Interstitial cystitis-an imbalance of risk and protective factors?

Interstitial cystitis (IC) presents as a chronic pain condition with variable combinations of symptoms depending on the species and individual patient. It is diagnosed by the presence of lower urinary tract signs and symptoms in combination with a variety of comorbid health problems, a history of life adversities, and the absence of other conditions that could cause the lower urinary tract signs. IC occurs naturally in humans and cats as a dimensional condition, with patients presenting with mild, moderate, and severe symptoms. Most patients appear to recover without specific treatment. A number of rodent models of IC have been used to study its causes and treatments. Unfortunately, current therapies generally fail to ameliorate IC symptoms long-term. The recent classification of IC as a chronic primary pain disorder calls for a rethinking of current clinical and research approaches to it. Beginning when a patient encounters a clinician, precipitating, perpetuating, and palliating risk factors can be addressed until a cause or reliably effective therapy is identified, and identifying predisposing and preventive factors can inform epidemiological studies and health promotion interventions. Predisposing, precipitating, and perpetuating risk factors, including environmental, psychological, and biological, increase the activity of the central threat response system (CTRS), which plays a clinically important role in IC symptoms. Studies in cats and rodent models have revealed that environmental enrichment (EE), in the absence of bladder-directed therapies, leads to amelioration of IC symptoms, implying a central role for the CTRS in symptom precipitation and perpetuation. Conceptually moving the source of IC pain to the brain as a motivational state rather than one resulting from peripheral nociceptive input offers both clinicians and researchers novel opportunities to improve care for patients with IC and for researchers to use more ecologically valid rodent models. It may even be that IC results from an excess of risk to protective factors, making this imbalance a targetable cause rather than a consequence of IC.

Stress and Feline Health

In the health sciences, stress often is defined in terms of stressors; events that are perceived as threats to one's perception of control. From this perspective, a stressor is anything that activates the central threat response system (CTRS). Recent research shows that the CTRS can be sensitized to environmental events through epigenetic modulation of gene expression. When CTRS activation is chronic, health and welfare may be harmed. Environmental modification can mitigate the harmful effects of chronic CTRS activation by reducing the individual's perception of threat and increasing its perception of control, which improves health and welfare.

Autonomic neurophysiologic implications of disorders comorbid with bladder pain syndrome vs myofascial pelvic pain

AIMS

The neuropathophysiology of a debilitating chronic urologic pain condition, bladder pain syndrome (BPS), remains unknown. Our recent data suggests withdrawal of cardiovagal modulation in subjects with BPS, in contrast to sympathetic nervous system dysfunction in another chronic pelvic pain syndrome, myofascial pelvic pain (MPP). We evaluated whether comorbid disorders differentially associated with BPS vs MPP shed additional light on these autonomic differences.

METHODS

We compared the presence and relative time of onset of 27 other medical conditions in women with BPS, MPP, both syndromes, and healthy subjects. Analysis included an adjustment for multiple comparisons.

RESULTS

Among 107 female subjects (BPS alone = 32; BPS with MPP = 36; MPP alone = 9; healthy controls = 30), comorbidities differentially associated with BPS included irritable bowel syndrome (IBS), dyspepsia, and chronic nausea, whereas those associated with MPP included migraine headache and dyspepsia, consistent with the distinct autonomic neurophysiologic signatures of the two disorders. PTSD (earliest), anxiety, depression, migraine headache, fibromyalgia, chronic fatigue, and IBS usually preceded BPS or MPP. PTSD and the presence of both pelvic pain disorders in the same subject correlated with significantly increased comorbid burden.

CONCLUSIONS

Our study suggests a distinct pattern of comorbid conditions in women with BPS. These findings further support our hypothesis of primary vagal defect in BPS as compared with primary sympathetic defect in MPP, suggesting a new model for chronic these pelvic pain syndromes. Chronologically, PTSD, migraine, dysmenorrhea, and IBS occurred early, supporting a role for PTSD or its trigger in the pathophysiology of chronic pelvic pain.

Comparison of Voiding Dysfunction Phenotypes in Women with Interstitial Cystitis/Bladder Pain and Myofascial Pelvic Pain: Results from the ICEPAC Trial

OBJECTIVE

To evaluate whether voiding parameters differ in patients with the common overlapping pelvic pain disorders, interstitial cystitis/bladder pain syndrome (IC/BPS), and myofascial pelvic pain (MPP).

METHODS

Uroflow and voiding diary assessed voiding phenotypes in this prospective cohort study (ICEPAC) of women comparing IC/BPS, IC/BPS +MPP, MPP, and healthy control (HC) subjects.

RESULTS

In 36 HC, 24 IC/BPS, 37 IC/BPS + MPP, and 14 MPP subjects, the voiding diary measurements indicate lower voided volumes in IC/BPS and IC/BPS + MPP groups (185 ± 24 mL, 169 ± 20 mL, respectively) compared to HC and MPP groups (294 ± 24 mL, 226 ± 36 mL, respectively; P <.05, P <.05), as well as higher 24-hour voiding frequency (11.6 ± 0.8 and 11 ± 1.2 voids/24 hours, respectively; HC 7.1 ± 0.5 voids/24 hours; P <.05, P <.05; MPP group 9 ± 1.2 voids/24 hours; P <.05, P <.05). Uroflow showed higher HC average flow rate (12.87 ± 0.92) compared to IC/BPS, IC/BPS+MPP, and MPP (8.31 ± 1.20, 8.02 ± 0.80, 8.17 ± 1.38, respectively; P <.01, P <.01, P <.05) and peak flow rate (27.0 ± 1.83) and IC/BPS, IC/BPS+MPP and MPP (16.20 ± 2.2, 17.33 ± 1.64, 17.21 ± 2.69 respectively; P <.01, P <.01, P <.05).

CONCLUSION

This quantitative evaluation of voiding diary and uroflow metrics reveals distinct voiding phenotypes, which can aid in the diagnosis of chronic pelvic pain syndromes. Patients with IC/BPS had more pain with a full bladder despite similar overall pain scores. Peak and average flow rates do not provide any differentiating power between IC/BPS and MPP patients. A longer time to peak flow may favor MPP though this finding needs confirmation.

