The RHDBank Grand Rounds is designed to demonstrate the types of communication impairments seen in individuals with Right Hemisphere Brain Damage (RHD). The intended audience includes educators, clinicians, students, and researchers. Our aims are:
The language behaviors and deficits associated with right hemisphere brain damage can be subtle and difficult to identify, measure, and treat. It has been estimated that at least 50% of adults with right hemisphere damage experience one or more cognitive-communication deficits (Blake, 2018; Tompkins, 2012). Specifically, impairments may be evident in topic maintenance (Myers, 1993), discourse coherence and cohesion (Marini, Carlomagno, Caltagirone & Nocentini, 2005), inference generation (Blake, 2009), turn-taking, question use (Minga, 2014), and integration of contextual nuance (McDonald, 2000). Discourse in some adults with RHD has been described as content-deprived (Joanette & Goulet, 1994), disinhibited, tangential (Brownell & Martino, 1998), and plagued with inappropriate comments and humor (Klonoff, Sheperd, O’Brien, Chiapello, & Hodak, 1990). Some of these behaviors are difficult to illustrate in short video samples, but we provide background, context, and the best examples we have in the current database. As the corpus grows, we will continue to add to this resource.
While the focus of the Grand Rounds is to highlight aspects of discourse production, many non-language-based deficits can be readily observed during the process of producing discourse. In the video clips, you may see or hear evidence of aprosodia and anosognosia, as well as deficits in attention and executive functions. Below are brief descriptions of some extra-linguistic impairments to watch and listen for in the videos.
Anosognosia is reduced awareness of one’s deficits or disorders. Anosognosia is not ‘all or none’. Individuals can be aware of some deficits but not others, and awareness can wax and wane over time or situations. Many individuals with RHD do not recognize any differences in their speech, language, or cognition even though they may be apparent to others. Clearly, not recognizing impairments can complicate an individual’s motivation for rehabilitation services (Azouvi & Peskine, 2012). The current anosognosia literature focuses primarily on hemiplegia after right hemisphere strokes. Anecdotally, it appears that anosognosia for cognitive-communication impairments extends into the chronic stages of recovery, but current research is insufficient to support or contradict these observations.
Aprosodia is present when individuals demonstrate a limited ability either to use prosodic variations in their speech or to identify and understand the meaning of prosodic features in another person’s speech. Individuals with RHD may sound monotone, or may not be able to pick up emotional cues in conversation (Leon & Rodriguez, 2008; Rodriguez 2009; Rosenbek et al., 2006; Tompkins, 2012). In a retrospective chart review of inpatient rehabilitation facilities, nearly 20% of adults with RHD were reported to exhibit aprosodia (Blake, Duffy, Myers, & Tompkins, 2002). Prosody can be subdivided into 2 types: affective and linguistic (Rodriguez, 2009). Affective prosody refers to the communication of emotional content via the prosodic features of speech. Linguistic prosody refers to using prosodic contours to convey meaning, such as using rising intonation to ask a question, or stressing a key word in a sentence (Tucker, Watson, & Heilman, 1977). Each of these forms of prosody can be further considered as having both receptive and expressive functions (Tompkins, 2012). In fact, impaired comprehension of emotional prosody was identified as the better indicator of cognitive deficits (when compared with neglect scores) in the acute period following a right hemisphere stroke (Dara, Bang, Gottesman, & Hillis, 2014).
Attention is a complex cognitive process that aids in modulating information for goal-directed behaviors. Various forms of attention contribute to communication. For example, sustained attention is the ability to focus on a task (e.g., reading a newspaper) for an extended period of time. Selective attention allows us to suppress unimportant or distracting information (e.g., the television in the background) and remain focused on a task (e.g., telling a story). Alternating attention is used when we switch back and forth between tasks (e.g., having a conversation and cooking dinner). Divided attention allows us to focus on 2 tasks at the same time (e.g., having a conversation while cooking dinner) (Barker-Collo, Feigin, Lawes, Parag & Senior, 2010; Blake 2018).
Attention processes have been localized to multiple areas of the left and right hemispheres (Blake, 2018). Some examples of the attention impairments seen in individuals with RHD are: 1) difficulty staying on topic and maintaining focus during cognitively demanding tasks like discourse production; and 2) inability to attend to items on the left side of their bodies or their environment, known as unilateral neglect. Reading and writing may be affected if individuals have difficulty attending to the left side of words or reading material, and this is called neglect dyslexia (Behrmann, Black, McKeeff, & Barton, 2002).
