Dermatological manifestations relating to nutritional deficiencies after bariatric surgery
case report and integrative literature review
Palavras-chave:
Bariatric surgery, Skin manifestations, Skin diseases, Deficiency diseasesResumo
BACKGROUND: The number of bariatric surgeries performed worldwide is growing. Among the main short, medium or long-term complications after surgery are nutritional deficiencies. Many of these, such as those of Zn, Cu and vitamins A, B1, B3, B6 and B12, are manifested by dermatological lesions before potentially fatal systemic disorders occur. OBJECTIVE: To identify the main dermatological manifestations associated with nutritional deficiencies after bariatric surgery, and the associated variables. DESIGN AND SETTING: Integrative literature review carried out at a public university in Brazil. METHODS: This was a case report and a review of health research portals and databases of national and international biomedical journals, without publication date limitation. The descriptors used for searches followed the ideal methodology for each database/search portal: “bariatric surgery”, “skin”, “skin disease”, “skin manifestation”, “deficiency disease” and “malnutrition”. RESULTS: A total of 59 articles were selected, among which 23 were review articles or articles that addressed specific dermatological manifestations. The other 36 articles described 41 cases, which were organized into a table with the clinical variables. CONCLUSIONS: Although nutritional deficiencies are expected as complications after bariatric surgery, few articles relating them to their dermatological manifestations were found. It is important to recognize skin changes caused by nutritional deficiencies in patients treated via bariatric surgery, as these may occur before systemic complications appear and are easier to diagnose when the patient does not have any systemic symptoms yet. However, there is generally a delay between the appearance of skin lesions and making the diagnosis of nutritional deficiency.
Downloads
Referências
Chu DT, Minh Nguyet NT, Nga VT, et al. An update on obesity: Mental consequences and psychological interventions. Diabetes Metab Syndr. 2019;13(1):155-60. PMID: 30641689; https://doi.org/10.1016/j.dsx.2018.07.015
Williams EP, Mesidor M, Winters K, Dubbert PM, Wyatt SB. Overweight and Obesity: Prevalence, Consequences, and Causes of a Growing Public Health Problem. Curr Obes Rep. 2015;4(3):363-70. PMID: 26627494; https://doi.org/10.1007/s13679-015-0169-4
Abu-Abid S, Szold A, Klausner J. Obesity and cancer. J Med. 2002;33(1-4):73-86. PMID: 12939106.
Kwok S, Adam S, Ho JH, et al. Obesity: A critical risk factor in the COVID-19 pandemic. Clin Obes. 2020;10(6):e12403. PMID: 32857454; https://doi.org/10.1111/cob.12403
Ryan DH, Ravussin E, Heymsfield S. COVID 19 and the Patient with Obesity - The Editors Speak Out. Obesity (Silver Spring). 2020;28(5):847. PMID: 32237212; https://doi.org/10.1002/oby.22808
Obesity and Overweight. The World Health Organization. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/ Accessed in 2021 (Jun 11).
Kruger RS, Pricolo VE, Streeter TT, Colacchio DA, Andrade UA. A bariatric surgery center of excellence: operative trends and long-term outcomes. J Am Coll Surg. 2014;218(6):1163-74. PMID: 24755190; https://doi.org/10.1016/j.jamcollsurg.2014.01.056
Malvi P, Chaube B, Pandey V, et al. Obesity induced rapid melanoma progression is reversed by orlistat treatment and dietary intervention: role of adipokines. Mol Oncol. 2015;9(3):689-703. PMID: 25499031; https://doi.org/10.1016/j.molonc.2014.11.006
Zeve JLM, Novais PO, Oliveira Jr ND. Técnicas em cirurgia bariátrica: uma revisão de literatura. Revista Ciência & Saúde, Porto Alegre. 2012;5(2):132-40. https://doi.org/10.15448/1983-652X.2012.2.10966
Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427-36. PMID: 23338049; https://doi.org/10.1007/s11695-012-0864-0
Swartz MH. Textbook of Physical Diagnosis: History and Examination. 7th ed. Philadelphia PA: WB Saunders; 2014.