Inflammation and Tissue Remodeling in the Bladder and Urethra in Feline Interstitial Cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating chronic disease of unknown etiology. A naturally occurring disease termed feline interstitial cystitis (FIC) reproduces many features of IC/BPS patients. To gain insights into mechanisms underlying IC/BPS, we investigated pathological changes in the lamina propria (LP) of the bladder and proximal urethra in cats with FIC, using histological and molecular methods. Compared to control cat tissue, we found an increased number of de-granulated mast cells, accumulation of leukocytes, increased cyclooxygenase (COX)-1 expression in the bladder LP, and increased COX-2 expression in the urethra LP from cats with FIC. We also found increased suburothelial proliferation, evidenced by mucosal von Brunn’s nests, neovascularization and alterations in elastin content. Scanning electron microscopy revealed normal appearance of the superficial urethral epithelium, including the neuroendocrine cells (termed paraneurons), in FIC urethrae. Together, these histological findings suggest the presence of chronic inflammation of unknown origin leading to tissue remodeling. Since the mucosa functions as part of a “sensory network” and urothelial cells, nerves and other cells in the LP are influenced by the composition of the underlying tissues including the vasculature, the changes observed in the present study may alter the communication of sensory information between different cellular components. This type of mucosal signaling can also extend to the urethra, where recent evidence has revealed that the urethral epithelium is likely to be part of a signaling system involving paraneurons and sensory nerves. Taken together, our data suggest a more prominent role for chronic inflammation and tissue remodeling than previously thought, which may result in alterations in mucosal signaling within the urinary bladder and proximal urethra that may contribute to altered sensations and pain in cats and humans with this syndrome.

Responsiveness of cats (Felidae) to silver vine (Actinidia polygama), Tatarian honeysuckle (Lonicera tatarica), valerian (Valeriana officinalis) and catnip (Nepeta cataria)

Background

Olfactory stimulation is an often overlooked method of environmental enrichment for cats in captivity. The best known example of olfactory enrichment is the use of catnip, a plant that can cause an apparently euphoric reaction in domestic cats and most of the Pantherinae. It has long been known that some domestic cats and most tigers do not respond to catnip. Although many anecdotes exist of other plants with similar effects, data are lacking about the number of cats that respond to these plants, and if cats that do not respond to catnip respond to any of them. Furthermore, much is still unknown about which chemicals in these plants cause this response.

Methods

We tested catnip, silver vine, Tatarian honeysuckle and valerian root on 100 domestic cats and observed their response. Each cat was offered all four plant materials and a control, multiple times. Catnip and silver vine also were offered to nine tigers. The plant materials were analyzed by gas chromatography coupled with mass spectrometry to quantify concentrations of compounds believed to exert stimulating effects on cats.

Results

Nearly all domestic cats responded positively to olfactory enrichment. In agreement with previous studies, one out of every three cats did not respond to catnip. Almost 80% of the domestic cats responded to silver vine and about 50% to Tatarian honeysuckle and valerian root. Although cats predominantly responded to fruit galls of the silver vine plant, some also responded positively to its wood. Of the cats that did not respond to catnip, almost 75% did respond to silver vine and about one out of three to Tatarian honeysuckle. Unlike domestic cats, tigers were either not interested in silver vine or responded disapprovingly. The amount of nepetalactone was highest in catnip and only present at marginal levels in the other plants. Silver vine contained the highest concentrations of all other compounds tested.

Conclusions

Olfactory enrichment for cats may have great potential. Silver vine powder from dried fruit galls and catnip were most popular among domestic cats. Silver vine and Tatarian honeysuckle appear to be good alternatives to catnip for domestic cats that do not respond to catnip.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-017-0987-6) contains supplementary material, which is available to authorized users.

AAFP-AAHA

Background and goals Cats have become the most popular pet in the United States, yet statistics about veterinary care for cats remain troubling. 1 Although most owners consider their cats to be family members, cats are substantially underserved, compared with dogs. In 2006, owners took their dogs to veterinarians more than twice as often as cats, averaging 2.3 times/year, compared with 1.1 times/year for cats, and significantly more dogs (58%) than cats (28%) were seen by a veterinarian one or more times/year. 2 Cat owners often express a belief that cats ‘do not need medical care’. Two reasons for this misconception are that signs of illness are often difficult to detect, and cats are perceived to be self-sufficient. 2 One role of the veterinarian is to develop a partnership with cat owners that will pave the way for a lifelong health care plan. These guidelines aim to outline an evidence-based life stage wellness program to aid the veterinary medical team in delivering the best comprehensive care for cats. Specific goals are to provide:

Recommendations for optimal health care for cats throughout the different life stages. Practical suggestions and tools to facilitate improved veterinary visits and to enhance the client-veterinarian clinical encounter. A foundation from which to access sources of additional information.

Life stage classification Distinct life stages (age groups) in cats are not well defined, in part because individual animals and body systems age at different rates, a process that is influenced by many factors. These guidelines follow one convenient classification (see box below). These age designations help to focus attention on the physical and behavioral changes that occur at different stages (eg, congenital defects in kittens, obesity prevention in the junior cat). It must be recognized, however, that any age groupings are inevitably arbitrary demarcations along a spectrum, and not absolutes.

Evidence-based health care Supporting references for specific recommendations are supplied where possible, and any previously published guidelines on particular topics are referred to where relevant. Readers should note, however, that the guidelines panel was hampered in its efforts by the relative paucity of disease incidence data by age group that is available, and there is an urgent need for research to guide the future of evidence-based feline health care. 3

Clinical evaluation of multimodal environmental modification (MEMO) in the management of cats with idiopathic cystitis

This prospective observational study evaluated client-reported recurrence of lower urinary tract signs (LUTS) and other signs of abnormalities in cats with idiopathic cystitis after institution of multimodal environmental modification (MEMO). Forty-six client-owned indoor-housed cats with idiopathic cystitis, diagnosed based on a history of recurrent LUTS and evidence of absence of urolithiasis or bacterial urinary tract infection were studied. In addition to their usual care, clients were offered recommendations for MEMO based on a detailed environmental history. Cases were followed for 10 months by client contact to determine the effect of MEMO on LUTS and other signs. Significant ( P<0.05) reductions in LUTS, fearfulness, nervousness, signs referable to the respiratory tract, and a trend ( P<0.1) toward reduced aggressive behavior and signs referable to the lower intestinal tract were identified. These results suggest that MEMO is a promising adjunctive therapy for indoor-housed cats with LUTS, and should be followed up with prospective controlled clinical trials.

