Tuesday, July 29, 2008

No Trans Fat Is Allowed In All New York Restaurants!

Trans fat has been classified as bad stuff that not only increases LDL (bad cholesterol) but also reduces HDL (good cholesterol). People with such pattern of cholesterol level are at higher risk of heart disease, and several other medical ailments.

Foods with trans fat can be found almost everywhere. Besides candy, noodles, cookies, chips, there are hundreds of other processed products available in supermarket do contain trans fat in different amounts. Despite its unhealthy nature, most foods with trans fat are favored by both children and adults.

On July 1, 2008, the artificial trans fat can no longer be presented in the menu in New York restaurants. In this way, the authorities in New York help remove a major cause of heart disease from their residents’ diets.

Last year, the authorities had already banned all restaurants from using frying oil and spreads containing trans fats. Now, the restriction will apply to all types of food, including the fat used by bakers and pastry chefs.

For all foods served, including baked goods, oils, shortenings and margarine used for baking, and pre-prepared items, the amount of artificial trans fat, must not be more than 0.5 grams of trans fat per serving. However, foods served in the manufacturer's original, sealed packaging, such as candy and crackers, can still be exempted for the time being.

According to the health department in New York, there was widespread acceptance of its last year's ban, with more than 98 percent of inspected restaurants were in compliance as at June 2008. Many restaurants had gone even further to voluntarily cut down the amount of saturated fat.

As confessed by the owner of one of the restaurants in New York, the transition he made 7 months ago by cooking his patties and baked goods with replacement shortenings has hurt neither the products nor his business. Meanwhile, he feels happy that the move is healthier for his customers.

The Food and Drug Administration (FDA) has pointed out that trans fat, which is made by adding hydrogen to vegetable oil. This increases "bad" cholesterol levels, raising the risk of coronary heart disease.

New York was the first city in the United States to start banning trans fats in restaurants, followed by Philadelphia last year.

Monday, July 28, 2008

Can Watching Football Match Really Lead to Heart Attack?

During the 2006 World Cup, researchers at the Munich University Clinic in southern Germany found that cardiac arrests and palpitations among men in the greater Munich area were more than tripled compared to the same period over 3 preceding areas. For women, the rate was double.

The researchers also found that “the more important the game, the greater the risk”. The number of heart attack cases actually surged when Germany played in the quarterfinals against Argentina (Germany won), and in the semifinal against Italy (Germany lost). Both games were decided after extra time and penalty shootout, which has already been found as a risk by previous research.

As the figures are so alarming, some experts urge patients with potential risk to take stress-receptor blockers, aspirin and statins, or even consider behavior therapy to calm them down before sitting down the soda to watch the football matches. The health experts even advise those patients who had a heart attack or who are considered to have a high cardiac risk to avoid watching important matches.

In fact, researchers at the University of Birmingham, in central England, already discovered that the number of heart attacks in Britain rose by 25 percent on the day England lost to Argentina on kicks in the 1998 World Cup. As such, they had suggested that penalty shootouts should be scrapped “on public health grounds”.

Then, there are the longer-term health problems for the football fans: they tended to develop into couch-potato lifestyle: non-stop boozing and snacking on starchy, fatty, salty or sweet foods. Such unhealthy lifestyle is partly responsible for major health problems like obesity, diabetes and heart disease found in Europe. Some health experts even blame the match organizations for advertising unhealthy products. They believe such act will do no good for the public health, and instead help the football spectators cultivate their unhealthy lifestyle.

Besides cardiac arrests, the reported number of emergency calls, wife beatings, depression, drunken driving, self-harm and even suicide is rising during major football sessions.

Can you imagine, a football fan would eventually be led to such a disaster by just watching football matches!

Thursday, July 24, 2008

If You Do Not Want To Be Overweight, Stop Skipping Your Breakfast!

Nowadays, it is not uncommon for people to skip breakfast, the first meal of the day. Either they prefer to sleep a little longer or they are simply too lazy to prepare breakfast. Such phenomenon does apply to many teenagers, too.

However, skipping breakfast not only means that you will miss the most important meal of the day, as suggested by some health experts, but also have some implications on the weight of teenagers.

