Growth, Development & Safeguarding — MCQs
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A 16-month-old boy presents to the emergency department with a swollen, painful right thigh. The father reports the child fell from a standing position. X-ray shows a spiral fracture of the right femur. The child appears well-nourished and developmental assessment shows he can walk independently and say 6 words. Blood tests show normal calcium, phosphate, alkaline phosphatase, and vitamin D. The family is known to social services due to previous domestic violence incidents. Analyzing all available information, which factor most significantly increases the probability that this injury is non-accidental?
A paediatric registrar reviews a 3-month-old infant with failure to thrive. Birth weight was on the 50th centile, but current weight is on the 2nd centile. The parents appear disheveled and the flat smells strongly of cannabis. The infant has poor eye contact and appears listless. There are no dysmorphic features or signs of organic disease. Observed feeding shows poor attachment and the mother appears disengaged. What combination of factors most strongly indicates this is neglect rather than an organic cause?
A 3-year-old boy is referred with concerns about language development. He can only say approximately 10 single words and does not combine words. He communicates mainly through gestures and becomes frustrated when not understood. He can follow simple one-step commands, plays appropriately with toys, and interacts well with his parents. His hearing test is normal. Which additional developmental domain assessment is most critical before determining the underlying cause?
A 14-year-old girl discloses to her GP that her stepfather has been touching her inappropriately for the past 6 months. She is very distressed and asks the doctor not to tell anyone as she fears breaking up the family. Her mother is in the waiting room. What is the most appropriate immediate action?
A 7-year-old girl has been growing along the 50th centile for height until age 5, but over the past 2 years her height has fallen to just below the 9th centile. Her weight remains on the 50th centile. She appears well but her mother is concerned. Bone age X-ray shows a bone age of 5 years. What is the most likely diagnosis?
A 6-week-old infant presents to the emergency department with a fractured left femur. The parents report the baby rolled off the sofa onto a carpeted floor. The infant was born at term with no complications and has been feeding well. On examination, there are no other injuries and the infant appears well-cared for. What is the most appropriate immediate action?
A 5-year-old boy is referred by his school due to concerns about his social interactions. He has excellent verbal skills with advanced vocabulary but struggles to make friends. He becomes very upset if his daily routine changes and has an intense interest in train timetables, which he can recite in detail. He avoids eye contact during the consultation. Which assessment tool would be most appropriate to aid diagnosis?
A 15-month-old girl is reviewed in the developmental clinic. She can walk holding onto furniture but cannot walk independently. She can say 3 words with meaning and can build a tower of 2 cubes. She can drink from a cup with help but cannot use a spoon. Her hearing and vision screening tests are normal. What is the most appropriate management?
A 2-year-old boy attends the emergency department with his mother. She reports he fell down three stairs yesterday. On examination, he has a 3cm bruise on his right cheek, appears withdrawn, and becomes upset when approached. His mother states he has always bruised easily. A full blood count, clotting screen, and von Willebrand factor assay are all normal. What is the most appropriate next step in management?
During a safeguarding training session, junior doctors discuss physical abuse patterns. A presentation shows photographs of various injuries in children. Which pattern of bruising would be most specific for non-accidental injury rather than accidental trauma in a mobile toddler?
Growth, Development & Safeguarding UK Medical PG Practice Questions and MCQs
Question 141: A 16-month-old boy presents to the emergency department with a swollen, painful right thigh. The father reports the child fell from a standing position. X-ray shows a spiral fracture of the right femur. The child appears well-nourished and developmental assessment shows he can walk independently and say 6 words. Blood tests show normal calcium, phosphate, alkaline phosphatase, and vitamin D. The family is known to social services due to previous domestic violence incidents. Analyzing all available information, which factor most significantly increases the probability that this injury is non-accidental?
