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Paul D Blumenthal - One of the best experts on this subject based on the ideXlab platform.
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evaluation of shorter Mifepristone to misoprostol intervals for second trimester medical abortion a retrospective cohort study
Contraception, 2020Co-Authors: Andrea Henkel, Paul D Blumenthal, Klaira Lerma, Kate A ShawAbstract:Abstract Objectives To assess shorter Mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (Mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion). Methods This retrospective cohort study included women who elected for a second trimester medical abortion with Mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of Mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals Results The study population included eighty-nine women, 47, 28, and 14 women in the Conclusions Shorter Mifepristone-misoprostol intervals (less than 24 h) significantly decrease the total abortion time while maintaining a clinically similar induction time. Implications Shortening the Mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems.
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continuing pregnancy after Mifepristone and reversal of first trimester medical abortion a systematic review
Contraception, 2015Co-Authors: Daniel Grossman, Paul D Blumenthal, Beverly Winikoff, Kari White, Lisa H Harris, Matthew F Reeves, David A GrimesAbstract:Objective: We conducted a systematic review of the literature on the effectiveness of medical abortion “reversal” treatment. Since the usual care for women seeking to continue pregnancies after ingesting Mifepristone is expectant management with fetal surveillance, we also performed a systematic review of continuing pregnancy after Mifepristone alone. Study design: We searched PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus and the Cochrane Library for articles published through March 2015 reporting the proportion of pregnancies continuing after treatment with either Mifepristone alone or after an additional treatment following Mifepristone aimed at reversing its effect. Results: From 1115 articles retrieved, 1 study met inclusion criteria for abortion reversal, and 13 studies met criteria for continuing pregnancy after Mifepristone alone. The one report of abortion reversal was a case series of 7 patients receiving varying doses of progesterone in oil intramuscularly or micronized progesterone orally or vaginally; 1 patient was lost to follow-up. The study was of poor quality and lacked clear information on patient selection. Four of six women continued the pregnancy to term [67%, 95% confidence interval (CI) 30– 90%]. Assuming the lost patient aborted resulted in a continuing pregnancy proportion of 57% (95% CI 25–84%). The proportion of pregnancies continuing 1–2 weeks after Mifepristone alone varied from 8% (95% CI 3–22%) to 46% (95% CI 37–56%). Continuing pregnancy was more common with lower Mifepristone doses and advanced gestational age. Conclusions: In the rare case that a woman changes her mind after starting medical abortion, evidence is insufficient to determine whether treatment with progesterone after Mifepristone results in a higher proportion of continuing pregnancies compared to expectant management. Implications: Legislation requiring physicians to inform patients about abortion reversal transforms an unproven therapy into law and represents legislative interference in the patient–physician relationship. © 2015 Elsevier Inc. All rights reserved.
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adjunct Mifepristone for cervical preparation prior to dilation and evacuation a randomized trial
Contraception, 2015Co-Authors: Kate A Shaw, Jonathan G Shaw, Michele Hugin, Griselda Velasquez, Frederick W Hopkins, Paul D BlumenthalAbstract:Abstract Objective The objective was to investigate Mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19 weeks of gestation, with the aim of improving procedure access, convenience and comfort. Methods This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7 weeks of gestation randomized to receive either one set of osmotic dilators plus Mifepristone the day prior to procedure (Mifepristone group) or two sets of osmotic dilators (placed 18–24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects. Results Mean gestational age was similar between groups (20 weeks); more nulliparous subjects were randomized to the Mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: Mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means − 56 s, with confidence interval (95% CI − 4:09 to + 2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was > 3 cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with Mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a “better than expected” experience. Conclusions Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety. Implications Use of Mifepristone for cervical preparation before surgical abortion after 19 weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.
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Mifepristone misoprostol dosing interval and effect on induction abortion times a systematic review
Obstetrics & Gynecology, 2013Co-Authors: Kate A Shaw, Jonathan G Shaw, Nicole J Topp, Paul D BlumenthalAbstract:OBJECTIVE:To examine the effect of the interval between Mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (Mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13–24 weeks).DAT
Beverly Winikoff - One of the best experts on this subject based on the ideXlab platform.