Calcaterra V, Cena H, Pelizzo G, et al. Bariatric Surgery in Adolescents: To Do or Not to Do? Children (Basel). 2021;8(6):453. PMID: 34072065; https://doi.org/10.3390/children8060453
th IFSO World Congress. Obes Surg. 2015;25(1):S1-364. https://doi.org/10.1007/s11695-015-1750-3
Brigida EPS, Costa VVL, Palheta RCA, et al. Correlation between the nutritional deficiencies with nutritional supplementation in the bariatric post-surgery patients. Revista Brasileira de Obesidade, Nutrição e Emagrecimento. 2017;11(67 Suppl 1):498-505. Available from: https://link.gale.com/apps/doc/A532075688/IFME?u=unicamp_br&sid=bookmark-IFME&xid=1fa3932a. Accessed in 2022 (Feb 18).
Chu AS, Mataga MA, Krueger L, Barr PA. Nutrient Deficiency-Related Dermatoses after Bariatric Surgery. Adv Skin Wound Care. 2019;32(10):443-55. PMID: 31567451; https://doi.org/10.1097/01.ASW.0000579688.97532.18
Concors SJ, Ecker BL, Maduka R, et al. Complications and Surveillance After Bariatric Surgery. Curr Treat Options Neurol. 2016;18(1):5. PMID: 26860932; https://doi.og/10.1007/s11940-015-0383-0
Clinicopathological Cases. British Journal of Dermatology. 2011;165(Suppl 1):12-19. https://doi.org/10.1111/j.1365-2133.2011.10320.x
Garcovich S, De Simone C, Giovanardi G, et al. Post-bariatric surgery hidradenitis suppurativa: a new patient subset associated with malabsorption and micronutritional deficiencies. Clin Exp Dermatol. 2019;44(3):283-9. PMID: 30144136; https://doi.org/10.1111/ced.13732
González-Sabín M, Rodríguez-Díaz E, Mallo-García S, Astola-Hidalgo I. Scurvy: an “almost” forgotten disease. Eur J Dermatol. 2017;27(5):539-40. PMID: 28690213; https://doi.org/10.1684/ejd.2017.3063
Halawi A, Abiad F, Abbas O. Bariatric surgery and its effects on the skin and skin diseases. Obes Surg. 2013;23(3):408-13. PMID: 23297168; https://doi.org/10.1007/s11695-012-0859-x
Hasan NA, Freije A, Abualsel A, Al-Saati H, Perna S. Effect of bariatric surgery on weight loss, nutritional deficiencies, postoperative complications and adherence to dietary and lifestyle recommendations: a retrospective cohort study from Bahrain. Sultan Qaboos Univ Med J. 2020;20(3):e344-e351. PMID: 33110651; https://doi.org/10.18295/squmj.2020.20.03.015
Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28(6):669-85. PMID: 21034991; https://doi.org/10.1016/j.clindermatol.2010.03.029
Ledoux S, Flamant M, Calabrese D, et al. Micronutrient Deficiencies Responsible for the Most Common Nutritional Symptoms After Bariatric Surgery? Obes Surg. 2020;30(5):1891-7. PMID: 31960214; https://doi.org/10.1007/s11695-020-04412-8
Lie C, Liew CF, Oon HH. Alopecia and the metabolic syndrome. Clin Dermatol. 2018;36(1):54-61. PMID: 29241753; https://doi.org/10.1016/j.clindermatol.2017.09.009
th IFSO World Congress. Obes Surg. 2019;29(Suppl 5):347-1720. PMID: 31350717; https://doi.org/10.1007/s11695-019-04101-1
Mahawar KK, Bhasker AG, Bindal V, et al. Zinc Deficiency after Gastric Bypass for Morbid Obesity: a Systematic Review. Obes Surg. 2017;27(2):522-9. PMID: 27885534; https://doi.org/10.1007/s11695-016-2474-8
Manzoni AP, Weber MB. Skin changes after bariatric surgery. An Bras Dermatol. 2015;90(2):157-66. PMID: 25830984; https://doi.org/10.1590/abd1806-4841.20153139
