Table of Contents [Hide]
- The Prevalence Of Asthma And Asthma Attacks
- The Different Aspects Of Asthma
- The Difference Between Asthma And An Asthma Attack
- The Symptoms Of Asthma
- The Symptoms Of An Asthma Attack
- What Causes Asthma?
- Asthma Risk Factors
- How Asthma Is Diagnosed
- Asthma Control And Management Plant
- Conventional Treatment Options For Asthma
Asthma is a long-term condition that causes the airways that carry air into and out of the lungs to become swollen. When these airways swell up, they become narrow, which causes the patient to experience several unpleasant symptoms, such as problems with their ability to breath. Asthma can also lead to other symptoms, such as a shortness of breath, wheezing and coughing. When the patient’s airways swell up, excess mucus is often also produced, which can cause the symptoms the patient is experiencing to worsen. While this condition only results in minor symptoms in some patients, other patients find asthma to be a severe problem in their lives since the symptoms that are caused by the condition can often interfere with their day-to-day activities.
The Prevalence of Asthma and Asthma Attacks
The prevalence of asthma has increased during the last few decades. Centers for Disease Control and Prevention reports that the condition affected 7.3% of the global population in 2001. Nine years later, in 2010, the prevalence of the condition increased to 8.4% – at this time, a total of 25.7 million individuals had been diagnosed with asthma. Between 2008 and 2010, there was a higher prevalence of asthma among children than there was among adults. The prevalence of the condition was also higher among American Indians, native Alaskans and black people when compared to the prevalence among white people. Asthma also had a higher widespread presence among black people – including diagnosis of the condition and death caused by asthma attacks – between 2007 and 2009.
Asthma UK reports that, at the moment, there are about 5.4 million people in the United Kingdom that are currently receiving ongoing treatment for asthma. This includes about 4.3 million adult citizens and 1.1 million children. They also report that as much as three people die every day from asthma-related complications. A review by the Seoul National University College of Medicine in Korea reports that up to 11.9% of Asia’s entire population (which accounts for as much as 60% of the global population) experience symptoms of asthma. According to Asthma Australia, approximately 11.11%, or 2.5 million individuals, have been diagnosed with asthma by a doctor.
The Different Aspects of Asthma
To understand exactly how asthma works, it is important to consider the different aspects that are involved in the disease. Since the condition is a long-term disease that does not currently have a cure, these factors are present at all times and, when they flare up, symptoms start to develop and can lead to an asthma attack. The University of Illinois’s Hospital & Health Sciences System explains that the three major aspects that are involved in the disease include:
- Inflammation – Inflammation is the core problem that contributes to the symptoms of asthma and has also been linked to the other two factors that we will also discuss here. Inflammation is often seen as a positive attribute of the human body as it can prevent infections from developing and it helps the body repair damaged tissue. In some cases, however, inflammation can be a negative attribute and contribute towards the development of certain chronic diseases – such as asthma in this case. In patients with asthma, the walls of their airways are always inflamed – this is the main cause of asthma symptoms and, when inflammation gets worse, it can cause the person to experience severe and life-threatening symptoms. Apart from being swollen, the airways of an asthmatic patient often produce excessive amounts of mucus. The combination of inflammation and mucus results in a narrowing of the space that is available for air to travel through, which causes breathing problems.
- Airway Hyper-responsiveness – Another aspect related to asthma is called airway hyper-responsiveness. This term refers to the fact that an asthmatic patient’s airway is extremely sensitive to certain substances – ones that a person without asthma would not be sensitive to. When a substance enters the body (one example of such a substance is dust), the airway triggers a reaction due to its sensitivity. This reaction, in turn, then causes the muscles located in the airway to squeeze. When this happens, several symptoms can develop, with the most obvious symptom being difficulty breathing. Coughing and wheezing are also common symptoms that patients experience when this factor occurs.
- Excessive Bronchoconstriction – The third factor related to this disease is known as excessive bronchoconstriction. This aspect refers to the fact that the muscles in the airway quickly contracts in patients who have asthma, which results in a further restriction of space available for air to move in and out of the lungs. The smooth muscle tissue found in the airways of an asthmatic patient is usually stronger and much larger it is in a person without asthma.