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continuing pregnancy after Mifepristone and reversal of first trimester medical abortion a systematic review
Contraception, 2015Co-Authors: Daniel Grossman, Paul D Blumenthal, Beverly Winikoff, Kari White, Lisa H Harris, Matthew F Reeves, David A GrimesAbstract:Objective: We conducted a systematic review of the literature on the effectiveness of medical abortion “reversal” treatment. Since the usual care for women seeking to continue pregnancies after ingesting Mifepristone is expectant management with fetal surveillance, we also performed a systematic review of continuing pregnancy after Mifepristone alone. Study design: We searched PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus and the Cochrane Library for articles published through March 2015 reporting the proportion of pregnancies continuing after treatment with either Mifepristone alone or after an additional treatment following Mifepristone aimed at reversing its effect. Results: From 1115 articles retrieved, 1 study met inclusion criteria for abortion reversal, and 13 studies met criteria for continuing pregnancy after Mifepristone alone. The one report of abortion reversal was a case series of 7 patients receiving varying doses of progesterone in oil intramuscularly or micronized progesterone orally or vaginally; 1 patient was lost to follow-up. The study was of poor quality and lacked clear information on patient selection. Four of six women continued the pregnancy to term [67%, 95% confidence interval (CI) 30– 90%]. Assuming the lost patient aborted resulted in a continuing pregnancy proportion of 57% (95% CI 25–84%). The proportion of pregnancies continuing 1–2 weeks after Mifepristone alone varied from 8% (95% CI 3–22%) to 46% (95% CI 37–56%). Continuing pregnancy was more common with lower Mifepristone doses and advanced gestational age. Conclusions: In the rare case that a woman changes her mind after starting medical abortion, evidence is insufficient to determine whether treatment with progesterone after Mifepristone results in a higher proportion of continuing pregnancies compared to expectant management. Implications: Legislation requiring physicians to inform patients about abortion reversal transforms an unproven therapy into law and represents legislative interference in the patient–physician relationship. © 2015 Elsevier Inc. All rights reserved.
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acceptability of home use of Mifepristone for medical abortion
Contraception, 2013Co-Authors: Yael Swica, Erica Chong, Tamer Middleton, Linda Prine, Marji Gold, Courtney A Schreiber, Beverly WinikoffAbstract:Abstract Background Most medical abortion protocols require women to take Mifepristone in the doctor's office. We assessed the acceptability of home use of Mifepristone among women and their providers. Study Design In this multicenter trial, eligible women requesting termination of early pregnancy ( n = 301) chose whether to take Mifepristone in the office or at home. Data on safety, efficacy, acceptability and disability were collected. Results One hundred thirty-nine women (46%) chose to take Mifepristone at home, and 162 (54%) chose office administration. Ninety-five percent of home users said that they would take the Mifepristone in the same place in the future. Home users were not more likely to call the doctor's office or make an unplanned visit, and providers would recommend home use again for 95% of patients who chose home use. Conclusions Home administration of Mifepristone was safe and acceptable to women and providers in our study. Women should be offered this choice to allow more flexibility, comfort and privacy in their abortion experiences.
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comparing two early medical abortion regimens Mifepristone misoprostol vs misoprostol alone
Contraception, 2011Co-Authors: Nguyen Thi Nhu Ngoc, Jennifer Blum, Sheila Raghavan, Nguyen Thi Bach Nga, Rasha Dabash, Ayisha Diop, Beverly WinikoffAbstract:Abstract Background Nonsurgical abortion methods have the potential to improve access to high-quality abortion care. Until recently, availability and utilization of Mifepristone medical abortion in low-resource countries were restricted due to the limited availability and perceived high cost of Mifepristone, leading some providers and policymakers to support use of misoprostol-only regimens. Yet, this may not be desirable if misoprostol-only regimens are considerably less effective and ultimately more costly for health care systems. This study sought to document the differences in efficacy between two nonsurgical abortion regimens. Study Design This double-blind randomized placebo-controlled trial enrolled women with gestational ages up to 63 days seeking early medical abortion from August 2007 to March 2008 at a large tertiary hospital in Ho Chi Minh City, Vietnam. Eligible consenting women received either (1) two doses of 800 mcg buccal misoprostol 24 h apart or (2) 200 mg Mifepristone and 800 mcg buccal misoprostol 24 h later. Participants self-administered all study drugs and returned to the hospital for follow-up 1 week later. The trial is registered at ClinicalTrials.gov as NCT00680394. Results Four hundred women were randomized to either misoprostol-only (198) or Mifepristone+misoprostol (202). Complete abortion occurred for 76.2% ( n =147) of women allocated to misoprostol-only vs. 96.5% ( n =194) of those given Mifepristone+misoprostol (RR 0.79, 95% CI 0.73–0.86). Ongoing pregnancy was documented for 16.6% (32) of misoprostol-only users and 1.5% (3) of Mifepristone+misoprostol users (1.62, 0.68–3.90). Side effects were generally similar for both groups, although significantly more women allocated to misoprostol-only reported diarrhea. Conclusions Mifepristone+misoprostol is significantly more effective than use of misoprostol-alone for early medical abortion. The number of ongoing pregnancies documented with misoprostol-only warranted an early end of the trial after unblinding of the study at interim analysis. Policymakers should advocate for greater access to Mifepristone. Future research should prioritize misoprostol-only regimens with shorter dosing intervals.
