TMS is given 5 days a week for at least 4 weeks. Transcranial magnetic stimulation (TMS) is an effective treatment for depression but is limited in that the optimal therapeutic target remains unknown. Findings from large multi-site, sham-controlled RCTs. Greenbrook TMS therapy and nasal esketamine are covered by major insurance companies in Missouri, including but not limited to those listed above. There are a few key publications that highlight the growth in TMS over the last 10 years (see table). Our clinics offer non-invasive, prescription drug-free therapies that are used to treat conditions such as depression, anxiety, OCD, ADHD, and PTSD. Port Saint Lucie, FL 34986. “About 60% respond well to therapy and medication, and another 20% respond when switched to an alternative medication. One of the best Psychiatrists businesses at 544 NW University Blvd, Suite 102, Port St. com. +1 360-616-0543. TMS is an FDA-cleared, non-invasive therapy for the treatment of Major Depressive Disorder (MDD) & Obsessive Compulsive Disorder in patients that u000Bhave failed drug treatments or have not reached full remission from symptoms. Severe depression, or MDD (Major Depressive Disorder), is defined by long. , something else than the wonderful success stories on the sites of the clinics that sell the treatment). If a person has treatment-resistant depression, a doctor may. Senova et al. Find Reviews, Ratings, Directions, Business Hours, Contact Information and book online appointment. , P. Learn about the The Center for Brain Circuit Therapeutics that offers transcranial magnetic stimulation (TMS) for treatment-resistant depression and other neurological and psychiatric disorders. et al. 0 Port Orchard, WA. 98366. & Associates Call 312-488-9599 Locations in Skokie & Chicago Loop 1/3. Thank you for joining us today for this lecture on the risks and safety of transcranial magnetic stimulation, TMS. SeattleNTC – Neuropsychiatric Treatment Center TMS TREATMENT TMS TREATMENT Safe, non-invasive, FDA-approved treatment for depression, OCD, and more. Dawna Gutzmann, M. TMS therapy is one of the few depression treatments without medications or drugs. Clinical studies have shown that TMS can significantly reduce depressive symptoms in patients who do not respond to traditional treatments. . Contact. what is tms therapy? find relief with tms; tms therapy success rate; tms reviews; conditions treated. Old Orchard TMS. Find Bipolar Disorder Therapists, Psychologists and Bipolar Disorder Counseling in Port Orchard, Kitsap County, Washington, get help for Bipolar Disorder in Port Orchard, get help with Manic. This causes more activity. In the psychiatric field, TMS is being used increasingly as a treatment. 201-465-8019. TMS is a non-invasive form of brain stimulation that involves using a magnetic coil to stimulate the brain. Dr. The most common use of TMS is for treating depression. (859) 309-2655In 1985, Anthony Barker and his team developed transcranial magnetic stimulation (TMS) when they produced a motor response by noninvasively applying a magnetic field to the human motor cortex. If you're getting few results, try a more general search term. Call 1-855-940-4867 to find a nearby location or enter your ZIP code in our center locator. Repetitive Transcranial Magnetic Stimulation (rTMS; hereafter TMS) is a nonconvulsive intervention that uses rapidly fluctuating magnetic fields to induce neuronal depolarization ( Rowny and Lisanby, 2008 ), and can be. For example when you sprain your. 9 customer reviews of NeuroStim TMS Kitsap. Common issues I work with are. Front Street Clinic Inc. A course of at least 20 sessions over consecutive weekdays is typically recommended for therapeutic results. Transcranial magnetic stimulation (TMS) is a treatment technique that uses a magnetic field to influence brain activity. FDA-approved treatments began in 2008 and have continued for 14 years with encouraging results. “In the U. TMS is helpful for most people with depression who receive this treatment. Portland, Oregon 97210. Open-label, evidence-based analysis finds TMS to be an effective and long-lasting depression. Email: tms@mgh. Upset digestive system. How Depression Is Treated. Most patients have TMS therapy sessions five days a week for four to six weeks. 0004 V/m compared with repetitive transcranial magnetic stimulation (rTMS), which. In rare cases, serious side effects such as seizures can occur. Add Your TMS Center; Provider Tips; More Info. Anna Kielak, Psychiatric Nurse Practitioner, Poulsbo, WA, 98370, (360) 842-0002, I believe that mental health conditions can be compared to physical injuries. TMS works by using magnetic pulses to stimulate a brain region that is underactive in people with depression. " When used repetitively, TMS is said to alter the excitability of the brain area that has been stimulated. Insurance; Telehealth Visits; Locations; Forms; Employment Opportunities; Online Payment; Blog; Call (360) 697-1141. 