhang K(2016)Correlations of Japanese Orthopaedic Association Scoring Systems with gait parameters in patients with degenerative spinal diseases.Orthop Surg 8:447-453.
Aebli N,Wicki AG,Ruegg TB,Petrou N,Eisenlohr H,Krebs J(2013)The Torg-Pavlov ratio for the prediction of acute spinal cord injury after a minor trauma to the cervical spine.Spine J 13:605-612.
Alexander M,Aslam H,Marino RJ(2017)Pulse article:How do you do the international standards for neurological classification of SCI anorectal exam?Spinal Cord Ser Cases 3:17078.
Altman DG,Vergouwe Y,Royston P,Moons KG(2009)Prognosis and prognostic research:validating a prognostic model.BMJ338:b605.
Armstrong AJ,Clark JM,Ho DT,Payne CJ,Nolan S,Goodes LM,Harvey LA,Marshall R,Galea MP,Dunlop SA(2017)Achieving assessor accuracy on the international standards for neurological classification of spinal cord injury.Spinal Cord 55:994-1001.
Chen IH,Liao KK,Shen WY(1994)Measurement of cervical canal sagittal diameter in Chinese males with cervical spondylotic myelopathy.Zhonghua Yi Xue Za Zhi(Taipei)54:105-110.
Chen TY,Dickman CA,Eleraky M,Sonntag VK(1998)The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis.Spine(Phila Pa 1976)23:2398-2403.
Chen X,Liu Z,Sun T,Ren J,Wang X(2014)Relationship between nutritional status and mortality during the first 2 weeks following treatment for cervical spinal cord injury.J Spinal Cord Med 37:72-78.
Dang GD,Sun Y,Liu ZJ(2003)Cervical spinal cord injury without radiological abnormality and the surgical treatment of it.Zhongguo Jizhu Jisui Zazhi 13:581-582.
Diaz JJ,Jr.,Aulino JM,Collier B,Roman C,May AK,Miller RS,Guillamondegui O,Morris JA,Jr.(2005)The early work-up for isolated ligamentous injury of the cervical spine:does computed tomography scan have a role?J Trauma 59:897-904.
Franz S,Kirshblum SC,Weidner N,Rupp R,Schuld C,EMSCI study group(2016)Motor levels in high cervical spinal cord injuries:Implications for the International Standards for Neurological Classification of Spinal Cord Injury.J Spinal Cord Med 39:513-517.
Fukui M,Chiba K,Kawakami M,Kikuchi S,Konno S,Miyamoto M,Seichi A,Shimamura T,Shirado O,Taguchi T,Takahashi K,Takeshita K,Tani T,Toyama Y,Wada E,Yonenobu K,Tanaka T,Hirota Y;Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association(2007)An outcome measure for patients with cervical myelopathy:Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire(JOACMEQ):Part 1.J Orthop Sci 12:227-240.
Furlan JC,Catharine Craven B(2016)Psychometric analysis and critical appraisal of the original,revised,and modified versions of the Japanese Orthopaedic Association score in the assessment of patients with cervical spondylotic myelopathy.Neurosurg Focus40:E6.
Grosso MJ,Hwang R,Mroz T,Benzel E,Steinmetz MP(2013)Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery.J Neurosurg Spine 18:537-544.
Gu J,Ghosal S,Roy A(2008)Bayesian bootstrap estimation of ROCcurve.Stat Med 27:5407-5420.
Gupta SK,Rajeev K,Khosla VK,Sharma BS,Paramjit,Mathuriya SN,Pathak A,Tewari MK,Kumar A(1999)Spinal cord injury without radiographic abnormality in adults.Spinal Cord 37:726-729.
Herzog RJ,Wiens JJ,Dillingham MF,Sontag MJ(1991)Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players.Plain film radiography,multiplanar computed tomography,and magnetic resonance imaging.Spine(Phila Pa 1976)16:S178-186.
Hong Y,Zhang QM,Li X,Guan H(2005)Expansive laminoplasty as a method for managing cervical spinal cord injury coincident with no fracture and dislocation.Zhongguo Jizhu Jisui Zazhi 15:19-22.
Janssens AC,Deng Y,Borsboom GJ,Eijkemans MJ,Habbema JD,Steyerberg EW(2005)A new logistic regression approach for the evaluation of diagnostic test results.Med Decis Making 25:168-177.
Kawano O,Ueta T,Shiba K,Iwamoto Y(2010)Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression:a multicenter prospective study.Spinal Cord 48:548-553.
Kawano O,Maeda T,Mori E,Yugue I,Takao T,Sakai H,Ueta T,Shiba K(2014)Influence of spinal cord compression and traumatic force on the severity of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament.Spine(Phila Pa 1976)39:1108-1112.