Kate A Shaw - One of the best experts on this subject based on the ideXlab platform.
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evaluation of shorter Mifepristone to misoprostol intervals for second trimester medical abortion a retrospective cohort study
Contraception, 2020Co-Authors: Andrea Henkel, Paul D Blumenthal, Klaira Lerma, Kate A ShawAbstract:Abstract Objectives To assess shorter Mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (Mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion). Methods This retrospective cohort study included women who elected for a second trimester medical abortion with Mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of Mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals Results The study population included eighty-nine women, 47, 28, and 14 women in the Conclusions Shorter Mifepristone-misoprostol intervals (less than 24 h) significantly decrease the total abortion time while maintaining a clinically similar induction time. Implications Shortening the Mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems.
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adjunct Mifepristone for cervical preparation prior to dilation and evacuation a randomized trial
Contraception, 2015Co-Authors: Kate A Shaw, Jonathan G Shaw, Michele Hugin, Griselda Velasquez, Frederick W Hopkins, Paul D BlumenthalAbstract:Abstract Objective The objective was to investigate Mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19 weeks of gestation, with the aim of improving procedure access, convenience and comfort. Methods This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7 weeks of gestation randomized to receive either one set of osmotic dilators plus Mifepristone the day prior to procedure (Mifepristone group) or two sets of osmotic dilators (placed 18–24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects. Results Mean gestational age was similar between groups (20 weeks); more nulliparous subjects were randomized to the Mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: Mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means − 56 s, with confidence interval (95% CI − 4:09 to + 2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was > 3 cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with Mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a “better than expected” experience. Conclusions Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety. Implications Use of Mifepristone for cervical preparation before surgical abortion after 19 weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.
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Mifepristone misoprostol dosing interval and effect on induction abortion times a systematic review
Obstetrics & Gynecology, 2013Co-Authors: Kate A Shaw, Jonathan G Shaw, Nicole J Topp, Paul D BlumenthalAbstract:OBJECTIVE:To examine the effect of the interval between Mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (Mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13–24 weeks).DAT
Daniel R. Mishell - One of the best experts on this subject based on the ideXlab platform.
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a prospective randomized double blinded placebo controlled trial comparing Mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy
Human Reproduction, 2002Co-Authors: John K Jain, Caryn Dutton, Bryna Harwood, Karen R Meckstroth, Daniel R. MishellAbstract:BACKGROUND Vaginal misoprostol has been shown to be an effective single agent for medical abortion. This randomized, double-blinded, placebo-controlled trial compared a regimen of Mifepristone and misoprostol with misoprostol alone for termination of early pregnancy. METHODS 250 women with gestations < or = 56 days were randomized by a random number table to receive either 200 mg Mifepristone orally or placebo followed 48 h later by 800 microg vaginal misoprostol. Administration of misoprostol was repeated every 24 h up to three doses if abortion failed to occur. Abortion success was defined as complete abortion without the use of surgical aspiration. RESULTS Successful medical abortions occurred in 114 out of 119 subjects (95.7%) after Mifepristone followed by vaginal misoprostol. In all, 110 out of 125 subjects (88.0%) successfully aborted after placebo and vaginal misoprostol. The higher success rate of complete abortion with the Mifepristone and misoprostol regimen was statistically significant compared with the placebo and misoprostol regimen (P < 0.05). CONCLUSIONS A regimen of Mifepristone and misoprostol was significantly more effective for termination of pregnancies < or = 56 days than misoprostol alone. The 88% efficacy obtained with vaginal misoprostol alone may be clinically acceptable when Mifepristone is not available.
