The Migraine-Food Intolerance Connection

This piece of research came across the desks of one of the ND’s here at StoneTree that supports what we have all seen time and time again with our patients: food intolerances and migraines are related.

We’ve written about food intolerances many times before. When we eat foods that we are intolerant to, our immune systems see these foods as foes, not friends. The normal response to a foe by the immune system is to create inflammation in an effort to get rid of the threat.

This works very well when the threat is a virus or bacteria. It works less well when the threat is a food you eat every day. The threat is never eliminated–it just keeps showing up on your plate, day after day, and your body keeps fighting the fight.

Over time, the result is an accumulation of low-grade inflammation that can cause symptoms throughout the entire body. One of those places is the vasculature of the brain. Result: migraines.

Testing for food intolerance is an easy blood test. If you are suspect that foods are causing a problem for you, this time of year is a great time to do intolerance testing. Most extended health benefit plans will cover this lab test if done through your naturopathic doctor. (Curious about what a test looks like? You can find a sample here.)

 To learn more about food intolerance and other lab tests, book online, or call the clinic at 705-444-5331.

World Diabetes Day: What’s Your Sugar Status?

World Diabetes Day started in 1991 and has been celebrated on November 14th every year since. It was initiated by the World Health Organization (WHO) and the International Diabetes Federation (IDF) in response to the rapid rise of diabetes incidence around the world.

This year, World Diabetes Day focuses on Women with Diabetes, and for good reason:

  • There are currently over 199 million women living with diabetes. This is projected to increase to 313 million by 2040.
  • Two out of every five women with diabetes are of reproductive age.
  • Diabetes is the ninth leading cause of death in women globally.
  • 1 in 7 births is affected by gestational diabetes.
  • 2% of live births to women in 2015 had some form of hyperglycemia in pregnancy.
  • Approximately half of women with a history of gestational diabetes go on to develop type 2 diabetes within five to ten years after delivery.
  • Half of all cases of hyperglycemia in pregnancy occur in women under the age of 30.

These are some sobering statistics, and they don’t begin to cover it all. Diabetes can lead to nerve damage, kidney failure, and blindness. If you have diabetes, your risk of developing heart disease is twice that of the rest of the population, and you’re more susceptible to depression and infections.

Diabetes is dangerous. But it’s also a largely treatable and more importantly preventable disease. In fact, according to the IDF, more than 70% of type 2 diabetes could be prevented through the healthy lifestyle.

Where do you begin? Diabetes is a lifestyle disease, and naturally, food and movement are key.

Eat right. Eat foods that nature makes, mostly plants, not too much. It really is as simple as that. If a food package is making a health claim, be suspicious. The foods sitting in the veggie aisle with no claims and no packaging are where your diet should be focused.

Start with these 10 recipes that will save your life!

Exercise regularly. You don’t need to be a marathon runner to get the diabetes prevention benefit of exercise. Walk every day for 30 minutes. It’s all you need to do to make an enormous difference.

Test your blood sugar. Find out if your blood sugar is a problem before it’s a problem–testing your blood sugar regularly can give you an idea if your body is heading down the diabetes track.

Blood sugar tests look at the following:

  • Fasting blood sugar. This is the test we are all very familiar with. We fast overnight and get our blood taken first thing in the morning. Any value over 6.0 mmol/L should get your attention that you may be heading down the wrong track.
  • Hemoglobin A1c. This test measures how much sugar is attached to the red blood cells. The more that is attached, the more likely you are not getting the sugar out of your blood fast enough. Because the lifespan of the RBC’s is around 3 months, this test gives us an idea of what your AVERAGE blood sugar has been over a 3 month period. Values over 6% are a sign that things are not going well.
  • Two-hour post-prandial blood glucose. This test measures how well your body deals with sugar within 2 hours of eating it. If your blood sugar is over 7.8 mmol/L 2 hours after eating the sugar, you could be heading down the wrong track.

Interested in learning about your blood sugar levels? Tests are inexpensive, and we can take your blood sample right here in the clinic! Book online, or call 705-444-5331 for more information.

Tuning Your Hormonal Orchestra

Hormones are your body’s chemical messenger system. They control many, if not most, of your major body functions, including digestion, mood, sleep, metabolism, respiration, stress, growth, movement and mood. Hormones, in short, are a big deal.