The Difference Between Asthma and An Asthma Attack
Asthma is a disease that develops due to inflammation in the airways. The condition causes many symptoms to develop in the patient that can be inconvenient and disrupt their daily lives. When a patient has been diagnosed with asthma, it means they have chronic inflammation in their airways. Even when the patient does not experience any of the symptoms that are related to asthma, their airways are still inflamed all of the time. Certain elements can then trigger the inflammation to become worse, which causes the disease to flare up. This leads to the development of symptoms that are related to the disease, such as problems with the patient’s ability to breathe properly, excessive coughing and more.
An asthma attack, on the other hand, isn’t an actual disease, but rather a condition that is caused by the asthma disease. When a patient experiences severe symptoms of asthma, the muscles that surround their airways contracts. The airway’s lining also swells up more and thicker mucus is produced in larger quantities. This is known as an asthma attack. An asthma attack is often mild, which means, with treatment, the patient’s airways open up in a relatively short amount of time. In other cases, however, the asthma attack can be more severe and completely restrict the airway, which means air cannot get into or out of their lungs.
The Symptoms of Asthma
While asthma causes the airways of a patient to be inflamed permanently, the inflammation cannot always be experienced as a symptom. To better understand how asthma feels and to know if you might be suffering from this disease, it is important to consider the specific symptoms that are linked to the disease. These symptoms can range from mild to extremely severe and often defers from one patient to another. Every patient who has asthma also don’t experience all of the symptoms or the same symptoms. One patient may experience one or two of the symptoms, while another experiences all of them. These are the symptoms that are associated with asthma:
- A shortness of breath and breathing difficulty is the most common and obvious sign that a patient has asthma. At times the patient will find that their ability to breath become worse, while other times it may seem to become better.
- Coughing is also a common symptom that patients with asthma experiences and exhibits. Coughing is usually at its worse while the patient laughs or while they are participating in physical activity, such as jogging. A lot of patients with asthma also experience worse coughing at night.
- Many asthmatic patients also note a whistling sound coming from their chest while they are breathing. The whistling sound is often worse while the patient exhales than it is while they inhale.
- A tight feeling in the chest area is also a common symptom that asthma causes. Many people find that this symptom causes them to feel like a band is being tightened around their chest.
The Symptoms of An Asthma Attack
An asthma attack occurs when a patient experiences a sudden worsening effect in the asthma symptoms they experience. While the symptoms of an asthma attack are very similar to asthma itself, it is important to note that additional symptoms may also be experienced. The symptoms that occur in asthma patients and during an asthma attack is much worse during the attack. The following symptoms are linked to an asthma attack:
- The wheezing sound that is projected from the patient’s chest becomes severe while they inhale and exhale.
- The patient usually starts to cough excessively. In many cases, the patient is unable to stop coughing during the asthma attack.
- The tight feeling in the patient’s chest is accompanied by a pressure feeling.
- The patient will start to breathe rapidly and they will find it difficult to speak during the attack.
- The patient’s face becomes pale, accompanied by excessive sweating on the face.
- Retractions are also rather common in patients who experience an asthma attack. This causes the chest and neck muscles to tighten.
- A panic or anxious feeling is often experienced during the attack.
- In some cases, especially when the asthma attack is severe, the patient’s fingernails and lips may turn blue.
Is it an Asthma Attack or A Panic Attack?
An asthma attack and a panic attack often cause similar symptoms to develop in a patient. For this reason, many people confuse the two and a patient interprets their particular situation incorrectly (a patient may think they are having an asthma attack, but, in reality, they may be having a panic attack). The fact that the two attacks are often associated with each other and that similar symptoms may develop make it much more important to know about the differences in the two conditions. This will allow a patient to determine the specific type of attack they are having (if they should ever have on) and will help them follow appropriate treatment methods. If a patient does not know which type of attack they are having, then the incorrect treatment methods may be executed, which means the condition will not be treated effectively and symptoms can worsen.
Since we have already covered the most common symptoms of both asthma and an asthma attack, let’s take a look at the symptoms that are associated with a panic attack and what a panic attack really is. You should note that a panic attack is considered to be less dangerous than an asthma attack. A common symptom that patients experience is tightness in their throat. This is also the reason why people often get confused between these two attacks – while the one makes it feel like the airways are becoming narrow, the other one actually does make the airways narrower by inducing inflammation and producing mucus. Several symptoms have been associated with a panic attack, but a patient may not always experience all of them at the same time. To classify a situation as a panic attack, a patient should experience at least for of the symptoms though. These symptoms include:
- Shaking and trembling
- Excessive sweating, usually throughout the entire body.
