The Health Benefits of Pet Ownership.

Most people have pets for reasons other than good health. It is now recognised that pets can provide some very important health benefits to owners and the community in general. The health benefits of pets are even being discussed in medical journals. The Australian Family Practitioner had an article on the benefits of pet ownership in the June edition, which I have summarised here.

We get pets for companionship, for something to exercise with, for other recreational purposes such as obedience or agility training, and to teach kids the many lessons that come with pet ownership such as responsibility and even how to cope with death.

What many people fail to realise is the health benefits of pet ownership. It has been show that pet owners consistantly have better physical, psychological and social health than non-pet owners. There are many ways pets keep people healthy, but these are the most significant:

Physical Health:
Cardiovascular Health - pet ownership has been shown to reduce stress and lower blood pressure. We all know how relaxing and reassuring it is to simply sit and pat a dog, or watch gold fish swimming around. It has also been shown that pet owners have improved recovery from cardiovascular surgery.

Physical Fitness (especially dog owners) - dogs are great running or walking partners, and hence dog ownership comes with a reduced risk of obesity and better physical health.

Immune System Development - pet ownership and exposure to pets, particularly with children, has been shown to significantly lower the risk of developing allergies and asthma.

Psychological Health:
Animal Assisted Therapy (AAT) - this is where animal contact is used as part of a persons therapy to help with various conditions. AAT has been shown to increase morale, eating and overall health of Alzheimers patients, decrease violent behaviour and increase language and social skills in childern with ADHD, and reduce stress in children in clinical settines.

Mental Health: Pet owners are less likely to experience loneliness and depression as the pets provide companionship and a sense of purpose. Older people with pets are also less stressed by major adverse life events.

Child Development:Pets play an important role in the social and emotional development of children, including self esteem, independence and empathy. Children who own pets show increased trust, community feeling, safety, self confidence and self enhancement.

Social Health:
Pets as social enablers: Pets are a great way to meet new people, including strangers neighbours, as well as providing other social opportunities such as animal clubs and societies. Pet attachment is positively correlated with family cohesion and adaptability. They also improve social interactions for the elderly.

As you can see, the health benefits of pet ownership are many and varied. but I think that most pet owners already realise they get far more out of their pets than they have to put in.

Should I Worry About a Lump?

One of the more common things we see pets for are lumps and bumps. It is almost always a stressful visit, as people often worry that the lump may be cancerous.

It is a bit of an irony that people often don't bring their pet in because they are worried that their pet has cancer. For far too long the vet profession has approached cancer as a "sorry, your pet has cancer. There's nothing we can do" disease. That has all changed now, but the single most important thing that determines what we can do is how soon we see the case.

There is nothing more upsetting than seeing someones pet with cancer and being unabe to help it when we know if we had seen it sooner we could have treated it successfully.

When you bring a pet in to see us with a lump, we will normally ask a few questions about when it was first noticed, how fast has it grown, etc. This gives us an idea as to how aggressive the lump may be.

Depending on the nature of the lump, we may take a sample with a needle in the consult room and examine it under the microscope. This will often tell us if the lump is inflammatory or if it may be a cancerous lump.

For most cancerous lumps, we need to do further test to determine if it is a benign tumour (the "good" kind, which do not tend to spread), or if it is malignant (the "bad" kind, which may spread and invade surrounding tissues). This further testing may be in the form of a biopsy, where we remove a small part of the lump and send it to the lab for analysis, or an excisional biopsy, where we remove the whole lump and send it off to the lab. Which technique we use will depend on the location of the lump, and what we have found on the needle sample.

The vast majority of lumps we see can be cured surgically if we see them soon enough. Even the more aggressive tumours can be fully removed if they are operated on while small. In the last few months we have also been able to use daily or 3 times weekly medication to stop aggressive cancers regrowing once they have been partially removed, allowing us to successfuly treat aggressive cancers on legs and heads without the need for radical surgery or amputation.

If you find a lump on your pet, please book it in to be seen as soon as possible. Most lumps are actually benign, so we can put your mind at ease with some simple tests. In other cases where the lump is malignant, early diagnosis may allow us to cure your pet. There is almost no cases where a vet properly trained in treating cancer cannot make a significant difference to the quality and length of your pets life.