Galimberti F, Mesinkovska NA. Skin findings associated with nutritional deficiencies. Clevel Clin J Med. 2016;83(10):731-9. PMID: 27726828; https://doi.org/10.3949/ccjm.83a.15061
Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16-19 March 2016 : Poster Presentations. Surg Endosc. 2016 Mar;30 Suppl 1:325-500.. PMID: 26913535; https://doi.org/10.1007/s00464-016-4771-7
Ribeiro de Moraes M, Lúcia de Mendonca Soares B, Maio R, Pessoa de Araújo Burgos MG. Clinical-nutritional evolution of older women submitted to Roux-en-Y gastric bypass. Nutr Hosp. 2014;31(3):1330-5. PMID: 25726230; https://doi.org/10.3305/nh.2015.31.3.8112
Rojas P, Gosch M, Basfi-fer K, et al. Alopecia en mujeres con obesidad severa y mórbida sometidas a cirugía bariátrica [Alopecia in women with severe and morbid obesity who undergo bariatric surgery]. Nutr Hosp. 2011;26(4):856-62. PMID: 22470035; https://doi.org/10.1590/S0212-16112011000400028
Sethi M, Chau E, Youn A, et al. Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data. Surg Obes Relat Dis. 2016;12(9):1697-705.. PMID: 27425842; https://doi.org/10.1016/j.soard.2016.03.006
Talebpour M, Sadid D, Talebpour A, Sharifi A, Davari FV. Comparison of Short-Term Effectiveness and Postoperative Complications: Laparoscopic Gastric Plication vs Laparoscopic Sleeve Gastrectomy. Obes Surg. 2018;28(4):996-1001. PMID: 29043548; https://doi.org/10.1007/s11695-017-2951-8
Wollina U, Dreßler M, Lohmann T. Bariatric surgery - a dermatologic perspective. J Eur Acad Dermatol Venereol. 2015;29(5):835-41. PMID: 25376665; https://doi.org/10.1111/jdv.12820
Abad L, Omiste T, Vera J, Gilaberte Y. Phrynoderma after biliopancreatic diversion. Actas Dermosifiliogr. 2015;106(4):327-9. PMID: 25456111; https://doi.org/10.1016/j.ad.2014.08.009
IFSO 2017 22nd World Congress. Obes Surg. 2017;27(Suppl 1):1-1253. PMID: 28646415; https://doi.org/10.1007/s11695-017-2774-7 Erratum in: Obes Surg. 2017.
Al-Douri A, Chambers J, John J. Nutritional deficiencies in a patient with Roux-en-Y gastric bypass surgery. American Journal of Gastroenterology. 2019;114:S1535. https://doi.org/10.14309/01.ajg.0000600640.63227.f1
Ashourian N, Mousdicas N. Images in clinical medicine. Pellagra-like dermatitis. N Engl J Med. 2006;354(15):1614. PMID: 16611952; https://doi.org/10.1056/NEJMicm050641
Bae-Harboe YS, Solky A, Masterpol KS. A case of acquired zinc deficiency. Dermatol Online J. 2012;18(5):1. PMID: 22630571; https://doi.org/10.5070/D340w733sk
Boutin D, Cante V, Levillain P, Piguel X, Guillet G. Kwashiorkor chez l'adulte: une complication rare de la chirurgie bariatrique [Adult kwashiorkor: A rare complication of bariatric surgery]. Ann Dermatol Venereol. 2015;142(2):99-103. PMID: 25554665; https://doi.org/10.1016/j.annder.2014.11.006
Cunha SF, Goncalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J. 2012;130(5):330-5. PMID: 23174873; https://doi.org/10.1590/s1516-31802012000500010
Evans JB, Hastings JG, Kaffenberger BH. Acquired Pili Torti. JAMA Dermatol. 2019;155(4):488. PMID: 30810707; https://doi.org/10.1001/jamadermatol.2018.4677