A pilot study of health and wellness coaching for fibromyalgia

BACKGROUND

The purpose of this study was to test the hypothesis that a health and wellness coaching (HWC)-based intervention for fibromyalgia (FM) would result in sustained improvements in health and quality of life, and reductions in health care utilization.

METHODS

Nine female subjects meeting American College of Rheumatology criteria for a diagnosis of primary FM were studied. The HWC protocol had two components, which were delivered telephonically over a twelve-month period. First, each patient met individually with a coach during the 12 month study at the patient's preference of schedule and frequency (Range:22-32 × 45-min sessions). Coaches were health professionals trained in health and wellness coaching tasks, knowledge, and skills. Second, each patient participated in bimonthly (first six months) and monthly (second six months) group classes on self-coaching strategies during the 12 month study. Prior to the intervention, and after 6 months and 12 months of coaching, the Revised Fibromyalgia Impact Questionnaire (FIQR) was used to measure health and quality of life, and the Brief Pain Inventory-Short Form (BPI) was used to measure pain intensity and interference with function. Total and rheumatology-related health encounters were documented using electronic medical records. Data were analyzed using repeated measures ANOVA.

RESULTS

All nine patients finished the HWC protocol. FIQR scores improved by 35 % (P = 0.001). BPI scores decreased by 32 % overall (P = 0.006), 31 % for severity (P = 0.02), and 44 % for interference (P = 0.006). Health care utilization declined by 86 % (P = 0.006) for total and 78 % (P < 0.0001) for rheumatology-related encounters.

CONCLUSION

The HWC program added to standard FM therapy produced clinically significant improvements in quality of life measures (FIQR), pain (BPI), and marked reductions in health care utilization. Such improvements do not typically occur spontaneously in FM patients, suggesting that HWC deserves further consideration as an intervention for FM.

Abnormalities in Expression of Structural, Barrier and Differentiation Related Proteins, and Chondroitin Sulfate in Feline and Human Interstitial Cystitis

PURPOSE

We analyzed the urothelium of cats diagnosed with feline interstitial cystitis to determine whether abnormalities in protein expression patterns could be detected and whether the expression pattern was similar to that in patients with human interstitial cystitis/bladder pain syndrome. The proteins analyzed are involved in cell adhesion and barrier function, comprise the glycosaminoglycan layer or are differentiation markers.

MATERIALS AND METHODS

Formalin fixed biopsies from 8 cats with feline interstitial cystitis and from 7 healthy control cats were labeled by immunohistochemistry and scored with a modified version of a system previously used for human samples. Cluster analysis was performed to investigate relationships between markers and samples.

RESULTS

Of the feline interstitial cystitis bladders 89% showed abnormal protein expression and chondroitin sulfate patterns while only 27% of normal tissues showed slight abnormalities. Abnormalities were found in most feline interstitial cystitis samples, including biglycan in 87.5%, chondroitin sulfate, decorin, E-cadherin and keratin-20 in 100%, uroplakin in 50% and ZO-1 in 87.5%. In feline interstitial cystitis bladders about 75% of chondroitin sulfate, biglycan and decorin samples demonstrated absent luminal staining or no staining. Cluster analysis revealed that feline interstitial cystitis and normal samples could be clearly separated into 2 groups, showing that the urothelium of cats with feline interstitial cystitis is altered from normal urothelium.

CONCLUSIONS

Feline interstitial cystitis produces changes in luminal glycosaminoglycan and several proteins similar to that in patients, suggesting some commonality in mechanism. Results support the use of feline interstitial cystitis as a model of human interstitial cystitis.

From FUS to Pandora syndrome

New concepts:

Ideas about the causes of lower urinary tract signs (LUTS) in cats have changed significantly in the past 40 years. Recent research is challenging the conventional view that the bladder is always the perpetrator of LUTS, and suggests that the bladder can also be one victim of a systemic process associated with a sensitized central stress response system.

Aim:

In this article the authors provide their perspective on the implications of these findings for the diagnosis and treatment of cats with LUTS, provide some historical context, and suggest ways that the veterinary profession might work together to better understand the disorders underlying these signs, and possibly reduce their prevalence.

Effects of interstitial cystitis on the acoustic startle reflex in cats

OBJECTIVE

To compare acoustic startle reflexes (ASRs) of healthy cats and cats with interstitial cystitis (IC).

ANIMALS

28 healthy cats (11 males and 17 females) and 20 cats with IC (13 males and 7 females).

PROCEDURES

To evaluate the effect of neutering on ASRs, ASRs in neutered and unneutered healthy cats were measured. To evaluate the effect of housing facility acclimation on ASRs in cats with IC, ASRs were measured in cats with IC within 1 month after arrival at the housing facility and again 2 to 3 months after arrival. To evaluate the effect of the environment on ASRs, ASRs were evaluated in all cats with and without IC after acclimation but before and then after environmental enrichment.

RESULTS

Neutering led to a significant decrease in overall ASR in the healthy cats. Habituation to the housing facility resulted in a significant decrease in overall ASR of female but not male cats with IC. Environmental enrichment led to a significant decrease in ASR in cats with IC but not in healthy cats.

CONCLUSIONS AND CLINICAL RELEVANCE

The magnitude of the ASR appeared to be sensitive to environmental conditions and affected by sex, both in healthy cats and cats with IC. It was also higher in cats with IC versus healthy cats, except when cats were housed in a highly enriched environment.

IMPACT FOR HUMAN MEDICINE

Treatment approaches that include reduction of a patient's perception of environmental unpredictability may benefit humans with IC.

A bloodspot-based diagnostic test for fibromyalgia syndrome and related disorders

The aim of this study was to investigate the ability of a rapid biomarker-based method for diagnosis of fibromyalgia syndrome (FM) using mid-infrared microspectroscopy (IRMS) to differentiate patients with FM from those with osteoarthritis (OA) and rheumatoid arthritis (RA), and to identify molecular species associated with the spectral patterns. Under IRB approval, blood samples were collected from patients diagnosed with FM (n = 14), RA (n = 15), or OA (n = 12). Samples were prepared, placed onto a highly reflective slide, and spectra were collected using IRMS. Spectra were analyzed using multivariate statistical modeling to differentiate groups. Aliquots of samples also were subjected to metabolomic analysis. IRMS separated subjects into classes based on spectral information with no misclassifications among FM and RA or OA patients. Interclass distances of 15.4 (FM vs. RA), 14.7 (FM vs. OA) and 2.5 (RA vs. OA) among subjects, demonstrating the ability of IRMS to achieve reliable resolution of unique spectral patterns specific to FM. Metabolomic analysis revealed that RA and OA groups were metabolically similar, whereas biochemical differences were identified in the FM that were quite distinctive from those found in the other two groups. Both IRMS and metabolomic analysis identified changes in tryptophan catabolism pathway that differentiated patients with FM from those with RA or OA.

