IKPUTA SUGAR DIABETES

Ọrịa shuga mellitus (Latin diabetes mellitus) bụ otu ọrịa nke ọrịa endocrine na-etolite n'ihi oke ma ọ bụ onye ikwu (mmekọrịta na-emetụta mkpụrụ ndụ ebumnuche) ụkọ homonụ, n'ihi nke hyperglycemia na - ebulite - mmụba na - abawanye na glucose ọbara. Ihe oria a bu ihe ndi mmadu na aru ike ma ndi nke metabolism: carbohydrate, fat, protein, mineral na salt-salt.

E nwere ọtụtụ nhazi ọkwa nke shuga n'ọtụtụ ụzọ. N'uzo, a haputara ha n’usoro iji choputa ya ma nyekwa nkọwa zuru oke banyere onodu onye ọrịa oria mamria.

Nkewa nke oria shuga site na etiology

I. 1dị nke shuga atọ mellitus ma ọ bụ “ọrịa shuga”, Otú ọ dị, ndị nọ n'afọ ndụ ọ bụla nwere ike ịrịa ọrịa (mbibi nke b-mkpụrụ ndụ, na-eduga na mmepe nke ụkọ insulin ogologo ndụ)

II. 2dị ọrịa shuga mellitus 2 (nke nwere insulin na ntụpọ insulin)

· ỌR. - ntụpọ mkpụrụ ndụ ihe nketa na ọrụ nke b-sel.

III. Formsdị ọrịa shuga ndị ọzọ:

• 1. ntụpọ nke mkpụrụ ndụ ihe nketa (abnormalities) nke insulin na / ma ọ bụ ndị na-anabata ya,
• 2. ọrịa nke exocrine pancreas,
• 3. Ọrịa endocrine (endocrinopathies): syndrome Hisenko-Cushing, acromegaly, ihe otiti na-egbu egbu, pheochromocytoma na ndị ọzọ,
• 4. ọrịa shuga na-akpata
• 5. ọrịa shuga butere ọrịa
• 6. ụdị ọrịa shuga na-enweghị atụ,
• 7. mkpụrụ ndụ ihe nketa tinyere ọrịa shuga.

Nkem. Ọnọdụ afọ ime bụ mellitus bụ ọrịa nke ọrịa shuga na-apụta n'oge afọ ime ụmụ nwanyị ụfọdụ, ọ na-apụkarị n'anya oge ịmụ nwa. Udiri oria a n’adiri iche iche ka amara n’etiti ndi mmadu ndi nwere oria shuga.

Dika ntuziaka ndi WHO siri kwuo, a na-amata udi oria shuga n’ime ndi nwanyi di ime:

• 1. Type 1 diabetes mellitus achọpụtara tupu ịtụrụ ime.
• Typedị ọrịa shuga abụọ nke mellitus hụrụ tupu afọ ime.
• 3. Mellitus na-arịa afọ ime - okwu a na --eme ka nsogbu ọ bụla nke glucose na-adị n'oge ime.

Dika ogo nke oria oria shuga nwere ogo okpomoku ato:

Udiri oria (ogo nke mbu) ka oria a di ala site na ihe eji eme glycemia, nke n’enweghi ihe kariri 8 mmol / l n’onu efu, mgbe enweghi otutu okpomoku di n’ime obara n’ime ubochi nile, glucosuria abaghi ​​uru kwa ubochi (site na onodu rue 20 g / l). A na-akwụ ụgwọ ụgwọ site na usoro ọgwụgwọ nri. Site n'ụdị ọrịa shuga dị nfe, enwere ike ịchọpụta angioeuropathy nke usoro izizi na nke ọrụ na onye ọrịa nwere ọrịa mellitus.

Site na ogo ogo abụọ (ogo nke abụọ) nke ọrịa shuga mellitus, ibu ọnụ glycemia na-ebili, dịka iwu, ruo 14 mmol / l, mgbatị glycemic kwa ụbọchị, glucosuria kwa ụbọchị anaghị agafe 40 g / l, ketosis ma ọ bụ ketoacidosis mgbe ụfọdụ na-amalite. A na-akwụghachi ụgwọ maka ọrịa shuga site na nri nri na ọnụnọ hypoglycemic na-elekọta mmadụ ma ọ bụ insulin. N'ime ndị ọrịa a, enwere ike ịchọpụta angioneuropathies na-arịa ọrịa shuga nke mpaghara dị iche iche na ọkwa ọrụ.