- Heart rate that is accelerated, accompanied by a pounding heart and often palpitations.
- Discomfort in the chest, often accompanied by pain.
- A light-headed, dizzy feeling. Some patients feel like they are going to faint and, in rare cases, they do faint.
- Tingling or a numbness sensation. This could affect the entire body, but is sometimes experienced in concentrated areas.
- Heat or chill sensations.
While these are not the only symptoms that have been associated with a panic attack, they are the ones that patients most commonly experience in such a scenario.
What Causes Asthma?
Scientists have not discovered exactly why asthma develops in the human, but they have identified some potential aspects that contribute to the development of the symptoms related to the disease. Mayo Clinic reports that, in most cases, asthma is not caused by a single element, but rather by a combination of certain genetic, risk and environmental factors. Several elements within each range of these factors have been identified by medical experts. By considering these factors, a patient can determine how big of a risk they have of developing the disease – the more factors present in the patient’s life, the higher their chance of being diagnosed with asthma. To better understand how asthma develops and what causes an increased risk of developing this disease, let’s take a look at the elements that are involved with each category of causes that have been associated with asthma.
Asthma triggers refer to environmental factors that irritate the airways and cause an allergic reaction in the body to be triggered. When a “trigger substance” enters the patient’s body and it triggers their allergies, ten symptoms of asthma may start to flare up. Many younger people who have asthma experience the symptoms related to the disease due to asthma triggers. It is important to note that asthma triggers are not the same for every person – a substance that triggers such a reaction in one patient might not trigger the same response in another patient that has been diagnosed with asthma. In some cases, asthma triggers are not allergens, but rather other substances that can worsen the symptoms of the disease and cause flare-ups. The most common substances and factors referred to as asthma triggers include:
- As we have already discussed, allergens can be an asthma trigger and cause the symptoms of the disease to worsen. Different patients react differently to certain allergens; thus the specific allergen asthma triggers can vary from one patient to another. Some common types of allergens that can cause an asthma flare-up includes animal dander, pollen, house dust mites, molds and more.
- A bacteria or viral infections can also cause symptoms of asthma to worsen and is also referred to as asthma triggers. Some popular examples of viral infections that have an impact on asthma include sinusitis and the common cold.
- Being exposed to certain weather changes or conditions, such as dry air that is very cold, can also trigger an asthmatic response.
- Certain prescription and over-the-counter medication is also known to be asthma triggers as they can worsen the symptoms a patient with asthma experiences. Medication that is used to treat certain conditions, such hypertension, migraines and heart disease are popular examples of drugs and medication that can induce such a response in the body. Specific examples include beta-blockers and NSAIDs, also known as non-steroidal anti-inflammatory drugs, like ibuprofen.
- If a user has acid reflux, they may find that it also worsens the symptoms they are experiencing. Acid reflux can be an asthma trigger even when it is not accompanied by heartburn.
- Patients who smoke tobacco products also often find that the smoking is causing their symptoms to flare up – sometimes dramatically. This is because the smoke irritates the airways, which can cause an inflammatory response that can lead to asthmatic symptoms.
- Exercise-induced bronchoconstriction, also known as EIB, is also caused by an allergy trigger – which is physical exercise in the case. If a patient has asthma and participates in an exercise routine, they may experience a sudden worsening of the symptoms due to a restriction placed on their airways during physical activity.
- In some cases, stress and anxiety can also contribute towards the worsening of asthma symptoms. This can sometimes even lead to an asthma attack. Patients should realize that anxiety and stress can also lead to a panic attack, which may exhibit similar symptoms as asthma does; thus it is often difficult to determine the specific kind of attack a patient is experiencing.
Asthma Risk Factors
Apart from asthma triggers, medical experts have also identified certain risk factors that contribute to a higher chance of developing asthma. Some risk factors account only for younger children, while others account for older people or patients of any age. Understanding the elements that are associated with an increased risk of developing asthma helps a patient better understand how they could have developed the disease.