Co-morbidities of interstitial cystitis

Introduction: This study aimed to estimate the proportion of patients with interstitial cystitis/painful bladder syndrome (IC/BPS) with systemic dysfunction associated co-morbidities such as irritable bowel syndrome (IBS) and fibromyalgia (FM). Materials and Methods: Two groups of subjects with IC/BPS were included: (1) physician diagnosed patients with IC/BPS and (2) subjects meeting NIDDK IC/PBS criteria based on a questionnaire (ODYSA). These groups were compared to healthy controls matched for age and socio-economic status. NIDDK criteria required: pain with bladder filling that improves with emptying, urinary urgency due to discomfort or pain, polyuria >11 times/24 h, and nocturia >2 times/night. The ODYSA instrument evaluates symptoms pertaining to a range of disorders including chronic fatigue, orthostatic intolerance, syncope, IBS, dyspepsia, cyclic vomiting syndrome, headaches and migraines, sleep, Raynaud’s syndrome, and chronic aches and pains. Results: IC/BPS was diagnosed in 26 subjects (mean age 47 ± 16 years, 92% females), 58 had symptoms of IC/BPS by NIDDK criteria (mean age 40 ± 17 years, 79% females) and 48 were healthy controls (mean age 31 ± 14 years, mean age 77%). Co-morbid complaints in the IC/BPS groups included gastrointestinal symptoms suggestive of IBS and dyspepsia, sleep abnormalities with delayed onset of sleep, feeling poorly refreshed in the morning, waking up before needed, snoring, severe chronic fatigue and chronic generalized pain, migraines, and syncope. Discussion: Patients with IC/BPS had co-morbid central and autonomic nervous system disorders. Our findings mirror those of others in regard to IBS, symptoms suggestive of FM, chronic pain, and migraine. High rates of syncope and functional dyspepsia found in the IC/BPS groups merit further study to determine if IC/BPS is part of a diffuse disorder of central, autonomic, and sensory processing affecting multiple organs outside the bladder.

Environmental enrichment for indoor cats: implementing enrichment

In a previous article, we described our approach to implementation of effective environmental enrichment, which begins with the diagnosis of environmental features to determine how well they meet the behavior and welfare needs of indoor-housed cats. We formulate this diagnosis based on a pertinent history and physical evaluation. A pertinent history allows us to identify features of the cat and environment that may precipitate or contribute to observed behavioral and physical problems. Physical evaluation of the environment means determination of the presence and quality of physical and behavioral resources available to the cat. As discussed in the previous article, we organize the environment into five basic systems: physical, nutritional, social, elimination, and behavioral, and methodically investigate each one to identify any features that may benefit from improvement. Our first article offered practical means of meeting the environmental needs of cats within each system. The objective of this article is to present methods for reviewing the information obtained with the client and developing an effective implementation plan. Rather than blaming the client for any identified environmental shortcomings, we choose to emphasize areas of improvement that the client believes can be accomplished. Effective communication skills increase the probability of implementation of and adherence to the plan.

Idiopathic cystitis in domestic cats--beyond the lower urinary tract

Signs of lower urinary tract (LUT) disease in domestic cats can be acute or chronic, and can result from variable combinations of abnormalities within the lumen of the LUT, the parenchyma of the LUT itself, or other organ system(s) that then lead to LUT dysfunction. In the majority of cats with chronic signs of LUT dysfunction, no specific underlying cause can be confirmed after standard clinical evaluation of the LUT, so these cats typically are classified as having idiopathic cystitis. A syndrome in human beings commonly known as interstitial cystitis (IC) shares many features in common with these cats, permitting comparisons between the two species. A wide range of similarities in abnormalities has been identified between these syndromes outside as well as inside the LUT. A variety of potential familial and developmental risk factors also have been identified. These results have permitted generation of the hypothesis that some of these people have a disorder affecting the LUT rather than a disorder of the LUT. This perspective has suggested alternative diagnostic strategies and novel approaches to treatment, at least in cats. The purpose of this review is to summarize research investigations into the various abnormalities present in cats, to compare some of these findings with those identified in human beings, and to discuss how they might modify perceptions about the etiopathogenesis, diagnosis, and treatment of cats with this disease. Dedication: I dedicate this contribution to Professor Dennis J. Chew, whose collaboration, patience, and support made it all possible.

Urodynamic evaluation of female cats with idiopathic cystitis

OBJECTIVE

To compare values of urodynamic measurements of cats with idiopathic cystitis (IC) with previously published data for healthy female cats.

ANIMALS

11 female cats with IC.

PROCEDURES

2 sequential cystometrograms and 2 urethral pressure profiles were obtained for each cat. All tracings were evaluated for evidence of overactive urinary bladder (OAB). Maximum urethral pressure (MUP), maximum urethral closure pressure (MUCP), and functional profile length were recorded.

RESULTS

Only 3 cats had obvious micturition events. None of the 11 cats had evidence of OAB. Although not significant, threshold pressure was lower in cats with IC than in healthy cats (mean ± SD, 89.0 ± 12.0 cm H(2)O vs 75.7 ± 16.3 cm H(2)O, respectively); however, the total volume infused was significantly lower in cats with IC (4.8 ± 2.1 mL/kg vs 8.3 ± 3.2 mL/kg). The MUCP was significantly higher in cats with IC than in healthy cats (158.0 ± 47.7 cm H(2)O vs 88.9 ± 23.9 cm H(2)O, respectively). The MUP was also significantly higher in all portions of the urethra in cats with IC.

CONCLUSIONS AND CLINICAL RELEVANCE

No evidence of OAB was identified in any cat evaluated; therefore, medications used to target this abnormality did not appear justified. The high MUCP in cats with IC suggested that α(1)-adrenoceptor antagonists or skeletal muscle relaxants may be useful in this disease, and if these data were applicable to male cats, then α(1)-adrenoceptor antagonism may help prevent recurrent obstructive IC. Further studies are indicated to determine the effects, if any, these drugs might have in cats with IC.

