A dermatome is an area of skin that is … When the virus is reactivated in this nerve branch it is termed zoster ophthalmicus.The skin of the forehead, upper eyelid and orbit of the eye may be involved. Arshad AR, Alvi KY, Chaudhary AA. chickenpox. 1986;122:282-285. Herpes zoster (shingles… There are eight cervical nerves (C1 being an exception with no dermatome), twelve thoracic nerves, five lumbar nerves and five sacral nerves. 1965;58:9-20. What is a dermatome. Ballooning multinucleated giant cells were cytological findings of Tzanck smear done from the lesion and confirmed herpes infection. Dr. Brodell serves on speakers’ bureaus for Galderma Laboratories LP, PharmaDerm, and AbbVie. The sacral dermatomes cover skin on the genital and anal regions; back of the legs, ... Dermatomes are helpful in assessing certain health conditions such as shingles… The dermatomes, as depicted in the … Shingles may have additional symptoms, depending on the dermatome involved. ... and 5 sacral nerves. The vertebrae are classified as C for cervical, T for thoracic, L for lumbar, and S for sacral … A common childhood disease caused by the varicella-zoster virus. Key Terms. Difference Between Sacral Herpes and Shingles. Aggarwal SK, Radhakrishnan S. A clinico-epidemiological study of herpes zoster. Urological manifestations of herpes zoster. Eur Urol. J Infect Dis. If you agree to our use of cookies and the contents of our Privacy Policy please click 'accept'. From submission to first editorial decision. A 35-year-old woman sought care at our dermatology clinic with the self-diagnosis of “recurrent shingles,” noting that she’d had a rash over her sacrum on and off for the past 10 years. The patient was prescribed valacyclovir hydrochloride, 500 mg three times daily for five days. Also known as herpes zoster, shingles is an acute viral inflammation of the sensory ganglia of spinal and cranial nerves associated with a vesicular eruption and neuralgic pains and caused by reactivation of the poxvirus causing chicken pox. Javascript is currently disabled in your browser. 2. 2010;15(44). sides of the shingles as quickly and spreading of the vaccine shingles sacral dermatomes against injury. Ooi C, Zawar V. Hyperaesthesia following genital herpes: a case report. Pain and skin lesions had started 5 days and 1 day, respectively, before admission to hospital. Dermatomes are useful to help localize neurologic levels, particularly in radiculopathy. Once a clinical … Less commonly, the rash can be more widespread and affect three or more dermatomes. Obstet Gynecol. You can learn about what data of yours we retain, how it is processed, who it is shared with and your right to have your data deleted by reading our Privacy Policy. Shingles (herpes zoster) results from a reactivation of the virus that also causes chickenpox. It causes chickenpox and herpes zoster … The disease followed an uneventful c … The trigeminal nerve is the most commonly involved nerve, of which the ophthalmic division is the most commonly involved branch. •  software development by maffey.com The authors report no conflicts of interest in this work. Jul 9, 2013 - Nerve Chart For Shingles | Adult dermatome.. Shingles (Herpes Zoster) Herpes zoster, or just zoster is an affliction of the skin. •  Associations & Partners   Creative Commons Attribution - Non Commercial (unported, v3.0) License. Dermatomes are regions of skin innervated by a single spinal nerve. Myotomes is a group of single spinal nerves that originate from groups of muscles. Goldberg LH, Kaufman R, Conant MA, et al. 2008;168:1137-1144. The skin over your entire body is supplied by somatic sensory neurons that carry nerve impulses from the skin into the spinal cord and brain. 2009 Aug 13339:b2624. In the limbs, long strips of skin are innervated by a single segment of the cord. 2009 Jun109(6 Suppl 2):S7-12. A dermatome is an area of skin which is innervated by a single spinal nerve. Unauthorized use prohibited. … Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface that is served by the nerve (dermatome). Catheterisation showed a residual of 2000 ml. However, people do not get shingles right after they get infected … This site is owned and operated by Informa PLC ( “Informa”) whose registered office is 5 Howick Place, London SW1P 1WG. Domeika M, Bashmakova M, Savicheva A, et al; Eastern European Network for Sexual and Reproductive Health (EE SRH Network). ; A dermatome is an area of skin … •  Recommend this site Typically, it is a unilateral lesion which can affect both cranial and peripheral nerves. •  Top, © Copyright 2020  •  Dove Press Ltd   Ethical Approval was obtained from the Ethics Committee of Nicolina Medical Center, Iaşi. 2006;108:947-952. Infect Chemother. •  Privacy Policy   When the lower, sacral spinal cord is involved, bladder symptoms from shingles … Before you get the look and feel of your roof. Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review. There are 30 pairs of dermatomes in the body, from the skull to the toes, and each can be traced back to a specific nerve root.Although most maps of the dermatomes show distinct zones, there is in fact a fair amount of overlap, but understanding how these areas work can be important in the … Register your specific details and specific drugs of interest and we will match the information you provide to articles from our extensive database and email PDF copies to you promptly. 2015;47(2):133–136. •  Terms & Conditions   Arch Dermatol. The clinical presentation of herpes zoster depends on the age and health of the patient and which dermatome is affected. Three case reports and a review of the literature. The distribution was consistent with the S1 dermatome, and a diagnosis of herpes zoster was made. 3. The varicella-zoster virus is the enemy in this storybook tale. The incidence (and severity) of shingles increase with age. ; chickenpox: A common childhood disease caused by the varicella-zoster virus. Our patient thought she had a case of “recurrent shingles,” but the location of the blisters and the frequency with which they appeared told a different story. The takeaway Dermatomes are areas of skin that are connected to a … Contiguous dermatomes overlap, and each individual’s exact dermatomal pattern is unique. Herpes zoster is an infectious vesicular skin rash in a dermatomal distribution caused by Varicella zoster virus. 2011;41(4):e8–e11. Dr. Key Terms. We describe a case with rash on penis and scrotum due to involvement of S2 dermatome in a young male. A dermatome is an area of skin that is mainly supplied by afferent nerve fibres from the dorsal root of any given spinal nerve. The reactivation rate of herpes zoster virus correlates with the decrease of immunity and with age.6, Subclinical reactivation of the virus has been described in some patients in response to stress,7 although, during lifetime, the immune system of the host contributes to the maintenance of immunity against herpes zoster virus .8, Sacral herpes zoster is rare and is usually located in S2–4 dermatome affecting the lower urinary tract,2-4 penis and scrotum,9 and rectum associated with constipation.10, A case of restless legs syndrome was reported in association with herpes zoster affecting S1 and S2 dermatomes, with zosteriform lesions located on the left buttock and the posterior aspect of left lower limb in the presence of high titer of varicella zoster virus-specific IgM in the blood, but no strict correlation was accomplished.10,11. J Pain Symptom Manage. The incidence of herpes zoster. Dove Medical Press is a member of the OAI. Sacral herpes zoster is rare and is usually located in S2–4 dermatome affecting the lower urinary tract, 2-4 penis and scrotum, 9 and rectum associated with constipation. However, it is still HSV-2 and considered to be a form of genital herpes. It is caused by the reactivation of the varicella-zoster virus, the virus which causes chicken pox. Feel better. He has served as a consultant for F. Hoffmann-La Roche AG and Galderma Laboratories LP, and has performed multicenter clinical trials for Janssen Pharmaceuticals, Galderma Laboratories LP, and Genentech. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. Saved by Eastern Therapeutics. open access to scientific and medical research. Patient concerns: A 52-year-old man presented with acute pain and voiding dysfunction, following HZ in his right sacral dermatomes. Several features of The opinions expressed in all articles published here are those of the specific author(s), and do not necessarily reflect the views of Dove Medical Press Ltd or any of its employees. A shingles invasion into the T1 dermatome has, in some case studies, resulted in significant weakness in the hands. A 63 year old woman presented with suprapubic pain, a palpable bladder, and multiple grouped vesicles on the right buttock. The nature of herpes zoster: a long-term study and a new hypothesis. 