- A. The child's young age makes any fracture highly suspicious regardless of mechanism
- B. Spiral fractures are pathognomonic of non-accidental injury in all age groups
- C. The combination of implausible mechanism, high-force injury type, and pre-existing safeguarding concerns (Correct Answer)
- D. Normal biochemistry rules out organic causes, therefore injury must be inflicted
- E. Independent walking ability means the injury could easily be accidental from a fall
Explanation: ***The combination of implausible mechanism, high-force injury type, and pre-existing safeguarding concerns***- A **femoral fracture** in a child requires significant force; a simple fall from standing height in a 16-month-old is considered an **implausible mechanism** for this degree of injury.- The context of **domestic violence** within the family significantly increases the clinical suspicion of **Non-Accidental Injury (NAI)**, as these factors often co-occur.*The child's young age makes any fracture highly suspicious regardless of mechanism*- While fractures in **non-mobile infants** are highly suspicious, a 16-month-old who walks independently is at higher risk for **accidental trauma**.- Age is a risk factor, but the **discrepancy between the history and the injury** is a more significant indicator of abuse than age alone.*Spiral fractures are pathognomonic of non-accidental injury in all age groups*- **Spiral fractures** occur due to rotational force and can happen accidentally, such as a "toddler's fracture" in the tibia from a tripping incident.- No single fracture pattern is 100% **pathognomonic** for abuse; the diagnosis relies on the **constellation of clinical and social evidence**.*Normal biochemistry rules out organic causes, therefore injury must be inflicted*- Normal **Calcium, Phosphate, and ALP** help exclude **Metabolic Bone Disease** or Rickets, but their absence does not automatically prove NAI.- Ruling out organic causes is a necessary step in the workup but serves as **supporting evidence** rather than a definitive diagnosis of abuse.*Independent walking ability means the injury could easily be accidental from a fall*- Although independent mobility increases the chance of accidents, it does not explain the **high-energy torque** required to fracture a femur from a standing height.- This option ignores the **safeguarding red flags** and the biomechanical mismatch between the reported fall and the resulting **spiral fracture**.
Question 142: A paediatric registrar reviews a 3-month-old infant with failure to thrive. Birth weight was on the 50th centile, but current weight is on the 2nd centile. The parents appear disheveled and the flat smells strongly of cannabis. The infant has poor eye contact and appears listless. There are no dysmorphic features or signs of organic disease. Observed feeding shows poor attachment and the mother appears disengaged. What combination of factors most strongly indicates this is neglect rather than an organic cause?
- A. Cannabis smell in the home and disheveled parental appearance
- B. Crossing down through centiles combined with lack of dysmorphic features
- C. Poor feeding technique observed with normal physical examination findings
- D. Weight on 2nd centile with listless behavior and poor eye contact
- E. Maternal disengagement during feeding combined with disproportionate weight loss and absence of organic findings (Correct Answer)
Explanation: ***Maternal disengagement during feeding combined with disproportionate weight loss and absence of organic findings*** - This combination directly links the **infant's poor growth** (disproportionate weight loss from 50th to 2nd centile) to a failure in **caregiving behavior** (maternal disengagement during feeding). - The **absence of organic findings** further strengthens the diagnosis of **non-organic failure to thrive (NOFTT)**, making neglect the most likely underlying cause. *Cannabis smell in the home and disheveled parental appearance* - While these are significant **safeguarding concerns** and suggest a potentially unstable environment, they are indirect indicators and do not directly explain the specific mechanism of the infant's **failure to thrive**. - These factors indicate **risk**, but don't provide the definitive clinical link between caregiving and the infant's physical state as strongly as observed disengagement. *Crossing down through centiles combined with lack of dysmorphic features* - **Crossing down through centiles** is a defining feature of any **failure to thrive**, whether organic or non-organic, and therefore is not specific to neglect. - The **lack of dysmorphic features** helps rule out genetic syndromes but does not differentiate between other organic causes (e.g., malabsorption) and **environmental neglect**. *Poor feeding technique observed with normal physical examination findings* - **Poor feeding technique** can be a result of lack of education or support, rather than deliberate disengagement or **neglect**. - While **normal physical examination findings** are crucial for ruling out organic disease, this option lacks the direct evidence of a problematic caregiver-infant interaction that points specifically to neglect. *Weight on 2nd centile with listless behavior and poor eye contact* - A **weight on the 2nd centile** simply confirms the diagnosis of **failure to thrive**, but doesn't explain its cause. - **Listless behavior** and **poor eye contact** are non-specific signs of an unwell and potentially malnourished infant, which can be seen in both severe organic illness and severe **neglect**.
Question 143: A 3-year-old boy is referred with concerns about language development. He can only say approximately 10 single words and does not combine words. He communicates mainly through gestures and becomes frustrated when not understood. He can follow simple one-step commands, plays appropriately with toys, and interacts well with his parents. His hearing test is normal. Which additional developmental domain assessment is most critical before determining the underlying cause?
