Flu Shot or Mist?

[+ FreshFluff]

To all the doctors and other medical experts: Would you recommend the flu shot or flu mist to those under 50, not pregnant and have no other known health issues? (The mist is apparently less effective in people who are 50+.)

 

From my online research, the flu mist apparently treats 4 different viruses while the shot treats only 3, and the mist doesn't cause soreness afterwards. However, it seems that the shot has been around longer and has been tested better. I did see that the mist is contraindicated in those with weak immune systems, which makes me wonder if it's less effective.

 

I'm not afraid of needles, so that's not a factor. The clinic at work offers both, so I'm trying to decide which to pick.

[+ purplekow]

The nasal mist is a live attentuated virus, basically a weakened virus that for the most part causes an antigenic response, antibodies, without causing the disease or causes a very mild disease.

Flu vaccination

The flu immunization injection, it essentially a means of building up antibodies against certain portions of the virus without using the intact virus. You cannot get the flu from it and that is why this is the one recommended for those with impaired immune systems.

The flu immunization injection is about 25% effective in stopping one from getting the flu and it significantly reduces both the severity of the illness and the likelihood of death from the flu. About 36000 people a year die of the flu.

Both are valuable tools in limiting the negative consequences of the yearly flu virus.

I prefer the flu shot, so I can truthfully tell the patient, you will not get the flu from the shot.

[+ FreshFluff]

Thanks, PK. Does that fact that the mist protects against 4 different viruses make it more effective in practice?

[bigvalboy]

Thanks, PK. Does that fact that the mist protects against 4 different viruses make it more effective in practice?

 

Interesting... as I was curious why no one had inquired about the flu shot or mist this year. I asked around and have decided to get the shot. I am probably fairly low risk, since I don't work in an environment where I am exposed to anyone, but I figured. "better safe than sorry"..I think in the end, for those that are at risk, they should just establish a routine daily that helps to protect them. Most of what protects us is a no brainer....

[Diverdan]

Some of the injections that are available also protect against 4 strains of the virus, at least that what I was told when I got my shot. I always get the shot every year. You might also ask your Doctor about getting the shingles shot. While highly recommended for people over 60, the physicians I know also recommend it for people younger than that. I think the mist has not been around enough to evaluate its efficacy, although no "flu shot" will necessarily protect one from all the variations of the virus that constantly mutates to try and get ahead of our protection. When in doubt, have a conversation with your physician.

[+ sam.fitzpatrick]

Shot every time. It's done the trick in the past for me, so why change it up?

[+ Gar1eth]

Some of the injections that are available also protect against 4 strains of the virus, at least that what I was told when I got my shot. I always get the shot every year. You might also ask your Doctor about getting the shingles shot. While highly recommended for people over 60, the physicians I know also recommend it for people younger than that. I think the mist has not been around enough to evaluate its efficacy, although no "flu shot" will necessarily protect one from all the variations of the virus that constantly mutates to try and get ahead of our protection. When in doubt, have a conversation with your physician.

 

The shot has previously been trivalent-it protected against 2 strains of type A influenza and one type of type B. The new quadrivalent adds another strain of type B. This quadrivalent INJECTABLE is new for this year. While the CDC, does not make recommendations regarding which vaccination to take--it seems to me--without any proof to back it up--but if you are going to get a shot to begin with why not get the most protection possible. And remember that people 65 years or older should get the higher dose trivalent vaccine. All the injectible vaccines are of inactivated virus and cannot give you the flu.

 

 

gman

[gallahadesquire]

As long as we're on the subject:

 

Consider the Pneumococcus vaccine, agains Pneumococcal Pneumonia. (The P's are silent). Smae criteria: Not perfect health, over 60, other chronic diseases ...

[Samai139]

I won't repeat all the factors above in favour of the shot. I just had the shot on Wednesday and there was no soreness afterward---none. Perhaps the nurse giving it was just great???

[Steven_Draker]

I've got the flu shot this week as I get it every year. I'm not in one of the high-risk groups, however I don't want to take any chances and be stuck in bed for several days.

 

Apparently only 20% of the flu shots available this year are quadrivalent.

 

http://www.cdc.gov/flu/protect/vaccine/quadrivalent.htm

[whipped guy]

I get the shot every year... It only makes sense and I try to get it prior to any travel plans as being stuck in a closed invoronment such as an airplane cabin certainly does not help matters...