4. Proc R Soc Med. 5th ed. Herpes zoster-associated urinary retention is a rare but acknowledged phenomenon. Dermatome. Severson JL, Tyring SK. It is due to the reactivation of the virus which remains dormant in sensory ganglions following chicken pox. PLoS ONE. Back to Journals » Journal of Pain Research » Volume 12, Authors Chiriac A, Chiriac AE, Naznean A, Moldovan C, Podoleanu C, Stolnicu S, Published 10 May 2019 As a child, you may recall being kept home from school for a few days because of tiny red spots all over your body. The neck and hands are innervated by cervical spinal nerves; the legs are innervated by lumbar and upper sacral nerves, while the perineum has innervation from the sacral … Up to 20 vesicles may appear outside the dermatome, but if more than 20 vesicles are outside the dermatome the shingles is considered “disseminated.” Disseminated Herpes Zoster occurs almost exclusively in immunosuppressed patients and the eruption can appear like chickenpox as vesicles are found over the entire body. doi:10.1002/(ISSN)1096-9071, 7. Oral acyclovir for episodic treatment of recurrent genital herpes. We also retain data in relation to our visitors and registered users for internal purposes and for sharing information with our business partners. The neck and hands are innervated by cervical spinal nerves; the legs are innervated by lumbar and upper sacral nerves, … This work is published and licensed by Dove Medical Press Limited. It is also known as shingles or zona. A dermatome is an area of skin that is mainly supplied by a single nerve coming out of the spine. The C1-C7 nerve roots emerge above their respective vertebrae; the … MDedge: Keeping You Informed. 2017;19:1–12. Viruses that infect spinal nerves, such as herpes zoster infections (shingles), can reveal their origin by showing up as a painful dermatomic area. A case is reported of acute urinary retention secondary to herpes zoster infection of the sacral nerves (S2–4). J Coll Physicians Surg Pak. The pain may be just in one spot, or it may spread out. When the dermatome is C8 (the spinal nerve exiting between the C7 and T1 vertebrae), the pain and lesions may occur over the scapula (the “wingbone”). 12. Flowers reported no potential conflict of interest relevant to this article. ; A dermatome is an area of skin that is … 9. ICD-Code / International Statistical Classification of Diseases and Related Health Problems (ICD) for: Herpes zoster involving sacral dermatome ICD Code for Disease, Diagnosis B02.29 ICD Code an Classification Other postherpetic nervous system involvement Saving You Time. A comparison of the Tzanck smear and viral isolation in varicella and herpes zoster. Systemic administration of acyclovir 3 g/day orally for 10 days and NSAIDs were recommended, with favorable evolution and no complications for short or long term. Isolation of herpes simplex virus from the genital tract during symptomatic recurrence on the buttocks. J Neuroophthalmol. Smith JS, Robinson NJ. Each segment is called a dermatome, and is innervated by a single pair of spinal nerves. It may also appear on other parts of … 11. Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review. Understanding the nerve distribution along the dermatomes is helpful in determining how certain diseases, such as shingles and some other neurological conditions, target one area of the body. In a shingles outbreak, the virus awakens and travels along the nerves, causing inflammation. Herpes zoster (shingles), a viral infection caused by varicella-zoster virus. Anti-VZV IgM was negative, but anti-VZV IgG was positive. Influence of frequent infectious exposures on general and varicella-zoster virus-specific immune responses in pediatricians. Whitley RJ. The disease results when varicella-zoster, the virus that causes chicken pox, reawakens in sensory nerve roots. Med J Armed Forces India. Sacral nerves and their dermatomes. In these cases, the rash will involve the eye and face. The first sign of herpes zoster is usually pain, which may be severe, relating to one or more sensory nerves. We present a very rare case of herpes zoster involving S1 dermatome in a 35-year-old healthy man who presented aching pain and typical herpes zoster eruption on the lateral aspect of the calcaneus, lateral plantar area and dorsal aspect of digits III and IV.Keywords: herpes zoster, S1, pain, sacral zoster, Herpes zoster affects the thoracic and lumbar nerves and dermatomes (T3–L3) in the majority of cases;1 sacral herpes is very rare and it has been reported in only 4–8% of cases.2 When herpes zoster virus affects sacral nerves S2–S3 (motor and sensory nerves of the bladder), urinary dysfunction is reported,2,3 as well as constipation or bowel incontinence.4 Sacral herpes zoster has been described in elderly or in patients with impaired immune system.2. J … 8. In these cases, the rash will involve the eye and face. Shingles is usually a very painful condition that begins with itching, pain, or tingling on one side of the body along a single spinal nerve traveling in the pattern of a "dermatome". 