According to a study conducted by the University of Minnesota's department of epidemiology and community health, teenagers who eat breakfast consume more daily calories yet weigh less. The findings of the study, code named “Project EAT (Eating Among Teens)”, were published on March 3, 2008 on the journal of the American Academy of Pediatrics.

By observing more than 2,200 teens over 5 years, the Project EAT showed that teens who start their day with breakfast tend to consume more calories, carbohydrate and fiber over the course of the day than those who skipped the meal. Meanwhile, the breakfast-eaters weighed less. Those kids who eat breakfast every day are at a lower obesity-risk.

This new study clearly supports what other studies have shown: kids who skip breakfast tend to gain more weight, and would thus be at a higher risk for obesity. Nevertheless, Project EAT is an observational study. In order to find out the link between breakfast habits and body weight, the researchers of Project EAT stressed that experimental study into breakfast habits will be required.

Citing a biennial study dating from 2005, the “F as in Fat” report, issued in 2007 by the Trust for America’s Health, also indicated that 16 percent of American teenage boys and 10 percent of teen girls were overweight, and the number of teenagers in the United States with a weight problem has tripled in the past 20 years.

People who are overweight or are obese are known to be possible victims of various medical disorders including heart disease, diabetes, high blood pressure, stroke, etc.

Wednesday, July 23, 2008

Liquid Lunch May Be A Healthy Way to Lose Weight!

Finding a way to prevent from weight gain is never an easy task. Being common among people, overeating will eventually cause people to become overweight or even obese. These overweight or obese persons will be at a high risk of developing certain types of cancer, heart disease, diabetes, high blood pressure, stroke, and so on and so forth.

Recently, scientists have suggested that people could bulk up the volume of food with certain gases or water so that they would feel fuller than otherwise. This will help reduce the amount of food they eat afterwards.

In May 2008, scientists from Unilever's research laboratories presented their finding at the European Congress on Obesity in Geneva that the gas-filled meal actually reduced appetite more than the standard one. In the study, they actually tested on 24 people a full milkshake-like meal, and a half-sized version bulked up with gas similar to that used in aerosol whipped cream.

The researchers are surprised to find out that satiety (feeling full) was maintained for 1 - 2 hours or even longer. It is known that there is always a problem with satiety, which is often lost after 15 minutes or so. Therefore, what they found in the study was a pleasant surprise.

In reality, many people who are trying to lose weight do find the maintenance of the weight-loss regime very difficult. Therefore, finding the types of food that could keep a person feeling full will help people eat less.

Nevertheless, not all gases would work. For instance, carbon dioxide, such as those found in carbonated drinks, does not do the job. The study found that only gases that can be stabilized in the food so it does not leave the body before it reaches the stomach.

The scientists admitted that they have yet to find out the answers on why such gas-filled liquid meals work or whether the same effect could be found on solid food. As such, they would still require to do further studies so that more evidence could be gathered.

Monday, July 21, 2008

Broccoli Can Protect Your Heart, Too!

“Broccoli is good for our health!” I am quite sure no one would deny this statement. This is because broccoli is not only rich in calcium but also has anti-cancer properties. Now, this famous vegetable is found to have the ability of protecting the heart against ailments such as high blood pressure, heart disease and stroke, as revealed by a group of researchers at the University of Connecticut.

In the study, rats that were fed with broccoli had decreased blood pressure and inflammation in the heart, comparing to the control group that was fed regular rat food. When oxygen-deprivation test was performed on the rats, those on the broccoli diet were found to have better blood-pumping ability, less heart damage and higher levels of heart-healthy chemicals.

It is believed that broccoli contains sulforaphane, a compound that would trigger the body's production of the protein known as thioredoxin, which protects against cell damage in the heart.

In addition to its ability to protect the heart, broccoli is beneficial for the entire body, too.

Being high in vitamins A and C, folic acid, calcium and fiber, broccoli is a rich source of antioxidants that help protect against cancer and a good source of calcium for people who do not take dairy products.

Having high vitamins, broccoli contains twice the amount of Vitamin C that spinach has. Therefore, saying broccoli is a great immune-booster is not exaggerated. Meanwhile, its high mineral content (potassium, iron, magnesium and folic acid) makes it a good stress-buster. The sulphurous compounds and high-fiber content in broccoli places it high in the list of good cancer-fighting food. Both the soluble and insoluble fibers can be found in broccoli, a serving of which provides one's daily need for both types of fiber.