 

While many are technically not in "high-risk groups" those in certain "businesses" are definitely exposed at a much greater level than probably are the average individual... and that certainly includes those in the "oldest business". While not in the "oldest business", occupational factors (coupled with extracaricular activities) indeed dictate that I get the shot every year.

[maninsoma]

I got a shot last Monday and, for the first time, definitely had some side effects related to it. I spoke with a couple of other people who also got the flu shot and some had similar reactions to mine while others had no negative side effects. For me, I felt really run down for a few days (even a bit dizzy at times), with some mild body aches and a bit of a cough. Most worrisome was that four days after I received the vaccination, my left hand went nearly numb and I temporarily lost the ability to make a complete fist. I went online and read about flu shot side effects and then got very alarmed after I read about the possibility (albeit extremely remote) of developing Guillain–Barré Syndrome, but given that my numbness didn't spread to other parts of my body and subsided within 24 hours I got over my worry quickly.

[Steven_Draker]

I've noticed the same thing: some years I have no side effects and others I have soreness where the shot was given, muscle aches and fatigue.

 

Not related to these side effects, I saw that part of the medical community was warning about a possible toxicity due to the Mercury present in the flu shots.

 

http://www.prnewswire.com/news-releases/new-study-verifies-mercury-in-flu-shots-is-toxic-118432874.html

[+ Funguy]

I get the vaccine every year tho it is only about 50 per cent effective

For us "older" guys anything is better than nothing. As far as most vs injection, I always go for the mist. No sore arm, etc. And really good absorption from nasal mucosa. All my doctor friends do the same

[whipped guy]

It is always wise to sit and relax for a short while after receiving the vaccine as there is always the possibility that one might have a reaction to one of the components in the preparation. For example, a very small trace amount of neomycin is usually present in many versions of the vaccine so as to prevent bacterial contamination. While a topical dermatitis is quite common with neomycin, reactions associated with the vaccine are rare. However, the flu vaccine is available in a neomycin free version. If you are definitely allergic or fear that you might be allergic to neomycin, it might be wise to request the neomycin free version. Having a severe reaction might be stretching things a bit, but it is certainly better to be safe than sorry... and especially since many flu shots are administered in non-medical locations such as supermarkets. One certainly does not want to go into anaphylactic shock (even though the odds would be very slim) while strolling through the produce section...

 

Incidentally, and as an addendum, the shingles vaccine is still not available in a neomycin free version. If there is a possibility that you might be allergic to neomycin it is wise to be tested by an allergist or dermatologist to try and definitively determine if you are indeed allergic, as an allergy to neomycin is currently one of the contraindications.

[Guest]

I've noticed the same thing: some years I have no side effects and others I have soreness where the shot was given, muscle aches and fatigue.

 

Not related to these side effects, I saw that part of the medical community was warning about a possible toxicity due to the Mercury present in the flu shots.

 

http://www.prnewswire.com/news-releases/new-study-verifies-mercury-in-flu-shots-is-toxic-118432874.html

 

The thimerosal toxicity has been thoroughly debunked. Interesting that your reference is an article which doesn't actually provide a reference for any scientific studies (it just states that the studies exist). Nothing wrong with getting the flu mist if one is a suitable candidate.

[Steven_Draker]

Here are the links for the scientific studies you requested.

 

"Despite recommendations made by the US Centers for Disease Control and Prevention (CDC) in 1999 that Thimerosal, a mercury-based preservative, be removed from vaccines, the toxic chemical is still added to the majority of flu vaccines administered to women, children, and the elderly, according to the Coalition for Mercury-Free Drugs (CoMeD), a Maryland-based non-profit organization. And according to three recent studies, the symptoms of mercury poisoning are nearly identical to those of autism symptoms, which strongly suggests that mercury in vaccines is responsible for causing autism.

 

Mercury is already a known neurotoxin that causes cancer (carcinogen), damages DNA (mutagen), alters proper embryonic development (teratogen), and disrupts the immune system. It is exactly the type of harmful chemical that you would never want to put in your body, and yet it is still added in the form of Thimerosal to millions of flu vaccines administered to the public.