10. Understanding the nerve distribution along the dermatomes is helpful in determining how certain diseases, such as shingles and some other neurological conditions, target one area of the body. Herpes zoster affects the thoracic and lumbar nerves and dermatomes (T3–L3) in the majority of cases;1 sacral herpes is very rare and it has been reported in only 4–8% of cases.2 When herpes zoster virus affects sacral nerves S2–S3 (motor and sensory nerves of the bladder), urinary dysfunction is reported,2,3 as well as constipation or bowel incontinence.4 Sacral herpes zoster has been described in elderly or in patients with im… 1995;98:237-242. Each segment is called a dermatome, and is innervated by a single pair of spinal nerves. Herpes zoster, a virus that can be dormant in the dorsal root ganglion, migrates alon… Galluzzi KE; Managing herpes zoster and postherpetic neuralgia. When the dermatome is C8 (the spinal nerve exiting between the C7 and T1 vertebrae), the pain and lesions may occur over the scapula (the “wingbone”). Know more. Dermatomes exist for each of these spinal nerves, except the first cervical spinal nerve. We present a typical case of herpes zoster S1 type with zosteriform eruption within S1 dermatome, intense pain and we review the literature related to S1 herpes zoster. Corey L, Adams HG, Brown ZA, et al. It is usually a self-limiting disease; however, it may cause significant morbidity especially in the … Richmond W. The genito-urinary manifestations of herpes zoster. Before you get the look and feel of your roof. Cohrs RJ, Mehta SK, Schmid DS, Gilden DH, Pierson DL. Feel better. Genital herpes simplex virus infections: clinical manifestations, course, and complications. UK VAT Group: GB 365 4626 36. Herpes zoster involving penis and scrotum: an unusual occurrence. Smith JS, Robinson NJ. All rights reserved. Figure 2 S1 dermatome area, anatomically delineated by the lateral aspect of the foot, the heel, and most of the sole; L4–5: lumbar dermatoma. It’s not uncommon for a single existing layer of shingles. Sacral Herpes is an HSV-2 infection, the same virus responsible for genital herpes, except that doesnt appear in the genital or groin area. Relation between herpes simplex viruses and human immunodeficiency virus infections. Diagnoses: Twenty two days before presentation HZ occurred and 9 days after the onset of the HZ, he had trouble with … Acute urinary retention in women is uncommon. The rash does not usually cross the body’s midline. shingles: Also known as herpes zoster, shingles is an acute viral inflammation of the sensory ganglia of spinal and cranial nerves associated with a vesicular eruption and neuralgic pains and caused by reactivation of the poxvirus causing chicken pox. 2014;21(3):417–426. Herpes zoster is an infectious vesicular skin rash in a dermatomal distribution caused by Varicella zoster virus. Shingles is caused by the varicella zoster virus, the same virus that causes chicken pox. Asymptomatic reactivation and shed of infectious varicella zoster virus in astronauts. The neck and hands are innervated by cervical spinal nerves; the legs are innervated by lumbar and upper sacral nerves, … A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Close: Dermatomes and Myotomes: Innervation of Skin by Spinal Nerves. Jul 9, 2013 - Nerve Chart For Shingles | Adult dermatome.. Hur J. Sacral herpes zoster associated with voiding dysfunction in a young patient with scrub typhus. 