Freitas J, Bliven P, Case R. Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass. BMJ Case Rep. 2019;12(8):e230605. PMID: 31377720; https://doi.org/10.1136/bcr-2019-230605
Garcia D, Nielson CB, Gillihan R, et al. Xerotic Eruption and Purpura: Answer. Am J Dermatopathol. 2020;42(3):221-3. PMID: 32079821; https://doi.org/10.1097/DAD.0000000000001323
Garcovich S, Di Stefani A, Capizzi R, Massi G, Peris K. Occurrence of hidradenitis suppurativa and phrynoderma after bariatric surgery. J Eur Acad Dermatol Venereol. 2016;30(7):1215-7. PMID: 25879252; https://doi.org/10.1111/jdv.13140
Clinical Vignettes/Case Reports-Obesity. Am J Gastroenterol. 2017;112(S1):S1293-S1297. PMID: 28981039; https://doi.org/10.1038/ajg.2017.322
Abstracts from the 2016 Society of General Internal Medicine Annual Meeting. J Gen Intern Med. 2016;31 Suppl 2(Suppl 2):85-922. PMID: 27114361; https://doi.org/10.1007/s11606-016-3657-7
Jaffe AT, Heymann WR. Kwashiorkor/zinc deficiency overlap following partial gastrectomy. Int J Dermatol. 1998;37(2):134-7. PMID: 9542673; https://doi.org/10.1046/j.1365-4362.1998.00374.x
Katugampola RP, Patel GK, Farrell AM. Intestinal bypass syndrome presenting as erythema nodosum. Clin Exp Dermatol. 2004;29(3):261-4. PMID: 15115506; https://doi.org/10.1111/j.1365-2230.2004.01476.x
Khanal S, Ghimire P, Bhat U, et al. 1695: Reversal of coma and MRI findings on correction of bariatric surgery-associated hyperammonemia. Crit Care Med. 2016;44(12):499. https://doi.org/10.1097/01.ccm.0000510368.81422.93
Abstracts presented at the 22nd Annual Congress of the Belgian Society of Internal Medicine, 15-16 December 2017, Dolce La Hulpe, La Hulpe, Belgium. Acta Clin Belg. 2017;72(sup2):1-56. PMID: 29198176; https://doi.org/10.1080/17843286.2017.1401314
Lopez JF, Halimi S, Perillat Y. Erythème pellagroïde après gastroplastie verticale calibrée pour obésité morbide [Pellagra-like erythema following vertical banded gastroplasty for morbid obesity]. Ann Chir. 2000;125(3):297-8. PMID: 10829515; https://doi.org/10.1016/s0001-4001(00)00135-5
Mankaney GN, Vipperla K. Images in clinical medicine. Acquired acrodermatitis enteropathica. N Engl J Med. 2014;371(1):67. PMID: 24988559; https://doi.org/10.1056/NEJMicm1312911
Clinical Vignettes/Case Reports - Small Intestine/Unclassified. Am J Gastroenterol. 2016;111(S1):S971-S1076. PMID: 27685313; https://doi.org/10.1038/ajg.2016.374
Monshi B, Stockinger T, Vigl K, et al. Phrynoderma and acquired acrodermatitis enteropathica in breastfeeding women after bariatric surgery. J Dtsch Dermatol Ges. 2015;13(11):1147-54. PMID: 26513075; https://doi.org/10.1111/ddg.12795
Ocón J, Cabrejas C, Altemir J, Moros M. Phrynoderma: a rare dermatologic complication of bariatric surgery. JPEN J Parenter Enteral Nutr. 2012;36(3):361-4. PMID: 22269897; https://doi.org/10.1177/0148607111422067
Panetta C, Paolino G, Muscardin L, Donati M, Donati P. Biliopancreatic diversion: when a cure becomes a disease. Am J Dermatopathol. 2014;36(3):258-9. PMID: 23719482; https://doi.org/10.1097/DAD.0b013e3182926665
Ramos-Leví AM, Pérez-Ferre N, Sánchez-Pernaute A, Torres García AJ, Rubio Herrera MA. Severe vitamin A deficiency after malabsorptive bariatric surgery. Nutr Hosp. 2013;28(4):1337-40. PMID: 23889662; https://doi.org/10.3305/nh.2013.28.4.6610