Udiri oria ojoo di uku (III ogo) ka akpukpo ahu di nkpa (n’otutu nzuzu kari ihe kariri 14 mmol / l), mgbanwe di nkpa na obara obara n’obere ubochi, elu glucosuria (karie 40-50 g / l). Ha na-ekpughere ọgwụ dị iche iche ọrịa angioneuropathies.

Dabere na nkwụghachi ụgwọ nke carbohydrate metabolism ọrịa shuga nwere usoro atọ:

• 1. Usoro ịkwụ ụgwọ
• 2. Oge mmeju
• 3. Oge usoro decompensation

Dị ọrịa shuga kwụrụ ụgwọ bụ ezigbo ọnọdụ onye ọrịa nwere ọgwụgwọ ga-enweta shuga dị n'ọbara yana ọnụnọ ya na mmamịrị zuru oke. Site n'ụdị shuga na-agbakọta, ọ gaghị ekwe omume iru nsonaazụ dị elu dị otú a, mana ọkwa glucose ọbara adịghị iche na usoro, ya bụ, ọ bụ ihe karịrị 13.9 mmol / l, ọnwụ shuga kwa ụbọchị na mmamịrị erughị 50 g. N'otu oge ahụ, acetone na mmamịrị. na-efu kpamkpam. Ọnọdụ kachasị njọ bụ ụdị ọrịa shuga na-agbawa agbaze, n'ihi na n'ọnọdụ nke a, ọ gaghị ekwe omume ịkwalite metabolism na obere shuga ọbara. N'agbanyeghị ọgwụgwọ ahụ, ọkwa shuga dị elu karịa 13.9 mmol / l, ọnwụ nke glucose na mmamịrị kwa ụbọchị karịrị 50 g, acetone na-apụta na mmamịrị. Hyperglycemic coma kwere omume.

Na onyonyo onyonyo banyere oria oria oria, o bu omenaala n’iche iche n’etiti otu ihe mgbaàmà: isi ya na nke ozo.

Nhazi ọkwa nke ọrịa shuga mellitus (WHO, 1985)

A. Klas

I. Ọrịa shuga

1. Mellitus na-arịa ọrịa shuga na-arịa insulin.

2. Mellitus na-abụghị insulin na-arịa ọrịa shuga (DIA)

a) n'ime ndị nwere oke ahụ ha

b) n'ime ndi mmadu buru ibu

3. Ọrịa shuga metụtara erighị ihe na-edozi ahụ

4. ofdị ọrịa shuga ndị ọzọ jikọtara ya na ụfọdụ ọnọdụ na syndromes:

a) Ọria akwara

b) Ọrịa endocrine,

c) ọnọdụ nke ị medicationsụ ọgwụ ma ọ bụ ikpughe kemịkal,

dNorm insulin ma ọ bụ nnabata ya

e) ụfọdụ mkpụrụ ndụ ihe nketa,

e) steeti gwakọtara.

II. Nnukwu nnabata glucose

a) n'ime ndị nwere oke ahụ ha

b) n'ime ndi mmadu buru ibu

c) jikọtara ya na ụfọdụ ọnọdụ na syndromes (lee paragraf nke 4)

B. Klaasị n'ihe ize ndụ ihe ọmụmụ (ndị nwere nsogbu glucose nkịtị mana ha nwere nnukwu nsogbu ibute ọrịa shuga)

a) Nnukwu nnabata glucose n'oge gara aga

b) Nnabata nnabata glucose.

