Without a safety plan, you may be in danger of harming yourself or someone else. This selective review of pharmacogenomics and pharmacogenomic … Previous Figure Next Figure. Title: Considerations in the Pharmacotherapy of Bipolar Disorder During and After Pregnancy VOLUME: 6 ISSUE: 5 Author(s):Verinder Sharma Affiliation:850 Highbury Avenue Regional Mental Health Care-London, London, ON N6A4H1, Canada. This is called a mixed bipolar state. Psychotropic drugs and adverse events in the treatment of bipolar disorders revisited. McCauley-Elsom K, Gurvich C, Elsom SJ, Kulkarni J. Antipsychotics in pregnancy. The episodic nature of this disease warrants rational use of medications and proper monitoring for adverse events. Lithium versus other mood-stabilizing medications in a longitudinal study of bipolar … I feel that I have developed many coping skills over the years, things to help me survive. Summary of large, placebo-controlled clinical trials with lamotrigine[1,5,11,12,28-31] Study no./ No.  |  People with BPD are among the most at risk of attempting suicide or engaging in other high-risk activities. Soon, the bipolar will become too demanding and volatile. in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection Alfredo B. Cuéllar‑Barboza1,2,Susan L. McElroy 3,Marin Veldic 1,Balwinder Singh 1,Simon Kung 2, [Drawing up guidelines for the attendance of physical health of patients with severe mental illness]. Bipolar disorder sometimes is called manic-depressive disorder or manic depression, which are older terms. Early interventions, even those in the prodromal phase, pose ethical questions for both clinicians and researchers. I will be keeping this one in mind so as to use it! (2019). Too many people with bipolar get "stuck" sometimes and don't really think things through. Bipolar disorder usually appears in adolescence or early adulthood, but can emerge in childhood or onset later in adulthood. Summary of large, placebo-controlled clinical trials with lamotrigine[1,5,11,12,28-31] Study no./ No. Thus, a … I like the cat in the background of the video...cute! However, each medication may cause adverse events (AEs). It seems to me a bit inappropriate to mention the words safety, lockdown, and dangers in an article about people with bipolar disease. People with depression also tend to have lower levels of omega-3 fatty acids in their blood. Bipolar disorder is a long-term chemical imbalance that causes rapid changes in mood and behavior. Regular and continued use of medication can … Medication-related side effects and monitoring strategies highlight the importance of safety and tolerability considerations, which, along with efficacy information, should be given equal merit. Effect of Bipolar Disorder on Family is Far Reaching. Students with bipolar disorder may or may not have a need for specialized instruction provided within an IEP. If weapons or pills are around the house, the depressed patient may be tempted to hurt himself in a suicide attempt. - Natasha Tracy. 2014 Dec;169 Suppl 1:S34-44. You can find Natasha Tracy on Facebook or Google+ or @Natasha_Tracy on Twitter or at Bipolar Burble, her blog. Being on "lockdown" has helped me avoid making mistakes and I'm sure that it has kept me from being hospitalized for mania - which I have been several times in the past. Do not use drugs or alcohol. As it is now, when there is a major news story about a shooting, plane crash, or act of violence, I count the seconds it takes before the news media mentions "bipolar is suspected." If you are at home, you cannot go on a spending spree! This paper reviews the tolerability and safety of lamotrigine, an anticonvulsant recommended in the 2002 American Psychiatric Association guidelines as a first-line treatment for acute depression in bipolar disorder and one of several options for maintenance therapy. Encephale. Population surveys show that persons with BD often self-medicate with complementary and alternative medicine (CAM) or integrative therapies in spite of … So, what are your bipolar safety tips? Regular and continued use of medication can … The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: knowledge to date and directions for future research. I'd also suggest limiting credit cards and keeping the allowed balances low. I'm proof of this....as a B2 patient I was so hypomanic one day I purchased a car on my Mastercard!! What would be on your bipolar lockdown list of things to do? Bipolar symptoms can get out of control and sometimes we need to consider safety tips for bipolar. If not taking drugs or alcohol, they are no more a dangerous than anybody else in society. While experiencing depression, people may think about death a lot, feel suicidal, or feel like harming others. In short, though, it’s about protection. These safety tips can apply during a bipolar mania, hypomania or depression. It is prudent to have precise knowledge of the individual drug's side-effect profile, pharmacokinetics, and pharmacodynamics, to plan a treatment regimen. It is associated with high disability, higher comorbidity due to medical illnesses, and significant social and economical consequences for patients, their families, and society. This site needs JavaScript to work properly. There is no known method to prevent bipolar disorder. Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. It can cause unusual, often extreme and fluctuating changes in mood, energy, activity, and concentration or focus. Hafeman DM, Rooks B, Merranko J, et al. Bipolar Disord. Nursing care is provided throughout this process. 2008 Feb;69(2):302-9. doi: 10.4088/jcp.v69n0217. Tell someone if you feel a manic or depressive period might be coming on. Treatment in bipolar disorder (BD) is commonly applied as a multimodal therapy based on decision algorithms that lack an integrative understanding of molecular mechanisms or a biomarker associated clinical outcome measure. Very rarely are the Bipolar 2 patients violent toward the public; however, the danger is to their own lives & relationships once the consequences must be faced for regrettable behavior. Bipolar lockdown is a state in which you protect yourself from dangers because you know your bipolar symptoms are out of control. Try to practice mindfulness (being in the here and now) if you can. Bipolar Safety Plan. Bipolar disorder affects 2.6% of all adults, regardless of gender or race. CARE AGREEMENT: Manage bipolar disorder: Watch for triggers of bipolar disorder symptoms, such as stress. J Clin Psychiatry. A review of sensitivity and tolerability of antipsychotics in patients with bipolar disorder or schizophrenia: focus on somnolence. The Bipolar Safety Plan should be copied and filled out when you are doing relatively well. 18, No. Keywords:Bipolar disorder, lactation, pharmacotherapy, postpartum, pregnancy, treatment, psychotropic drugs, psychiatric comorbidity Bipolar disorder challenges patients, families and professional caregivers for many reasons, not the least of which is obtaining an accurate diagnosis. Several pharmacological agents are approved by the US FDA for the treatment of pediatric BPD. It is important to develop a well-defined safety plan before the next episode of depression or mania. My team has only asked me to do it once that I questioned....and looking back they were right. Bipolar Manic Episode Safety Plan STAY SAFE (however you have to)—stay in your safety zone. But special treatment considerations are necessary for some women, particularly during pregnancy. There is no known method to prevent bipolar disorder. Tolerability and safety are important considerations in optimising pharmacotherapy for bipolar disorder. 2019 Jun 26;: Authors: Sun AY, Woods S, Findling RL, Stepanova E Abstract Introduction: The standard of treatment of pediatric bipolar disorder (BPD) often requires life-long psychopharmacological management.  |  Scand. Pay attention to your sleep. Learn about its possible risk factors. If checkbooks and credit cards are left lying around the hypomanic patient will most likely act out with an completely illogical shopping spree for items or services not ever needed. Various drug classes, such as mood stabilizers, antipsychotics, benzodiazepines, and antidepressants, are used for the acute and maintenance treatment of bipolar disorder. For some students, simply being granted accommodations that make allowance for the side effects of medications, related anxiety issues, or results of mood changes is sufficient. There are some safety concerns with lithium, carbamazepine, ... Close more info about Considerations When Treating Patients for Mood Disorders Background: Bipolar disorder (BD) is a debilitating syndrome that is often undiagnosed and undertreated. Browse All Figures Return to Figure Change zoom level Zoom in Zoom out. Epub 2016 Nov 18. Epub 2009 Jul 9. Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. Shefali Srivastava, M.D. Learn new ways to relax, such as deep breathing, to manage your stress. Safety and Tolerability of Lamotrigine for Bipolar Disorder 175 Table I. Don’t watch sad movies or listen to sad music. More research is needed to understand potential risks of various drugs and to devise and incorporate monitoring protocols in the treatment regimen. ... Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. A safety plan is a critical part of treatment for borderline personality disorder (BPD). Various drug classes, such as mood stabilizers, antipsychotics, benzodiazepines, and antidepressants, are used for the acute and maintenance treatment of bipolar disorder. HHS The bubble headed bleached blonde comes on at five. Bipolar disorder seems to be less common in countries where people consume fish and fish oil. Put yourself on a strict schedule for healthy eating and sleeping – even though you likely won’t feel like it. Site last updated January 16, 2021, Lost Marbles: Insights into My Life with Depression & Bipolar, Cause of Death: Bipolar Disorder, Mental Illness, How The United States Treats Psychosis Is All Wrong, Why Looking Forward with Bipolar Is So Hard, The Bipolar Brain – A Radio Station You Can’t Turn Off, The Relationship Between Bipolar and Anger / Aggression, Depression – I Can’t Make a Decision, Everything Feels Wrong, HONcode standard for I don't kid myself about that any longer. John, with much respect, I believe this "lockdown" article is not about society's safety but that of the patients. APA ReferenceTracy, N. When I feel that I am escalating into mania, I stay at home at night, take my night medication by 8 p.m. and go to bed early. Safety considerations in the psychopharmacology of pediatric bipolar disorder. I appreciate this article. 2019 Jun 26;: Authors: Sun AY, Woods S, Findling RL, Stepanova E Abstract Introduction: The standard of treatment of pediatric bipolar disorder (BPD) often requires life-long psychopharmacological management. I'd think the best advice for a bipolar person would be to do a number of these things all the time. However, a substantial number of patients show a suboptimal response to treatment and still suffer from frequent episodes, persistent interepisodic symptoms and poor social functioning. Thank you very useful! Acta Psychiatr. References: 1. Saravane D, Feve B, Frances Y, Corruble E, Lancon C, Chanson P, Maison P, Terra JL, Azorin JM; avec le soutien institutionnel du laboratoire Lilly. Hi Sandy, Safety considerations in pharmacotherapy of bipolar disorder. Natasha Tracy is a renowned speaker, award-winning advocate and author of Lost Marbles: Insights into My Life with Depression & Bipolar. It won't be that much longer that I can continue to stay in the job force. Do not be alone if at all possible (be around someone who is aware of the manic symptoms of bipolar disorder and can help you control them). Title: Considerations in the Pharmacotherapy of Bipolar Disorder During and After Pregnancy VOLUME: 6 ISSUE: 5 Author(s):Verinder Sharma Affiliation:850 Highbury Avenue Regional Mental Health Care-London, London, ON N6A4H1, Canada. Bipolar disorder in women: reproductive events and treatment considerations. Please enable it to take advantage of the complete set of features! COVID-19 is an emerging, rapidly evolving situation. Bipolar disorder is a mental condition causing severe shifts in mood. If weapons or pills are around the house, the depressed patient may be tempted to hurt himself in a suicide attempt. Tolerability and safety are important considerations in optimising pharmacotherapy for bipolar disorder. My husband, son, psychiatrist, say down together and made "emergency plans" that include these steps. Imagine the panic I felt once my meds kicked in and I saw my monthly credit card bill!! Ask a friend or family member to help watch you for bipolar symptoms. Bipolar disorder is associated with a high risk of suicide. In a study that sought to evaluate the safety and tolerability of second-generation antipsychotic (SGA) polytherapy compared with monotherapy in patients with bipolar disorder receiving open naturalistic treatment in the 22-site Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), Brooks et al concluded that although polytherapy was fairly common in bipolar disorder… Wrap yourself in safety, when your bipolar endangers you, whenever possible. Expert Opinion on Drug Safety: Vol. of patients Study design Patient population Treatments Duration of Low moods are called depression. And, like I said, none of this precludes medical intervention. Very rarely are the Bipolar 2 patients violent toward the public; however, the danger is to their own lives & relationships once their brain straightens out again. The article is about a lockdown we choose to put ourselves under for our own safety and the safety of our lifestyles. Bipolar disorder is a chronic or episodic (which means occurring occasionally and at irregular intervals) mental disorder. Expert Opin Drug Saf. Pharmacogenetics/genomics study the individual genetic variation associated with drug response. Depending on the nature of an individual's manic-depressive illness (aka bipolar disorder), the family will be affected in many ways. Bipolar disorders are mood disorders that comprise of one or more manic or hypomanic episode and usually one or more depressive episodes with periods of relatively normal functioning in between. 