1 Despite continuing advances in the development of antidepressant drugs, the condition of about 30% of patients remains refractory to drug treatment 2 and may require electroconvulsive. One of the best Psychiatrists businesses at 544 NW University Blvd, Suite 102, Port St. Easy ApplyPartly in response to this dilemma, a number of neuromodulation approaches are in development. TMS is drug-free, non-invasive and FDA approved. Since that TMS session Ive been severely depressed. Careers at NeuroStim TMS. Sound Sport & Spine. Clinical TMS research studies. Success TMS supports an accessible internet. Part-time | Full-time $20 - $23 an hour 6 days ago. Electrodes are implanted in specific regions targeting the underlying cause of the disease. Port Saint Lucie, FL 34986. New Port Richey 4800 Rowan Rd New Port Richey, FL 34653 p: 727-483-5912 f: 727-376-3652; Tampa 5100 W. Search . In real world outcomes, 83% of patients experience an improvement in the severity of their depression, with 62% of patients showing complete remission. Kennedy Blvd, Suite 160Life presents many challenges. Clinical outcomes. There is a growing interest in the use of noninvasive brain stimulation to reduce suicidal thoughts and behaviors. Find the best Clinic around East Bremerton, Washington and get detailed driving directions with road conditions, live traffic updates, and reviews. A new transcranial magnetic stimulation (TMS) approach that compresses weeks of conventional TMS therapy into a few days can significantly reduce depression symptoms, according to the results of a pilot study published in AJP in Advance. Deep Brain Stimulation (DBS) Deep brain stimulation (DBS) is an emerging treatment option that is showing promise in clinical trials for mood and cognitive disorders such as major depression and Alzheimer’s disease. The observed average total HAM-D. Get Direction. Over the course of treatment, the brain remakes these neuropathways and patients experience relief. TMS is a highly effective, FDA. Easy ApplyMedical Technician (TMS) / Patient Advocate. Although TMS is noninvasive and doesn’t require any downtime, it’s not a one-stop, single-treatment solution. On a sheer treatment basis, TMS is clearly less expensive than ECT. Background: Repetitive Transcranial Magnetic Stimulation (rTMS) shows efficacy in the treatment of major depressive disorder using a standard course of 20-36 treatment sessions. Dr. ** ,12 Research shows response rates for medication decrease with every subsequent treatment. The Port Orchard office phone number is (360) 616-0543. I use holistic approach in my clinical work and perceive an individual’s issues in bio-psycho. At Innovative Mental Health & Pain Care our mission is to promote healthy families by alleviating physical and emotional pain. Dr. A relatively new systematic qualitative analysis published January 8, 2019, in BMJ Psychiatry indicates the sooner treatment-naïve patients start TMS in the current depressive episode, the better the outcome. Part-time $19 - $22 an hour. Food and Drug Administration (FDA), TMS usually is used only when. 11 people checked in here. Mild TMS side effects can include headaches, dizziness, and light-headedness. Lacking clear neurobiological substrates of depression, psychiatry traditionally explained this clinical heterogeneity in. TMS modulates networks in the brain that are responsible for mood regulation. Neuroinflammation process is often reported to be closely linked to the pathophysiology of depression. DispatchHealth is a health care delivery service designed to reduce emergency room visits for non-emergencies and ensure patients with acute health care needs receive care in a timely manner. Experts don't know exactly how TMS helps relieve symptoms. Transcranial magnetic stimulation is an FDA-approved, noninvasive treatment for people with major depression who have not benefited from antidepressant medications. Success TMS - Depression Treatment Specialists located at 544 NW University Blvd Suite 102, Port Saint Lucie, FL 34986 - reviews, ratings, hours, phone number, directions, and more. He graduated from Harvard Medical School in 2001. Transcranial Magnetic Stimulation ( TMS) is a medical breakthrough for treating Major Depression, OCD, PTSD, Anxiety, and other disorders. NeuroStim TMS Kitsap located at 450 S Kitsap Blvd Suite 160, Port Orchard, WA 98366 - reviews, ratings, hours, phone number, directions, and more. Now, that could be about. Existing evidence on the efficacy of TMS in adolescent MDD awaits quantitative synthesis. Side effects are usually mild and short-lived, but TMS is still. A randomized control trial of 199 patients found that TMS quadrupled the odds of remission after six weeks when compared with a sham procedure (6). FAX: 253-514-6239. 