Ọ bụrụ n ’nhazi ọkwa nke kọmịshọnụ nke WHO kọwapụtara gbasara ọrịa mellitus (1980), e jiri okwu ndị a“ DIA-type i diabetes ”na“ DIA - type II diabetes ”mee ihe, a ga-ewepụ okwu ndị bu“ ụdị oria shuga ”na“ ọrịa shuga II ”n’elu nkewa. Site na ha na-atụ aro ọnụnọ nke usoro nje a na-enwetabeghị nke kpatara ọrịa a (usoro autoimmune maka ụdị shuga na ọria insulin ma ọ bụ ihe omume ya maka ụdị shuga II). Ebe ọ bụ na ọ bụghị ụlọọgwụ niile nwere ike ikpebi immunological phenomena na ihe nrịba ama nke ụdị ọrịa shuga ndị a, yabụ, dị ka ndị ọkachamara WHO si kwuo, n'ọnọdụ ndị a, ọ ka mma iji okwu IZD na IZND. Agbanyeghị, n'ihi eziokwu ahụ bụ na a na-eji okwu ahụ bụ “ụdị m ọrịa shuga mellitus” na “ụdị nke mellitus nke abụọ” ugbu a na mba niile nke ụwa, a na-atụ aro ịtụle ha dị ka mmezu zuru oke nke okwu ndị a bụ IZD na IZND iji zere ọgba aghara, nke anyị kwenyere kpamkpam. .

Dịka ụdị nnwere onwe dị mkpa (nke izizi), ọrịa shuga na-arịa ọrịa na-edozi ahụ. Ọrịa a na-ahụkarị na mba ndị na-emepe emepe ebe okpomọkụ na ndị na-erubeghị afọ 30, ogo nke ụmụ nwoke na ụmụ nwanyị nwere ụdị ọrịa a bụ 2: 1 - 3: 1. Na mkpokọta, enwere ụdị ọrịa shuga dị nde iri abụọ.

Kacha nkịtị bụ ụzọ abụọ dị iche iche nke ọrịa shuga a. Nke mbu bu ihe akporo oria oria akwara nke buru oria fibrocalculeous. A na - achọta ya na India, Indonesia, Bangladesh, Brazil, Nigeria, Uganda. Ihe e ji mara ihe bu oria a bu oria nke nkume n’ime ogwe akwara nke oma ma o buru na akwara nke oma. Na eserese ụlọ ọgwụ, a na-ahụkarị mwakpo na-egbu mgbu nke afọ, oke ibu dị oke elu na akara ndị ọzọ nke nsogbu erighị nri. Ọkpụkpụ, na-adịkarị elu, hyperglycemia na glucosuria nwere ike iwepụ naanị site na enyemaka nke ọgwụgwọ insulin. Enweghị ketoacidosis bụ ihe e ji mara ya, nke kọwara ya site na mbelata nke imepụta insulin na izochi ya na glucagon site na ngwa belet nke pancreas. Nsonaazụ nke x-ray, retrograde cholangiopancreatography, ultrasound ma ọ bụ ntụgharị tomograf, na-enyocha ọnụnọ nke okwute n'ime akwara. Ekwenyere na ihe kpatara ọrịa fibrocalculeous pancreatic diabetes bụ oriri nke mgbọrọgwụ cassava (tapioca, kassava) nwere cyanogenic glycosides, gụnyere linamarine, nke ewepụtara hydrocyanic acid n'oge hydrolysis. Emeghariri ya na ntinye amino acids nwere sulphur, na enweghi ihe oriri protein, nke a na-ahụkarị n’obodo ndị a, na-eduga n'ịba cyanide n’ahụ, nke bụ ihe kpatara fibrocallera.

Thezọ nke abụọ bụ ọrịa shuga na-akpata ọrịa mamịrị, mana enweghị protein na akwara. Ejiri ya na nguzogide na mmepe nke ketoacidosis na nguzogide insulin na-adi nma. Dịka iwu, ike gwụ ndị ọrịa. A na - ebelata insulin insulin, mana ọ bụghị ruo n'ókè ahụ (dịka nzuzo nke C-peptide) dị ka ndị ọrịa nwere ọrịa shuga, nke na - akọwa enweghị ketoacidosis.

Enweghị ụdị nke atọ nke ọrịa shuga a na nhazi nke WHO - a na-akpọ ụdị ọrịa shuga J (nke a hụrụ na Jamaica), nke na-ekerịta ọtụtụ njirimara nke ọrịa shuga na-akpata na ụkọ protein.

Mwepu nke nhazi ọkwa ndị WHO nakweere na 1980 na 1985 bụ na ha anaghị egosipụta atụgharị ahụike na njirimara mgbanwe nke ọrịa mellitus. Dabere na ọdịnala nke ọrịa diabetology, nhazi ọkwa nke ọrịa shuga mellitus nwere ike ịbụ, n'echiche anyị, gosipụtara dị ka ndị a.

