复合镇痛在超脉冲点阵二氧化碳激光治疗小儿烧伤后增生性瘢痕中的应用效果的前瞻性随机对照研究

杨姣; 石珊; 王玲; 李娜; 韩军涛; 胡大海

doi:10.3760/cma.j.cn501120-20210507-00171

复合镇痛在超脉冲点阵二氧化碳激光治疗小儿烧伤后增生性瘢痕中的应用效果的前瞻性随机对照研究

doi: 10.3760/cma.j.cn501120-20210507-00171

空军军医大学第一附属医院烧伤与皮肤外科，全军烧伤中心，西安　　710032

基金项目:

国家自然科学基金青年科学基金项目 81901965

详细信息

通讯作者:
石珊，Email：343351619@qq.com

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出版历程
- 收稿日期: 2021-02-21

A prospective randomized controlled study on the effects of compound analgesia in ultra-pulsed fractional carbon dioxide laser treatment of post-burn hypertrophic scars in children

Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital of Air Force Medical University, Xi′an 710032, China

Funds:

Youth Science Foundation Project of National Natural Science Foundation of China 81901965

More Information

Corresponding author: Shi Shan, Email: 343351619@qq.com

摘要

摘要: 目的探讨复合镇痛在超脉冲点阵二氧化碳激光（UFCL）治疗小儿烧伤后增生性瘢痕中的应用效果。方法采用前瞻性随机对照研究方法。2018年4月—2020年3月，将空军军医大学第一附属医院收治的169例烧伤后增生性瘢痕患儿按照随机数字表法分为单纯全身麻醉组［39例，男19例、女20例，年龄35（21，48）个月］、全身麻醉+利多卡因组［41例，男23例、女18例，年龄42（22，68）个月］、全身麻醉+布洛芬栓组［41例，男25例、女16例，年龄38（26，52）个月］以及应用全身麻醉+利多卡因+布洛芬栓的三联用药组［48例，男25例、女23例，年龄42（25，60）个月］，各组患儿在行UFCL治疗瘢痕时分别采用对应的镇痛方案，并针对患儿治疗过程进行全程综合护理。分别于首次麻醉清醒后0（即刻）、1、2、4 h，采用儿童疼痛行为量表FLACC对患儿瘢痕进行疼痛程度评估。首次麻醉清醒后4 h疼痛评估结束后，采用自制的镇痛满意度调查表对患儿或其家属对镇痛效果的满意度进行评估并计算满意率。首次术后2 h内，观察并记录患儿不良反应，如恶心呕吐、头痛头晕、嗜睡等发生情况。首次治疗前和末次治疗结束后1个月，选用温哥华瘢痕量表（VSS）对患儿瘢痕情况进行评估并计算两者的差值。对数据行LSD检验、Kruskal-Wallis H检验、χ²检验或Fisher确切概率法检验。结果首次麻醉清醒0 h，全身麻醉+利多卡因组、全身麻醉+布洛芬栓组和三联用药组患儿的FLACC评分均明显低于单纯全身麻醉组（P<0.01），全身麻醉+布洛芬栓组和三联用药组患儿的FLACC评分均明显低于全身麻醉+利多卡因组（P<0.01），三联用药组患儿的FLACC评分明显低于全身麻醉+布洛芬栓组（P<0.01）。首次麻醉清醒1、2 h，全身麻醉+布洛芬栓组和三联用药组患儿的FLACC评分均明显低于单纯全身麻醉组和全身麻醉+利多卡因组（P<0.01），三联用药组患儿的FLACC评分明显低于全身麻醉+布洛芬栓组（P<0.01）。麻醉首次清醒4 h，全身麻醉+布洛芬栓组和三联用药组患儿的FLACC评分均明显低于单纯全身麻醉组和全身麻醉+利多卡因组（P<0.01）。首次麻醉清醒后4 h，4组患儿或其家属对镇痛效果的满意率分别为79.49%（31/39）、85.37%（35/41）、87.80%（36/41）、97.92%（47/48），三联用药组患儿的满意率高于单纯全身麻醉组、全身麻醉+利多卡因组、全身麻醉+布洛芬栓组。麻醉清醒后术后2 h内，4组患儿恶心呕吐、头痛头晕、嗜睡等不良反应发生情况总体比较，均无明显差异（P>0.05）。4组患儿首次治疗前、末次治疗结束后1个月瘢痕的VSS评分及两者差值的组间总体比较，均无明显差异（P>0.05）。结论在UFCL治疗小儿增生性瘢痕中进行三联用药镇痛的效果良好，患儿或其家属对镇痛效果的满意度高，且治疗效果及不良反应发生率与其他镇痛方案类似，推荐临床中推广使用。
- 瘢痕 /
- 疼痛 /
- 激光疗法 /
- 围手术期护理 /
- 布洛芬 /
- 复合镇痛
Abstract: Objective To investigate the effects of compound analgesia on ultra-pulsed fractional carbon dioxide laser (UFCL) treatment of post-burn hypertrophic s in children. Methods A prospective randomized controlled study was conducted. From April 2018 to March 2020, 169 pediatric patients with post-burn hypertrophic s admitted to the First Affiliated Hospital of Air Force Medical University were randomly divided into general anesthesia alone group (39 cases, 19 males and 20 females, aged 35 (21, 48) months), general anesthesia+lidocaine group (41 cases, 23 males and 18 females, aged 42 (22, 68) months), general anesthesia+ibuprofen suppository group (41 cases, 25 males and 16 females, aged 38 (26, 52) months), and three-drug combination group with general anesthesia + lidocaine+ibuprofen suppository (48 cases, 25 males and 23 females, aged 42 (25, 60) months), and the pediatric patients in each group were treated with corresponding analgesic regimens when UFCL was used to treat s, and the pediatric patients were given comprehensive care throughout the treatment process. The pain degree of pediatric patients scar was evaluated by facial expression,legs,activity,cry,and consolability (FLACC) of children's pain behavior scale at 0 (immediately), 1, 2, and 4 h after awakening from the first anesthesia, respectively. At 4 h after awakening from the first anesthesia of postoperative pain assessment, the self-made analgesia