Executive functions (EF) include a number of higher level cognitive processes that are necessary for the performance of goal-directed tasks. Components of EF include initiation, planning, organizing, self-monitoring, reasoning and problem solving, among others (Cicerone et al., 2000). EF impairments have often been reported in adults with RHD, although few studies have directly examined this (Blake, 2018). Furthermore, the prevalence and severity of EF deficits in individuals with RHD as compared to those with left hemisphere damage has received little research attention, so it is unclear whether these deficits are a more frequent or severe component of RHD than aphasia (Blake, 2018). It is certainly possible that EF deficits may impact communication and daily functional tasks, including discourse in people with RHD. In fact, initial analysis of our data suggests that EF impairments may be correlated with some of the discourse impairments observed in individuals with RHD, such as impaired coherence (Cator, Johnson, Fromm, & MacWhinney, 2017; Wright, Capiluto, & Koutsoftas, 2013). Further research is warranted in this area.
In the cases presented here, we refer to people by a first name that is a pseudonym rather than using the actual first name. We do not advocate calling clients by their first names, but in these cases the individuals said that they preferred to be addressed by their first names. These adults with RHD have agreed to share their videos for educational and research purposes.
Brady is a 31-year-old Caucasian male who had a stroke involving the right middle cerebral artery (MCA) in 2014. This video was made just over two years post-stroke. Brady is right-handed with normal hearing as determined by a pure-tone hearing screening. He reports that the speech-language treatment he received in the acute phase of recovery focused primarily on swallowing, with a single session devoted to his attention deficits. He has 14 years of education and is married with children.
In this task, Brady was asked to tell the investigator what he thought about his speech and what he remembered about when he had his stroke. Watch the clip and observe his responses.
Questions for discussion
1. In his stroke story, what behaviors did Brady exhibit that may suggest anosognosia? Caution is warranted in making this judgment as people having a stroke (left hemisphere as well) are often confused. That being said, people with aphasia (following left hemisphere stroke) who remember their stroke often describe the event, mentioning symptoms such as garbled speech, no speech, weakness or numbness in an arm and/or leg, dizziness, falling, etc. They often know something is wrong.
2. Does Brady have typical intonation in these samples?
3. In your opinion, do you agree with Brady that his speech is “alright”? Why or why not?
4. Would you plan to target expressive prosody in treatment? Is there other information you would need before deciding whether to target prosody?
In this task, Brady was asked to tell the story of Cinderella using his prior knowledge and a picture book he looked through before telling the story. Again, watch the clip and observe his response.
Questions for discussion
1. Brady’s story was informative and coherent, though at times he was vague with his pronoun referents and specific nouns. Did you notice any of those?
2. In your opinion, does Brady successfully convey the Cinderella story? What essential elements of the story does he omit? Which parts of his story, if any, strike you as different from what you might hear from someone without brain damage?
In this first-encounter conversation (Kennedy et al., 1994), Brady was asked to "get to know" a student whom he had never met. The student clinician was told this was not an interview and she was to converse with Brady just as she would if she were meeting someone for the first time. The whole encounter lasted about 10 minutes during which Brady asked no questions and initiated no topics. The first video clip is from the first five minutes, where there were no long periods of silence for Brady to jump in (to ask the student a question or initiate a topic of conversation), but you will get a sense of his conversational communication skills. Pay particular attention to his pragmatic skills. The second 1-minute video clip shows a long period of silence where he still does not initiate.
Questions for discussion
1. What pragmatic aspects of language could be judged as intact?
2. In your opinion, was Brady successful in meeting the task goal of “getting to know” another person? Why or Why not?
3. How do you think our own pragmatic skills (as clinicians, conversation partners) influence an interaction and ultimately our ability to diagnose pragmatic deficits in our clients/patients?
In this task, Brady was asked to explain how to make a peanut butter and jelly sandwich. See what you think about the quality of his response.
Questions for discussion
Brady gives a very efficient explanation! However, he left out many details that were mentioned by 33% of a large sample of control participants who did the same task (Richardson & Dalton, 2015). (He even left out a couple that were mentioned by 50% and 67% of the control sample.) Did you notice any missing details?