I. lindị ọrịa shuga

1. Ọrịa shuga na-akpata insulin (ụdị nke ịrịa ọrịa shuga)

nje butere ya ma ọ bụ kpochapụwo (ụdị IA)

autoimmune (ụdị IB)

2. Ọrịa shuga na-abụghị insulin (ụdị shuga II)

ndị mmadụ n'otu n'otu na-ahụkarị ahụ

na obese

n'ime ndị na-eto eto - MODdị ụdị

3. Ọrịa shuga metụtara erighị ihe na-edozi ahụ

fibrocalcule pancreatic diabetes

protein protein pancreatic na-arịa protein

4. formsdị ọrịa shuga ndị ọzọ (nke abụọ, ma ọ bụ akara Symbol, ọrịa shuga):

a) mkpụrụ ndụ ihe endocrine (Hisenko-Cushing's syndrome, acromegaly, inye mmadụ golf, pheochromocytoma, wdg)

b) Ọrịa nke akwara (tumo, mbufụt, lee, hemochromatosis, wdg)

c) oria ndi mmadu n’enweghi ike iburu (ị various nara ogwu di iche-iche, syndromes nke onuogugu, onodu insulin na-adighi nma, ihe ndi mmadu n’anabata insulin.

5. Ọrịa shuga dị ime

A. ogo nke ọrịa shuga

B. Compkwụ ụgwọ ụgwọ

B. Ihe isi ike ọgwụgwọ

1. Usoro ọgwụgwọ insulin - mmeghachi omume nfụkasị mpaghara, ụjọ anaphylactic, lipoatrophy

2. Ogwu hypoglycemic ọgwụ - mmeghachi omume nfụkasị, ọgbụgbọ, nsị nke eriri afọ, wdg.

G. Nnukwu nsogbu nke ọrịa shuga (ọtụtụ oge n'ihi ọgwụgwọ ezughi oke)

a) ketoacidotic coma

b) hyperosmolar coma

c) lactic acidosis coma

g) hypoglycemic coma

D. Mbido ọrịa shuga

1. Microangiopathy (retinopathy, nephropathy)

2. Macroangiopathy (infarction myocardial, ọrịa strok, gangrene ụkwụ)

G. Ahụhụ nke akụkụ ndị ọzọ na sistemu - enteropathy, hepatopathy, cataracts, osteoarthropathy, dermopathy, wdg.

II. Nkwekọrịta shuga na - arịa ọrịa shuga - latent ma ọ bụ ọrịa shuga latent

a) n'ime ndị nwere oke ahụ ha

b) n'ime ndi mmadu buru ibu

c) jikọtara ya na ụfọdụ ọnọdụ na syndromes (lee paragraf nke 4)

III. Klaasị ma ọ bụ ìgwè dị iche iche n'ihe ize ndụ, ma ọ bụ ọrịa shuga (ndị nwere nsogbu glucose nkịtị, mana ha nwere nnukwu nsogbu ibute ọrịa shuga mellitus):

a) Ndi mmadu ndi nwere ikike ịnabata ọrịa glucose na mbụ

b) ndi nwere ikike nnabata glucose.

A na - ahuta uzo ato n’otu n’onodu ihe omimi banyere oria mellitus: 1) ikike ibu nnabata glucose n’azu, ma obu oria bu, i.e. ndi mmadu nwere onodu ihe egwu di egwu, 2) nnabata glucose, ma obu oria mamellitus latent ma obu oria, 3) ma obu gosiputara oria mellitus, EDI na ADI, nke nwere ike idi nwayọ, ogha aka ma dikwa oke.

Mellitus di nkpa di nkpa nke syndromes buru ibu, site na otutu ihe ana egosiputa n’olu oma banyere oria oria oria. E gosipụtara ọdịiche Pathogenetic dị n'etiti IDD na IDD n'okpuru.

Isi ọdịiche dị n'etiti EDI na ADI

Ihe nrịba ama nke ụdị M ụdị nke II ụdị nke akaebe

Afọ iji bido nwata, ọ na abụkarị iri afọ anọ

Ọrịa ruru afọ iri atọ

Nnukwu Mmalite

Ibe Atụrụ ahụ belatara n'ọtụtụ oge

Inwe nwoke: o yikarịrị ka ụmụ nwoke na-arịa ọrịa.