They also pack a powerful punch, and so they need to be balanced. To keep things running smoothly and to keep your body “in tune”, they have to be produced in exactly the right amounts at the right time.

This makes your hormonal system a little like an amplified orchestra with various instruments and roles to play:

  1. The pineal gland is the timer, to tell the system when to sleep and when to play.
  2. The hypothalamus is the sound man, detecting signals from the audience and reading the sound levels, balancing the output of control hormones.
  3. The pituitary gland, like a conductor, tells the individual players when and how forcefully, to do their part. If all is in balance, the individual player does just the right amount of work and the system is in tune.
  4. The thyroid hormone is the rate controller, increasing the speed of the beat and the efficiency of the instruments.
  5. The neurosteroids, or sex hormones, control tuning, maintenance and repair of the many instruments.

All of this must work in a complex biological harmony. Otherwise, like a poorly tuned orchestra, the results can be pretty awful.

Fortunately, the hormonal orchestra is usually an elegant and effective performance. The problem arises as we age, when hormone production begins to slow. It’s then that we hear the first problems in the musical score that is your body.

The progressive loss of hormones begins with the pineal, at about age 20, followed at about age 25-26 by declining growth hormone. After that, pregnenolone decreases, then DHEA, testosterone and progesterone, with estrogen in women following closely behind testosterone in men.

As hormones decline, your poor thyroid is left to handle the bulk of the work, like a lone musician trying to play an entire symphony alone.

Off Key: The Effects of Low Hormones

If we look at blood tests just a few months into menopause, a woman’s blood may contain:

  • Zero estrogen, testosterone, growth hormone and melatonin, and;
  • almost zero pregnenolone, progesterone and DHEA.

Is it any wonder things feel different? Like a poorly tuned orchestra, these changes don’t usually go unnoticed:

  • Low testosterone and/or progesterone causes depression and panic attacks.
  • Low progesterone causes menstrual irregularity, painful menses, water retention, poor sleep, reduced memory capacity, reduced self-esteem and inadequate maintenance and repair of the brain and nervous system.
  • Low estrogen causes hot flashes, night sweats, poor sleep and general misery.

All of this elevates your stress levels and further inhibits the ability of your thyroid hormone to do an increasingly difficult job. As more time goes by, the orchestra slips further out of tune. Your body loses its balance, can’t manage sugar and cholesterol metabolism, and is unable to heal quickly, fight off infections, avoid autoimmune diseases and kill cancer cells.

It’s reasonable to conclude that many of our age-related disabilities (if not all) have their root in this progressive reduction of hormone production. Add the stress of modern life to the mix, and you have a musical score for accelerating the development of disease and the aging process.

The good news is that it’s possible to bring the orchestra back into tune! Using accurate testing and bio-identical hormone replacement, you can relieve some of the troublesome symptoms of aging and your body can begin to play a more pleasing score.

To learn more about your hormonal orchestra—and bring your instruments back into tune—contact the clinic at 705-444-5331, or book an appointment with Dr. Gervais Harry, MD online here.

Are You Addicted to Your Phone?

Tens of thousands of years ago, when we homo sapiens were just getting started, we had to be able to effectively meet our goals in order to survive–we had to find water, get enough to eat, seek shelter, and generally get things done. Unlike now, if we just lay about all day not accomplishing anything, we’d die. We had to be goal-oriented.

The key driver for this goal-seeking behaviour was, and is, a neurotransmitter called dopamine. Dopamine is the reward chemical–it provides the little hit of “goodness” we feel when we accomplish a goal. (That delightful feeling of crossing something off your to-do list? Dopamine.) It’s an evolutionary gift from a long line of ancestors that helped us survive. It helps us see rewards, and take action to get them.

So what does this have to do with your cell phone?

Because accomplishing goals like “find food” were so critical, dopamine became a pretty addictive chemical in the brain. We LIKE the feeling of dopamine, and are driven to do what creates the release of it. We’re  easily addicted to things that deliver it.

The problem is that some things that have nothing to do with creating a meaningful life create dopamine for us. Things like alcohol, nicotine, gambling and yes, that delightful little “ding” your cell phone makes when you get a text.

Every time you hear the sound of a new message or see the tiny alerts or badges onscreen, your reward system swings into gear. Almost all of this happens below the level of your awareness. All you know is that you simply can’t resist checking your phone.