Although broccoli has a higher uric content than most vegetables, it is still less than that of meat and seafood. Thus, people with gout can still consume broccoli in moderation, say half a cup per week.

There is no fix rule on how much broccoli one should have; but having 2 to 3 servings each day seems acceptable for normal healthy persons. If possible, broccoli should be one of the greens to include in daily servings.

Varying types of vegetables consumed is always recommended. This is because different colored vegetables provide different vitamins, antioxidants and phytochemicals needed in your diet.

Friday, July 18, 2008

How Much Do You Know About Congenital Heart Disease?

Congenital heart disease is a structural heart defects that are present when a baby is born. Such malformations are usually a result of abnormal development during the fetal formation of heart structures. Congenital heart disease is a condition, which affects 8 out of 1,000 live births here in Singapore.

At present, the underlying causes of congenital heart disease are unknown. However, it is believed that certain environmental and genetic factors may play a role. For example, mothers with antenatal infections like rubella may give birth to babies with heart defects. Meanwhile, having poorly managed diabetes during pregnancy might also interfere with the development of the fetus' heart. Babies with chromosomal abnormalities, such as Down's Syndrome, are also genetically predisposed to congenital heart disease.

There are over 30 types of congenital heart defects, and the most common types are simple defects due to holes in the heart chambers or narrowing of the heart valves.

Babies born with congenital heart disease may appear in "blue", breathless and have heart murmurs. Some of these babies may have delays in motor milestones like walking or running. They may also have problems in feeding and gaining weight.

In general, babies with major heart defects are often breathless due to increased workload to the heart or lung congestion. Sucking milk, which requires strength, can tire the baby out. Breast-feeding is the ideal way to feed these babies as breast milk can help protect against infections. Nevertheless, babies who are too breathless from the heart condition, should use tube feeding through a nasogastric or oral gastric tube because this decreases the workload and allows the baby to conserve energy and take enough food to gain weight.

The current technology allows many heart defects to be detected even before the baby is born. Fetal heart scans, called echocardiograms, can locate heart defects in an unborn baby by using sound waves to create a picture of the baby's heart. However, it is impossible to pick up all cases immediately during the pregnancy. For instance, those with small defects may be undetected by the echocardiograms.

Besides highly complex ones, most cases are treatable. Even the major defects can be repaired surgically. Surgery has also made possible for many patients to survive major heart defects and live closed to normal lives in adulthood.

Wednesday, July 16, 2008

Don’t Overlook Pre-Diabetes Stage!

When one is diagnosed with Type-2 diabetes, it is often too late to reverse the condition. According to health experts, early detection and intervention in the pre-diabetes stage may help prevent or delay Type-2 diabetes.

So, what exactly is pre-diabetes stage? Pre-diabetes refers to a state when a person’s blood sugar is slightly higher but not high enough to be diagnosed as diabetes. Clinically, it is known as Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG).

People with pre-diabetes not only have a higher chance of becoming Type-2 diabetes, but also have a higher risk of developing other medical complications such as heart disease and stroke.

A person having pre-diabetes stage is very likely to progress to diabetes, if nothing is done. However, this may be delayed or even prevented with correct lifestyle modification. In fact, studies have shown that up to a third of people with pre-diabetes may be able to bring their blood glucose levels back to normal over time. Weight loss, regular exercise and medication can correct a key defect in pre-diabetes (namely the hormone insulin, which is ineffective in controlling blood sugar). These three measures help body becomes more sensitive to the action of insulin so that insulin works better in controlling blood sugar, and sometimes, diabetes can be prevented in the pre-diabetes stage.

Unfortunately, pre-diabetes stage does not have significant signs and may just be undetected. The fastest and surest way to find out if one has pre-diabetes is to go for a blood test. IFG can be detected by an early morning blood sample after an overnight fast, while IGT can be detected using an Oral Glucose Tolerance Test (OGTT). This involves taking a glucose drink and a second blood sample 2 hours after the first blood test. For people who are diagnosed with either IFG or IGT, the most important thing for them to do is to relook their lifestyles and modify accordingly. Some medications may also help.

Monday, July 14, 2008

Is Smoking Ban In Public A Right Decision?

Smoking is bad for health! This message has been publicized and circulated for years, yet how many smokers have accepted the advice and kicked the habit.