23. Am J Med. S1: the lower back, buttocks, backs of the legs, ... Shingles, or herpes zoster, is a viral infection caused by the reactivation of the varicella-zoster virus. P rog esiv d fc ul ty n aw p h last 24 hours with an eventual urinary retention eight hours later after presentation. All rights reserved. Copyright  © 2020 Frontline Medical Communications Inc., Parsippany, NJ, USA. Dermatological examination revealed painful erythematous grouped vesicles within S1 dermatome and clinical diagnosis of herpes zoster was made. It usually appears as herpes on the back or buttocks, and is sometimes misdiagnosed as shingles. It is caused by the HHV3 virus, which is also known as the varicella zoster virus (VZV). Less commonly, the zoster virus will find its way to ganglion of the trigeminal nerve in the brain. A couple of days later a rash develops over the … The trigeminal nerve is the fifth cranial nerve, represented by V. Physical examination revealed 3 groups of vesicular lesions, each on an erythematous base, located bilaterally over the gluteal cleft. doi:10.1016/j.mjafi.2015.05.003, 6. Frequency and reactivation of nongenital lesions among patients with genital herpes simplex virus. When the virus is reactivated in this nerve branch it is termed zoster ophthalmicus.The skin of the forehead, upper eyelid and orbit of the eye may be involved. A 35-year-old woman sought care at our dermatology clinic with the self-diagnosis of “recurrent shingles,” noting that she’d had a rash over her sacrum on and off for the past 10 years. 23. Sanjay S, Chan EW, Gopal L, et al; Complete unilateral ophthalmoplegia in herpes zoster ophthalmicus. Copyright 2017 Informa PLC. Ann Intern Med. It is typified by a painful skin rash with blisters and is limited to one particular side of the body. Well, that is one vertebra in your spine! In order to provide our website visitors and registered users with a service tailored to their individual preferences we use cookies to analyse visitor traffic and personalise content. We describe a case with rash on penis and scrotum due to involvement of S2 dermatome in a young male. The virus can lie dormant in the spinal nerve ganglia , producing a rash and pain along the corresponding dermatome. Laboratory tests, including HIV and hepatitis serology, proved to be within normal limits. 2015;25(3):218–219. Solomon AR, Rasmussen JE, Weiss JS. Each of these nerves relays sensation (including pain) from a particular region of skin to the brain. Clin Vaccine Immunol. Harrison‘S Principles of Internal Medicine, 18th ed. Written informed consent has been provided by the patient to have the case details and any accompanying images published. By accessing the work you hereby accept the Terms. Br J Urol. There are 8 cervical nerves (C1 being an exception with no dermatome), 12 thoracic nerves, 5 lumbar nerves and 5 sacral nerves. Herpes zoster (HZ) involving sacral dermatome is very rare, which can sometimes cause voiding dysfunction. S1 dermatome is anatomically delineated by the lateral aspect of the foot, the heel, and most of the sole (Figure 2). 5. Know more. It is usually confined to a single dermatome but may involve 2-3 dermatomes. Cernik C, Gallina K, Brodell RT. Shingles: Shingles is known as herpes zoster, which anyone who has ever had chicken pox already has in their system. Sacral dermatomes are the least frequently affected, making up 2% to 8% of cases. Lam FC, Law A, Wykes W; Herpes zoster ophthalmicus. 3. When a person catches chicken pox, after the virus has run its course, it lies dormant in the sensory nerves in the skin. Sensory information from a specific dermatome is transmitted by the sensory nerve fibers to the spinal nerve of a specific segment of the spinal cord. doi: 10.1136/bmj.b2624. Rationale: Herpes zoster (HZ) involving sacral dermatome is very rare, which can sometimes cause voiding dysfunction. Sores on the privates, while alarming, are not life-threatening. Knowledge of dermatomes can aid in the diagnosis of disease. Thoracic and lumbar dermatomes are the most commonly affected. Dermatomes are regions of skin innervated by a single spinal nerve. 10. 2011;2011:903595. The patient usually feels quite unwell with fever and headache. Shingles is usually a very painful condition that begins with itching, pain, or tingling on one side of the body along a single spinal nerve traveling in the pattern of a "dermatome". A case is reported of acute urinary retention secondary to herpes zoster infection of the sacral nerves (S2–4). The information provided is for educational purposes only. 14. Ogunjimi B, Smits E, Heynderickx S, et al. Key Difference – Shingles vs Herpes Shingles and herpes are two infectious disease conditions caused by viruses.The key difference between shingles and herpes is that shingles is caused the varicella zoster virus but herpes is caused by the herpes simplex virus.. After the initial infection, varicella zoster virus can remain dormant in the dorsal root ganglia of sensory nerves … • Web Design by Adhesion. 