How Do You Know if You’re Addicted?

The same brain chemistry that casinos hijack to keep you sitting at a slot machine for hours is being hijacked to keep you staring at a screen. Your phone has been doing a remarkable job of training you. And not just to respond to whistles and signals like a trained seal, but to find it intolerable to suffer even a few moments without stimulation.

Here are some questions to ask yourself?

  • When you wake up in the morning do you check your phone before you go to the bathroom?
  • Do you walk from room to room holding your phone all the time?
  • If you get a text while driving, do you find it impossible to wait the ten minutes until you get home to look at it and respond?
  • Do you regularly respond to texts while reading your kid a bedtime story?
  • Are you unable to leave your phone in the car when you are having dinner out with friends?
  • Are you incapable of sitting quietly for ten minutes without looking at your phone?
  • Do you use your phone while watching TV or eating?

Why is it important to ask ourselves these questions? Here are a few things you might find interesting about high cell phone use. It’s been linked to:

  • Higher anxiety
  • Lower grades
  • Decreased happiness
  • Lower quality sleep
  • Poor posture
  • Lower relationship satisfaction
  • Reduced activity
  • Less time outdoors
  • Less time spent with others

Are those weather alerts and social media updates really that valuable?

What to Do?

Every recovering alcoholic will tell you that the first step to fixing a problem is to admit that you have one in the first place. If you can do that, what do you do next?

  • Turn off your alerts. Those little badges and sounds and flashes are designed to trigger your reward system. You don’t need to get alerts from every app.
  • Use “do not disturb” mode. Most devices will allow you to shut down your phone’s alert systems, while still letting through calls from a specified list of people. That way you can still get a call from your teenager or spouse, for example, but not from anyone else.
  • Set time periods in which you shouldn’t use your phone (i.e., 9 p.m. to 7 a.m.).
  • Designate activities in which your phone is forbidden (e.g., driving, dinner time).
  • Schedule break times to access your phone or social media.
  • Practice being bored. Your phone is gradually eroding your ability to simply be. Try taking longer and longer periods away from it. Reclaim your ability to live without constant digital stimulation.

If you find you can’t do these things, or instinctively push back against them, that might be the most powerful indicator of all that you have a problem.

Are you using your phone, or is it using you?

The 2 Big Reasons We Use IV Vitamins

We have administered over 10,000 IV vitamin/mineral infusions here at StoneTree. That’s a lot!

Why so many? The obvious reason is the results–using IV therapy just works.

For complaints like migraine headaches, colds and flus, muscle cramping, wound healing, allergies, chronic fatigue, and many, many others, it’s a therapy that can get our patients better faster than with diet changes or oral supplements alone. (Read on for a longer list of conditions and complaints that we’ve used IV therapy with.)

But the results don’t tell you why. And the why is important.

There are two main reasons we use IV therapies for our patients:

Reason #1: To ensure nutrients actually get into your cells

When you eat food (or take supplements), you absorb nutrients from your intestines into your blood. At least, that’s the idea, and if all your digestive mechanisms are working right, it’s a great system.

As you age, however, or if you’re sick or things just aren’t working correctly for any number of reasons, you often don’t absorb nutrients as well. Your food and supplements don’t give you the same benefit. When we put vitamins and minerals directly into the blood via IV we bypass the intestines entirely, ensuring that the nutrients are available.

The other place that nutrient absorption happens is at the cellular level. Nutrients from our blood need to get into our cells and this is not a passive process. Your cells have to “actively” transport nutrients inside. Compromised cells don’t do this as effectively as they should.

When we put vitamins and minerals directly into the blood, the concentration in the blood changes so that it’s higher outside the cell than inside. The nutrients can then passively diffuse into the cell. That can allow the cell to get the nutrients it needs to start the active transport system again. Think of it as jumpstarting your cells to give them what they need to continue the process on their own.

Reason #2: To get a specific biochemical effect

Vitamins and minerals have real biochemical effects in the body. Just like pharmaceutical drugs, if you can get the blood concentrations at high enough levels, you can get the body to respond in specific ways. Vitamin C, for example, has a wonderful anti-allergy effect at high enough blood concentrations.