Being a risk factor for heart disease, lung cancer, and many other ailments, smoking can not only harmful to the smokers themselves, but also to the people around them through second-hand smoke. According to World Health Organization (WHO), smoking kills about 4 million people each year, causing a quarter of deaths related to heart disease.

In recent years, many Western nations have begun varying types of smoking bans in public places like restaurants, pubs, cafes, etc to protect people from second-hand smoke. On June 30, 2008, WHO has also published a report indicated that “smoking bans are an effective way of preventing heart disease, getting cigarette users to quit, and protecting children from second-hand smoke.”

These policies have undoubtedly achieved their aim of protecting the health of non-smokers by decreasing exposure to second-hand smoke. In addition, they have many effects on the smoking behavior that compound the health benefits.

The scientists at the WHO's International Agency for Cancer Research, who are responsible for the report, reviewed more than 900 studies and government reports looking at the impact of smoking bans across the world. They also cited studies that suggest smoke-free workplaces have lead to a 10 to 20 percent decrease in hospital admissions for heart disease a year, after a smoking ban.

They believe that implementation of such policies can have a broader population effect of increasing smoke-free environments.

As indicated in a separate report released by Cancer Research UK on June 30, 2008, England's ban adopted a year ago has spurred more smokers to kick the habit, and it was predicted the restrictions would prevent 40,000 deaths over the next 10 years.

Friday, July 11, 2008

New Source of Heart Stem Cells Was Discovered!

A person with heart failure will lose heart muscle cells known as cardiomyocytes, so the only way to reverse heart failure is to make more of these cells.

Researchers from Children's Hospital in Boston, Massachusetts have discovered a new group of stem cells that can give rise to cardiomyocytes. Located in the outermost layer of the heart, the stem cells could one day play a critical role in regenerating injured heart tissue. The discovery was published online in the journal Nature on June 22, 2008.

In 2006, scientists identified another cardiac stem cell, marked by the expression of a gene called Nkx2-5, with the potential of becoming either heart muscle or cells lining blood vessels in the organ's left-sided chambers. Other United States researchers also discovered a related progenitor heart cell that produces the same cell types in the right-sided heart chambers.

For the first time, the new research shows that new heart stem cells can also be derived from a third type of cardiac stem cell, located within the surface of the organ and identifiable through its expression of a gene called Wt1.

The researchers also showed that the cells from the heart's outer lining (known as the epicardium) could metamorphose into cardiomyocytes and smooth muscle cells, endothelial cells, which line the interior of blood vessels, and fibroblasts, found in connective tissue. When regenerating tissue, it is necessary to regenerate the whole tissue and not just the cardiomyocytes.

Their discovery of the new stem cells was purely an accident. In order to study the role a different gene in the epicardium, the researchers labeled cells in live mouse embryos with red fluorescent protein. Unexpectedly, they saw that these epicardial cells were becoming cardiomycytes. It was indeed a lucky observation.

The next challenge for the researchers is for them to figure out how a progenitor stem cell decides to become a certain type of functioning cell within the heart, and then how to develop methods to trick the stem cells into transforming into the desired tissue.

For more information on cardiomyocytes, please visit:


Wednesday, July 09, 2008

Diet That May Help Prevent From Diabetes!

In general, there are 2 types of diabetes, namely Type-1 and Type-2. Type-1 is caused by permanent destruction of insulin-producing beta cells in the pancreas. This type of diabetes usually appears in patients during the early stage in life. On the other hand, the adoption of sugary and fatty diets and sedentary lifestyle has caused Type-2 diabetes to become an epidemic in developed and developing countries. Without a proper medical treatment, diabetes might lead to kidney failure, blindness, heart disease and even death.

According to the estimation by the International Diabetes Federation, the number of cases, including many adolescents, will raise from 246 million today to 380 million by 2025.

Recently, researchers from the University of Navarra in northern Spain reported in the British Medical Journal on May 29, 2008 that Mediterranean diet, which is believed to benefit the cardiovascular system, also helps protect against diabetes.

Mediterranean diet comprises mainly olive oil, fish, grains, fruit, nuts and vegetables, usually supplemented by a modest amount of red wine. Only a small portion of meat and dairy products are included the diet.