Retrospective evaluation of parenteral nutrition in alpacas: 22 cases (2002-2008)

BACKGROUND

Parenteral nutrition is an important method of nutritional support in hospitalized animals, but minimal information has been published on its use in camelids.

HYPOTHESIS/OBJECTIVES

The purpose of this study was to characterize the use of total parenteral nutrition (TPN) in alpacas, evaluate the formulations used, and determine potential complications.

ANIMALS

Twenty-two alpacas hospitalized at the Tufts Cummings School for Veterinary Medicine (site 1: n = 8) and the Ohio State University Veterinary Teaching Hospital (site 2: n = 14).

METHODS

A retrospective analysis of all alpacas that received TPN between 2002 and 2008 was performed to assess clinical indications, clinical and clinicopathologic data, and outcome.

RESULTS

The most common underlying diseases in animals receiving TPN were gastrointestinal dysfunction (n = 16), hepatic disease (n = 2), and neoplasia (n = 2). Several metabolic abnormalities were identified in animals (n = 20/22) before TPN was initiated, including lipemia (n = 12/22), hyperglycemia (11/22), and hypokalemia (n = 11/22). Median age was significantly lower for site 1 cases (0.1 years; range, 0.01-11.0) compared with those from site 2 (4.9 years; range, 0.1-13.7; P = .03). Animals at site 2 also had a longer duration of hospitalization (P = .01) and TPN administration (P = .004), as well as higher survival rate (P < .02). Twenty-one of 22 alpacas developed at least 1 complication during TPN administration. Metabolic complications were most prevalent (n = 21/22) and included hyperglycemia (n = 8/21), lipemia (n = 7/21), hypokalemia (n = 3/21), and refeeding syndrome (n = 3/21).

CONCLUSIONS AND CLINICAL IMPORTANCE

TPN is a feasible method of nutritional support for alpacas when enteral feeding is not possible. Prospective studies are warranted to determine optimal TPN formulations for alpacas.

Sickness behaviors in response to unusual external events in healthy cats and cats with feline interstitial cystitis

OBJECTIVE

To compare sickness behaviors (SB) in response to unusual external events (UEE) in healthy cats with those of cats with feline interstitial cystitis (FIC).

DESIGN

Prospective observational study.

ANIMALS

12 healthy cats and 20 donated cats with FIC.

PROCEDURES

Cats were housed in a vivarium. Sickness behaviors referable to the gastrointestinal and urinary tracts, the skin, and behavior problems were recorded by a single observer for 77 weeks. Instances of UEE (eg, changes in caretakers, vivarium routine, and lack of interaction with the investigator) were identified during 11 of the 77 weeks. No instances of UEE were identified during the remaining 66 weeks, which were considered control weeks.

RESULTS

An increase in age and exposure to UEE, but not disease status, significantly increased total number of SB when results were controlled for other factors. Evaluation of individual SB revealed a protective effect of food intake for healthy males. An increase in age conferred a small increase in relative risk (RR) for upper gastrointestinal tract signs (RR, 1.2) and avoidance behavior (1.7). Exposure to UEE significantly increased the RR for decreases in food intake (RR, 9.3) and for no eliminations in 24 hours (6.4). Exposure to UEE significantly increased the RR for defecation (RR, 9.8) and urination (1.6) outside the litter box.

CONCLUSIONS AND CLINICAL RELEVANCE

SB, including some of the most commonly observed abnormalities in client-owned cats, were observed after exposure to UEE in both groups. Because healthy cats and cats with FIC were comparably affected by UEE, clinicians should consider the possibility of exposure to UEE in cats evaluated for these signs.

Environmental enrichment for indoor cats

Recommendations to cat owners to house their cats indoors confer the responsibility to provide conditions that ensure good health and welfare. Cats maintain their natural behaviors, such as scratching, chewing, and elimination, while living indoors, and they may develop health and behavior problems when deprived of appropriate environmental outlets for these behaviors. This article divides the environment into five basic "systems" to enable identification of features that may benefit from improvement. It also addresses practical means of meeting cats' needs in each of these systems.

A protocol for managing urethral obstruction in male cats without urethral catheterization

OBJECTIVE

To determine efficacy of a protocol for managing urethral obstruction (UO) in male cats without urethral catheterization.

DESIGN

Clinical trial.

ANIMALS

15 male cats with UO in which conventional treatment had been declined.

PROCEDURES

Laboratory testing and abdominal radiography were performed, and cats with severe metabolic derangements or urinary calculi were excluded. Treatment included administration of acepromazine (0.25 mg, IM, or 2.5 mg, PO, q 8 h), buprenorphine (0.075 mg, PO, q 8 h), and medetomidine (0.1 mg, IM, q 24 h) and decompressive cystocentesis and SC administration of fluids as needed. Cats were placed in a quiet, dark environment to minimize stress. Treatment success was defined as spontaneous urination within 72 hours and subsequent discharge from the hospital.

RESULTS

Treatment was successful in 11 of the 15 cats. In the remaining 4 cats, treatment was considered to have failed because of development of uroabdomen (n=3) or hemoabdomen (1). Cats in which treatment failed had significantly higher serum creatinine concentrations than did cats in which treatment was successful. Necropsy was performed on 3 cats in which treatment had failed. All 3 had severe inflammatory disease of the urinary bladder, but none had evidence of bladder rupture.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that in male cats, a combination of pharmacological treatment, decompressive cystocentesis, and a low-stress environment may allow for resolution of UO without the need for urethral catheterization. This low-cost protocol could serve as an alternative to euthanasia when financial constraints prevent more extensive treatment.

Developmental influences on medically unexplained symptoms

BACKGROUND

Medically unexplained (or 'functional') symptoms (MUS) are physical symptoms that prompt the sufferer to seek healthcare but remain unexplained after an appropriate medical evaluation. Examples of MUS also occur in veterinary medicine. For example, domestic cats suffer a syndrome comparable to interstitial cystitis, a chronic pelvic pain syndrome of humans.