The Itchy Pet

Does your dog have an ear infection, lick its paws, belly or armpit? If so, your dog may have an allergic condition called Atopic Dermatitis, or Atopy.



This is a very common condition of dogs, and represents around 90% of the skin problems we see in our clinic. It is an impoprtant problem to recognise early, as prompt treamtent can help prevent inflamed skin and ears becoming infected.

Atopic Dermatitis is essentially the dog equivalent to hay fever. Pretty much anything that causes hayfever or asthma attacks in people can be a trigger for Atopic Dermatitis. This includes pollens, dust mites, carpets, grasses, etc.  Just like hayfever, it can sometimes be difficult to determine exactly which pollen or mite is causing the infection, and in most cases there multiple allergens. We can use a blood test or intradermal skin testing to find out the exact causes in some cases.

Treatment for this condition depends on the severity and the presence of secondary infection. I certainly encourage early treatment as we can often avoid the need for steroids and antibiotics with prompt presentation. Secondary bacterial and fungal infections are common if this condition is left untreated, which adds considerably to the cost and difficulty of treatment.

For mild cases or those presented early, my first line of treatment involves using a fatty acid and zinc supplement to help improve the skins natural protective oils. I may also use various antihistamines if needed. My own dog has Atopic Dermatitis, and I find that the zinc/fatty acid supplement I use for him called Nutricoat controls his itchyness almost completely, so I don't need any other medications for him.

For the more severe cases, or where there are infections present, we use a combination of antibiotics, creams, ointments and sometimes steroids or other immune modulating drugs such as cyclosporin. If we can determine the cause of the allergy, we may also consider a course of hyposensitisation injections.

Allergies in cats look a bit different. We tend to see something called Milliary Dermatitis in cats, which looks like scabs either in one location or all over their body. Once again, prompt treatment can prevent secondary infections from setting in, and makes the condition much easier to control. With cats, these allergies are often considered multifactorial, meaning there are several things that combine to create the disease. Often there is the underlying allergy, but we don't see signs until the cat is stressed by something such as a new cat in the area.

Because of the multifactorial nature of this condition, we often look at managing the stress a cat may be experiencing with products such as Feliway (a feline facial pheromone) or hormonal injections. We will sometimes also use steroids to help control the allergy, which are generally very well tollerated in cats.

Allergic skin disease can be a major problem for cats and dogs, but early diagnosis and treatment can significantly improve the pets quality of life.

Pet Insurance

I was asked recently what to look for with Pet Insurance Policies. There are a few things to consider when looking for any policy.

The two main types of insurance policy are Annual and Life Long Policies. Annual policies cover the pet for 12 months from when the condition is first diagnosed. The benefit of this type of policy is it is generally cheaper than Life Long policies. These can be quite useful if the pet has an acute injury or short term illnes such as a broken leg or an infection, or any condition that can be fully resolved within that 12 month period.

What I would recommen is a Life Long policy. This type of policy covers pet for its entire life, as long as the pet remains covered. This means if the pet develops a chronic illness such as arthritis, diabetes or even some types of cancer where treament may be spread over several years, the insurance company will continue to pay for the treatment (although you will generally be charge one excess per condition per year). The only real downside of these types of policies is they are slightly more expensive than Annual policies.

At the Bunbury Vet Clinic, we recommend Pet Plan pet insurance. The main reasons we recommend Pet Plan are:

• they cover for life - if you insure your pt before 8 years of age (5 years for certain breeds) they will continue to insure your pet. They won't refuse to renew your insurance when your pet gets old and you are more likely to need to make a clain
• if your pet is insured with Pet Plan and it ruptures a cruciate ligament, they will still cover you for the second leg if that also ruptures. It has been found that around 70% of dogs that rupture one cruciate ligament will go on to rupture the second ligament within 18  months. Some policies will not cover the second leg as they will clasify it as a pre-existing condition. this is not the case with Pet Plan. They will cover both cruciates if your policy remains valid
• they don't sell anything other than pet insurance - you won't get a pile of unwanted emails/mail about home, car, income protection insurance from them

If your cat or dog is between 8 weeks and 12 months of age we are able to offer you a free 4 week trial of Pet Plan pet insurance which will cover you for up to $3000 of vet treatment. If you sign up in the clinic the cover will start straight away for injury, with a 72 hour waiting period for illness. We can sign your pet up when it comes in for its puppy or kitten vaccinations, or you can bring your pet in and one of our staff can sign you up.