2. In your opinion, does Brady’s brevity suggest any impairment? Was his behavior or language unusual? Was he successful in communicating how to make a peanut butter and jelly sandwich?
Case 1 Reflections
Now that you’ve seen multiple tasks, consider revisiting the interpretations you made along the way:
1. After hearing his first-encounter conversation, does your impression of Brady’s prosody change? If so, how?
2. After hearing his procedural discourse (PB&J sandwich task), paucity of speech seems like a possible diagnostic characteristic. Does that change after hearing his first-encounter conversation excerpts?
3. What kinds of discourse production activities are easier vs. harder for Brady?
Phil is a 68-year-old male who had a right hemisphere ischemic stroke in 2014. The locus of his lesion is unknown. He was 2.2 years post-stroke at the time of the recording. Phil has 24 years of education (advanced degrees in English) and worked as a teacher. He reports that in the acute phase of his recovery he received speech-language therapy focused primarily on swallowing. Currently, he attends a college-based clinic where he has worked on pragmatics, executive function skills, and prosody. (Apologies for the darkness around his face in the recordings.)
In this task, Phil was asked to tell the investigator what he thought about his speech and what he remembered about his stroke. Phil is able to provide many details about his rehabilitation, although he does not remember the onset of his symptoms. He also provides a detailed description of how he perceives his current speech, voice, and prosodic characteristics. Watch the clip and observe his responses.
Questions for discussion
1. Does Phil's prosody sound impaired to you? What do you hear in his sample as compared to Brady’s (Case 1)?
2. Most of the other people featured here think their speech is okay when asked about it. How about Phil? Does he think his speech is okay?
3. In your opinion, what does Phil mean by “I lack fluidity” and “I think my voice is rather high above my larynx and I think it should drop lower”?
4. How would you judge Phil’s stroke story? Did it embody some of the characteristics of right hemisphere discourse? If so, which ones -- information content, organization, coherence, prosody, etc.?
5. Did you notice the emotion he conveyed about having to be picked up off the floor after a couple days? Did that surprise you? Why or why not?
In this task, Phil was asked to look through a Cinderella picture book to refresh his memory of the story and then tell the story of Cinderella, using anything he knew about the story in addition to the book. Phil was initially uncertain whether he could recall the story. He spent about one minute examining the book before he asked if he should tell the story. The investigator then urged him to look through the entire book. He then spent about three minutes examining the pages of the book before being prompted to tell the story. Observe his responses in this excerpt from his story.
Questions for discussion1. Adults with RHD may demonstrate a variety of discourse characteristics, as you've seen in the cases here. Would you agree that Phil’s story could be described with the terms listed below? What other terms might you use instead or in addition?
2. What cognitive impairments may contribute to the characteristics of Phil's narrative content?
3. Phil tells a story that is filled with details, many of which are highly unusual. We include some examples below. Again, do you agree with this assessment? What aspects of Phil’s story did you think were unusual?
4. What could explain his unusual story and the confidence with which he told it?
5. How do you think Phil’s story compares to those told by control participants?
Case 2 Reflections
1. Based on the excerpts from these 2 discourse tasks, would you have a basis for recommending SLP treatment for Phil?
2. How important would it be in this case (or the other cases presented here) to find out about the participant’s communication style prior to the stroke?
Miranda is a 53-year-old, right-handed, African American female who had a stroke in 2010 that involved the right middle cerebral artery, affecting the temporo-parietal region and the posterior frontal lobe. This video was made in July 2016, approximately 5.4 years post-stroke. Miranda’s hearing is within functional limits as determined by a pure-tone hearing screening. She reports that she received skilled services from a speech-language pathologist for the first six months following her stroke. The focus of treatment was language, organization, left neglect, and memory. She has 18 years of education with a master’s degree. Miranda is unmarried and lives with her teenage daughter. Miranda self-identified for the study after receiving information about communication impairments following RHD from a stroke support group meeting. She reported that she returned to work after her stroke but was unable to keep up with the demands. She said that it was overwhelming for her. We present her case as an example of someone whose speech and discourse sound "pretty normal" but who has had trouble resuming her previous activities.
In this task, Miranda was asked what she thought of her speech and what she remembered about her stroke. Watch these two clips to make your own observations about her response.