 

"We have scientific studies clearly demonstrating that mercury causes neurological damage, and we have a cost-effective alternate that has already been used to replace Thimerosal as the preservative in vaccines," said Dr. Paul G. King, PhD, science advisor to CoMeD.

 

One such study published in the December 2010 issue of the journal Folia Neuropathologica explains that the mercury used in vaccines appears to directly cause neurodevelopmental disorders like autism (http://science.naturalnews.com/2010/81137_Lasting_neuropathological_changes_in_rat_brain_after_intermittent_neonatal_administration.html). Another study published in the journal Middle East Current Psychiatry states that "[m]ercury poisoning and autism have nearly identical symptoms" (http://journals.lww.com/mecpsychiatry/Fulltext/2011/01000/Study_of_some_biomarkers_in_hair_of_children_with.2.aspx?WT.mc_id=HPxADx20100319xMP).

 

And a study recently published in the Journal of Immunotoxicology directly states that "[n]ot only is every major symptom of autism documented in cases of mercury poisoning but also biological abnormalities in autism are very similar to side effects of mercury poisoning itself" (http://informahealthcare.com/doi/abs/10.3109/1547691X.2010.545086).

 

It remains unclear why the toxic preservative is still used in vaccines -- especially when there are safer alternatives available -- and why mainstream science continues to deny the obvious and scientifically-verifiable link between mercury and autism. The issue is not even one of opposition to vaccinations as much as it is one of opposition to neurotoxic poisons like Thimerosal that continue to deliberately be added to them."

 

source: http://www.naturalnews.com/031678_mercury_autism.html#ixzz2iLsnjVQJ

[Guest]

Here are the links for the scientific studies you requested.[/color]

 

"Despite recommendations made by the US Centers for Disease Control and Prevention (CDC) in 1999 that Thimerosal, a mercury-based preservative, be removed from vaccines, the toxic chemical is still added to the majority of flu vaccines administered to women, children, and the elderly, according to the Coalition for Mercury-Free Drugs (CoMeD), a Maryland-based non-profit organization. And according to three recent studies, the symptoms of mercury poisoning are nearly identical to those of autism symptoms, which strongly suggests that mercury in vaccines is responsible for causing autism.

 

Mercury is already a known neurotoxin that causes cancer (carcinogen), damages DNA (mutagen), alters proper embryonic development (teratogen), and disrupts the immune system. It is exactly the type of harmful chemical that you would never want to put in your body, and yet it is still added in the form of Thimerosal to millions of flu vaccines administered to the public.

 

"We have scientific studies clearly demonstrating that mercury causes neurological damage, and we have a cost-effective alternate that has already been used to replace Thimerosal as the preservative in vaccines," said Dr. Paul G. King, PhD, science advisor to CoMeD.

 

One such study published in the December 2010 issue of the journal Folia Neuropathologica explains that the mercury used in vaccines appears to directly cause neurodevelopmental disorders like autism (http://science.naturalnews.com/2010/81137_Lasting_neuropathological_changes_in_rat_brain_after_intermittent_neonatal_administration.html). Another study published in the journal Middle East Current Psychiatry states that "[m]ercury poisoning and autism have nearly identical symptoms" (http://journals.lww.com/mecpsychiatry/Fulltext/2011/01000/Study_of_some_biomarkers_in_hair_of_children_with.2.aspx?WT.mc_id=HPxADx20100319xMP).

 

And a study recently published in the Journal of Immunotoxicology directly states that "[n]ot only is every major symptom of autism documented in cases of mercury poisoning but also biological abnormalities in autism are very similar to side effects of mercury poisoning itself" (http://informahealthcare.com/doi/abs/10.3109/1547691X.2010.545086).

 

It remains unclear why the toxic preservative is still used in vaccines -- especially when there are safer alternatives available -- and why mainstream science continues to deny the obvious and scientifically-verifiable link between mercury and autism. The issue is not even one of opposition to vaccinations as much as it is one of opposition to neurotoxic poisons like Thimerosal that continue to deliberately be added to them."

 

source: http://www.naturalnews.com/031678_mercury_autism.html#ixzz2iLsnjVQJ

 

Did you think I wasn't going to check your sources? The first link was to a Polish study in which they injected rats with large amounts of thimerosal. The second was an Egyptian study published in a little-known Arab journal which looked at mercury levels in hair and had nothing to do with thimerosal. The last two were simply opinion pieces which presented no original data.