In the study, 13,753 people with graduate-level education were recruited between December 1999 and November 2007. These subjects had no history of diabetes when they were enrolled. Over the following months and years, their health and dietary habits were then tracked in details.

During the follow-up period (an average of 4.4 years over the range of participants), 103 people became diagnosed with Type-2 diabetes. A large percentage of these cases are those who did not follow the basics of the Mediterranean diet. Meanwhile, those who adhered to the diet most strictly had a relative reduction of 83 percent in the risk of diabetes.

Interestingly, many people in this group also had accumulated many risk factors for the disease: they were older, were fatter, had a family history of diabetes, more sedentary lifestyle or were ex-smokers. Yet, they appear to have been protected by the diet.

Numerous previous studies have proved that Mediterranean diet helps cardiac and vascular health. A paper published in January 2008 in the British journal Thorax revealed that women who followed the diet while pregnant might also protect their baby from childhood asthma and allergy.

Tuesday, July 08, 2008

How To Save Some 2,000 Lives Each Year?

Why is British government willing to spend a huge amount of money for a national program of vascular checks for some 3 million people a year? Let us look at the statistics.

Every year, vascular diseases kill 170,000 people in England. Conditions such as stroke, diabetes, heart disease and kidney disease affect the lives of 4.1 million people and account for a fifth of all hospital admissions. According to the government estimates, earlier detection by health screening could actually prevent up to 9,500 heart attacks and strokes, and thus save the lives of 2,000 every year. Therefore, setting a national program of vascular checks is compelling.

On April 1, 2008, the Health Secretary of England announced a free health-screening program for people aged between 40 and 74 for the identification of those who are at risk of vascular diseases. This program, to be introduced in the 2009-2010 financial year, would cost the government 250 million pounds including any aftercare that results from the tests. The government believes that the benefits of a healthier population far outweigh the upfront costs. The program, when operational fully, aims to check 3 million people a year with a recall every 5 years.

Presently, only around a fifth of adults have the checks that cover cholesterol level, weight relative to height, blood pressure and smoking record. Those who are at risk will be given advice on lifestyle changes, such as stopping smoking and doing more exercise. In addition, those whose health is most seriously threatened will also be given medication.

In order to cover all parts of the population, including those most deprived, the government plans to offer the health checks in community centers, pharmacies and doctors' surgeries.

Though such program does draw some doubts in terms of its effectiveness, most still feel that the program would have positive results.

Sunday, July 06, 2008

Vitamin That May Protect One Against Heart Attack!

If one’s body is deficient of certain type of vitamin, he or she may face a high risk of having heart attack. In January 2008, researchers from Harvard Medical School reported that people with low level of Vitamin D might have a higher risk for heart attack, heart failure and stroke. The study was published in June 2008 in the journal Archives of Internal Medicine.

In their study of identifying possible health benefits from Vitamin D, researchers from the Harvard School of Public Health and Brigham and Women's Hospital in Boston found that men with low levels of Vitamin D have a higher risk of getting heart attack.

The study involved 454 health professionals ages between 40 and 75 who had suffered a nonfatal heart attack or died of heart disease, and 900 other men with no history of cardiovascular disease. These subjects were followed for 10 years after providing blood samples to measure their Vitamin D levels.

The researchers compared participants who were deficient in Vitamin D (no more than 15 nanogrammes per milliliter of blood) with participants who were in the lower end of the normal range (at least 30 nanogrammes per milliliter of blood).

Men classified as deficient in vitamin D were about 2 and a half times more likely to have a heart attack than those with higher levels of the vitamin. In fact, those with low Vitamin D, besides being at higher risk for heart attack, were at particularly high risk to have a fatal heart attack.

Vitamin D is also known as “sunshine vitamin” because body makes Vitamin D when the skin is exposed to sunlight. It can be found in milk and fatty fish like salmon. Vitamin D helps our body to adsorb calcium and benefits bone health. Vitamin D deficiency can lead to osteoporosis for adults, rickets for children.

Several recent studies have also indicated that Vitamin D may offer a variety of other health benefits. This includes protecting against colon cancer, breast cancer, peripheral artery disease and tuberculosis.

Vitamin D may protect against heart attack in a number of ways. It might lower blood pressure, regulate inflammation, reduce calcification of coronary arteries, affect the heart muscle or reduce respiratory infections in winter.