Questions for discussion
1. What do you notice about Miranda’s narrative skills during her stroke story?
2. Did Miranda report any awareness that she was having a stroke or experiencing any effects of a stroke at the time of onset?
3. Do you agree with Miranda’s report that her “talking” is “pretty good”? Do you think that she demonstrates any issues with her communication? Do you notice any subtle behaviors?
In this task, Miranda was asked to tell the story of Cinderella using her prior knowledge and pictures from a book she looked through before she began telling the story. Again, this could be considered a “pretty normal” retelling of the story. The following clip shows her Cinderella story.
Questions for discussion
1. Did you notice some humor in Miranda's story?
2. Did you notice any important details missing or poorly recollected?
3. In your opinion, does Miranda effectively tell the Cinderella story? Why or why not?
In this first-encounter conversation (Kennedy et al., 1994), Miranda was asked to "get to know" a student whom she had never met. The student clinician was told this was not an interview and to converse just as she would if she were meeting someone for the first time. This 9:57-minute video clip is intended primarily to show the absence of any questions posed by Miranda to get to know the student. Yes, it is a bit odd to watch almost 10 minutes of a video to confirm that something did NOT happen. However, it is clear from watching this and other videos from a variety of individuals that the behaviors of a conversation partner can have a major effect on a communication exchange. Thus, sometimes you have to watch a lot to really get a sense of a person’s pragmatic strengths and weaknesses.
For purposes of comparison, the average number of questions posed by control participants (n=5) doing the same task (same instructions, protocol, and amount of time) was 19.4! Representative examples of the types of questions the controls asked include: “Are you from Raleigh?”, “How’d you like Wilmington?”, “What else do you do besides go to school?”, “Where did you do your undergraduate?”, “What was your undergraduate in at Ithaca?”, “What is your main line of study?”. The average number of questions posed by the three individuals featured in this Grand Rounds was 6.33, and most of those were not specific to getting to know the other person.
With that long intro, watch as much of this video clip as you choose. Pay particular attention to Miranda’s pragmatic skills and signs of memory issues.
Questions for discussion
1. What pragmatic deficits do you see in Miranda during this clip?
2. Did you notice any clues suggesting impairments in cognitive processes such as attention and memory?
3. In your opinion, is Miranda successful in meeting the task goal of ‘getting to know’ another person? Why or Why not?
4. As with Brady, how do you think the conversational partner impacted Miranda’s performance?
In this task, Miranda was asked to explain how to make a peanut butter and jelly sandwich. See what you think of her response, and be sure to watch for signs of visuospatial neglect.
Questions for discussion
1. What did you notice about Miranda's explanation?
2. Did you notice any signs of visuospatial neglect? An adult with RHD who has neglect may not attend to objects, people, and sometimes even their own body on the left side.
Case 3 Reflections
1. Based on what you’ve seen in these excerpts, how would you summarize Miranda’s strengths and weakness in terms of her discourse skills, intonation, and pragmatics?
2. Is there any area you would recommend as a therapy target?
The cases presented highlight well-documented areas of RHD deficits while providing information about possible communication behaviors in adults with RHD. We are indebted to the the people who graciously agreed to participate in the RHDBank research project. None of this would have been possible without the support and guidance of Brian MacWhinney (Carnegie Mellon University). Lily Jarold was enormously helpful with the video processing. We also thank Margaret Blake, Margaret Forbes, and Audrey Holland for their wise and constructive input on previous versions of this Grand Rounds.
The following are some research highlights on several of the behaviors you just saw in these examples. Following these highlights is a reference list for literature cited in this Grand Rounds presentation.
Literature on memory:
Fleming, Ownsworth, Doig, Hutton, Griffin, Kendall, and Shum (2017). The efficacy of prospective memory rehabilitation plus metacognitive skills training for adults with traumatic brain injury: Study protocol for a randomized controlled trial
Summary: The authors of this study used previously gained knowledge of compensatory strategies as a useful approach to rehabilitation of memory loss. They added metacognitive skills training to further develop self-awareness techniques such as self-correction and intellectual awareness in efforts to enhance treatment outcomes and generalization.