satisfaction questionnaire was used to evaluate the satisfaction for the analgesic effect of the pediatric patients or their families, and the satisfaction rate was calculated. Within 2 h after the first operation, the occurrences of adverse reactions of the pediatric patients, such as nausea and vomiting, headache, dizziness, drowsiness, etc, were observed and recorded. Before the first treatment and 1 month after the last treatment, the Vancouver scar scale (VSS) was used to evaluate the pediatric patients scar, and the difference value between the two was calculated. Data were statistically analyzed with least significant difference test, Kruskal-Wallis H test, chi-square test and Fisher's exact probability test. Results At 0 h after awakening from the first anesthesia, the FLACC scores of pediatric patients in general anesthesia+lidocaine group, general anesthesia+ibuprofen suppository group and three-drug combination group were significantly lower than those in general anesthesia alone group (P<0.01). The FLACC scores of the pediatric patients in anesthesia+ibuprofen suppository group and three-drug combination group were significantly lower than that in general anesthesia+lidocaine group (P<0.01), and the FLACC score of the pediatric patients in three-drug combination group was significantly lower than that in general anesthesia+ibuprofen suppository group (P<0.01). At 1 and 2 h after awakening from the first anesthesia, the FLACC scores of pediatric patients in general anesthesia+ibuprofen suppository group and three-drug combination group were both significantly lower than those in general anesthesia alone group and general anesthesia+lidocaine group (P<0.01), and the FLACC score of the pediatric patients in three-drug combination group was significantly lower than that in general anesthesia+ibuprofen suppository group (P<0.01). At 4 h after awakening from the first anesthesia, the FLACC scores of the pediatric patients in general anesthesia+ibuprofen suppository group and three-drug combination group were significantly lower than those in general anesthesia alone group and general anesthesia+lidocaine group (P<0.01). At 4 h after awakening from the first anesthesia, the satisfactions rate with the analgesic effect in the four groups of pediatric patients or their families were 79.49% (31/39), 85.37% (35/41), 87.80% (36/41), and 97.92% (47/48), respectively. The satisfaction rate of the pediatric patients in three-drug combination group was significantly higher than those in general anesthesia alone group, general anesthesia+lidocaine group, general anesthesia+ibuprofen suppository group. Within 2 h after the first operation, there was no significant difference in the overall comparison of adverse reactions such as nausea and vomiting, headache, dizziness, and drowsiness of pediatric patients among the 4 groups (P>0.05). The VSS scores of pediatric patients before the first treatment, 1 month after the last treatment, and and the difference value between the two in the 4 groups were not significantly different (P>0.05). Conclusions Three-drug combination for analgesia has a good effect in the treatment of hypertrophic scars after burn in pediatric patients with UFCL. Pediatric patients or their families are highly satisfied with the effect, and the treatment effect and incidence of adverse reactions are similar to other analgesic regimens, so it is recommended to be promoted in clinical practice.
- Cicatrix /
- Pain /
- Laser therapy /
- Perioperative care /
- Ibuprofen /
- Compound analgesia
杨姣、石珊：数据分析、文章撰写；王玲、李娜：数据整理与数据分析；韩军涛、胡大海：研究指导、论文修改