2021 HealthyPlace Inc. All Rights Reserved. ... Valproate should not be used to treat women with epilepsy or bipolar disorder who are pregnant or who plan to become pregnant unless other medications have failed to provide adequate symptom control or are otherwise unacceptable. Sun, Steven Woods, Robert L Findling, Ekaterina Stepanova School of Medicine I also make sure to see my psychiatrist as soon as possible. We got rid of a gun we had. Treatment for bipolar disorder is generally the same for men and women. Great article! Electroconvulsive therapy (ECT) is useful in a number of instances in patients with bipolar disorder, such as when rapid, definitive medical/psychiatric treatment is needed; when the risks of ECT are less than that of other treatments; when the bipolar disorder is refractory to an adequate trial with other treatment strategies; and when the patient prefers this treatment modality. He is the Bipolar Disorder Section Editor for Psychiatric Times. Each group of drugs is associated with wide array of adverse events and drug interactions, which are the main hurdles in treatment outcome and compliance. See the following video for more on how I’ve jeopardized my safety because of bipolar (mentions self-harm) and how you might use bipolar lockdown to help. Don’t start a project you can’t reasonably finish. Safety Tips for Bipolar: Bipolar Lockdown, HealthyPlace. Safety considerations in the psychopharmacology of pediatric bipolar disorder. Bipolar disorders are mood disorders that comprise of one or more manic or hypomanic episode and usually one or more depressive episodes with periods of relatively normal functioning in between. Introduction: The standard of treatment of pediatric bipolar disorder (BPD) often requires life-long psychopharmacological management. This is especially important for people with bipolar disorder . Clipboard, Search History, and several other advanced features are temporarily unavailable. Safety and Tolerability of Lamotrigine for Bipolar Disorder 175 Table I. Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. trustworthy health. Can bipolar disorder be prevented? Although the disorder is defined by the manic and hypomanic episodes, for most people the depression episodes are the more virulent aspect of the illness. I'm proof of this....as a B2 patient I was so hypomanic one day I purchased a car on my Mastercard!! That is correct. Safety Tips for Bipolar Depression Here are a few other safety tips for bipolar you might want to consider: Put yourself on a strict schedule for healthy eating and sleeping – even though you likely won’t feel like it. Nursing care - Acute phase-Focus is on safety and maintaining physical health.-Therapeutic Milieu … Bipolar disorder. Special considerations in treating bipolar disorder in women. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Ghaemi, SN, Ostacher, MM, El-Mallakh, RS et al (2010) Antidepressant discontinuation in bipolar depression: a Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-bipolar disorder) randomized clinical trial of long-term effectiveness and safety… Many times, I have had to call off from work because I am in, or feel the beginning wave, of a deep depression. As a family member, here's what you need to know. As with any new diagnosis, the diagnosis of Bipolar disease can come as a shock and even be overwhelming.  |  112(2), 88-96 (2005). Bipolar disorder is a serious mental disorder that causes extreme changes in mood, energy and functioning. 2009 Sep;35(4):330-9. doi: 10.1016/j.encep.2008.10.014. They are said to be linked to biochemical imbalances in the brain and it is said that the disease is genetically transferred.. It affects approximately 1.3% of the population, and men and women are equally likely to develop the illness. Vivien K Burt. Bipolar disorder is associated with a high risk of suicide. Close Figure Viewer. Nursing Care Plans. Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. Thank God for FMLA. 777-794. Retrieved 2002;63 Suppl 3:15-20. 