To find out whether one’s Vitamin D level is normal, just visit the family doctor and take a blood test. Those with very low levels can take Vitamin D supplements.

Friday, July 04, 2008

Blood Pressure Better Controlled Through Internet Health Care!

Patients with hypertension (high blood pressure) will usually have their blood pressure measured only at doctors’ clinics when they visit them for routine check-up. Although patients may have been advised to check and record their blood pressure at home, it seems that not many patients will actually do this. It is therefore difficult for the doctors to prescribe the relevant medications and appropriate dosage to have their patients’ blood pressure under control. High blood pressure, if not managed appropriately, can lead to stroke, heart disease, and other medical conditions.

In the last week of June 2008, a report published in Journal of the American Medical Association by researchers from Group Health in Seattle indicated that people with high blood pressure would get their condition under control when they get advice and medications delivered via Internet, along with home blood pressure monitoring.

The aim of the study is to find out whether high blood pressure could be managed over the Internet, without visiting a doctor.

778 patients with uncontrolled high blood pressure and Internet access were involved in the clinical trial. They were randomly assigned to usual care, to home BP monitoring and Web services training, or to home monitoring, Web services training, and management by a pharmacist delivered through Internet communications. The participants were middle-aged, working people for whom Web-based care is convenient.

With Web services, patients could email their doctors, refill prescriptions, request appointments, get test results, and look up health information. Meanwhile, the pharmacists in the study were also allowed to prescribe medications. By using email communication, they could also manage the patients' blood pressure and adjust medications accordingly until the target blood pressure was reached.

After 12 months, about one-third of the patients in the first 2 groups achieved a normal blood pressure, and those with the Internet-based pharmacist care, more than half of the patients got their blood pressure down to normal.

According to the researchers, Web communication could improve health care because it is always available (24 hours and 7 days a week), it allows people to respond at a time which they feel convenient, and it is in a briefer way than over the telephone or during a personal visit.

It is believed that greater use of electronic medical records, Web communications, and empowering patients to take a greater role in their care will eventually lead to improved health outcomes and lower health care costs. As such, the researchers urged more efforts should be devoted to make these services available to all.

Tuesday, July 01, 2008

Turn Recycled Heart Into Beating Again!

In the United States alone, approximately 50,000 patients die because of the lack of donor hearts every year. Meanwhile, some 22 million people worldwide are living with the threat of heart failure. If scientists could devise a way to develop transplantable blood vessels or whole organs that are made from human’s own cells, then many lives could be saved.

It seems that this hope should not be too far away, especially when a group of scientists from United States has coaxed recycled hearts taken from animal cadavers into beating in the laboratory after reseeding them with live cells.

The new study was carried out by scientists from the University of Minnesota and their finding was published on January 13, 2008 in the British journal Nature Medicine. There has been research in generating living heart tissue in the laboratory, but this is the first time that an entire, 3-dimensional bio-dimension bio-artificial heart has been brought to life.

If such procedure could be extended to humans, then an almost limitless supply of hearts and possibly many other organs would be made available to millions of terminally ill humans, who are waiting helplessly for a new lease on life.

In the study, a procedure called decellularisation was used. During the procedure, all the cells from an organ (in this case the heart of a dead rat) were stripped away using powerful detergents, leaving only a bleached-white scaffolding composed of proteins secreted by the cells. This matrix was then injected with a mixture of cells taken from the heart of a newborn rat and placed in a sterile laboratory setting, where the scientists hoped it would grow. After only 4 days, contractions started, and on the 8th day, the hearts were pumping. The researchers were stunned when they saw the result. Decellularisation has indeed changed the way scientists think about engineering organs.

In humans, the objective would be to inject stem cells drawn directly from the recipient of the donated organ, thus eliminating the danger of rejection of the new organ by the immune system.

Recent breakthroughs in stem cell research from non-embryo sources would mean that new tissues should be easy to generate. If organs derived from a patient's own cells would become available on a large scale, then millions of patients suffering from organ failure would benefit.

The research team is now working on making the recycled organs more efficient, and has even transplanted some of these hearts into the abdomens of rats and connected them to the animals' aortas, a standard way of testing whether a donor organ can keep an animal alive.

The Minnesota researchers have also successfully applied the new technique to pig hearts, which are closer to human hearts in size and complexity, although this was not reported in the current study.