Because of the absorptive mechanisms in the digestive tract, however, it can be challenging to get the blood concentration high enough to get the biochemical effect you want. (Anyone who has taken lots of Vitamin C will attest to the effect of taking too much: the bowels become overwhelmed, the Vitamin C isn’t absorbed, and you have to run to the toilet with an acute case of diarrhea.)

When Vitamin C is given IV, we bypass the intestines and the side effects of a large oral dose. The blood concentration can easily rise to the level needed for the anti-allergy effect, and the patient gets allergy relief without the drowsy side-effect of anti-histamines.

What We Use IV Therapy For

Those 10,000 IV’s we’ve administered? We’ve used them for many things–here’s a list of some complaints and uses:

  • Arrhythmia
  • Anxiety
  • Autoimmune issues
  • Adrenal fatigue
  • Alcohol craving
  • Anemia
  • Asthma
  • Athletic performance
  • Bipolar (mania)
  • CFS
  • Chronic candida
  • Chronic EBV
  • Chronic fatigue
  • Cold/flu
  • Constipation
  • Depression
  • Dermatitis Herpetiformis
  • Diabetes (Type 2)
  • Diabetic neuropathy
  • Dysmenorrhea
  • Eating disorders
  • Fibromyalgia
  • Headaches (all types)
  • Hypertension
  • Infections
  • Insomnia
  • Lupus
  • Macular Degeneration
  • Mercury toxicity
  • Mono
  • Muscle cramps
  • Parkinson
  • Peptic Ulcers
  • PID
  • Polymyalgia Rheumatica
  • Post-surgical wound healing
  • Restless Leg Syndrome
  • Rheumatoid Arthritis
  • Seasonal Allergy
  • Shingles
  • Sinusitis
  • Ulcerative colitis or Crohn’s

And more!

This powerful treatment tool has been very helpful here at StoneTree over the years. Talk to your naturopathic doctor to find out if it’s the right fit for you.

You can book an appointment here, or call 705-444-5331.

Decreasing Heart Attack Risk by Tackling Inflammation

Recent research in the New England Journal of Medicine looked at 10,000 patients who had had a heart attack AND a positive hsCRP result. (This is a blood test for inflammation.)

All of the patients received high doses of statins, which is the present standard of care, then they were split into two groups. Half of the patients received an injection every three months of a drug called Canakinumab, the other half received a placebo injection of normal saline. This trial went on for four years.

Canakinumab is a form of anti-inflammatory medication. It’s used predominately in those with rheumatoid arthritis. But according to the research, when you give it to people with heart attack risk you get some interesting results:

  • 15% reduction in risk of a cardiovascular event like a fatal or non-fatal heart attack or stroke
  • 30% reduction in the need for expensive interventional procedures like bypasses or stents
  • No change in death rates in the 2 groups.

You can read some mainstream coverage of the news here, including the impact on cancer rates.

The short story? Reducing inflammation is good for your health, in particular your heart.

What’s the Catch?

All of this sounds like good news, and in theory, it is. But nothing comes for free. The problem with Canakinumab is that it decreases inflammation by suppressing the immune system. That means patients who take it may be more susceptible to infections, require increased healing time if injured.

Enter the Better News

Chronic inflammation is often lifestyle-related. A poor diet, being sedentary, being over-stressed and under-slept, smoking and/or exposures to other toxins—all of these things contribute to your overall inflammatory set point. And the magic of lifestyle issues is that they can often be fixed without medication.

Dealing with inflammation is a big part of what Naturopathic Doctors do. We have written about it often, and dealing with it in some form or another is a common part of our treatment plans.

It stands to reason that dealing with and improving your inflammatory lifestyle challenges would be helpful in decreasing inflammation. If you could reduce your risk without the need for intense anti-inflammatory medicines that suppress your immune system, wouldn’t you want to?

The starting point is easy. Finding out if inflammation is a problem for you is as simple as a quick and inexpensive blood test called hsCRP–the same one used in the study. All you need to do is get started!

For information on hsCRP testing or inflammation reduction, book online or call 705-444-5331.

Is Your Thyroid Medication Working for You?

Often, patients who have had a conventional thyroid test have been told that everything is fine. They know better. The symptoms of low thyroid function seem to be ubiquitously suffered, especially by middle aged women. A week doesn’t go by that we are not asked by one of our patients to look into their thyroid function.