9, pp. The depressed phase of bipolar disorder is associated with a different set of risks, which include: Self-injury, including suicide. If checkbooks and credit cards are left lying around the hypomanic patient will most likely act out with an completely illogical shopping spree for items or services not ever needed. That step can be critical too. Many people with bipolar disorder find if they stick to a daily schedule, it helps them control their mood. Get rid of these things from your home. Care as usual primarily consists of pharmacotherapy and supportive treatment. This can really help relieve this type of mood. They are said to be linked to biochemical imbalances in the brain and it is said that the disease is genetically transferred.. Safety considerations in the psychopharmacology of pediatric bipolar disorder Amanda Y. of patients Study design Patient population Treatments Duration of Adverse effects such as somnolence are tolerability concerns and can be managed easily; others, such as diabetes mellitus, are safety concerns. on 2021, January 16 from https://www.healthyplace.com/blogs/breakingbipolar/2015/04/safety-tips-for-bipolar-bipolar-lockdown. The average age of onset is 25, but symptoms may emerge earlier. Bipolar disorder is a mental condition causing severe shifts in mood. Find Natasha Tracy on her blog, Bipolar Burble, Twitter, Instagram, Facebook and YouTube. It is associated with high disability, higher comorbidity due to medical illnesses, and significant social and economical consequences for patients, their families, and society. In bipolar disorder, however, there is relatively little evidence for the safety and efficacy of most CAM or integrative treatments. Phillips ML, Swartz HA. 777-794. 18, No. Vivien K Burt. Sometimes you will feel manic and sometimes you will feel depressed. Bipolar affective disorder is a recurrent, disabling, and potentially lethal illness that typically begins early in life. Common side effects seen with several agents, particularly antipsychotics, are somnolence, weight gain, extrapyramidal symptoms, dyslipidemia, type-2 diabetes, and hyperprolactinemia. Stay away from shopping outlets – online and in person. The episodic nature of this disease warrants rational use of medications and proper monitoring for adverse events. In addition to the tips mentioned in the video, you might consider these bipolar lockdown safety tips for mania or hypomania: Here are a few other safety tips for bipolar you might want to consider: Of course, the bipolar lockdown you might enact may be different – it all depends on the kind of symptoms you, personally, experience. The care of the client with bipolar disorder will be based on the phase of mania the client is experiencing. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Also, I know that in these times, I am particularly vulnerable to mood swings. Shefali Srivastava. High moods are called mania. Can bipolar disorder be prevented? Would you like email updates of new search results? For example, alcohol and drugs would be at the top of my list of things to avoid all of the time. Bipolar disorder is a severe mental illness with serious consequences for daily living of patients and their caregivers. Bipolar disorder is a type of mental disorder. These opportunities include consideration of safety, future health, emotional support and the environment. This site complies with the HONcode standard for Important Safety Considerations 1,2. Safety considerations in the psychopharmacology of pediatric bipolar disorder. Imagine the panic I felt once my meds kicked in and I saw my monthly credit card bill!! If you’re likely to get teary over memories, don’t go through picture books or dwell on the past. Search for more papers by this author ... Bipolar Disorder. John, with much respect, I believe this "lockdown" article is not about society's safety but that of the patients. You can have mania and depression at the same time. (2019). Gao K, Ganocy SJ, Gajwani P, Muzina DJ, Kemp DE, Calabrese JR. J Clin Psychiatry. Bipolar disorders impact the ability to make judgements and to take decisions during mood episodes and remain a stigmatised condition. CONCLUSIONS: The current paper summarises the treatment recommendations relating to each phase of bipolar disorder while providing additional, evidence-based, practical insights. Because its exact cause has not yet been determined, it is especially important to know its symptoms and seek early intervention. 2017 Oct;43(5):464-470. doi: 10.1016/j.encep.2016.09.005. This paper reviews the tolerability and safety of lamotrigine, an anticonvulsant recommended in the 2002 American Psychiatric Association guidelines as a first-line treatment for acute depression in bipolar disorder and one of several options for maintenance therapy. Treatment During Pregnancy. Major drug interactions are seen with drugs such as carbamazepine, due to hepatic enzyme induction. 