Studies which actually looked at thimerosal vaccines given to actual children include articles in the New England Journal of Medicine, http://www.nejm.org/doi/full/10.1056/NEJMoa071434 , and The Lancet http://www.ncbi.nlm.nih.gov/pubmed/12480426 , the two most reputable US and European medical journals, respectively. In fact, The Lancet publically retracted a prior study they had posted about possible dangers to thimerosal when they found out the researcher was paid off by plaintiff attorney groups: http://www.nytimes.com/2010/02/03/health/research/03lancet.html?_r=0.

The NEJM ended with this cautionary tale about false science: http://www.nytimes.com/2010/02/03/health/research/03lancet.html?_r=0

[Steven_Draker]

I'm very glad to read about this, since I'm one of those who get the flu shot every year :-)

[+ Funguy]

Interesting.......the whole issue about mercury/thimerosol preservatives began years ago (mid nineties) with childrens' vaccines and the question of autism. Andrew Wakefield in England published a study linking MMR vaccine and autism but the study was bogus (patients selected as autistic and vaccinated, less than 10 patients in the study, doctor was paid for each of the patients and to do the study by attorneys so they could represent autistic patients in suits against their doctors, and on and on). All the other physicians removed their names from the study except Wakefield who would not recant. In the end, he lost his license.

 

The problem, however, was that vaccines in general (not just MMR) were given a bad name not only in England but in US. When vaccination stopped, there were measles outbreaks everywhere and several hundred kids died from the measles. Parents, even now, refuse vaccines on the basis of fear of autism even tho there has not been one shred of evidence that there is any connection. There is not one single, peer-reviewed, published case of actual proof of association of any vaccine with autism.

 

That brings us to the preservatives which used to be in the vaccines. When no real, provable connection could be shown between the measles vaccine and autism, people began to look for other ways to discredit the vaccines. There is a risk and danger from mercury/thimerosol so, many years ago, it was removed from ALL pediatric vaccines (approximately 15 different vaccines - not doses - by the age of 18, not including flu vaccines). Since they are used in single dose forms and there is no need for preservative. Some multi-dose vials must contain the preservative but very few MD's use those; they are used in high-volume clinics/offices/markets/pharmacies, etc. because the cost is much cheaper than single dose vials. It is still present in some, but not all, Flu vaccines: again, pediatric offices CAN and do get Flu vaccine without mercury preservative.

This entire vaccine issue is a hotbed of misinformation, especially when parents, who want the best for their kids, arm themselves with info from the WEB and believe everything they read on the WEB just because it is on the WEB. Pediatricians often spend entire visits simply trying to educate.

 

This then brings us full circle to the issue at hand: injection vs mist. They both only work about 50% of the time, you cannot get the flu from the vaccine (injectable is killed virus and mist is live but weakened.) Yes, there can be side effects, rarely, from either. My own feeling is that the mist is better because it is the live vaccine and is absorbed through the nasal mucosa and stimulates better immunity. Either form takes about 2 weeks to stimulate enough immunity for effectiveness. But, remember, we are talking about Influenza - not a bit of achiness and cold symptoms with a 99-100 temperature. We are talking high fever - 102-103+, aching, chills, cough, vomiting, headache. It does kill - esp. kids and the geriatric crowd. Why not at least TRY to protect. You could also try hand washing!

 

Other vaccines WE ought to have: Hepatitis B (series of 3), Gardasil for HPV infection (series of 3). Most MD's dealing with our higher-risk population don't care about the 26 year age recommendation for Gardasil because that was only the age group in which it was tested. Pneumonia and Shingles vaccines too. With Shingles, even if you have had a case already, the vaccine can prevent or weaken future outbreaks. Also, the usual: Hepatitis A, DTaP (for the whooping cough portion). Consider, if traveling, Polio (injectable only) and Meningitis. Very few adults need the chicken pox vaccine and can always be tested to find if susceptible.

 

WG is absolutely right about the neomycin issue and people who are allergic need to watch out. Many know they are allergic only because sometime earlier in their lives they were given an eye ointment or drop containing neomycin and wound up with a reaction. Other live vaccines are produced in eggs and those allergic to eggs can still have those vaccines but it should be done in the MD's office (preferable an allergist's office) and be watched for any reaction.