There is another group of patients that come to us for help. They’re the people who are already taking thyroid medication but are convinced it isn’t working for them. Even though their blood tests suggest that it should be working, their bodies are telling them otherwise.

If you’re one of those people, it turns out you might be right.

The Problem with Thyroid Meds

The thyroid, a butterfly shaped gland in our necks, secretes thyroid hormone. This hormone is a big player, acting on almost every cell in your body, and it exists in a few different forms. The most common is T4, or thyroxine. This form of the hormone is not active. Instead, it’s the responsibility of our cells to use iodine and CONVERT this T4 to T3, or triiodothyronine, which is the active form of the hormone.

When patients are diagnosed with low thyroid function, they are given a drug form of T4. Levothyroxine is the most common, also known as Synthroid or Eltroxin. The assumption is that the patient taking this drug will convert it to T3, the cells will be happy, and all will be well.

What this piece of research tells us is that is not always the case. In fact, more than 20% of patients may not be converting to the active form of the hormone effectively.

Looking in All the Wrong Places

The real problem here is less that patients aren’t converting their medication, but that we are not doing the right tests to notice.

When these “non-converting” patients go to the doctor to complain about their thyroid symptoms, a thyroid test is done and it will almost always come back normal. That test, however,  is measuring TSH, or thyroid stimulating hormone….which is not a thyroid hormone at all.

The level of TSH in the blood is dependent on the level of T4, NOT on the conversion of T4 to T3. That means that TSH and T4 levels in the blood can appear normal, even in a person who is NOT converting properly.

Remember it is the CONVERSION that allows the symptoms of low thyroid to be corrected by medication. If you’re not converting, the medication may not work.

So how do you know if your thyroid is working? Test the WHOLE picture. Work with a health professional who understands this relationship and can help your medication work better for you!

For information on thyroid and other testing, contact the clinic at 705-444-5331, or book an appointment online.

Reflux Meds: the Good, the Bad and the Ugly

Last month, the medical journal BMJ Open published research linking the use of PPI’s, or proton-pump inhibitors, with increased risk of death.

PPI’s are frequently used to treat serious gastrointestinal issues like ulcers, GI bleeds and reflux, and are one of the most commonly used classes of drugs. They’re a powerful tool, but research continues to show that long-term use is a bad idea.

PPI’s are generally meant to be short-term prescriptions, but people often end up taking them for months or years to control symptoms, especially in the US where they’re available over the counter in various forms.

According to the study, however, the longer the drugs are used, the higher the risk of mortality. Past research has also linked this class of drugs to kidney damage, dementia, and bone fractures.

The moral of the story? Take it when you need it and no more!

But My Digestive Issues are Ruining My Life!

GI issues can be extremely challenging to live with. It’s no wonder people turn to whatever works. But there are other solutions for many sufferers. Issues of the gastrointestinal tract are where naturopathic medicine shines, and there are many ways to treat upper GI complaints without prescription medications.

The place to start, of course, is your diet. That may seem obvious, but astonishingly, this is still frequently discounted in conventional medicine. Despite the fact that your entire GI tract exists to deal with food, we seemed determined to not see food as a GI issue. It is.

Here are a few suggestions from the naturopathic toolkit:

  • Food intolerances and inflammatory foods are real culprits here. Get yourself tested, and avoid reactive foods strictly.
  • Avoid coffee, cigarettes, and booze. They all stimulate acid secretion and an inflammatory response. If you are doing these things and also NOT eating, that makes things worse. You are stimulating the digestive tract and not putting anything in it–a double whammy.
  • Cultivate a healthy flora. Probiotics and foods that support healthy flora, like fermented foods, keep the digestive tract working well and help prevent H.pylori and other imbalances of GI bacteria that can cause trouble.
  • Talk to your chiropractor or osteopath. Sometimes the “valve” that keeps the contents of the stomach in the stomach gets stuck open. This can be made worse by sitting too much. An adjustment can get things back in line.
  • Better still, as always, stay active and maintain a healthy weight for your body type.

Digestive issues are among the most challenging to diagnose, and they often mean difficult lifestyle changes, at least in the short term. But compared to the side-effects of long-term PPI use, the sacrifices are small!

To uncover your food intolerances, or get to the root cause of your digestive troubles, book an appointment with one of our Collingwood naturopathic doctors. 

Vitamin C and Sepsis (& Other Infections!)