12,25–33 Existing literature is almost entirely comprised of case reports and open-label studies. Each treatment session takes less than 45 minutes and patients rarely require any down time. Depression and Anxiety 29:587–596, 2012. However, the clinical gains from active treatment may be lost over time. Newer forms of the technology include deep TMS. Welcome to Greenbrook TMS. One of the best Healthcare business at 450 S Kitsap Blvd Suite 160, Port Orchard WA, 98366 United States. Trans-cranial Magnetic stimulation (TMS) as a non-invasive method of altering brain activity has widened the array of therapeutic options available for various psychiatric disorders. was conducted in ten women with MDD in the second or third-trimester pregnancy []. Services Learn More About Our Recent News Dr. 13. 6,7. Most. SAINT is an innovative form of transcranial magnetic stimulation (TMS) that combines MRI-guided selection of the targeted brain region with an accelerated stimulation regimen involving multiple short. Phone: 617-726-5340. Find top doctors who treat Treatment Resistant Depression near you in Port Orchard, WA. If you have a heart for helping people, love. Transcranial magnetic stimulation (TMS) is a noninvasive treatment that uses magnetic pulses to stimulate and regulate nerve cells in areas of the brain related to various psychiatric disorders. Transcranial magnetic stimulation (TMS) is an exciting development in the field of psychiatry. Approximately 30% of patients reach clinically significant remission after an adequate trial of antidepressant medication (Trivedi et al. TMS was approved by the U. TMS can offer a lifeline for those whose depression does not respond to antidepressants. Multiple studies support the efficacy of TMS for depression. Benefits. Procedure . If you have any questions about our accessibility features, please contact us at 866. 3 people like this. You can also speak with our TMS. Email: admin@innovativenp. Nearby Areas. Dr. Merabet, A. Lower sex drive. Response rates seen in groups of patients with treatment. Transcranial magnetic stimulation (TMS) can be a safe and effective choice for the treatment of depression. Cleared for use by the FDA in October 2008, TMS is a non-invasive, non-systemic treatment that utilizes. 6076 and/or info@successtms. Please fill out this short form today for a free phone consultation with NeuroStim TMSSuccess TMS - Depression Treatment Specialists, Coconut Creek, FL, 33073, (954) 231-2372, My passion is helping people with DEPRESSION. What is Depression? Depression is a condition that affects over 15 million Americans and an estimated 300 million individuals worldwide. Gig Harbor, WA 98335. Patients sit comfortably in a chair and TMS is administered by a certified treater. The side effects are usually mild and temporary. Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis. Over 5. Transcranial magnetic stimulation (TMS) is a non-invasive stimulation of brain tissue through the production of the high or low-intensity magnetic field thought to modulate cortical excitability. If you are suffering from depression, OCD, anxiety or similar disorders, and have not had satisfactory results from pharmaceutical medications or other treatments, NeuroStim TMS may be able to help through TMS Therapy. A magnetic coil that produces pulsing energy is placed on selected parts of the scalp, carefully set to the level of energy needed to stimulate a patient's brain cells. ,. Approved over a decade ago, transcranial magnetic stimulation (TMS) is moderately effective. Kaster TS, Fitzgerald PB, Downar J, et al: Considerable evidence supports rTMS for treatment-resistant depression. The FDA approved TMS for use in adults with. If you are experiencing low self-esteem, anxiety, depression, or are going through a difficult change in your life, I can help you by providing therapy and, if needed, psychiatric medications. However, early influential studies suggested that rTMS is less effective. 'It. , at any moment,1 in 20 people is depressed in some capacity,” said George. In spite of newer antidepressant drugs. Get help for your depression and anxiety at Success TMS. ”Introduction. 928. If you have any questions about our accessibility features, please contact us at 866. Dawna Gutzmann, M. TMS is approved by the Food and Drug Administration (FDA) as a safe and effective outpatient treatment for people with depression who haven’t responded to or cannot take standard medication therapy. 