 

Good luck all and make an EDUCATED choice!

 

Always,

Funguy

[Guest]

This then brings us full circle to the issue at hand: injection vs mist. They both only work about 50% of the time, you cannot get the flu from the vaccine (injectable is killed virus and mist is live but weakened.) Yes, there can be side effects, rarely, from either. My own feeling is that the mist is better because it is the live vaccine and is absorbed through the nasal mucosa and stimulates better immunity. Either form takes about 2 weeks to stimulate enough immunity for effectiveness. But, remember, we are talking about Influenza - not a bit of achiness and cold symptoms with a 99-100 temperature. We are talking high fever - 102-103+, aching, chills, cough, vomiting, headache. It does kill - esp. kids and the geriatric crowd. Why not at least TRY to protect. You could also try hand washing!

 

Other vaccines WE ought to have: Hepatitis B (series of 3), Gardasil for HPV infection (series of 3). Most MD's dealing with our higher-risk population don't care about the 26 year age recommendation for Gardasil because that was only the age group in which it was tested. Pneumonia and Shingles vaccines too. With Shingles, even if you have had a case already, the vaccine can prevent or weaken future outbreaks. Also, the usual: Hepatitis A, DTaP (for the whooping cough portion). Consider, if traveling, Polio (injectable only) and Meningitis. Very few adults need the chicken pox vaccine and can always be tested to find if susceptible.

 

WG is absolutely right about the neomycin issue and people who are allergic need to watch out. Many know they are allergic only because sometime earlier in their lives they were given an eye ointment or drop containing neomycin and wound up with a reaction. Other live vaccines are produced in eggs and those allergic to eggs can still have those vaccines but it should be done in the MD's office (preferable an allergist's office) and be watched for any reaction.

 

Good luck all and make an EDUCATED choice!

 

Always,

Funguy

 

Nice summary. Theoretically, the FluMist can offer a more powerful immunity, since it induces both IgA antibodies, which are secreted in mucous, as well as IgG, which stay in the bloodstream. However, there is no proof of its superiority in practice. As with any live virus, FluMist can, on rare occasions, induce real disease--even close contacts of the immunized (for example, if you take care of someone with AIDS, you should not get FluMist). The HPV vaccines aren't tested or approved for adults over 26, and I don't know any health care provider who injects them in older adults, though there are probably some who do. I've certainly never heard of a health care provider who's ballsy enough to give a flu shot to someone with a true egg allergy (not just "it gives me gas")--that's contrary to the product insert, and would certainly exposed said health care provider to liability.

[+ purplekow]

ober 22, 2013[h=1]Which Flu Vaccine is Right for Your Patient?[/h]

http://media.empr.com/images/2013/10/22/influenza-flu-shot_480500.jpg?format=jpg&zoom=1&quality=70&anchor=middlecenter&width=320&mode=pad

What's New with Flu? A Look at the 2013-14 Flu Vaccine

It's that time of year again. Patients will be flocking to your office looking to get vaccinated from the flu. Generally, it is important for healthcare providers to begin offering the flu vaccine as soon as it becomes available, preferably by October.

Several new flu vaccines have been recently approved by the FDA giving providers greater access to the vaccine and patients a better opportunity to be immunized.

In addition to the trivalent influenza vaccine (which contains an A/California/7/2009 (H1N1)-like virus, an H3N2 virus antigenically like the cell-propogated prototype virus A/Victoria/361/2011, and a B/Massachusets/2/2012-like virus), a quadrivalent vaccine, containing a B/Brisbane/60/2008-like virus has also been made available by several manufacturers.

Four quadrivalent vaccines have been approved by the FDA: Flumist Quadrivalent (MedImmune),Fluarix Quadrivalent (GlaxoSmithKline), Fluzone Quadrivalent (Sanofi Pasteur), and Flulaval Quadrivalent (GlaxoSmithKline).

While these vaccines may differ by indication and route of administration, the CDC has no preferential recommendation for any one specific influenza vaccine product over another with regards to efficacy.