Sepsis is a life-threatening illness caused by your body’s response to an infection that has gotten out of control.

Sepsis develops when the chemicals of the immune system that are released into the bloodstream to fight an infection instead cause wide spread inflammation throughout the entire body. When sepsis turns into septic shock things get really serious. Organs start to fail and 30-50% of patients will die.

Dr. Paul Marik MD, a critical care doctor, found something completely by accident: using high doses of vitamin C in septic patients seems to change outcomes quite a bit for the better.

After reading a paper on Vitamin C given to him by a colleague, Dr. Marik came across a patient in the ICU with septic shock who was in critical and not expected to live. Remembering the paper on vitamin C, he gave the women a dose of it–a last-ditch effort that he didn’t expect to work.

When Marik arrived back at the hospital the next day he found his patient still very much alive, and in fact improving! This lead him to use the therapy again and again with similar results.

Dr. Marir published his research in the medical journal Chest. The results are astonishing.

  • In the control group (patients managed with the usual sepsis approach), 40.4% of the group died.
  • In the Vitamin C-treated group, only 8.5% of those in the treated group died.

Of course, we all know by now that stats can be deceiving. Here are the real numbers:

  • In the control group,  19 of 47 people died.
  • In the Vitamin C group, 4 out of 47 people died.

It’s no secret that I’m a fan of Vitamin C. It’s a tool we use all the time. But people should be shouting these results from the rooftops! I don’t know of many treatments that get those kind of success rates.

If you’re interested in digging in more.

The Long History of Vitamin C and Infection

Really, I shouldn’t be surprised by these results. Vitamin C has been a vitamin of interest to treat various infections for decades. Medical Doctors in the 1930’s were using it to treat polio and counter diptheria toxiod

This was important stuff–at the time there were no vaccines for these diseases and very few good treatments.

Andrew Saul, PhD is one of North American’s leading experts in vitamin therapy, and he does a good job of presenting the old and lost research on the value of Vitamin C for various infections and diseases. If you have any interest in the awesome little vitamin, this 53-minute lecture is definitely worth your time.

How to Decide What to Eat

North Americans are obsessed with figuring out what is or isn’t the BEST food or diet.

Reports in the media like this one report on a single food that is magic for a specific health complaint–in this case nuts and colon cancer. No doubt some media outlet will post an article the soon that nuts are bad for you because they are too fattening, too contaminated or likely to cause diverticulitis.

It seems like there is just no knowing what is good for you and what isn’t.

In fact, the International Food Information Council Foundation’s annual Food and Health survey this spring reported that 78% of those surveyed reported they encountered conflicting information about healthy food, and the follow-up questions indicated that 58% of respondents reported that this conflicting info created doubt in the food choices they were making.

We’re confused, in other words, and we don’t know what to do.

How To Decide What To Eat

Knowledge is power…expect when it isn’t. The way that health and nutrition is reported in western media is not making us healthier and more empowered. It’s doing the exact opposite.

The best resource I have found to take the confusion out of healthy food and healthy eating is Michael Pollen’s book, In Defense of Food.  He digs into lots of great detail to support his thesis which is simple, easy and NOT confusing: eat food, not too much, mostly plants.

By “food”, Pollan means things your great-grandmother would recognize as food. Whole foods. The more processed a food becomes the less it should be eaten.

  • Strawberries? Yes. Strawberry jam…less so.  “Strawberry” milkshake from McDonalds? No.
  • Non-GMO corn? Yes. GMO, round-up ready corn…less so. Organic corn chips even less so. High fructose corn syrup? No.
  • Sunflower seeds? Yes. Sunflower oil…less so. Commercially produced, low-fat salad dressing with sunflower oil? No.
  • Grass fed beef. Yes. (Assuming you eat meat.) Commercially farmed corn feed beef…less so. Processed beef patties with fake cheese and simulated bacon flavouring? No.

It’s a good rule of thumb. Eat food, not too much, mostly plants. If you want to learn more, you can watch the documentary “In Defense of Food” on Netflix.

By they way…Pollan followed up In Defense of Food with Food Rules, a guide to answer the question, “What should I eat?” Guess what the last rule is?

“Break the rules once in a while.”

Worth considering. All these years of study and worry and research and media don’t seem to have made us any healthier!

Eat food, not too much, mostly plants.