Knottnerus JA(1992)Application of logistic regression to the analysis of diagnostic data:exact modeling of a probability tree of multiple binary variables.Med Decis Making 12:93-108.
Koyanagi I,Iwasaki Y,Hida K,Akino M,Imamura H,Abe H(2000)Acute cervical cord injury without fracture or dislocation of the spinal column.J Neurosurg 93:15-20.
La Rosa G,Conti A,Cardali S,Cacciola F,Tomasello F(2004)Does early decompression improve neurological outcome of spinal cord injured patients?Appraisal of the literature using a meta-analytical approach.Spinal Cord 42:503-512.
Maeda T,Ueta T,Mori E,Yugue I,Kawano O,Takao T,Sakai H,Okada S,Shiba K(2012)Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury.Spine(Phila Pa 1976)37:E1560-1566.
Pang D,Wilberger JE,Jr.(1982)Spinal cord injury without radiographic abnormalities in children.J Neurosurg 57:114-129.
Royston P,Moons KG,Altman DG,Vergouwe Y(2009)Prognosis and prognostic research:developing a prognostic model.BMJ338:b604.
Saruhashi Y,Hukuda S,Katsuura A,Asajima S,Omura K(1998)Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma.Spinal Cord 36:567-573.
Schuld C,Franz S,Brüggemann K,Heutehaus L,Weidner N,Kirshblum SC,Rupp R,EMSCI study group(2016)International standards for neurological classification of spinal cord injury:impact of the revised worksheet(revision 02/13)on classification performance.J Spinal Cord Med 39:504-512.
Song KJ,Choi BW,Kim SJ,Kim GH,Kim YS,Song JH(2009)The relationship between spinal stenosis and neurological outcome in traumatic cervical spine injury:an analysis using Pavlov’s ratio,spinal cord area,and spinal canal area.Clin Orthop Surg 1:11-18.
Suk KS,Kim KT,Lee JH,Lee SH,Kim JS,Kim JY(2009)Reevaluation of the Pavlov ratio in patients with cervical myelopathy.Clin Orthop Surg 1:6-10.
Takao T,Morishita Y,Okada S,Maeda T,Katoh F,Ueta T,Mori E,Yugue I,Kawano O,Shiba K(2013)Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation.Eur Spine J 22:2228-2231.
Tanaka N,Konno S,Takeshita K,Fukui M,Takahashi K,Chiba K,Miyamoto M,Matsumoto M,Kasai Y,Kanamori M,Matsunaga S,Hosono N,Kanchiku T,Taneichi H,Hashizume H,Kanayama M,Shimizu T,Kawakami M(2014)An outcome measure for patients with cervical myelopathy:the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire(JOACMEQ):an average score of healthy volunteers.J Orthop Sci 19:33-48.
Tanaka Y(2018)“The Power of Yamato”:The 33rd annual research meeting of the Japanese orthopedic association.J Orthop Sci23:715-716.
Tetreault LA,Cote P,Kopjar B,Arnold P,Fehlings MG;AOSpine North America and International Clinical Trial Research Network(2015)A clinical prediction model to assess surgical outcome in patients with cervical spondylotic myelopathy:internal and external validations using the prospective multicenter AOSpine North American and international datasets of 743 patients.Spine J 15:388-397.
Tewari MK,Gifti DS,Singh P,Khosla VK,Mathuriya SN,Gupta SK,Pathak A(2005)Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging:analysis of 40 patients.Surg Neurol 63:204-209.
Wang Z,Leng J,Liu J,Liu Y(2015)Morphological study of the posterior osseous structures of subaxial cervical spine in a population from northeastern China.J Orthop Surg Res 10:53.
Wenger M,Adam PJ,Alarcón F,Markwalder TM(2003)Traumatic cervical instability associated with cord oedema and temporary quadriparesis.Spinal Cord 41:521-526.
Yamazaki T,Yanaka K,Fujita K,Kamezaki T,Uemura K,Nose T(2005)Traumatic central cord syndrome:analysis of factors affecting the outcome.Surg Neurol 63:95-100.
Yue WM,Tan SB,Tan MH,Koh DC,Tan CT(2001)The Torg--Pavlov ratio in cervical spondylotic myelopathy:a comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic,nonmyelopathic population.Spine(Phila Pa1976)26:1760-1764.
Zheng CF,Liu YC,Hu YC,Xia Q,Miao J,Zhang JD,Zhang K(2016)Correlations of Japanese Orthopaedic Association Scoring Systems with gait parameters in patients with degenerative spinal diseases.Orthop Surg 8:447-453.