- A. Assessment of gross motor skills including running and jumping ability
- B. Detailed assessment of social interaction and communication patterns (Correct Answer)
- C. Evaluation of visual acuity and eye movement coordination
- D. Assessment of self-care skills including dressing and feeding
- E. Evaluation of attention span and activity levels
Explanation: ***Detailed assessment of social interaction and communication patterns*** - A 3-year-old using only 10 single words has a significant **expressive language delay**; the priority is to differentiate between an isolated language disorder and **Autism Spectrum Disorder (ASD)**. - While the child interacts well with parents, a formal assessment of **social reciprocity**, **joint attention**, and **non-verbal communication** is critical to confirm or exclude ASD. *Assessment of gross motor skills including running and jumping ability* - **Gross motor skills** are typically independent of language development and are rarely the primary cause of isolated speech delays. - In conditions like **Global Developmental Delay**, multiple domains would be affected, but motor skills do not help differentiate the etiology of language impairment. *Evaluation of visual acuity and eye movement coordination* - While vision is important for general learning, it is not a direct requirement for **expressive language production** or early word acquisition. - **Visual deficits** do not typically present as isolated language delay with preserved social and motor interest. *Assessment of self-care skills including dressing and feeding* - **Adaptive/self-care skills** reflect general cognitive and motor maturity but are not the primary diagnostic focus for a specific **speech-language delay**. - Evaluating dressing or feeding would not provide the necessary clinical information to distinguish between **Social Communication Disorder** and other developmental pathologies. *Evaluation of attention span and activity levels* - Although **ADHD** can coexist with language delays, it is not a core diagnostic requirement for determining the initial cause of a toddler's failure to speak. - High activity levels or short attention spans are common in toddlers and do not explain a severe deficit in **expressive vocabulary** and word combination.
Question 144: A 14-year-old girl discloses to her GP that her stepfather has been touching her inappropriately for the past 6 months. She is very distressed and asks the doctor not to tell anyone as she fears breaking up the family. Her mother is in the waiting room. What is the most appropriate immediate action?
- A. Respect her confidentiality, provide support, and arrange follow-up to see if she changes her mind
- B. Discuss the disclosure with her mother immediately to get both sides of the story
- C. Contact the designated safeguarding lead and children's social care the same day (Correct Answer)
- D. Refer to Child and Adolescent Mental Health Services for psychological support
- E. Arrange a joint meeting with the girl, her mother, and stepfather to address the allegation
Explanation: ***Contact the designated safeguarding lead and children's social care the same day*** - Disclosure of **sexual abuse** by a minor constitutes a significant risk of harm, mandating an immediate **safeguarding referral** that overrides confidentiality. - The GP has a **statutory duty** to protect the child; therefore, they must notify the **Designated Safeguarding Lead (DSL)** and make a same-day referral to **social care** or the police. *Respect her confidentiality, provide support, and arrange follow-up to see if she changes her mind* - While respecting confidentiality is crucial, it is not absolute when there is a risk of **significant harm** to a child, as in cases of **child abuse**. - Delaying action leaves the child in a dangerous environment and fails to meet **statutory safeguarding obligations**, potentially exacerbating harm. *Discuss the disclosure with her mother immediately to get both sides of the story* - Informing the mother immediately could place the child at **further risk** if the mother is not protective or alerts the **alleged perpetrator**. - **Safeguarding protocols** dictate that social services or the police should manage family notification to avoid compromising investigations and ensure the child's safety. *Refer to Child and Adolescent Mental Health Services for psychological support* - **CAMHS** provides crucial psychological support, but it is not an emergency service responsible for immediate physical protection from ongoing abuse. - While psychological support will be essential long-term, the **immediate priority** is removing the child from the risk of **ongoing abuse** and ensuring their safety. *Arrange a joint meeting with the girl, her mother, and stepfather to address the allegation* - Confronting the **alleged abuser** in a joint meeting is extremely dangerous and strictly **contraindicated** in child protection cases. - Such an action could lead to **coercion**, intimidation, or further physical or emotional harm to the child and may compromise any future investigation.
Question 145: A 7-year-old girl has been growing along the 50th centile for height until age 5, but over the past 2 years her height has fallen to just below the 9th centile. Her weight remains on the 50th centile. She appears well but her mother is concerned. Bone age X-ray shows a bone age of 5 years. What is the most likely diagnosis?