Please note we are not paid by Pet Plan to recommend their policies. We recommend them and pet insurance in general because when pets are insured, we can offer them the very best treatment available without owners needing to work out what the can and can't afford. Remember some conditions can cost $2000-$3000, so insurance can prevent a lot of stress at an already emotional time.

My First Disaster

I remember reading a James Herriot book when I was a kid. James, as a new graduate had just done something that lead to the death of a cow. He was distraught when he went to his boss and told him what had happened. His boss sat himself down and said something to the effect of "you've only killed one cow. You can't call yourself a vet until you've killed a whole fields worth of cattle."

It's a sad fact of the job that sooner or later, every vet will have an animal die because they did something wrong. I am no exception.

When I was working in Esperance, I had a call out to a cow that was down and couldn't get up. She was extremely aggressive, so the physical exam was a bit limited but I was happy with my diagnosis of low blood magnesium. This is often characterised by increased aggression and being unable to stand,so the cow fitted the description perfectly.

The treatment for this condition is intravenous magnesium, which must be given slowly or it can stop the heart. Because this cow was so aggressive, I had to jump in, give it a bit then jump back to avoid injury. I did this 3 times without her getting up. On the fourth attempt I gave her a bit more and she immediately gasped, then died. I had given her too much magnesium too fast and I had stopped her heart. The farmer and I both knew I had killed her.

I felt sick the entire drive back. As soon as I walked into the clinic, I asked the boss for a chat. He knew from the look on my face that something bad had happened. At this point I realised what a good boss I had. He told me he was glad I had told him the truth, and he straight away phoned the farmer and paid him the value of the cow as compensation.

Of course, farmers never let you forget when you are wrong, even when you save a cow. On another callout to this farm, I had to do a caesarian on a cow. She had developed an infection prior to giving birth, and I thought she was beyond saving. I told the farmer this, but he told me "you've driven this far to see her, you might as well try to save her".

Because the cow was so weak, she couldn't walk to the yards so we had to do a caesarian in the middle of the paddock, with dust blowing into the wound and no running water. After I had closed her up I gave her a shot of antibiotics and pain killers and gave the farmer another injection of antibiotics to give in two days if she was still alive.

Two days later the farmer rang me to ask if she really needed the second injection. "She's looking so good I can't catch the bloody thing!'

Every time I visited the farm after that until I left Esperance, the farmer would make sure he'd point out that cow and remind me "that's the one you said was going to die."

What's a Chinchilla?

I'm often asked how we know so much about so many different animals. We are lucky that many animals are put together in a similar way, so much of our knowledge can be transferred between species. Occasionally we get caught out though.

In my first job in the UK, I saw on my consult sheet that someone was bringing in a chinchilla that was unwell. "Easy", I thought to myself, as I knew a chinchilla was a breed of cat.

I called the client through, who carried the cat cage into the consult room and put it on the table. I reached in and pulled out an animal I didn't recognise.

 

A Chinchilla Cat: What I Expected to Find in the Cage

 

A Chinchilla: What I Found in the Cage

 

 

It's hard to figure out what to do when in a situation like this, so I decided to buy myself some time and listen to its heart, because when you've got your stethescope in your ears your client can't talk to you. It gives you a good minutes thinking time. After a bit of thinking time I announced to the client "this is a really interesting case, I had better keep it in for the day so I can work it up propperly".

 

Owners seem to love having "interesting cases" so they agreed to leave it with me for the day. I went straight out the back and grabbed the books. It turns out they are a South American rodent, and after a bit of research I figured out what was wrong with it and started a treatment plan.

 

In the following eight years in the UK I treated many Chinchillas, but still found myself baffled at times with constipated snakes, lame zebras and infected fish where books and "Dr Google" still had to be used to get me through.

Is it harder to be a vet than a doctor?

My wife is a doctor, and one of our common debates is who has the hardest job. I argue my job is harder because my patients can't tell me what is wrong, while my wife argues her job is harder because people often tell her what they think she wants to hear.

I remember when I was young a local vet and a doctor used to be good friends. they had a similar argument about who's job was harder. This debate went on for years until one day the vet became unwell and went to see his doctor friend.