Shum, Fleming, Gill, Gullo, and Strong (2011). A randomized controlled trial of prospective memory rehabilitation in adults with traumatic brain injury
Summary: The authors examined the rehabilitation of prospective memory in patients with TBI. They found that it is more effective to use a “top down” approach which includes self-awareness training followed by compensatory strategies rather than a “bottom up” approach which focuses on remediation of lost abilities.
Literature on anosognosia:
Azouvi and Peskine (2012). Anosognosia and denial after right hemisphere stroke
Summary: This study discusses anosognosia primarily for patients with hemiplegia from a RH stroke. There are many levels of unawareness to the impairments, and while fronto-parietal and temporo-parietal regions are typically associated with anosognosia, there is not an agreed upon locus of lesion for this disorder.
Besharati, Crucianelli, and Fotopoulou (2014). Restoring awareness: a review of rehabilitation in anosognosia for hemiplegia
Summary: This article is consistent with the current literature in terms of multiple possible lesions sites that are associated with AHP. Asking the patient questions by using a third person perspective was shown to be more effective. Vestibular stimulation is effective but only shows temporary results.
Statement on anosognosia: The current literature on anosognosia focuses primarily on hemiplegia after RHD. Researchers on anosognosia state that the unawareness of hemiplegia typically dissipates after the acute-subacute stages, however that does not seem to be the case for unawareness of cognitive-communication impairments. Current research is insufficient to support the contention that anosognosia for cognitive-communication impairments is present in the chronic stages, but it is worth closer examination.
Literature on neglect:
Aparicio-López, García-Molina, García-Fernández, López-Blázquez, Enseñat-Cantallops, Sánchez-Carrión, Muriel, Tormos and Roig-Rovira (2016). Combination treatment in the rehabilitation of visuo-spatial neglect
Summary: This study found that treatment for adults with visuospatial neglect is effective in both the combined use of computerized cognitive rehabilitation and patching the right visual field and the use of computerized cognitive rehabilitation on its own.
Kerkhoff and Schenk (2012). Rehabilitation of neglect: An update
Summary: This article reviews the current techniques that are being used to rehabilitate unilateral neglect following a right hemisphere stroke. Multiple techniques and approaches are described along with their efficacy in this article. The authors agree that more empirical research is still needed.
Literature on aprosodia:
Russell, Laures-Gore, and Patel (2010). Treating expressive aprosodia: A case study
Summary: Aprosodia can be treated by either an imitative approach, or a cognitive-linguistic approach. This case study found that by using an imitative approach, the patient improved in both expressive and receptive uses of prosody.
Parola, Gabbatore, Bosco, Bara, Cossa, Gindri, and Sacco (2016). Assessment of pragmatic impairment in right hemisphere damage
Summary: This study focused on assessing the pragmatic impairments in patients with RHD. Among the pragmatic deficits identified, the authors found that patients with RHD have a limited ability to use or identify paralinguistic aspects of conversation, such as tone, pitch, and intonation.
Literature on attention:
Loetscher and Lincoln (2013).
Cognitive rehabilitation for attention deficits following stroke
Summary: This review of cognitive rehabilitation examined different attention therapy approaches. The results highlighted that attentional improvements were only seen in the short term. These improvements do allow the patient to receive other forms of much needed rehabilitation. No specific approach was recommended by the authors.
Virk, Williams, Brunsdon, Suh, and Morrow (2015).
Cognitive remediation of attention deficits following acquired brain injury: A systematic review and meta-analysis
Summary: Multiple cognitive attention treatment approaches were analyzed and the authors found that divided attention showed the largest improvement. The improvements did not last longitudinally, but the authors mentioned that temporary divided attention improvement allows the patient to participate in other forms of necessary rehabilitation as well.
Barker-Collo, Feigin, Lawes, Parag, and Senior (2010).
Attention deficits after incident stroke in the acute period: Frequency across types of attention and relationships to patient characteristics and functional outcomes
Summary: This study primarily focused on the assessment of attention, however the results suggest that the earlier a patient is assessed, the greater the rehabilitation outcomes will be. The authors mention that assessment and treatment for attention deficits are more beneficial in the acute stages.
Cicerone, Langenbahn, Braden, Malec, Kalmar, Fraas, Felicetti, Laatsch, Harley, Bergquist, Azulay, Cantor, and Ashman, 2011.
Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008
Summary: After reviewing previous studies on attention treatment, the authors recommended a practice standard for attention remediation. They recommend direct attention and metacognitive therapy in the post-acute stage of recovery. A practice option of using computer based intervention was also recommended.
Couillet, Soury, Lebornec, Asloun, Joseph, Mazaux, and Axouvi (2010).
Rehabilitation of divided attention after severe traumatic brain injury: A randomised trial
Summary: A rehabilitation program that focused on divided attention in severe TBI patients was examined in this study. Twelve TBI patients in the subacute and chronic stages underwent 6 weeks of dual task therapy. Results showed significant improvement on divided attention accompanied by improvement in general mental flexibility.
Scolari, Seidl-Rathkopf, and Kastner (2015).
Functions of the human frontoparietal attention network: Evidence from neuroimaging
Summary: This neuroimaging study examined topographical areas of the brain in regards to space based, object based, feature based, and category based attention. The results suggest that the frontoparietal region is largely involved in these types of attention.
Ferrazzoli, Ortelli, Maestri, and Frazzitta (2017).
Focused and sustained attention is modified by a goal-based rehabilitation in parkinsonian patients
Summary: This study examined reaction times (RT) and multiple choice RT (MC RT) to measure focused and sustained attention in a multidisciplinary, intensive and goal-based rehabilitation treatment (MIRT). In patients with PD, it was found that focused and sustained attention are intact in those who have maintained alertness, suggesting that attention treatment is effective for PD patients without cognitive deficits.
Barker-Collo, Feigin, Lawes, Parag, Senior, and Rodgers (2009).
Reducing attention deficits after stroke using attention process training a randomized controlled trial
Summary: The efficacy of Attention Processing Training (APT) was measured on 78 stroke survivors diagnosed with attention deficit within two weeks post CVA. Fifteen participants in the APT group had a right hemisphere CVA. Results were encouraging, however future studies need to be done to determine specific populations for which this approach is most effective.
Literature on treatment:
There are few well-established treatment procedures that have a depth of evidence to support them (Blake, Frymark & Venedictov, 2013; Blake, 2017). Often, clinicians draw from literature of related areas (e.g., traumatic brain injury, aphasia, etc.). It is our hope that the RHDBank will stimulate further research into effective treatments for this important population.
Blake, M. L. (2017). The right hemisphere and disorders of cognition and communication: Theory and clinical practice. San Diego, CA: Plural Publishing.
Blake, Frymark, & Venedictov (2013). An evidence-based systematic review on communication treatments for individuals with right hemisphere brain damage
Ferré, Ska, Lajoie, Bleau, & Joanette. Clinical focus on prosodic, Discursive and pragmatic treatment for right hemisphere damaged adults: What's right?
Barker-Collo, S. L., Feigin, V. L., Lawes, C. M., Parag, V., & Senior, H. (2010). Attention deficits after incident stroke in the acute period: frequency across types of attention and relationships to patient characteristics and functional outcomes. Topics in Stroke Rehabilitation, 17(6), 463-476. doi: 10.1310/tsr1706-463.
Behrmann, M., Black, S. E., McKeeff, T. J., & Barton, J. J. S. (2002). Oculographic analysis of word reading in hemispatial neglect. Physiology & Behavior, 77(4-5), 613-619.
Blake, M. L. (2018). The right hemisphere and disorders of cognition and communication: theory and clinical practice. San Diego, CA: Plural.
Blake, M. L. (2009). Inferencing processes after right hemisphere brain damage: maintenance of inferences. Journal of Speech, Language, and Hearing Research, 52(2), 359-372.
Blake, M. L., Duffy, J. R., Myers, P. S., & Tompkins, C. A., (2002). Prevalence and patterns of right hemisphere cognitive/communication deficits: Retrospective data from an inpatient rehabilitation unit. Aphasiology, 16, 537-548.
Casale, S., Johnson, M., Reed, M., & Burry, C. (2017, November). Speech and music therapy co-treatment approach to aprosodia in Right Hemisphere Brain Damage. Poster presented at the annual meeting of the American Speech-Language Hearing Association, Los Angeles, CA.
Cator, J., Johnson, M., Fromm, D., & MacWhinney, B. (2017, November). Global coherence of story narratives in Right Hemisphere Brain Damage. Poster presented at the annual meeting of the American Speech-Language Hearing Association, Los Angeles, CA.
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