The American Lung Association reports that the following are the most common risk factors that contributes to a higher chance of being diagnosed as an asthmatic patient:
- Family History of Asthma – If a person has a parent with asthma or the disease runs in their family, they are at a much higher risk of developing the disease. In fact, it is reported that the risk of being diagnosed with asthma increases by 600% of a person’s parent is asthmatic.
- Exposures at The Workplace – People who are constantly exposed to certain substances at their workplace are more likely to experience asthmatic symptoms than those who are not exposed to such substances. Examples of potential substances that may cause these symptoms to occur include molds, wood and industrial dust, as well as chemical vapors and fumes.
- Regions With High Levels of Air Pollution – While there is a global epidemic regarding air pollution, some regions have much higher air pollution levels than others. People who live in the areas with higher levels of air pollution are also at a higher risk of becoming asthmatic. Urban living areas are often the regions that have higher levels of pollution in the surrounding air.
- Being Overweight Or Obese – Obesity and overweight have many complications for the human body and can also increase a person’s risk of being diagnosed as an asthma patient. The specific reasons why excess weight poses as a risk factor asthma are still unclear, but medical experts do believe that it is because of the low-grade inflammation that occurs in the human body when there is too much excess weight. Studies also suggest that asthmatic patients who are overweight experience worse symptoms that patients who are at a healthy weight.
The Complications Asthma Poses on A Patient’s Life
The symptoms of asthma can be controlled effectively, but the disease still poses a threat to any patient who has been diagnosed as asthmatic. This is why it is so important to follow a well-structured treatment plant that is set out by a doctor. The better the disease is managed, the fewer complications it may pose on a specific patient’s daily life. When a patient fails to properly control their asthmatic symptoms, then certain complications may become present.
- Asthma that is not properly management can lead to excessive tiredness.
- A lot of asthmatic patients who does not follow a decent treatment plant often find that their performance at school (or work) lacks. Many of these patients also notice that they are more absent from work. This can lead to a patient falling behind with work and missing out on important events.
- If a child has asthma and the disease is not controlled with effective medication and a treatment plant, then there may be problems with their growth and their puberty may be delayed.
- Leisure time and activities can be cut short or even put off due to asthmatic symptoms flaring up. Since an unexpected doctor’s appointment is often needed in such a case, the patient may have to skip an event or special function they were supposed to attend.
- Patients diagnosed with asthma who do not control their symptoms and receive ongoing treatment for the disease are more likely to develop an infection in their lungs, also known as pneumonia. Pneumonia, in turn, can cause a high fever, chills, chest pain and it can cause further problems with the patient’s ability to breath.
- If symptoms keep getting worse and the patient does not obtain adequate treatment to help them control the symptoms better, then more severe complications may develop. A common complication is a severe asthma attack that could completely block the airways of the patient, leading to the inability to breathe air into or out of their lungs.
- Asthma does not only hold complications for a patient’s physical health, but can also have a negative effect on their mental health. Since the symptoms of the disease can flare-up at any time and even lead to a severe asthma attack, patients often tend to develop anxiety and stress. In more serious cases, asthma may even contribute to the development of symptoms that are related to depression.
When Should You See A Doctor?
Whether you have asthma or think that you might have asthma, a visit to the physician should not only be a priority when an asthma attack strikes. In fact, getting a checkup at a doctor or certified asthma nurse is also important if a person is experiencing any of the symptoms that are related to asthma. Detecting and diagnosing the disease at an early stage often means it can be treated more effectively and the risks of the disease worsening to a severe state could also be reduced. A patient should see a doctor for the following factors:
- Asthma Attack – The most obvious reason for seeing a doctor is in case of an emergency. If a person experiences symptoms of an asthma attack, it is vital that they seek immediate medical attention. If asthmatic symptoms are not improving after a person uses an inhaler that provides quick relief, then they should also seek assistance from a doctor. Being short of breath after doing just a small amount of physical activity is also a sign that symptoms may be worsening, which is another concern for a doctor’s appointment.
- Experiencing Symptoms Of Asthma – Even if a person has not been diagnosed with asthma, they should still make an appointment with a doctor if they suspect they might have the disease. Experiencing symptoms such as a shortness of breath, coughing and a whistling sound while breathing is all signs of asthma. Experiencing these symptoms should not be taken lightly.