Ọnọdụ nro siri ike

Ọrịa shuga N’ọnọdụ ụfọdụ, labile Stable

Ketoacidosis Tendency na ketoacidosis anaghị etolite

A na-enwekarị ọkwa Ketone na-adịkarịkarị.

Ọkpụkpụ glucose na glucose na-enwekarị

Oge nke mbido oge mgbụsị akwụkwọ-ukọchị adịghị

Insulinopenia na insulin na C-peptide na Nkịtị ma ọ bụ hyper

plasma na-agbadata na C-peptide insulinemia (insulin)

na-abụ abụ obere oge, ọ na-abụkarị

Ọnọdụ Mbelata Ọnọdụ Agwaetiti

mkpụrụ ndụ ndị na-eme ka ihe pọdụrụ ọrụ, mkpochapụ ha, na pasent

mbelata ma ọ bụ enweghi nke b-, a, d- na PP-sel n’ime

ha nwere insulin, agwaetiti n’etiti afọ

mejupụtara sel- a, d- na nke PP

Lymphocytes na ndị ọzọ Nweta na nke mbụ Ọ na-anọghị ya

mkpụrụ ndụ mbufụt n’ime izu

Ọ na-abịakarị nso maka ọgwụ nje.

pancreas n'ọnọdụ niile na nke mbụ

Ntinye ihe n ’mkpụrụ ndụ ihe jikọtara ya na HLA-B8, B15, mkpụrụ ndụ HLA adịghị

DR3, DR4, Dw4 dị iche na ahụike

Mmechi na-erughi 50%

Ọrịa shuga na-erughị 10% karịa 20%

M digi na kinship

Ọgwụ nri, nri insulin (mbelata),

Nsogbu mbubreyo Predominantly

Ọgwụ shuga insulin na-arịa (EDI, ụdị nke m diabetes ọrịa shuga mellitus) bụ nnukwu ọrịa mmalite, insulinopenia, na-enwekarị mmepe nke ketoacidosis. Otutu mgbe, oria oria nke oria di n’etiti umuaka na ndi na etolite etolite, bu ndi akpotara ya na mbu “ndi oria oria oria”, ma ndi n’agba obula nwere ikeria oria. Ndụ nke ndị ọrịa na-arịa ụdị ọrịa shuga a na-adabere na nchịkwa insulin, nke enweghị ketoacidotic coma na-eto ngwa ngwa. Ajikọtara oria ya na ụfọdụ ụdị HLA, ọgwụ nje na Langerhans islet antigen na-ahụkarị n'ọbara. Ọtụtụ mgbe, nke macro- na microangiopathy (retinopathy, nephropathy), neuropathy.

Ọrịa insulin na-adabere na mkpụrụ ndụ ihe nketa. Ihe ndị dị na mpụga na-akpata ọrịa ga-eketa eketa bụ ọrịa na-efe efe dị iche iche na ọrịa autoimmune, nke a ga-akọwa n'ụzọ zuru ezu n'okpuru.

Ọrịa shuga na-abụghị insulin (NIDA, ụdị mellitus type II nke ọrịa shuga) na - apụta na obere nsogbu ọrịa metabolic na njirimara ọrịa shuga. Dịka iwu, ndị ọrịa na-eme na-enweghị insulin ọgwụ nje, yana usoro ọgwụgwọ ma ọ bụ ọgwụ ọnụ na -ebelata ọkwa shuga chọrọ ka ha kwụọ ụgwọ metabolism. Agbanyeghị, n'ọnọdụ ụfọdụ, enwere ike ịnweta ụgwọ zuru oke maka metabolism metabolism naanị na njikọ ọzọ nke insulin na-agbapụta na usoro ọgwụgwọ. Na mgbakwunye, ekwesịrị iburu n'uche na n'okpuru ọnọdụ dị iche iche na-akpata nchekasị (ọrịa, trauma, ịwa ahụ), ndị ọrịa a ga-anata ọgwụgwọ insulin.N'ime ụdị shuga a, a na-ahụ insulinopenia ọdịnaya nke insunoreactive insulin n'ọbara ọbara nkịtị, dị elu ma ọ bụ (dịtụ ụkọ). N'ọtụtụ ndị ọrịa, hyperglycemia na-ebu ọnụ nwere ike ịnwe ya, na ọtụtụ afọ, ha nwere ike ghara ịma banyere shuga ha.