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Mifepristone for preinduction cervical ripening beyond 41 weeks gestation a randomized controlled trial
Obstetrics & Gynecology, 2000Co-Authors: Deborah A Wing, Michael J Fassett, Daniel R. MishellAbstract:Objective: To compare the effect of Mifepristone with placebo on cervical ripening before labor induction in prolonged pregnancies. Methods: One hundred eighty women with pregnancies beyond 41 weeks and undilated, uneffaced cervices were assigned randomly to receive Mifepristone 200 mg or placebo and observed for 24 hours. We then gave intravaginal misoprostol 25 μg every 4 hours or intravenous oxytocin. We expected 60% of placebo-treated and 80% of Mifepristone-treated women to deliver vaginally within 48 hours. Results: Among 180 subjects, 97 received Mifepristone and 83 received placebo. The mean interval (± standard deviation [SD]) from start of induction to delivery was 2209 ± 698 minutes for Mifepristone-treated subjects and 2671 ± 884 minutes for placebo-treated subjects (P < .001, log-transformed data). Twelve (13.6%) Mifepristone-treated women and seven (10.8%) placebo-treated women delivered vaginally on day 1 (P = .60). After 24 hours, the median Bishop score for both groups was 3 (0–11) (P = .51). One hundred thirty-one subjects required misoprostol, 65 (67.0%) were Mifepristone-treated women, and 66 (79.5%) placebo-treated women (P = .06). The median (range) oxytocin dose was 871.5 (0–22,174) mU for Mifepristone-treated women and 2021.0 (0–24,750) mU for placebo-treated women (P = .02). Seventy-seven (87.5%) Mifepristone-treated women and 46 (70.8%) placebo-treated women delivered vaginally 48 hours after the start of treatment (P = .01). There were nine cesareans in the Mifepristone group and 18 in the placebo group (P = .02). More nonreassuring fetal heart rate patterns and uterine contractile abnormalities occurred in Mifepristone-treated subjects. There were no statistically significant differences in neonatal outcomes between groups. Conclusion: Mifepristone had a modest effect on cervical ripening when given 24 hours before labor induction, appearing to reduce the need for misoprostol and oxytocin compared with placebo.
Mitchell D Creinin - One of the best experts on this subject based on the ideXlab platform.
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Mifepristone antagonization with progesterone to prevent medical abortion a randomized controlled trial
Obstetrics & Gynecology, 2020Co-Authors: Mitchell D Creinin, Melody Y Hou, Laura Dalton, Rachel Steward, Melissa J ChenAbstract:Author(s): Creinin, Mitchell D; Hou, Melody Y; Dalton, Laura; Steward, Rachel; Chen, Melissa J | Abstract: ObjectiveTo estimate the efficacy and safety of Mifepristone antagonization with high-dose oral progesterone.MethodsWe planned to enroll 40 patients in a double-blind, placebo-controlled, randomized trial. We enrolled patients at 44-63 days of gestation with ultrasound-confirmed gestational cardiac activity who were planning surgical abortion. Participants ingested Mifepristone 200 mg and initiated oral progesterone 400 mg or placebo 24 hours later twice daily for 3 days, then once daily until their planned surgical abortion 14-16 days after enrollment. Follow-up visits were scheduled 3±1, 7±1, and 15±1 days after Mifepristone intake with ultrasonography and blood testing for human chorionic gonadotropin and progesterone. Participants exited from the study when they had their surgical abortion or earlier for gestational cardiac activity absence, gestational sac expulsion, or medically indicated suction aspiration. We assessed the primary outcome of continued gestational cardiac activity at approximately 2 weeks (15±1 day), side effects after drug ingestion, and safety outcomes including hemorrhage and emergent treatment.ResultsWe enrolled participants from February to July 2019 and stopped enrollment after 12 patients for safety concerns. Mean gestational age was 52.5 days. Two (one per group) voluntarily discontinued 3 days after Mifepristone ingestion for subjective symptoms (nausea and vomiting, bleeding). Among the remaining 10 patients (five per group), gestational cardiac activity continued for 2 weeks in four in the progesterone group and two in the placebo group. One patient in the placebo group had no gestational cardiac activity 3 days after Mifepristone use. Severe hemorrhage requiring ambulance transport to hospital occurred in three patients; one received progesterone (complete expulsion, no aspiration) and two received placebo (aspiration for both, one required transfusion). We halted enrollment after the third hemorrhage. No other significant side effects were reported.ConclusionWe could not estimate the efficacy of progesterone for Mifepristone antagonization due to safety concerns when Mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only Mifepristone may be at high risk of significant hemorrhage.Clinical trial registrationClinicalTrials.gov, NCT03774745.