- Worsened Symptoms – If an asthmatic patient feels that their symptoms are getting worse, then they should also contact their doctor for an appointment. Symptoms that are worsening can often be a sign of an oncoming asthma attack. A doctor will be able to determine what is causing the symptoms to worsen and provide the patient with an appropriate treatment solution.
- Monitoring – Patients diagnosed with asthma should not delay an appointment with their doctor until an emergency strike – even when symptoms are not severe, they should still make an appointment with their doctor frequently to monitor the progress of their disease and to ensure the medication are working efficiently. Since asthma can change in time, the treatment a patient receives may need to be changed without the patient knowing – a visit to the doctor will help a patient determine if there are any changes in their condition and whether changes to their treatment plan is needed.
How Asthma Is Diagnosed?
If a patient suspects they might have asthma and pay a visit to their doctor, then the doctor will have to perform several tests in order to determine whether or not asthma is, in fact, causing the symptoms. The doctor will start with a physical exam and a series of questions. This will help the doctor determine if the symptoms may be caused by another medical condition, like a respiratory infection. If the physical exam and questionnaire point towards the possibility of asthma, then the doctor will perform additional tests to diagnose the patient’s disease.
Lung Function Measurement
The first step is to measure the patient’s lung function. These tests allow the doctor to determine the amount of air that flows into their lungs while they inhale and how much air flows out of their lungs when they exhale. There are two standard tests that a doctor can use to measure a patient’s lung function. Both tests are usually performed with a bronchodilator (like albuterol). One test is done before and one test after usage of the device. If the patient’s condition improves with the use of a bronchodilator, then there is a good chance that they have asthma.
- A spirometry test is done to determine how narrow the bronchial tubes are. The test monitors the amount of air that is exhaled after the patient takes a deep breath, followed by quickly exhaling.
- A peak flow test is also done to determine how hard the patient can exhale. If the patient’s peak flow levels are too low, then it means their lungs are not working as they should be working.
In addition to the lung function measurement tests, a series of additional tests can also be used to medically diagnose asthma in a patient.
- A patient may be asked to inhale a substance known as Methacholine. The substance is an asthma trigger that will cause the patient’s airways to constrict mildly if they do have asthma.
- Nitric oxide levels in the patient’s breath may also be tested. High levels of this gaseous molecule may be an indication of asthma.
- Additional tests that may also be performed include x-rays, high-resolution computerized tomography tests, allergy tests, testing for cold-induced asthma, testing for exercise-induced asthma and a sputum eosinophils test.
Asthma Control and Management Plant
Once a patient has been diagnosed with asthma, a doctor will start by determining the severity of the patient’s specific condition and then discuss the available options with the patient. In addition to providing the patient with medication that will help control the symptoms of their disease, an asthma management plan will also be compiled with the patient to help them manage their symptoms and keep them from becoming worse. The National Asthma Council Australia reports that an asthma action plan is often considered to be the most efficient way to prevent asthma attacks and to reduce the risk of the disease-causing other severe symptoms. They also report that an action plant for asthmatic patients will help them lessen the number of days they are absent from work, reduce their number of hospital admissions and it can contribute to improving their overall lung function.
The goal of an asthma plan is to help a patient better understand their condition. It tells the patient when they need to seek medical attention, how to determine if their symptoms or getting worse, how different types of asthma medication can help them manage their symptoms and it will teach the patient how they can personally monitor their condition on a day-to-day basis. An action plan is also a way to keep the contact number of a doctor handy at all times and will also instruct family members and friends of the patient about what steps they need to take in case of an emergency.
Conventional Treatment Options for Asthma
As part of an asthma management plan, a doctor will most likely provide several treatment methods for the patient to reduce the severity of their symptoms and to control the condition. The disease itself, however, does not have any cures at the moment. There are, however, different types of medication that a patient can use to help them stay in control of the disease.
To understand how conventional treatment options work, a patient needs to understand that there are two types of medication that can be provided to them by their doctor. These two types include controller medications, which is used to prevent the patient from having an asthma attack and to help reduce the risks of triggers causing asthma symptoms to flare up, and quick-relief medications, which is often referred to as “rescue medications” – this type of medication is used when the patient experience a worsening of their symptoms as they relax the muscles that surround the patient’s airways, thus causing them to breathe easier.