Rana J, Plovanich M, Wallace EB, et al. Acquired acrodermatitis enteropathica after gastric bypass surgery responsive to IV supplementation. Dermatol Online J. 2016;22(11):13030/qt50v2f3mb. PMID: 28329567; https://doi.org/10.5070/D32211033150
Shackelton JB, Chabra IS, Liu JC, Swoger JM, Grandinetti LM. Nutritional dermatoses in the bariatric surgery patient. Internal Medicine Dermatology. 2012;66(4 Suppl 1):AB132. https://doi.org/10.1016/j.jaad.2011.11.558
Stephens JW, Boregowda K, Barry J, et al. Adrenal insufficiency following bariatric surgery. Obes Rev. 2012;13(6):560-2. PMID: 22385616; https://doi.org/10.1111/j.1467-789X.2012.00987.x
Abstracts from the 2019 Annual Meeting of the Society of General Internal Medicine. J Gen Intern Med. 2019;34(Suppl 2):99-867. PMID: 31090026; https://doi.org/10.1007/s11606-019-05007-5
Vales Montero M, Chavarría Cano B, Martínez Ginés ML, et al. Deficiencia clínica de vitamina A tras bypass gástrico. Descripción de un caso clínico y revisión de la literatura [Clinical vitamin A deficiency after gastric bypass. Description of a clinical case and review of the literature]. Nutr Hosp. 2016;33(4):404. PMID: 27571679; https://doi.org/10.20960/nh.404
Abstracts from the 2017 Society of General Internal Medicine Annual Meeting. J Gen Intern Med. 2017;32(Suppl 2):83-808. PMID: 28397154; https://doi.org/10.1007/s11606-017-4028-8
Velazquez A, Apovian CM, Istfan NW. The Complexities of Iron Deficiency in Patients After Bariatric Surgery. Am J Med. 2017;130(7):e293-e294. PMID: 28238687; https://doi.org/10.1016/j.amjmed.2017.01.040
Vick G, Mahmoudizad R, Fiala K. Intravenous zinc therapy for acquired zinc deficiency secondary to gastric bypass surgery: a case report. Dermatol Ther. 2015;28(4):222-5. PMID: 25754007; https://doi.org/10.1111/dth.12209
Wilson HO, Datta DB. Complications from micronutrient deficiency following bariatric surgery. Ann. Clin. Biochem. 2014;51(Pt 6):705-9. PMID: 24847133; https://doi.org/10.1177/0004563214535562
Zouridaki E, Papafragkaki DK, Papafragkakis H, Aroni K, Stavropoulos P. Dermatological complications after bariatric surgery: report of two cases and review of the literature. Dermatology. 2014;228(1):5-9. PMID: 24401283; https://doi.org/10.1159/000356160
Khorgami Z, Zhang C, Messiah SE, de la Cruz-Muñoz N. Predictors of Postoperative Aftercare Attrition among Gastric Bypass Patients. Bariatr Surg Pract Patient Care. 2015;10(2):79-83. PMID: 26155436; https://doi.org/10.1089/bari.2014.0053
Sunil S, Santiago VA, Gougeon L, et al. Predictors of vitamin adherence after bariatric surgery. Obes Surg. 2017;27(2):416-23. PMID: 27448232; https://doi.org/10.1007/s11695-016-2306-x
Mahawar KK, Clare K, O’Kane M, et al. Patient Perspectives on Adherence with Micronutrient Supplementation After Bariatric Surgery. Obes Surg. 2019;29(5):1551-6. PMID: 30652245; https://doi.org/10.1007/s11695-019-03711-z
Bodunova NA, Sabelnikova EA, Parfenov AI, et al. [The change in the concentration of vitamins after bariatric surgery]. Klin Med (Mosk). 2015;93(12):28-31. PMID: 27149810.