5–7 In. TMS can only directly stimulate the outermost layer of the brain, but a recent study by researchers at. Transcranial magnetic stimulation (TMS), since its introduction in 1985, has been studied for its efficacy in different psychiatric disorders. Appointments. A completed referral form is required prior to. My anxiety improved dramatically and his depression and PTSD completely disappeared. Fry's Chiropractic Office. Dr. Find reviews, ratings, directions, business hours, and. Transcranial magnetic stimulation (TMS) is a rather new and rare treatment for depression, and it is hard to find real experiences (i. It's used to treat certain health conditions. 0 Port Orchard, WATranscranial magnetic stimulation (TMS) is a unique treatment option that utilizes a magnetic field to jumpstart and potentially change activity in the brain. In the last decade, the field has seen significant advances in the understanding and use of this new technology. Location. 2701 NW Vaughn St. Mon 8:00 am - 5:00 pm Transcranial magnetic stimulation, or TMS, is a noninvasive form of brain stimulation. As a board-certified psychiatrist for over 10 years, and a certified rTMS provider, Dr. Regardless of our surroundings, anyone can fall victim to depression and anxiety, and sometimes they appear without seeming. Three weeks ago doctor offered me a free TMS session for depression, just to try it out, and I accepted. 544 NW University Drive. Antenna. 29 years (age range = 13-19 years). Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive. Nicholas Weiss, MD. New patients are welcome. TMS is a form of neurostimulation which effectively uses pulsing magnetic fields to either activate or suppress the brain centres associated with a number of medical and psychiatric disorders. com. Maintenance treatment of transcranial magnetic stimulation (TMS) for treatment-resistant depression patients responding to acute TMS treatment. If a person has treatment-resistant depression, a doctor may. For this review, we will use the term TMS. Costs. 2501 SE Mile Hill Dr Port Orchard, WA 98366 (360) 895-4843. The procedure may also. NeuroStim TMS Federal Way-Auburn clinic is in Federal Way, WA, on 3450 S 344th Way, Suite 115. There is considerable interest worldwide in the use of subconvulsive repetitive transcranial magnetic stimulation (rTMS) for the treatment of depression. Behavioral and Biomedical Sciences Building (BBSB) 1941 East Road Houston, Texas 77054 map. Transcranial magnetic stimulation (TMS) can be a safe and effective choice for the treatment of depression. Mercer Island WA 98040 . After years of lobbying, Medicare will soon partly fund repetitive Transcranial Magnetic Stimulation to treat severe depression. 1% per patient). TMS treatment involves stimulating underactive areas of the brain with brief magnetic pulses. 0 Port Orchard, WA. Learn more about this top honor. Up to 40% of people with depression do not recover . TMS has an 82% success rate in terms of significant improvement, and a 63% remission rate according to recent studies. What TMS Is. Dawna Gutzmann, M. Mental Health Clinics in Port Orchard, WA . Electrodes are implanted in specific regions targeting the underlying cause of the disease. Repetitive transcranial magnetic stimulation (rTMS) is an established treatment for patients with Major Depressive Disorder (MDD) who have failed to respond to one or more medication trials and its clinical application is supported by multiple trials and meta-analysis [1]. Add Your TMS Center; Provider Tips; More Info. 1 session lasts roughly 18 minutes and it takes 6-8 weeks of treatments. Transcranial Magnetic Stimulation is a non-invasive, personally-tailored approach to treating depression. Sarah Lisanby. Poulsbo, WA. If you haven’t benefited from anti-depressant medication, or would rather not take medication for depression, TMS therapy may be a good alternative. Medical Technician (TMS) / Patient Advocate- $20-$23/hour. The side effects are usually mild and temporary. 