Controller Medication (Long-Term Relief)
The most common controller medication that is given to patients with asthma includes the following:
- Mast Cell Stabilizers – This medication works by reducing the release of particular chemicals in the body that causes tissue to become inflamed. Mast Cell Stabilizers may cause some side effects to develop, such as a runny nose, an unpleasant taste in the patient’s mouth, headaches, irritation in the patient’s throat and coughing.
- Leukotriene Modifiers – This medication also blocks the release of chemicals that causes inflammation in the body. Side effects of Leukotriene Modifiers may include headaches, pain, muscle ache, a sore throat, an upset stomach and nausea.
- Beta-Agonists (Long-Acting) – This medication is also called a bronchodilator. It is often used during the initial lung function measurement tests. The medication opens up the patient’s airways. Common side effects include anxiety, muscle tremors, heart palpitations, nausea and headaches.
- Theophylline – This is also a bronchodilator that is specifically used to prevent symptoms from flaring up at night. Some patients have experienced vomiting, rapid heartbeats, confusion, shaking and severe headaches as side effects.
- Immunomodulators – This medication is in the form of an injection. It is used to provide relief of asthma in patients with moderate to severe levels of symptoms. The medication is specifically used to reduce the symptoms of asthma caused by allergies or when the immune system does not respond correctly to other drugs. Patients may experience some side effects, such as nausea, diarrhea, headaches and nausea.
While controller medication is used for long-term prevention of asthma symptoms, quick-relief medication is used whenever the symptoms of the disease start to get worse. It is often recommended to use quick-relief medication when the patient is experiencing symptoms that are related to an asthma attack. The following medications are classified as quick-relief medication:
- Beta-Agonists (Short-Acting) – This medication is a bronchodilator that offers fast acting results. They open up the airways to allow the patient to breathe.
- Systemic Corticosteroids – This medication is a particular type of anti-inflammatory drug that helps to reduce the severity of symptoms by reducing inflammation in the airways. Patients that use systemic corticosteroids to manage their symptoms often experience side effects that include mood swings, easy bruising, an increase in their appetite, weak muscles, a higher risk of obtaining an infection, a swollen face and blurred vision.
- Anticholinergics – This is another type of bronchodilators that are often used with the short-acting type of beta-agonists.
Homeopathic Treatment Options For Asthma
Many patients who learn they have asthma are not keen on using prescription medication to help them control their symptoms due to the potential side-effects that may develop. These people do have another option – homeopathic treatment methods. Homeopathic treatments include the use of natural substances to control the symptoms of the specific disease. Green Mountain Health reports that homeopathic treatment for asthma can help the patient reduce their allergic exposure, reduce their histamine exposure and provide other benefits that will help the patient control their symptoms more effectively.
Everyday Health recommends trying the following natural substances to find relief of the symptoms of asthma. Many of these substances will not provide an immediate positive effect, but rather work in the long-term to provide an efficient reduction in the severity of the patient’s disease.
Are There Ways To Prevent Asthma Attacks?
Patients who have asthma often find the symptoms to be unpleasant and it may even cause them to become anxious. The disease puts a lot of stress upon a patient as they constantly have to worry about possibly having an asthma attack when they are not in reach of emergency care. Fortunately, there are many different ways in which a patient can prevent their symptoms from becoming worse and even avoid an asthma attack. The most important part of prevention is to identify the patient’s specific asthma triggers. Since these varies from one person to another, each person will have to determine what triggers an asthmatic reaction in them. An allergist can often be helpful in determining asthma triggers. Once these triggers have been identified, the patient can take the appropriate steps to avoid them.
In some cases, asthma’s symptoms can be made worse by other medical conditions. When a patient develops a disease or illness that can increase the severity of the symptoms they experience due to asthma, then they should take appropriate actions to treat the medical condition as soon as possible to reduce the risk of the condition making things worse for them. Common medical conditions that interfere with asthma include psychological stress, reflux disease, sleep apnea and sinus infections.
Asthma may not always be a bothersome condition, but the airways of asthmatic patients are inflamed at most times and the inflammation can become worse at any time. When this happens, the patient may experience symptoms that can not only be uncomfortable and unpleasant, but also fatal. If symptoms become too worse, then the patient may have an asthma attack which, if not treated, can even lead to the death of the patient. Knowing the symptoms helps a patient detect the disease early, which helps the patient obtain an effective management plan that will help them control the symptoms and reduce the risk for life-threatening flare-ups.