2017;19:524-543. Biomarkers. The difference is I've agreed that if 3 people in my care team agree I need them (the above listed, my parents, and the pastor at my church I see for counseling), I agree to implement them even if I don't think I need them. Managing the side effects associated with commonly used treatments for bipolar depression. Dr. Phelps stopped accepting honoraria from pharmaceutical companies in 2008 but receives honoraria from McGraw-Hill and W.W. Norton & Co. for his books on bipolar disorders. Expert Opinion on Drug Safety: Vol. When we implement a series of these bipolar safety tips, I call it being on a self-imposed “bipolar lockdown.”. here. I give my over stock of pills to my wife. (2015, April 14). [Guidelines for the prescription of mood stabilizers for adolescents: A literature review]. I have never thought of it as "lockdown", although that is a very good description. If you experience such symptoms, you should contact emergency medical services, usually, 911, or … trustworthy health information: verify Nursing Care Plans. Pharmacologic Therapy. In any practice setting, you may be assigned to care for a patient with bipolar disorder. If you experience such symptoms, you should contact emergency medical services, usually, 911, or … I work at a "big box" store and there are many ways to get hurt, especially if you are not paying attention. Therefore, it is essential that the patient is educated on the different signs and symptoms associated with the mania, hypomania and depressive episodes. Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Give the bulk of you medication away to a friend so you don’t feel tempted to overdose. It is prudent to have precise knowledge of the … OBJECTIVE: Polypharmacy is common in the treatment of refractory bipolar disorder. RE: John Morgan's response Patients with type II bipolar disorders appear to commit suicide more often than those with type I bipolar disorders (24% v 17%) and those with bipolar disorders do so more than those with unipolar depression (12%).4 While experiencing depression, people may think about death a lot, feel suicidal, or feel like harming others. Appropriate medication depends on the stage of the bipolar disorder, or manic-depressive illness (MDI), the patient is experiencing. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. It's always better to make the plans while we are stable than wait till we need them! I can also contact my therapist when I'm in a crisis. 9, pp. NLM Special considerations in treating bipolar disorder in women. Adverse effects such as somnolence are tolerability concerns and can be managed easily; others, such as diabetes mellitus, are safety concerns. J Affect Disord. Because its exact cause has not yet been determined, it is especially important to know its symptoms and seek early intervention. USA.gov. Frye and colleagues took an important first step in this process by analyzing 7.5 ml blood samples from patients diagnosed with unipolar depression (n=52), bipolar II disorder (n=49), and bipolar I disorder (n=46) as well as 141 control subjects. Put yourself on a strict schedule for sleeping and healthy eating – even though you likely won’t feel like it. Encephale. This is when I lockdown. Bipolar disorder causes a range of symptoms that can be distressing and disruptive to your life. NIH The effects of a person's bipolar illness on the family may vary from mild to devastating. Ethics Commentary: Bipolar Disorder: Ethical Considerations in the Treatment of Bipolar Disorder. That could spell disaster if a customer caused my swing. If you have to, give these things away to a friend for a while. Give the bulk of you medication away to a friend so you don’t feel tempted to overdose. It’s important to remember that bipolar lockdown does not take the place of a visit to your psychiatrist or a trip to the hospital, if that’s what’s needed, but sometimes bipolar lockdown can be used in conjunction with those acts or during other times when things are going badly. doi: 10.1016/S0165-0327(14)70007-2. Safety considerations in the psychopharmacology of pediatric bipolar disorder. 4,5 A recent survey of older patients with a diagnosed major depressive disorder (n = 50) or bipolar disorder (n = 50) found that 44% of those with bipolar disorder use herbal and other natural products compared with only 16% of those who were depressed. RE: John Morgan's response Researchers and clinicians have long sought biological indicators for mental disorders, particularly for affective disorders. The purpose of this article is to review the safety and efficacy of mood stabilizers in combinations. Keywords:Bipolar disorder, lactation, pharmacotherapy, postpartum, pregnancy, treatment, psychotropic drugs, psychiatric comorbidity Expert Opin Drug Saf.