When the doctor asked what was wrong, the vet replied "moo". The doctor asked what he meant by that, and the vet replied "well, that's all my patients ever tell me so you figure it out!"

Even without the talking factor, I still feel that my job is more challenging but also far more interesting than being a doctor. When a GP diagnoses a patient with cancer, they refer them to an oncologist and move on the the next client. When we diagnose cancer in one of our pateints, we become the oncologist. We operate if needed, are in charge of the anaesthetic during the surgery, perform follow-up visits, administer chemotherapy if needed, and sometimes become the palliative care giver for the patient. In fact, our job is covered by over 30 human specialists. but that's why I love this job so much. We get to challenge ourselves every day,and get to know our patients really well.

Cancer Treatments in Pets

We are fortunate to live in a time where our ability to treat our beloved pets is increasing rapidly. With around half of our pets developing cancer at some point in their lives, cancer is something we are treating more and more.

When I first graduated, cancer was a death sentence. We could use some pain kilers to keep the pet comfortable, but a meaningful improvement in life expectancy and quality of life was difficult to obtain.

In 2010 I studied a Distance Education course in Medical Oncology through the university of Sydney. At the time, I realised cancer was a bit issue we were facing, but I didn't realise how many pets we could help.

The first thing I always discuss with people when we aim to treat a cancer is what are our aims. I no longer consider my job to be curing disease, but rather it is to make our pets feel well. And this is the aim of any cancer treatment.

We can cure many cancers with surgery, but how do we deal with the cases that can't be operated on? The dogs with lymphoma, sarcomas in locations we can't remove, or skin cancer that has spread still need something to help them. This is where chemotherapy becomes our main tool.

When we mention chemotherapy, many people think of the side effects such as vomiting and hair loss which can be experienced by people. these side effects come about because of the high doses of drugs used to try to cure the disease. In dogs and cats, I consider making the animal feel very unwell as an unacceptable side effect, so we use chemotherapy differently in pets.

In pets, we use chemotherapy as a tool to turn the cancer into a "chronic disease". Just the same as we can treat the symptoms of arthritis or heart failure in pets, we can treat the symptoms of the cancer. We know with arthritis or heart failure that the pet will eventually stop responding to medication, but we can give them good quality life again by using the right medications.We use similar drugs in pets as are used in people, but at a lower dose so the pet doesn't feel unwell in most cases, but the cancer is sent into remission.

A good example of how well this works is the treatment of lymphoma. Without treatment, most dogs with lymphoma will die within weeks. With the correct protocol, most dogs will live for more than a year. I most cases, people who know the animal will look at the dog and not even know it has cancer or that it is undergoing treatment. The results can be that good!

The treatment isn't cheap, with some protocols costing around $3000, but many people find the extra time they get with their beloved pet, and seeing how well the pet can be, makes it all worth while.

Why I No Longer Work With Cattle and Horses

For the first 10 years of my career, I worked in mixed practice. This is the traditional James Herriot style of vet work, where you had to be prepared for pretty much anything. In a day you could have a surgery to perform on a 1000kg bull, then head back to the clinic and need to diagnose the problem with someones pet mouse. In those 10 years I treated cattle, horses, sheep, goats, rats, mice, ferrets, rabbits, cats, dogs, snakes, lizards, chinchillas, alpacas, llamas, a zebra, kangaroos, deers and various bird species. For many of these species I have been a GP, anaesthetist, dentist, obstetrician, orthopaedic surgeon, general surgeon, oncologist, nutritionist, pediatrician, emergency and intensive care doctor. The amount we are expected to know about so many species is overwhelming, and I eventually had to make the decision to either get much better at fewer species, or continue as jack of all trades, master of none.

There is a lot I used to enjoy about the large animal work. Because you would often spend whole days working on a farm, the farmers became your friends. And when the weather was nice, being out on a farm was a great place to be. Farm work is also much less emotionally draining. when we work with peoples pets over a long period of time, we become quite attached to the pet and the owner. It can really upset you when you lose a patient, where as with farm work that emotional attachment to the animal doesn't create such issues.

Over my 10 years as a mixed practice vet, I felt pet owners and farmers expectations change. They all want to know that the best person possible is looking after their animal. Despite trying my best, I eventually realised that I couldn't match owners expectations, and when I really thought about it I realised I was struggling to meet my own high standards. Something had to go.