所有作者均声明不存在利益冲突

近年来，皮肤创面患者日益增多。在各种创面的治疗手段中，外源性生长因子的局部应用不可或缺，并已在许多国家得到推广。然而，它们是否具有可靠的效果仍有争议，而且从社会经济角度考虑，它们在皮肤创面治疗中的应用还需要进一步规范和优化。为此，中华医学会烧伤外科学分会在《Burns & Trauma》发文《Clinical guideline on topical growth factors for skin wounds》，该指南对临床常见的5种外用生长因子的疗效、应用细节、不良反应和注意事项进行了分级推荐和评价，以促进外用生长因子在皮肤创面中的合理应用，让更多患者受益。

张凡，编译自《Burns Trauma》，2020，8:tkaa035；肖健，审校

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1 门诊就诊拟行超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕患儿入院流程图

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表1 行超脉冲点阵二氧化碳激光治疗烧烫伤瘢痕的4组患儿一般资料比较

组别	例数	性别（例）		年龄［个月，M（Q₁，Q₃）］	体重［kg，M（Q₁，Q₃）］	瘢痕面积［%TBSA，M（Q₁，Q₃）］	瘢痕形成时间［d，M（Q₁，Q₃）］	手术时长［min，M（Q₁，Q₃）］	居住环境［例（%）］
组别	例数	男	女	年龄［个月，M（Q₁，Q₃）］	体重［kg，M（Q₁，Q₃）］	瘢痕面积［%TBSA，M（Q₁，Q₃）］	瘢痕形成时间［d，M（Q₁，Q₃）］	手术时长［min，M（Q₁，Q₃）］	城市	农村
单纯全身麻醉组	39	19	20	35（21，48）	16.0（10.0，22.0）	15.0（12.0，18.0）	47（25，67）	25（22，29）	16（41.0）	23（59.0）
全身麻醉+利多卡因组	41	23	18	42（22，68）	16.0（11.5，20.0）	15.0（12.0，18.0）	52（30，71）	25（22，27）	22（53.7）	19（46.3）
全身麻醉+布洛芬栓组	41	25	16	38（26，52）	14.0（11.0，19.5）	15.0（12.0，18.0）	61（47，80）	25（23，28）	24（58.5）	17（41.5）
三联用药组	48	25	23	42（25，60）	16.0（12.0，22.0）	16.0（12.0，17.8）	53（32，70）	24（22，28）	22（45.8）	26（54.2）
统计量值		χ²=1.37		H=4.27	H=2.42	H=1.13	H=7.57	H=0.98	χ²=3.77
P值		0.712		0.234	0.489	0.771	0.056	0.807	0.287
注：TBSA为体表总面积；三联用药指全身麻醉+利多卡因+布洛芬栓