Na ụdị II mellitus ọrịa shuga, macro- na microangiopathies, cataracts na neuropathies ka achọpụtara. Ọrịa ahụ na-etolite karịa mgbe afọ iri anọ gasịrị (ọnụnọ kacha elu pụtara na afọ 60), mana ọ pụkwara ime n'oge ị dị obere. Nke a bụ ụdị a na-akpọ ụdị MODY (ụdị ọrịa okenye nọ na-arịa ọrịa shuga), nke ụdị ihe nketa akụrụngwa na-egosipụta. N'ime ndị ọrịa nwere ọrịa shuga nke II, a na-akwụ ụgwọ metabolism ike site na nri nri na ọgwụ ọnụ na-ebelata ọkwa shuga. IDD, dị ka IDD, nwere usoro mkpụrụ ndụ, nke a na-akpọ karịa (ugboro ole ụdị ọrịa shuga dị na ya) karịa nke nwere IDD, na ụdị akara aka na-achịkwa onwe ya. Ihe dị na mpụga na-enyere aka ịghọta amụma banyere ihe nketa dị ụdị a bụ ị oveụbiga mmanya ókè, na-eduga na mmepe nke oke ibu, nke a hụrụ na 80-90% nke ndị ọrịa na-arịa ADHD. Hyperglycemia na nnabata glucose na ndị ọrịa a na-akawanye mma site na mbelata nke ahụ. Ihe mgbochi maka mgbochi nke agwaetiti nke Langerhans n'ụdị ọrịa shuga a adịghị.

Typesdị ọrịa shuga ndị ọzọ. Otu a gụnyere ọrịa shuga, nke na-apụta na usoro ọgwụgwọ ọzọ, nke enweghị ike ijikọ ya na ọrịa shuga.

1. Ọrịa nke pancreas

a) n'ime ụmụ amụrụ ọhụrụ - amụpụtara agwaetiti na pancreas, ọrịa shuga na-efe efe nke nwa amụrụ ọhụrụ, ntozu oke ọrụ nke usoro insulin insulin,

b) mmerụ ahụ, ọnya na ọnya nsị nke pancreas na - eme mgbe oge nke ọbara bu, ọrịa kansa, cystic fibrosis nke pancreas, hemochromatosis.

2. Ọrịa ụdị okike homonụ: pheochromocytoma, somastatinoma, aldosteroma, glucagonoma, ọrịa Hisenko-Cushing, acromegaly, goiter na-egbu egbu, mụbara progestins na estrogens.

3. Ọnọdụ kpatara eji ọgwụ na kemịkalụ eme ihe

a) bekee na-arụ ọrụ nke homonụ: ACTH, glucocorticoids, glucagon, homonụ thyroid, homonụ na-eto, mgbochi afọ, calcitonin, medroxyprogesterone,

b) diuretics na ihe ndị na - egbochi ọgwụ mgbochi: furosemide, thiazides, gigroton, clonidine, clopamide (brinaldix), ethaclates acid (uregite),

c) ihe ndị na-eme ihe ike: haloperidol, chlorprotixen, chlorpromazine, tricyclic antidepressants - amitriptyline (tryptisol), imizin (melipramine, imipramine, tofranil),

d) adrenaline, diphenin, isadrine (novodrin, isoproterenol), propranolol (anaprilin, obzidan, inderal),

e) analgesics, antipyretics, ihe mgbochi mkpali: indomethacin (methindole), acetylsalicylic acid na oke onunu ogwu,

e) ọgwụ chemotherapeutic: L-asparaginase, cyclophosphamide (cytoxin), megestrol acetate, wdg.

4. Mmebi nke ndị na - anabata insulin

a) ntụpọ nke ndị na - anabata insulin - ọrịa lipodystrophy nke ịmụ nwa, yana njikọta anụ ahụ na papillary dystrophy nke anụ ahụ (acantosis nigricans),

b) ọgwụ mgbochi nye ndị na - anabata insulin, yana ọrịa ndị ọzọ na - alụso ọrịa ọgụ.

5. Mkpụrụ ndụ mkpụrụ ndụ ihe nketa: ụdị m glycogenosis, nnukwu ihe na-efe efe porphyria, Down syndrome, Shereshevsky-Turner, Klinefelter, wdg.