[h=2]Considerations for Children 6 Months Through 8 Years of Age[/h]

The algorithm below illustrates the approach to dosing children who are between the ages of 6 months and 8 years. Children for whom one of these conditions is not met require 2 doses in 2013-2014. All children between 6 months through 8 years who are recommended 2 doses should receive their first dose as soon as possible after vaccine becomes available; these children should receive the second dose ≥4 weeks later.

 

[h=2]INFLUENZA VACCINE DOSING ALGORITHM: 6 MONTHS TO 8 YEARS OF AGE[/h]

http://media.empr.com/images/2013/10/22/influenza-chart_01_480402.jpg

 

[TABLE]

[TR=bgcolor: transparent]

[TD=bgcolor: black]NOTES[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent]

* Doses should be administered at least 4 weeks apart.

† This algorithm takes into consideration only doses of seasonal influenza vaccine received since July 1, 2010. Alternative approach: Settings where vaccination history from before July 1, 2010, is available, if a child aged 6 months–8 years is known to have received at least 2 seasonal influenza vaccines during any previous season, and at least 1 dose of a 2009 (H1N1)-containing vaccine (i.e., 2010–11, 2011–12, or 2012-13 seasonal vaccine or the monovalent 2009[H1N1] vaccine), then the child needs only 1 dose for 2013–14. Using this approach, children aged 6 months–8 years need only 1 dose of vaccine in 2013–14 if they have received any of the following: 1) 2 or more doses of seasonal influenza vaccine since July 1, 2010; 2) 2 or more doses of seasonal influenza vaccine before July 1, 2010, and 1 or more doses of monovalent 2009(H1N1) vaccine; or 3) 1 or more doses of seasonal influenza vaccine before July 1, 2010, and 1 or more doses of seasonal influenza vaccine since July 1, 2010. Children in this age group for whom one of these conditions is not met require 2 doses in 2013–2014.

[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: black]REFERENCES[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent]

From: Summary* Recommendations: Prevention and Control of Influenza with Vaccines Recommendations of ACIP, United States 2013; www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm

(Created 10/2013)

[/TD]

[/TR]

[/TABLE]

 

 

[h=2]Considerations for Pregnant Women[/h]

Live attenuated virus vaccine is not recommended for pregnant women therefore women who are or will be pregnant should be immunized with inactivated influenza virus vaccine. Postpartum women, however, may be vaccinated with either vaccine. Avoiding contact with persons vaccinated with live attenuated virus vaccine is not necessary for either pregnant or postpartum women.

[h=2]Considerations for the Elderly[/h]

All persons age 50 and older are considered at risk for medical complication due to influenza. However, not all vaccines are indicated for older patients (see Chart below). One specific influenza vaccine, Fluzone High-Dose, is FDA-approved for patients 65 years of age and older.

Page 1 of 3

• 
  [*=center]
  [*=center]
  [*=center]

1
[*=center]2
[*=center]3
[*=center]
[*=center]

[+ Funguy]

Thanks for your comments Unicorn.

 

As far as the HPV vaccine, you are correct that most MD's will not give if you are over 26. However, that age was picked because of the population (<26 yrs) it was tested on. Under normal circumstances that is reasonable. However, the age was picked because it was also felt that by age 26 most people will have been exposed to HPV and therefore the vaccine would not provide much, if any, protection. If you take into account that there are many, many men and women who practice safe sex, over age 26, gay included, and have not been exposed (as proven by blood tests), these men and women (they really don't want cervical cancer) are being given the vaccine. In point of fact, even heterosexual men and women who have been in monogamous relationships and have lost their partner for whatever reason, if tested susceptible are getting the vaccine. In speaking to a friend at the CDC, this situation has become very common. People are actually reacting, in part, to what Michael Douglas revealed when he implicated HPV infection with his throat (or tongue depending on who you believe) cancer.

 

With the flu vaccine, there are some people who really need to get the vaccine in certain circumstances. This might include having household members who are elderly, have compromised immune systems with cancer, HIV, etc. If they happen to be allergic to egg it really is no different than the child who needs the MMR vaccine and is allergic to egg. For many, many years Pediatricians have been sending these kids (hand carrying the vaccine in some cases) to Pediatric Allergists for administration and observation. The only difference is that these people will get the killed, injectable flu vaccine and not the FluMist.