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表2 行超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕的4组患儿麻醉清醒后不同时间点的儿童疼痛行为量表评分比较［分，M（Q₁，Q₃）］

组别	例数	0 h（即刻）	1 h	2 h	4 h
单纯全身麻醉组	39	9（8，9）	8（7，8）	6（5，6）	3（2，4）
全身麻醉+利多卡因组	41	6（5，7）^a	7（6，8）	5（4，6）	3（2，3）
全身麻醉+布洛芬栓组	41	5（5，6）^a	3（2，3）^ab	1（1，2）^ab	0（0，1）^ab
三联用药组	48	2（2，3）^abc	2（1，2）^abc	0（0，0）^abc	0（0，0）^ab
F值		138.02	134.02	136.57	128.78
P值		<0.001	<0.001	<0.001	<0.001
注：三联用药指全身麻醉+利多卡因+布洛芬栓；与单纯全身麻醉组比较，^aP<0.01;与全身麻醉+利多卡因组比较，^bP<0.01;与全身麻醉+布洛芬栓组比较，^cP<0.01

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表3 行超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕的4组患儿或其家属对镇痛的满意度（例）

组别	例数	非常满意	满意	不满意
单纯全身麻醉组	39	18	13	8
全身麻醉+利多卡因组	41	25	10	6
全身麻醉+布洛芬栓组	41	28	8	5
三联用药组	48	40	7	1
注：三联用药指全身麻醉+利多卡因+布洛芬栓

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表4 行超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕的4组患儿术后2 h内不良反应发生情况（例）

组别	例数	恶心呕吐	头痛头晕	嗜睡	面色潮红	水疱	皮肤局部红肿	尿潴留	呼吸抑制	红斑/紫癜
单纯全身麻醉组	39	0	0	1	1	0	0	0	0	1
全身麻醉+利多卡因组	41	1	0	0	0	0	0	1	0	0
全身麻醉+布洛芬栓组	41	0	0	1	0	0	1	0	0	0
三联用药组	48	0	0	0	1	0	0	0	1	0
注：三联用药指全身麻醉+利多卡因+布洛芬栓

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表5 行超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕的4组患儿治疗前后温哥华瘢痕量表评分及两者差值比较（分，x¯±s）

组别	例数	首次治疗前	末次治疗后1个月	治疗前后评分的差值
单纯全身麻醉组	39	8.0±1.3	4.0±1.5	4.0±1.1
全身麻醉+利多卡因组	41	7.9±1.3	4.0±1.8	3.9±1.3
全身麻醉+布洛芬栓组	41	7.8±1.5	4.1±1.9	3.7±0.9
三联用药组	48	8.0±1.5	4.3±1.8	3.7±1.2
F值		0.15	0.24	0.59
P值		0.932	0.872	0.624
注：三联用药指全身麻醉+利多卡因+布洛芬栓

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参考文献(37)