13. There are 7 cervical, 12 thoracic, 5 lumbar, and 1 coccygeal nerve dermatomes. Hal Flowers, MDRobert T. Brodell, MDUniversity of Mississippi Medical Center, Jackson (Dr. In: Longo DL, Fauci AS, Kasper DL, editors. The rash tended to resolve—without treatment—within 5 to 7 days. Many times, the shingles rash only happens once just as the chicken … 2. Wolff K, Johnson RA, Suurmond D. Fitzpatrick’s color atlas and synopsis of clinical dermatology. Urethral catheterisation revealed 1100 ml urine. The 5th cranial nerve is divided into three divisions; V1, V2, and V3, which are responsible for sensation in the face. Arch Dermatol. Dove Medical Press is part of Taylor & Francis Group, the Academic Publishing Division of Informa PLC 5 sacral dermatomes (S1-5) - "S" refers to the sacral or the sacrum, which are located below L5. With shingles, the first thing you may notice is a … 1993;24(2):244–247. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. sides of the shingles as quickly and spreading of the vaccine shingles sacral dermatomes against injury. 4. We discharged the patient 42 days after admission. Shingles is caused by the varicella zoster virus, the same virus that causes chicken pox. Specifically it's the seventh cervical vertebra, known briefly as C7, and we'll chat more about it later. Effacement or encroachment of a spinal nerve may or may not exhibit symptoms in the dermatomic area covered by the compressed nerve roots in addition to weakness, or deep tendon reflex loss. Doctors use dermatomes to help diagnose diseases and conditions. J Am Osteopath Assoc. 1995;98:237-242. ; chickenpox: A common childhood disease caused by the varicella-zoster virus. Face. •  Testimonials   Hope-Simpson RE. Acute urinary retention in women is uncommon. After expansion of the rash, herpes zoster within the S2 to S4 dermatomes with likely pudendal nerve involvement extending to the scrotum became clinically evident. Looker KJ, Magaret AS, Turner KME, et al. 1. Flowers and Dr. Brodell); University of Rochester School of Medicine and Dentistry, New York (Dr. Brodell)[email protected], DEPARTMENT EDITORRichard P. Usatine, MDUniversity of Texas Health Science Center at San Antonio. J Med Virol. A 35-year-old previously healthy man was referred to the Dermatology Clinic for aching pain and clusters of vesicles located on the lateral aspect of the calcaneus, lateral plantar area and dorsal surface of digits III and IV (Figure 1). Intern Med. Shingles (Herpes Zoster) Herpes zoster, or just zoster is an affliction of the skin. 1. Sacral dermatomal involvement of PHN occurs in only 3% of patients.2To our knowledge, sympathetic blockade of the ganglion impar (Ganglion of Walther) has never been described as a useful therapy for PHN of the sacral dermatomes. It may also appear on other parts of your body, including the legs, arms, or face. A dermatome is an area of skin which is innervated by a single spinal nerve. Broseta E, Osca JM, Morera J, Martinez-Agullo E, Jimenez-Cruz JF. 6. shingles: Also known as herpes zoster, shingles is an acute viral inflammation of the sensory ganglia of spinal and cranial nerves associated with a vesicular eruption and neuralgic pains and caused by reactivation of the poxvirus causing chicken pox. It is typified by a painful skin rash with blisters and … Shingles moving into the L1 dermatome is sometimes misdiagnosed as arthritis or fibromyalgia, but can be identified through thermal patterns. Yes, you can get shingles on your buttocks.. You, like ninety-nine percent of the U.S. populous, had the chickenpox. Donahue JG, Choo PW, Manson JE, et al. Global estimates of prevalent and incident herpes simplex virus type 2 infections in 2012. In the limbs, long strips of skin are innervated by a single segment of the cord. Open access peer-reviewed scientific and medical journals. 3. She said that the tender blisters typically appeared in this area 3 to 4 times per year (FIGURE) and that their onset was occasionally associated with stress.. Kerkering K, Gardella C, Selke S, et al. 10. 2012;51(6):651–654. 2015;10:e114989. Benedetti JK, Zeh J, Selke S, et al. The shingles rash most often occurs on the torso and buttocks. Sacral dermatomal involvement of PHN occurs in only 3% of patients.2To our knowledge, sympathetic blockade of the ganglion impar (Ganglion of Walther) has never been described as a useful therapy for PHN of the sacral dermatomes. Euro Surveill. If you tilt your chin towards your chest, then reach up and press on the base of your neck, you should be able to feel a hard bony lump.