I decided to focus on the small animal work as that was my strongest area. It's a decision I am very glad I made. My small animal medicine and surgery skills have improved dramatically. I can now offer my small furry patients a level of treatment I couldn't before, and I now am confident that I am providing a level of treatment I am proud of.

Payment in Cornish Pastys

One of the hardest parts of our job is dealing with the cost of treatments. We are able to offer a huge range of treatment options which allows us to do things that would have been impossible 10 or 20 years ago, but unfortunately these treatments come at a price. As much as we try to keep prices down so as many pets as possible are treated well, we realise we still need to make enough money to keep the doors open. We try to be strict when it comes to making sure everyone pays their share, but occasionally a case comes along where you need to break the rules.

When I was working in a town called Lostwithiel in the southwest of England, an elderly lady, Mary, with a dog called Nikki came in to see me. Nikki had been treated by another vet for a tumour on her back leg. The other vet had removed the tumour but had placed the sutures too tight around her leg. This created a tourniquet around the leg, causing much of the tissue below the sutures to die off.

Then I examined Nikki, I knew this was going to be expensive. There was almost no skin left on the end of her leg, two of her toes needed amputating, and I reallyy wondered if we could even save the leg. I had a chat to Mary about what was needed, what it would cost and what the likely outcome was. Mary was devistated. She was a pensioner, and couldn't really afford even basic treatment. She had spent all she could afford on the initial tumour treatment, so said we would need to put Nikki to sleep.

I don't think anyone could do anything other that feel sorry for this lady. She had tried to do the right thing for her pet, and it had become a disaster. The initial vet denied any responsibility and refused to help fix the situation, so I went cap in hand to my boss. I explained to her that this was a situation that reflected on the whole profession, and as I had never performed a skin graft this was a good opportunity for me to practice a new procedure. She must have been in a good mood that day, and she agreed to let me treat Nikki for free.

I returned to the consult room to give Mary the good news. I explained that Nikki would need bandage changes weekly initially, then a couple of surgeries to perform the skin graft She would be getting around $1500 of treatment for free. Mary wouldn't hear of me treating Nikki for free, as she didn't want to be seen as a charity case. She said that if I could pick up and drop off Nikki on her treatment days (it turns out Mary lived just down the road from me) she would make sure she had some lunch ready for me on those days as payment for my work.

For the next 6 weeks I picked up Nikki every Wednesday morning, and dropped her off when I could get away for lunch. Without fail Mary had two cornish pastys ready for me freshly made that morning, each nearly the size of a dinner plate. As I was single at the time, such a great feed was very much appreciated.

After 6 weeks of treatment, we managed to save Nikki's leg.She always had a bit of a limp, but we were all amazed at how well this little dog battled on. I worked at that clinic for another year after we had finished with Nikki, and Mary still insisted that I popped in every Wednesday at lunchtime to pick up my pastys. We became good friends over that time, and each time I went to Cornwall after that I would drop in and visit Mary and Nikki. I'm guessing Nikki still remembered me even three years after I finished her treamtent, as the last time I visited them Nikki saw me and ran off under the kitchen table and wouldn't come out. Dog's aren't much good at gratitude some times.

Cow Stuck in the Mud

If you have been in my consult room in the last couple of weeks, you may have noticed a certificate of merit from the UK RSPCA for helping rescue a jersey cow stuck in deep mud. Many people have asked me about it, (I put it up as a conversation piece) so I thought I'd share the story.

I worked in the UK doing locum work for around 8 years. My last job was in a town called Wadebridge, in north Cornwall. Around lunch time we received a call from the RSPCA requesting assistance for a cow stuck in mud. I thought this sounded like a bit of fun, so volunteered to head out.

I was met at the farm by the RSPCA inspector and 2 fire trucks.....this was going to be a bit harder than I thought. We walked down to the river and saw the cow sunk up to its neck in sticky, smelly mud. Apparently the RSPCA had inspected the farm the week before after someone complained about the lack of water for these cows. Instead of putting in a water trough, the farmer decided to move the fence line to include part of the river. The poor cow went down for a drink and got caught in the sucking mud. Luckily someone walking past had seen the cow struggling and called for help.