[1]	李娜, 杨丽, 程静, 等. 脉冲染料激光精细治疗增生性瘢痕的临床研究[J].中国医师杂志,2019,21(4):485-488,494. DOI: 10.3760/cma.j.issn.1008-1372.2019.04.002.
[2]	ConnollyKL, ChaffinsM, OzogD. Vascular patterns in mature hypertrophic burn scars treated with fractional CO2 laser[J]. Lasers Surg Med, 2014,46(8):597-600. DOI: 10.1002/lsm.22271.
[3]	NarsinghaniU, AnandKJ. Developmental neurobiology of pain in neonatal rats[J]. Lab Anim (NY), 2000,29(9):27-39. DOI: 10.1038/5000089.
[4]	孙光祥, 黎志宏. 布洛芬超前镇痛在儿童膝关节镜手术中的应用研究[J].临床小儿外科杂志,2010,9(4):281-283. DOI: 10.3969/j.issn.1671-6353.2010.04.013.
[5]	NoelM, ChambersCT, McGrathPJ, et al. The role of state anxiety in children's memories for pain[J]. J Pediatr Psychol, 2012,37(5):567-579. DOI: 10.1093/jpepsy/jss006.
[6]	张月嵘, 陈劼, 万园园, 等. 小儿围术期镇痛管理现状及效果研究[J].护士进修杂志,2019,34(16):1441-1444. DOI: 10.16821/j.cnki.hsjx.2019.16.001.
[7]	World Health OrganizationWHO normative guidelines on pain management: Report of a Delphi Study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO2007-10-162020-11-15https://m.doc88.com/p-9149413251101.html?r=1 World Health Organization. WHO normative guidelines on pain management: Report of a Delphi Study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO[EB/OL].(2007-10-16)[2020-11-15].https://m.doc88.com/p-9149413251101.html?r=1.
[8]	倪思利, 甘立强, 王华, 等. 复方利多卡因乳膏缓解激光治疗儿童血管瘤术中疼痛的临床分析[J].儿科药学杂志,2011,17(4):27-28.
[9]	张广源, 索生红, 杨森林. 布洛芬用于儿童和青少年骨折镇痛的效果和安全性:系统评价和Meta分析[J].国际麻醉学与复苏杂志,2018,39(7):650-657. DOI: 10.3760/cma.j.issn.1673-4378.2018.07.009.
[10]	李娜, 杨丽, 程静, 等. 脉冲染料激光与超脉冲点阵二氧化碳激光治疗烧伤后增生性瘢痕的临床对比研究[J].中华烧伤杂志,2018,34(9):603-607. DOI: 10.3760/cma.j.issn.1009-2587.2018.09.009.
[11]	刘小加, 罗明灿. 二氧化碳点阵激光治疗痤疮瘢痕的护理体会[J].中国美容医学,2016,25(9):110-112.
[12]	杨丽娜, 陈烨, 李丽丽, 等. 手术室护理与病房护理相衔接的护理模式在重型颅脑损伤患者中的应用[J].中国医药导报,2020,17(16):186-189.
[13]	徐嘉莹, 宋锴澄, 易杰, 等. 国外日间手术麻醉术前评估的新进展[J].中国卫生质量管理,2018,25(4):10-13. DOI: 10.13912/j.cnki.chqm.2018.25.4.04.
[14]	张艳, 王丹丹, 李宏丽, 等. 缩短术前禁食水时间对胃癌患者术后胰岛素抵抗的影响[J].中国临床研究,2019,32(1):130-132. DOI: 10.13429/j.cnki.cjcr.2019.01.033.
[15]	赵雪娇, 许敏, 胡嘉乐, 等. 国外护士参与麻醉前评估门诊研究现状及对我国的启示[J].中国护理管理,2018,18(9):1289-1292. DOI: 10.3969/j.issn.1672-1756.2018.09.030.
[16]	HenryTW, MatzonH, McEnteeR, et al. The clinical impact of ambient operating room temperature and other perioperative factors on patient comfort during wide-awake hand surgery using local anesthesia[J]. Arch Bone Jt Surg, 2021,9(1):110-115. DOI: 10.22038/abjs.2020.44850.2228.
[17]	刘明, 陈利琴, 郑佳丽. 儿童疼痛行为量表在唇腭裂患儿术后疼痛评估中的应用及其信效度[J].解放军护理杂志,2012,29(13):20-22,26. DOI: 10.3969/j.issn.1008-9993.2012.13.006.