450 S Kitsap Blvd Suite 160, Port Orchard, WA 98366. The magnetic fields stimulate underactive nerve. Psychology. Indication Medical Necessity. I believe in each person's and family's internal strength in making changes in their own lives. Schutter DJ. By Kasra Zarei. Check NeuroStim TMS Kitsap in Port Orchard, WA, South Kitsap Boulevard on Cylex and find ☎ (360) 616-0. We have convenient locations in Poulsbo, Silverdale, Port Orchard, Bainbridge Island, and Seattle, Washington. Dr. Find reviews, ratings, directions, business hours, and. –Cognitive task used to activate targeted circuit during TMS –Leverages spike-time dependent plasticity to enhance potency Pairing TMS with Task Performance to Control State Luber et al 2013; 2008; 2007 • TMS+Working Memory Task during 48hrs sleep dep prevented memory decrement a full 18 hrs after the last TMS • Clinical trial underway in44 customer reviews of Success TMS - Depression Treatment Specialists. These include depression, obsessive compulsive disorder (OCD), and anxiety disorders. Transcranial magnetic stimulation. TMS is approved by the Food and Drug Administration (FDA) as a safe and effective outpatient treatment for people with depression who haven’t responded to or cannot take standard medication therapy. S. 1. This method offers temporal and spatial resolution and can be combined with other neurocognitive and neuro-experimental techniques. Depression is a long-lasting mental disorder that affects more than 264 million people worldwide. Background The clinical efficacy of repetitive transcranial magnetic stimulation (rTMS) in treatment resistant patients (at least 4 medication trials) appears to be well accepted and forms the coverage policies and rTMS’s use in many of the largest US payers. TMS is a form of brain stimulation, also known as “neuromodulation,” that is used to treat depression by stimulating the brain using electromagnetic fields, completely non-invasively. S. Over 150 randomized controlled trials (RCTs) have been carried out, and its efficacy has been confirmed in dozens of meta-analyses. Mayo Clinic experts have. Dr. Greenbrook TMS therapy and nasal esketamine are covered by major insurance companies in Missouri, including but not limited to those listed above. S. Neuroscience research have shown that the left dorsolateral prefrontal cortex is underactive in depression [4-6] and results in symptoms of low mood and anhedonia (inability to feel pleasure in normally pleasurable activities). An electric pulse generator, or stimulator, is connected to a magnetic coil connected to the scalp. Hours. These events are transient; they occur during the TMS treatment course and do not occur for most patients after the first week of treatment. Transcranial Magnetic Stimulation (TMS) has been FDA-cleared and clinically proven to improve symptoms for treatment-resistant patients with depression. Extant literature generally shows similar efficacy. After a series of treatments, the magnetic pulses. We plan your treatment together by addressing your needs: anxiety, depression, trauma, eating disorders, among other mental health challenges- along with family and/or relationship complications. At Front Street Clinic Inc. Success TMS supports an accessible internet. Functional neuroimaging provides unique insights into the neuropsychiatric effects of antidepressant TMS. Columbia, SC. PubMed was. TMS, or transcranial magnetic stimulation, is a treatment that has been shown to help patients with depression who have not gotten better after trying therapy and medication. For further information of TMS Therapy, please contact the TMS Coordinator, Sue Tran: Phone: 03 9487 4628. TMS Providers by Practice 9. Currently Franciscan Medical Group Port Orchard's 5 physicians cover 5 specialty areas of medicine. Find one of our depression. NPR is not using her full name at her request because of. 2019 Mar:273:770-781. Location. Monash University and the Epworth Centre for Innovation in Mental Health have. Our office utilizes NeuroStar Advanced Therapy — a patented. They placed me the device for 15-40min, in the right side of the brain. Regular Hours. To this end, VA implemented a nationwide TMS program that included evaluating clinical outcomes within a naturalistic. In rare cases, serious side effects such as seizures can occur. Learn about mental and behavioral health problems. TMS is FDA approved for the treatment of depression and Obsessive Compulsive Disorder (OCD). following standard treatments such as medica-tion and psychotherapy. transcranial magnetic stimulation (TMS), psychological testing and counseling. Harvard Health Publishing: “Transcranial magnetic stimulation (TMS): Hope for stubborn depression. 2,3,6 The first study 3 randomized 325 medication-free patients with treatment-resistant depression to undergo 5 sessions per week of high. Pascual-Leone, in Encyclopedia of Neuroscience, 2009 The use of transcranial magnetic stimulation (TMS) in clinical neurology and neuroscience research has grown steadily during the past two decades. Only 8 Weeks to Experiencing Relief. are. The TMS treatment cost can vary because many people require a series of TMS sessions to see results. Antidepressant efficacy of high-frequency transcranial. 