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ovulation resumption after medical abortion with Mifepristone and misoprostol
Contraception, 2010Co-Authors: Courtney A Schreiber, Stephanie Sober, Sarah J Ratcliffe, Mitchell D CreininAbstract:Abstract Background As an antiprogestin, Mifepristone may have an impact on the return to ovulation in a manner that is not only attributable to its abortifacient activity. Our aim was to measure the time-to-ovulation in women who received Mifepristone 200 mg orally and misoprostol 800 mcg vaginally for abortion up to 63 days of gestation. Study Design This planned substudy was part of a multicenter randomized trial of Mifepristone 200 mg followed immediately or 24 h later by misoprostol 800 mcg vaginally. Women who had successful expulsion of the gestational sac based on ultrasound examination 1 week after Mifepristone treatment were enrolled. All subjects used nonhormonal contraception until study completion. Baseline serum progesterone (P) levels were drawn on day 8±1 after Mifepristone administration and then twice weekly until the P level was >3 ng/mL, consistent with ovulation. The mean time-to-ovulation was calculated using interval censored regression to address the censoring due to participant discontinuation. Results Fourteen (52%) of 27 enrolled women completed the substudy. The longest period of time that a subject who did not complete the study was followed was 29 days. Ovulation occurred 20.6±5.1 (range 8–36) days after Mifepristone administration. Time-to-ovulation was not affected by participant age, gestational age, study arm, body mass index or presence or absence of human chorionic gonadotropin. Conclusions Return to ovulation following medical abortion with Mifepristone and misoprostol occurs on average 3 weeks postabortion. Mifepristone 200 mg does not appear to have a lasting effect on ovarian function. Our results should be contextualized by the small sample size, although this is one of the larger studies on return to ovulation after abortion.
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a randomized comparison of misoprostol 6 to 8 hours versus 24 hours after Mifepristone for abortion
Obstetrics & Gynecology, 2004Co-Authors: Mitchell D Creinin, Michelle C Fox, Stephanie B Teal, Angela Chen, Eric A Schaff, Leslie A MeynAbstract:Objective To demonstrate equivalence between Mifepristone 200 mg followed 6 to 8 hours later and 24 hours later by misoprostol 800 microg vaginally for abortion in women up to 63 days of gestation. Methods Mifepristone 200 mg was swallowed by 1,080 women after which they were randomly assigned to self-administer misoprostol intravaginally 6 to 8 hours later (group 1) or 23 to 25 hours later (group 2) at home. Participants returned for an evaluation, including transvaginal ultrasonography, 7 +/- 1 days after initiating treatment. Subjects who had not aborted were offered a second dose of misoprostol. All participants returned approximately 2 weeks after receiving Mifepristone. Telephone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication. Results Complete abortion rates for groups 1 and 2 were 503 of 525 (95.8%, 95% confidence interval 93.7%, 97.3%) and 521 of 531 (98.1%, 95% confidence interval 96.6%, 99.1%), respectively, which were statistically equivalent. Side effects were significantly more common after Mifepristone administration for women in group 2. Nausea, vomiting, and heavy bleeding were also significantly greater for women in group 2 after misoprostol treatment. Pain and subject acceptability were similar between groups. Conclusion Mifepristone 200 mg followed 6 to 8 hours later by misoprostol 800 microg vaginally is as effective for abortion and has significantly fewer side effects as compared with regimens using a 24-hour dosing interval. Women receiving Mifepristone and vaginal misoprostol for abortion can have the flexibility to administer the misoprostol as soon as 6 hours after using the Mifepristone.