[18]	毋婷. 强脉冲光及激光治疗面部痤疮瘢痕后生活质量及护理满意度分析[J].内蒙古医学杂志,2017,49(11):1392-1394. DOI: 10.16096/J.cnki.nmgyxzz.2017.49.11.054.
[19]	梁新蕊, 张玲娟, 冯苹, 等. 无菌生物护创膜在小儿浅Ⅱ度烧伤换药疼痛管理中的应用效果[J].解放军护理杂志,2013,30(14):70-71. DOI: 10.3969/j.issn.1008-9993.2013.14.027.
[20]	吴巍巍,刘淑梅,贺婷婷,等.虚拟现实技术在烧伤疼痛干预中的研究进展[J].中华烧伤杂志,2020,36(7):620-622.DOI 10.3760/cma.j.issn.1009-2587.2020.07.103.
[21]	王凤乔, 庄蕾, 张富军. 儿童疼痛记忆的研究进展[J].上海交通大学学报(医学版),2021,41(4):546-549. DOI: 10.3969/j.issn.1674-8115.2021.04.022.
[22]	NoelM, RosenbloomB, PavlovaM, et al. Remembering the pain of surgery 1 year later:a longitudinal examination of anxiety in children's pain memory development[J]. Pain,2019,160(8):1729-1739. DOI: 10.1097/j.pain.0000000000001582.
[23]	NoelM, RabbittsJA, TaiGG, et al. Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall[J]. Pain, 2015,156(5):800-808. DOI: 10.1097/j.pain.0000000000000102.
[24]	罗婷. 小儿疼痛的评估及护理干预[J].中国保健营养,2015(7):4-5.
[25]	KliftoKM, AsifM, HultmanCS. Laser management of hypertrophic burn scars: a comprehensive review[J/OL]. Burns Trauma, 2020,8:tkz002[2022-04-01]. https://pubmed.ncbi.nlm.nih.gov/32346540/.DOI: 10.1093/burnst/tkz002.
[26]	章一新, 张书诺. A型肉毒毒素在瘢痕治疗中的临床应用及机制探讨[J].中华烧伤杂志,2021,37(8):705-710. DOI: 10.3760/cma.j.cn501120-20210701-00232.
[27]	王多友, 程守权. 小儿疼痛治疗:疼痛性记忆与记忆性疼痛[J].医学与哲学,2015(5):21-23,31.
[28]	何美媛, 吕小平. 地佐辛在全麻恢复初期镇痛中的临床应用与疗效观察[J].中国伤残医学,2013(11):128-129. DOI: 10.3969/j.issn.1673-6567.2013.11.103.
[29]	田皇华, 王双华, 赵超, 等. 右美托咪定复合七氟烷喉罩全麻在小儿斜疝修补术中的应用[J/CD].中华疝和腹壁外科杂志:电子版,2020,14(5):539-543. DOI: 10.3877/cma.j.issn.1674-392X.2020.05.019.
[30]	李平, 王健, 罗林丽, 等. 七氟烷吸入诱导麻醉的研究进展[J].华西医学,2017,32(7):1112-1115. DOI: 10.7507/1002-0179.201508176.
[31]	杨红伟, 杨倩倩, 刘德成. 复方利多卡因乳膏致角膜损伤的修复探讨[J].中国美容医学,2017,26(11):15-16.
[32]	谭启明. 复方利多卡因乳膏应用于无痛护理的研究进展[J].中华现代护理杂志,2013,19(26):3302-3304. DOI: 10.3760/cma.j.issn.1674-2907.2013.26.055.
[33]	李强, 胡华琨, 叶玲玲, 等. 布洛芬注射液用于腹腔镜下腹股沟斜疝修补术患儿术后镇痛的效果[J].临床麻醉学杂志,2021,37(4):360-363. DOI: 10.12089/jca.2021.04.006.
[34]	焦凤娟. 布洛芬栓塞肛与布洛芬混悬液口服治疗小儿发热的效果比较[J].中外医学研究,2013(32):158-158,159. DOI: 10.3969/j.issn.1674-6805.2013.32.111.
[35]	SheckterCC, StewartBT, BarnesC, et al. Techniques and strategies for regional anesthesia in acute burn care-a narrative review[J/OL]. Burns Trauma, 2021,9:tkab015[2022-04-02]. https://pubmed.ncbi.nlm.nih.gov/34285927/. DOI: 10.1093/burnst/tkab015.
[36]	赵恒娣, 郝雪莲, 王莉, 等. 烧伤患儿术后盐酸右美托咪定复合镇痛对感染的影响[J].中华医院感染学杂志,2016,26(5):1149-1151. DOI: 10.11816/cn.ni.2016-152165.
[37]	李灵匀, 李铁男. 银屑病药物治疗新进展[J].辽宁药物与临床,2003,6(1):7-8. DOI: 10.3969/j.issn.1673-0070.2003.01.004.