The cow was quite distressed, so I gave it a light sedative then we got to work trying to free it. The mud was that horrible sucking sort of mud that made it impossible to just pull her out. Luckily there was a large tree nearby so the fire brigade set up a pulley system overhead, put some planks around her so we had somewhere to stand, and we started digging her out. We had to dig her out by hand so we didn't injure her, which took us over an hour. The fire fighters had their hazardous chemical suits on so they kept pretty clean. I just has a pair of overalls, so I got pretty dirty by the end. We then used the pulley system to pull her out and swing her across to the riverbank.

After so long in the cold water, she was very hypothermic, so we set up the flood lights on her, dried her off and started moving her legs for her. After another hour or so she still wouldn't stand. We organised a large amount of hay to give her some deep bedding and some rugs to keep her warm. Once she looked comfortable and set up for the night, we started to walk off. I think she saw her opportunity and got up, ran past us and carried on down the road. Luckily one of the fire trucks had just left to return t station, so we radioed ahead and got them to chase her back.

The cow made a full recovery, and the farmer was let off with a warning. Unfortunately he didn't learn his lesson, and 4 weeks later one of my colleagues was back out to the farm rescuing another cow stuck in the same place.

The Better Business Booster Video

One day to go in the Commonwealth Bank's Better Business Booster Competion. So far we are doing well, so I thought I'd talk a bit about the animals in the competition video.

Marvin's story is already mentined in the video. He was discovered stuffed inside a cat cage on a hot day. He had obviously been subjected to a lifetime of abuse. He only weighed 13kg (a dog of his age and breed should be around 35kg), had lost the skin over his rump which was being eaten away by maggots, was severely anaemic and he was unable to stand.

A decision needed to be made. Could we save Marvin or should we put him to sleep. The big eyes and wagging tail helped convince us that Marvin could pull through. What followed was weeks of intensive care, physiotherapy and good quality nutrition. After 2 weeks, Marvin was strong enough to stand on his own.

I had always warned my wife we were unlikely to ever own a dog with 2 eyes and 4 legs, as I knew I would one day adopt a dog which really needed a home. Luckily Marvin has returned to nearly full health, though he has a couple of minor problems we manage on a regular basis. He is strong enough to chase the ball at the beach or run 10km with me.

The small, dark coloured dog missing a front leg is Buddy. Buddy came to us with a broken raduis and ulna. We tried to repair the leg with metal pins, but unfortunately the fracture wouldn't heal. After 10 weeks of trying, we realised we couldn't save the leg. We made the difficult decision to amputate. As you can see from the video, amputation hasn't slowed Buddy down. He's still a happy ball of energy.

Alfie is the other three-legged dog in the video. Alfie was lucky to survive his accident. The gate at his house blew open, Buddy escaped, and ran in front of a car. The car hit his back end, dislocating his right hip, removing a lot of skin on the right hind leg, and breaking his left back leg in several places exposing the bone in several places. The left leg was beyond saving, but with the right hip dislocated Alfie was going to struggle to function.

We put the hip back into place and Alfie was hospitalised for several days, but unfortunately the hip came back out of joint, so we needed to operate. The surgery took myself and Joc around 2 hours to repair the hip. After several more weeks of bandage changes, Alfie hasnow recovered well from his injuries.

You will also notice in the video other dogs wandering around the clinic. We have a practice policy of the staff being able to bring their dogs in to work. The dogs love coming in and being with the owners for the day, and the other pets in hospital seem to be reassured by these dogs walking around and being so relaxed here.

I would like to congratulate the other Better Business Booster finalists on getting this far. The level of professionalism and enthusiasm shown by these people is inspiring, and I wish them all the best for the future.

Welcome

Welcome to the Bunbury Vet Clinic Blog.
The Bunbury Veterinary Clinic is the longest established veterinary practice in country Western Australia. Since 1976 we have been providing high quality veterinary medicine to Bunbury and surrounding areas.
When you see one of our vets, you know your pet will be getting the best possible treatment. All our Vets, who are WA born and bred, have over 10 years experience and have worked overseas in countries such as the UK and New Zealand.
Our focus is entirely on domestic pets, including dogs, cats, birds, rabbits, ferrets and fish though we regularly treat wildlife and other less common pets.
We have full hospital status, which allows us to hospitalise animals overnight. Your pet can be monitored through the night by one of our highly experienced Vets as needed.

This blog is about life as a vet, as a business owner and everything that goes on around us.

I hope you enjoy it.