METHOD

Review of current evidence suggests the hypothesis that developmental factors may play a role in some cases of MUS. Maternal perception of a threatening environment may be transmitted to the fetus when hormones cross the placenta and affect fetal physiology, effectively 'programming' the fetal stress response system and associated behaviors toward enhanced vigilance. After birth, intense stress responses in the individual may result in similar vulnerability, which may be unmasked by subsequent stressors.

RESULTS

Epigenetic modulation of gene expression (EMGEX) appears to play a central role in creation of this 'survival phenotype'. The recent development of techniques to identify the presence of EMGEX provides new tools to investigate these questions, and drugs and other interventions that may reverse EMGEX are also under active investigation.

CONCLUSION

Viewing MUS from the perspective of underlying developmental influences involving EMGEX that affect function of a variety of organs based on familial (genetic and environmental) predispositions rather than from the traditional viewpoint of isolated organ-originating diseases has at least two important implications: it provides a parsimonious explanation for findings heretofore difficult to reconcile, and it opens whole new areas of investigation into causes and treatments for this class of disorders.

A candidate serum biomarker for bladder pain syndrome/interstitial cystitis

Reliable diagnostic markers for Bladder Pain Syndrome/Interstitial Cystitis (IC) currently are not available. This study evaluated the feasibility of diagnosing IC in humans and domestic cats from the spectra of dried serum films (DSFs) using infrared microspectroscopy. Spectra were obtained from films from 29 humans and 34 domestic cats to create classification models using Soft Independent Modeling by Class Analogy (SIMCA). Ultrafiltration of serum improved discrimination capability. The classification models for both species successfully classified spectra based on condition (healthy/sick), and a different set of masked spectra correctly predicted the condition of 100% of the subjects. Classification required information from the 1500-1800 cm(-1) spectral region to discriminate between subjects with IC, other disorders, and healthy subjects. Analysis of cat samples using liquid chromatography-mass spectroscopy revealed differences in the concentration of tryptophan and its metabolites between healthy and affected cats. These results demonstrate the potential utility of infrared microspectroscopy to diagnose IC in both humans and cats.

Increased startle responses in interstitial cystitis: evidence for central hyperresponsiveness to visceral related threat

PURPOSE

Hypersensitivity to visceral stimuli in interstitial cystitis/painful bladder syndrome may result from enhanced responsiveness of affective circuits (including the amygdala complex) and associated central pain amplification. Potentiation of the eyeblink startle reflex under threat is mediated by output from the amygdala complex and, therefore, represents a noninvasive marker to study group differences in responsiveness in this brain circuit.

MATERIALS AND METHODS

Acoustic startle responses were examined in female patients with interstitial cystitis/painful bladder syndrome (13) and healthy controls (16) during context threat (application of muscle stimulation electrodes to the lower abdomen overlying the bladder), and cued conditions for safety (no stimulation possible), anticipation and imminent threat of aversive abdominal stimulation over the bladder.

RESULTS

Patients showed significantly greater startle responses during nonimminent threat conditions (baseline, safe and anticipation periods) while both groups showed similar robust startle potentiation during the imminent threat condition. Higher rates of anxiety and depression symptoms in the patient group did not account for the group differences in startle reflex magnitude.

CONCLUSIONS

Compared to controls, female patients with interstitial cystitis/painful bladder syndrome showed increased activation of a defensive emotional circuit in the context of a threat of abdominal pain. This pattern is similar to that previously reported in patients with anxiety disorders as well as those with irritable bowel syndrome. Since these circuits have an important role in central pain amplification related to affective and cognitive processes, these results support the hypothesis that the observed abnormality may be involved in the enhanced perception of bladder signals associated with interstitial cystitis/painful bladder syndrome.

Adrenocortical hormone abnormalities in men with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To identify adrenocortical hormone abnormalities as indicators of endocrine dysfunction in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

We simultaneously measured the serum concentrations of 12 steroids in patients with CP/CPPS and controls, using isotope dilution liquid chromatography, followed by atmospheric pressure photospray ionization and tandem mass spectrometry.

RESULTS

We evaluated 27 patients with CP/CPPS and 29 age-matched asymptomatic healthy controls. In the mineralocorticoid pathway, progesterone was significantly greater, and the corticosterone and aldosterone concentrations were significantly lower, in the patients with CP/CPPS than in the controls. In the glucocorticoid pathway, 11-deoxycortisol was significantly lower and the cortisol concentrations were not different between the patients and controls. In the sex steroid pathway, the androstenedione and testosterone concentrations were significantly greater in those with CP/CPPS than in the controls. The estradiol, dehydroepiandrosterone, and dehydroepiandrosterone sulfate concentrations were not different between the patients and controls. The National Institutes of Health-Chronic Prostatitis Symptom Index total and pain domain scores correlated positively with the 17-hydroxyprogesterone and aldosterone (P <0.001) and negatively with the cortisol (P <0.001) concentrations.

CONCLUSIONS

Our results suggest reduced activity of CYP21A2 (P450c21), the enzyme that converts progesterone to corticosterone and 17-hydroxyprogesterone to 11-deoxycortisol. Furthermore, these results provide insights into the biologic basis of CP/CPPS. Follow-up studies should explore the possibility that patients with CP/CPPS meet the diagnostic criteria for nonclassic congenital adrenal hyperplasia and whether the hormonal findings improve or worsen in parallel with symptom severity.

In vivo evaluation of alpha(2)-adrenoceptors in cats with idiopathic cystitis

OBJECTIVE

To evaluate the in vivo response of alpha(2)-adrenoceptors to medetomidine administration in cats with feline idiopathic cystitis (FIC) during periods of stress and after environmental enrichment.

ANIMALS

13 cats with FIC and 12 healthy cats. Procedures-Cats were subjected to an acute-onset moderate stressor for 8 days. After stress, 20 microg of medetomidine/kg was administered IM on days 1, 3, and 8. Heart rate, blood pressure, pupil diameter, respiratory rate, and level of sedation were evaluated before and after administration of the drug. After day 8, cats were moved to an enriched environment, and tests were repeated on day 35.

RESULTS

Heart rate decreased and pupil diameter increased significantly after medetomidine administration in healthy cats, compared with cats with FIC. Cats with FIC had significantly lower respiratory rates. No significant differences in blood pressure or sedation level were found.

CONCLUSIONS AND CLINICAL RELEVANCE

Increased plasma catecholamine concentrations during the enrichment phase, which have been reported elsewhere, may have contributed to the differences in alpha(2)-adrenoceptor responses detected in cats with FIC.