Maverakis E, Fung MA, Lynch PJ, et al. Acrodermatitis enteropathica and an overview of zinc metabolism. J Am Acad Dermatol. 2007;56(1):116-24. PMID: 17190629; https://doi.org/10.1016/j.jaad.2006.08.015
Ogawa Y, Kinoshita M, Shimada S, Kawamura T. Zinc and Skin Disorders. Nutrients. 2018;10(2):199. PMID: 29439479; https://doi.org/10.3390/nu10020199
Nosewicz J, Spaccarelli N, Roberts KM, et al. The epidemiology, impact, and diagnosis of nutritional micronutrient dermatoses part 1: Zinc, selenium, copper, vitamin A, and vitamin C. J Am Acad Dermatol. 2022;86(2):267-78. PMID: 34748862; https://doi.org/10.1016/j.jaad.2021.07.079
Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O. Pellagra: a clinical, histopathological, and epidemiological study of 7 cases. Actas Dermosifiliogr. 2012;103(1):51-8. PMID: 22456595; https://doi.org/10.1016/j.adengl.2011.05.003
Román GC. Nutritional disorders in tropical neurology. Handb Clin Neurol. 2013;114:381-404. PMID: 23829926; https://doi.org/10.1016/B978-0-444-53490-3.00030-3
Slater GH, Ren CJ, Siegel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48-55; discussion 4-5. PMID: 14746835; https://doi.org/10.1016/j.gassur.2003.09.020
D'Ambrosio DN, Clugston RD, Blaner WS. Vitamin A metabolism: an update. Nutrients. 2011;3(1):63-103. PMID: 21350678; https://doi.org/10.3390/nu3010063
Goodman JC. Neurological Complications of Bariatric Surgery. Curr Neurol Neurosci Rep. 2015;15(12):79. PMID: 26493558; https://doi.org/10.1007/s11910-015-0597-2
Barr DJ, Riley RJ, Greco DJ. Bypass phrynoderma. Vitamin A deficiency associated with bowel-bypass surgery. Arch Dermatol. 1984;120(7):919-21. PMID: 6732263; https://doi.org/10.1001/archderm.120.7.919
Neill SM, Pembroke AC, du Vivier AW, Salisbury JR. Phrynoderma and perforating folliculitis due to vitamin A deficiency in a diabetic. J R Soc Med. 1988;81(3):171-2. PMID: 3357162.
Bikle DD. Vitamin D metabolism and function in the skin. Mol Cell Endocrinol. 2011;347(1-2):80-9. PMID: 21664236; https://doi.org/10.1016/j.mce.2011.05.017
Keen MA, Hassan I. Vitamin E in dermatology. Indian Dermatol Online J. 2016;7(4):311-5. PMID: 27559512; https://doi.org/10.4103/2229-5178.185494
Brescoll J, Daveluy S. A review of vitamin B12 in dermatology. Am J Clin Dermatol. 2015;16(1):27-33. PMID: 25559140; https://doi.org/10.1007/s40257-014-0107-3
Kang D, Shi B, Erfe MC, Craft N, Li H. Vitamin B12 modulates the transcriptome of the skin microbiota in acne pathogenesis. Sci Transl Med. 2015;7(293):293ra103. PMID: 26109103; https://doi.org/10.1126/scitranslmed.aab2009
Manzoni AP, Weber MB. Skin changes after bariatric surgery. An Bras Dermatol. 2015;90(2):157-66. PMID: 25830984; https://doi.org/10.1590/abd1806-4841.20153139
Mechanick JI, Apovian C, Brethauer S, et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring). 2020;28(4):O1-O58. PMID: 32202076; https://doi.org/10.1002/oby.22719
Ha J, Kwon Y, Kwon JW, et al. Micronutrient status in bariatric surgery patients receiving postoperative supplementation per guidelines: Insights from a systematic review and meta-analysis of longitudinal studies. Obes Rev. 2021;22(7):e13249. PMID: 33938111; https://doi.org/10.1111/obr.13249
Downloads
Publicado
Como Citar
Edição
Seção
Licença
Este trabalho está licenciado sob uma licença Creative Commons Attribution 4.0 International License.