12. The use of TMS dates back to 1985. Seattle, WA. Transcranial magnetic stimulation (TMS) for major depression: A multi-site naturalistic, observational study of acute treatment outcomes in clinical practice. One of the best Healthcare business at 450 S Kitsap Blvd Suite 160, Port Orchard WA, 98366 United States. The Food and Drug Administration (FDA) in September cleared the SAINT Neuromodulation System for the treatment of refractory depression in adults. 13. Our team can help you overcome treatment-resistant depress. Find Reviews, Ratings, Directions, Business Hours, Contact Information and book online appointment. Tailoring the treatment to individual brains may improve results. TMS — aka rTMS for repetitive transcranial magnetic stimulation — is a noninvasive type of brain stimulation treatment. performed a meta-analysis regarding the durability of the TMS-induced response and found 52. 400 Island Corporate Center, 7525 SE 24th St. Closed. Get relief from depression in under 8 weeks without meds. We have convenient locations in Poulsbo, Silverdale, Port Orchard, Bainbridge Island, and Seattle. D. Talented individuals who desire to make a difference in patient care with a breakthrough, FDA cleared medical treatment are encouraged to apply for our TMS. It works by stimulating key areas of the brain. 29201. Website to the provider page. As a non-invasive technique, this was initially introduced in 1985 for inducing motor movement by direct magnetic stimulation of the brain [ 1 ]. Port Orchard WA 98367. TMS therapy is an alternative treatment option for patients living with Major Depressive disorder (MDD) that have not achieved a satisfactory response to antidepressant medication. 1%, which was not statistically different Clinical Point One review found that the rate of affective switch in patients with bipolar depression who were treated with TMS was 3. For some people, TMS therapy may be cost-prohibitive. When TMS doesn't work. Transcranial Magnetic Stimulation (TMS) is a technological breakthrough for treating Major Depression, PTSD, Anxiety, OCD & other mood disorders. Privacy Policy; Terms & ConditionsIt works by creating changes in neuronal activity, impacting specific regions of the brain. In addition, Dr. In the last decade, the field has seen significant advances in the understanding and use of this new technology. PRC-20155321. TMS is a form of brain stimulation, also known as “neuromodulation,” that is used to treat depression by stimulating the brain using electromagnetic fields, completely non-invasively. " If you've had a good response with TMS before, there's a good chance you would respond again if future treatments are needed for a reoccurrence of depression symptoms. Meet our experienced team of depression specialists fighting mental illness. Not long after TMS was introduced, reports of a therapeutic effect began to emerge. NeuroStar TMS is typically used when medications aren’t providing relief from depression symptoms. Transcranial magnetic stimulation (TMS) is a procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of major depression. It is non-invasive and there are no systemic side effects commonly associated with medication. Awan was trained in TMS treatment many years prior to its FDA clearance and is pleased to add this valuable and effective treatment for. Washington's leading provider of Transcranial Magnetic Stimulation (TMS Therapy). Front Street Clinic Inc is a locally owned business offering comprehensive mental health services. Check NeuroStim TMS Kitsap in Port Orchard, WA, South Kitsap Boulevard on Cylex and find ☎ (360) 616-0. Transcranial magnetic stimulation (TMS) is a treatment technique that uses a magnetic field to influence brain activity. , 2001), because of its ability to stimulate focal areas of brain cortex non. Front Street Clinic Inc is a locally owned business offering comprehensive mental health services. Essentially, TMS for depression has been studied. Transcranial magnetic stimulation (TMS) is an effective treatment for acute MDE . Transcranial Magnetic Stimulation (TMS) is a safe, non-invasive and effective FDA-approved treatment for patients suffering from depression who haven’t improved with antidepressants. Associated Behavioral Health offers a convenient online course that fulfills the legal requirements established under the Washington Administrative Code for court-referred clients. After years of lobbying, Medicare will soon partly fund repetitive Transcranial Magnetic Stimulation to treat severe depression. Functional neuroimaging provides unique insights into the neuropsychiatric effects of antidepressant TMS. Table 1 summarizes existing therapeutic studies of TMS for adolescents with depression.