Risk factors associated with clinical signs of lower urinary tract disease in indoor-housed cats

OBJECTIVE

To determine associations between environmental and cat-related factors and lower urinary tract signs in indoor-housed domestic cats.

DESIGN

Case-control study. Animals-238 healthy cats, 157 cats with clinical signs of lower urinary tract disease, and 70 cats with other diseases.

PROCEDURE

Data collected from owners of the cats were analyzed. Descriptive statistics, environmental variables, and physical and behavioral signs were analyzed by use of ANOVA and logistic regression analysis to assess which factors were associated with clinical signs of lower urinary tract disease.

RESULTS

The only demographic or environmental factors associated with lower urinary tract signs were older age and months owned. In contrast, cats with clinical signs of lower urinary tract disease had significantly greater owner-observed gastrointestinal tract signs and scratching, fearful, nervous, and aggressive behaviors.

CONCLUSIONS AND CLINICAL RELEVANCE

Lower urinary tract signs in indoor-housed cats may be more closely associated with cat-related factors than with demographic or environmental factors.

Evaluation of the effects of stress in cats with idiopathic cystitis

OBJECTIVE

To determine the effects of stress in cats with feline idiopathic cystitis (FIC) by evaluating bladder permeability, sympathetic nervous system function, and urine cortisol:creatinine (C:Cr) ratios during periods of stress and after environmental enrichment.

DESIGN

Prospective study.

ANIMALS

13 cats with FIC and 12 healthy cats.

PROCEDURE

Cats subjected to an acute-onset moderate stressor for 8 days received IV injections of fluorescein. Serum fluorescein concentrations were determined and compared with those of controls to evaluate bladder permeability, and urine C:Cr ratios were compared to evaluate function of the hypothalamic-pituitary-adrenal (HPA) axis. Plasma catecholamine concentrations were analyzed in a subset of cats. After 8 days of moderate stress, cats were moved to an enriched environment, and tests were repeated after 21 days.

RESULTS

Serum fluorescein concentrations were significantly higher in cats with FIC at all time points. In the cats in which plasma catecholamine concentrations were determined, concentrations of dihydroxyphenylalanine, norepinephrine, and dihyroxyphenylglycol were significantly higher in cats with FIC at all time points, whereas no differences in urine C:Cr ratio between groups were observed.

CONCLUSION AND CLINICAL RELEVANCE

Cats with FIC appeared to have altered bladder permeability, most notably during the period of initial stress. The increase in plasma dihydroxyphenylalanine concentration suggests that there may be stress-induced increase in the activity of tyrosine hydroxylase, which catalyzes the rate-limiting step in catecholamine synthesis. In contrast, no effects of stress on C:Cr ratios were observed, which suggests there was dissociation between the sympathetic nervous system and HPA-axis responses to stress.

Abnormal excitability in capsaicin-responsive DRG neurons from cats with feline interstitial cystitis

Interstitial cystitis (IC) is a painful disorder which affects urinary bladder function in cats and humans. We used patch clamp techniques to measure firing properties and K+ currents of dorsal root ganglion (DRG) neurons (L4-S3) from normal cats and cats with feline interstitial cystitis (FIC) to examine the possibility that the properties of primary afferent neurons are changed in cats with FIC. We found that capsaicin (CAPS)-responsive neurons from FIC cats were increased in size, had increased firing in response to depolarizing current pulses and expressed more rapidly inactivating K+ currents. CAPS-sensitive neurons from FIC cats were 28% larger than those from normal cats but were otherwise similar with respect to membrane potential and action potential (AP) threshold. CAPS-responsive neurons from normal cats fired 1.5 APs in response to a 600 ms depolarizing current pulse, 60-200 pA in intensity. The number of APs was increased 4.5 fold in FIC neurons. Neurons from FIC cats also exhibited after hyperpolarization potentials which were on the average 2x slower than those in normal cat neurons. In addition, there was a lack of K+ currents in the critical voltage range of action potential generation (between -50 to -30 mV). These changes were not detected in CAPS-unresponsive neurons from normal and FIC cats. Our data suggest that FIC afferent neurons exhibit abnormal firing which may be due to changes in the behavior of K+ currents and show that these changes are restricted to a subpopulation of CAPS-responsive neurons.

Bladder Adelta afferent nerve activity in normal cats and cats with feline interstitial cystitis

PURPOSE

Symptoms associated with interstitial cystitis (IC) (urinary frequency, urgency and pain) resemble those in cats diagnosed with feline IC (FIC). Patients with IC also show enhanced sensitivity to intravesical application of KCl solution. In the current study we compared the effect of bladder distention and intravesical infusion of KCl solution on Adelta bladder afferent nerve activity in normal and FIC cats.

MATERIALS AND METHODS

Cats were anesthetized with alpha-chloralose (60 to 70 mg/kg intravenously). Single and multiunit afferent nerve activity was recorded with platinum electrodes from fibers dissected from the transected pelvic nerve. Bladder Adelta afferents were activated by bladder distention at constant pressures (5 to 80 cm H2O) by infusing saline or KCl solution (80 to 300 mM).

RESULTS

Increasing bladder pressure by saline infusion over a range of constant pressures (5 to 80 cm H2O) increased afferent firing in normal and FIC cats. However, the slope of the pressure-firing curve was significantly steeper in cats with FIC. In normal cats KCl infusion (80 to 300 mM) into the bladder produced a pressure-firing curve similar to that induced by saline infusion. However, in FIC cats KCl at concentrations of 150 to 300 mM produced almost complete inhibition of afferent firing at pressures between 30 and 80 cm H2O.

CONCLUSIONS

These data suggest that 1) bladder Adelta afferents in FIC cats are more sensitive to pressure changes than are afferents in normal cats and 2) the inhibition of afferent firing by high concentrations of KCl in FIC cats is likely the result of afferent nerve depolarization and it is consistent with the idea of increased permeability of bladder epithelium in FIC.

COMORBIDITY OF INTERSTITIAL CYSTITIS WITH OTHER UNEXPLAINED CLINICAL CONDITIONS

PURPOSE

The aims of this review are 1) to consider the hypothesis that interstitial cystitis (IC) is not a single disease entity in all patients by reviewing the evidence for the presence of IC subtypes and for the comorbidity of various unexplained clinical conditions in some patients with IC, and 2) to describe recent results obtained in humans and in cats with severe feline IC (FIC) that suggest the presence of an underlying neuroendocrine abnormality.

MATERIALS AND METHODS

The IC literature concerning comorbidity with other disorders was reviewed and these findings were compared with those of investigators studying the comorbid disorders and comparable data on cats with FIC.

RESULTS

A significant overlap of symptoms exists among a number of unexplained clinical conditions and a common stress response pattern of increased sympathetic nervous system function in the absence of comparable activation of the hypothalamic-pituitary-adrenal axis occurs in a subset of patients with many of these conditions. A comparable pattern exists in cats with FIC, which also includes increased corticotropin releasing factor activity and decreased adrenocortical reserve.

CONCLUSIONS

Further investigation of the stress response system of patients with IC seems merited, which may provide novel approaches to therapy in some patients.

Evaluation of owner education as a component of obesity treatment programs for dogs

OBJECTIVE

To compare results of a conventional obesity treatment program with those of an obesity treatment program that included education of owners of obese dogs.

DESIGN

Nonblinded prospective clinical trial.

ANIMALS

60 obese dogs with a body condition score (BCS) of 8/9 or 9/9.

PROCEDURE

Dogs were randomly assigned to control or owner education (EDU) treatment groups. A 6-month weight loss period was followed by an 18-month weight maintenance period. Daily caloric intake to induce loss of 1% of body weight/wk was calculated for each dog after assessment of prior diet history. The daily caloric intake for weight maintenance was estimated to be 20% greater than that calculated for weight loss with adjustments of +/- 5% as required. Weight and BCS were recorded monthly for each dog. Owners of dogs in the EDU group were required to attend monthly classes that addressed nutrition-related topics during the 6-month weight loss period.

RESULTS

Dogs in both treatment groups had significantly lower weight at the end of the weight loss period, compared with initial weight. Mean weight loss at 6 months was 14.7% in the control group and 15% in the EDU group; this difference was not significant. During the weight maintenance period, percentage weight loss was maintained in both treatment groups. Mean changes in BCS at 6 months (relative to time 0) were -1.5 in the control group and -1.7 in the EDU group. At 24 months, mean changes in BCS (relative to time 0) were -2.1 in the control group and -2.2 in the EDU group. No significant differences in BCS were identified between treatment groups at either 6 or 24 months.

CONCLUSIONS AND CLINICAL RELEVANCE

Mean decrease in BCS of 2 and mean weight loss of 15% were achieved and maintained in all dogs. An obesity treatment program that included dietary changes and monthly weight checks during the weight loss and weight maintenance periods was sufficient to achieve these results.

Feline idiopathic cystitis: current understanding of pathophysiology and management

Many indoor-housed cats seem to survive perfectly well by accommodating to less than perfect surroundings. Neuroendocrine abnormalities in the cats we treat, however, do not seem to permit adaptive capacity of healthy cats, so these cats may be considered a separate population with greater needs. Moreover, veterinarians are concerned more with optimizing environments of indoor cats than with identifying minimal requirements for indoor survival. Further information about environmental enrichment and conflict is available at http://www.nssvet.org/ici/.

Small adrenal glands in cats with feline interstitial cystitis

PURPOSE

We documented the uncoupling of sympathetic nervous system activity from the hypothalamic-pituitary-adrenal axis in cats with feline interstitial cystitis (FIC). Altered hypothalamic-pituitary-adrenal activity was recently suggested in some humans with interstitial cystitis (IC) but to our knowledge no information exists on adrenal gland size and histopathology in this disease. To investigate further adrenal function in cats with FIC we determined cortisol responses to 125 microg synthetic adrenocorticotropic hormone (ACTH) as well as adrenal size and histology.

MATERIALS AND METHODS

ACTH stimulation studies were performed in 11 healthy cats and 20 with FIC. Adrenal glands obtained at autopsy in 8 healthy cats and 13 with FIC were weighed, measured and examined histologically.

RESULTS

Cats with FIC had significantly decreased responses to ACTH (2-way repeated measures ANOVA p <0.05). Mean weight +/- SD (58 +/- 50 vs 241 +/- 60 mg) and volume (264 +/- 72 vs 410 +/- 115 mm3) of adrenal glands were significantly smaller in cats with FIC than in healthy cats (p <0.05).

CONCLUSIONS

These results suggest that cats with FIC may have mild primary adrenal insufficiency. Decreased adrenal size has been observed in patients with chronic fatigue syndrome, which can be a co-morbid condition in some patients with IC. If these abnormalities are confirmed in humans with IC, hormone replacement therapy may be indicated in select patients.

Norepinephrine content and adrenoceptor function in the bladder of cats with feline interstitial cystitis

PURPOSE

Interstitial cystitis is a chronic syndrome affecting humans and domestic animals, including cats (feline interstitial cystitis). The aggravation of interstitial cystitis symptoms by stress suggests involvement of the sympathetic nervous system. Studies have identified increased sympathetic nervous system activity in patients with interstitial cystitis but to our knowledge effects on bladder function have not been reported. To address this question we measured bladder norepinephrine (NE) content, the electrical field stimulation flux of NE and acetylcholine (ACh), and the effects of feline interstitial cystitis on adrenoceptor (AR) mediated bladder strip contractility.

MATERIALS AND METHODS

Bladders were obtained from healthy cats and cats with feline interstitial cystitis. In experiment 1 bladder tissue NE content was determined and the simultaneous release of 3H-NE and 14C-ACh in perfusion bath effluent after electrical field stimulation was measured. NE and ACh release was calculated from the area under the efflux curve. In experiment 2 electrical field stimulation induced contractility of bladder body strips was measured in the presence of 100 nM. to 25 microM. NE only or combined with atipamezole (an alpha2-AR antagonist), propranolol (a beta-AR antagonist) or phentolamine (an alpha-AR antagonist). Antagonists were added to the bath at least 15 minutes before stimulation, after which NE was added in cumulative doses and dose response curves were constructed.

RESULTS

Significant increases in NE content and efflux in the absence of alterations in ACh efflux were identified. In the bladder strip studies decreased alpha2 and beta1-AR function was found in strips from cats with feline interstitial cystitis, whereas beta3 or atypical beta-ARs were tentatively identified.

CONCLUSIONS

These results support and extend previous studies by identifying an effect of increased sympathetic activity on bladder function in cats with feline interstitial cystitis.