- A. Constitutional delay of growth and puberty
- B. Growth hormone deficiency (Correct Answer)
- C. Familial short stature
- D. Turner syndrome
- E. Coeliac disease
Explanation: ***Growth hormone deficiency*** - This presentation features **crossing centiles downward** (from 50th to 9th) over 2 years, which indicates a pathologically reduced **growth velocity**. - The preservation of weight (50th centile) relative to falling height leading to a high BMI, combined with a **delayed bone age**, is a classic triad for **Growth hormone deficiency**. *Constitutional delay of growth and puberty* - While this involves a **delayed bone age**, growth usually tracks along or parallel to a lower centile rather than showing a dramatic **recent departure** from a previously normal centile. - This is more commonly diagnosed during the adolescent years when the **pubertal growth spurt** is delayed compared to peers. *Familial short stature* - Children with this condition typically grow consistently along a **lower centile** (matching family height) from early life, without crossing downward. - The **bone age** is usually consistent with chronological age, unlike the 2-year delay seen in this patient. *Turner syndrome* - While it is a common cause of short stature in girls, it often presents with other **stigmata** like webbed neck, broad chest, or cubitus valgus. - Height failure in **Turner syndrome** often begins earlier in childhood, and a karyotype would be required for confirmation. *Coeliac disease* - Malabsorption in **Coeliac disease** typically causes the **weight centile** to fall before or more significantly than the height centile. - This patient's weight remains on the 50th centile, making a **nutritional or gastrointestinal** cause of growth failure much less likely.
Question 146: A 6-week-old infant presents to the emergency department with a fractured left femur. The parents report the baby rolled off the sofa onto a carpeted floor. The infant was born at term with no complications and has been feeding well. On examination, there are no other injuries and the infant appears well-cared for. What is the most appropriate immediate action?
- A. Arrange orthopaedic management and discharge home with safeguarding advice
- B. Admit for skeletal survey, safeguarding investigation, and multidisciplinary assessment (Correct Answer)
- C. Refer to genetics for assessment of osteogenesis imperfecta before further action
- D. Obtain parental consent for social services involvement and arrange outpatient follow-up
- E. Document concerns in the notes and arrange review by the health visitor within 48 hours
Explanation: ***Admit for skeletal survey, safeguarding investigation, and multidisciplinary assessment*** - A **femur fracture** in a 6-week-old (a **non-mobile** infant) is a major **red flag** for **Non-Accidental Injury (NAI)**, as substantial force is required to break a femur. - The history provided is **developmentally inconsistent**, as infants typically cannot **roll over** independently at 6 weeks of age, necessitating immediate **hospital admission** and a full **child protection** evaluation. *Arrange orthopaedic management and discharge home with safeguarding advice* - Discharging the infant would place them at extreme **risk of further harm** or fatal injury before a proper assessment is completed. - **Safeguarding advice** is insufficient; NAI must be formally excluded through a **skeletal survey** and social services investigation while the child is in a safe environment. *Refer to genetics for assessment of osteogenesis imperfecta before further action* - Although **Osteogenesis Imperfecta** is a differential for multiple fractures, **safeguarding investigations** must run in parallel and cannot be delayed for genetic testing results. - The **implausible mechanism** of injury makes trauma from abuse a much higher priority for immediate management to ensure the child's safety. *Obtain parental consent for social services involvement and arrange outpatient follow-up* - **Parental consent** is not required to initiate a safeguarding referral or medical investigation when there is a significant suspicion of child **abuse**. - **Outpatient follow-up** is inappropriate for an acute fracture in an infant where the safety of the home environment has not been established. *Document concerns in the notes and arrange review by the health visitor within 48 hours* - A **health visitor review** is a community-level follow-up and does not provide the **acute medical or legal protection** required for a suspected NAI. - Relying solely on documentation and delayed review fails to fulfill the clinician's **legal and professional duty** to investigate life-threatening injuries immediately.
Question 147: A 5-year-old boy is referred by his school due to concerns about his social interactions. He has excellent verbal skills with advanced vocabulary but struggles to make friends. He becomes very upset if his daily routine changes and has an intense interest in train timetables, which he can recite in detail. He avoids eye contact during the consultation. Which assessment tool would be most appropriate to aid diagnosis?
- A. Conners' Rating Scale
- B. Autism Diagnostic Observation Schedule (ADOS) (Correct Answer)
- C. Strengths and Difficulties Questionnaire (SDQ)
- D. Griffiths Mental Development Scales
- E. Child Behaviour Checklist (CBCL)
Explanation: ***Autism Diagnostic Observation Schedule (ADOS)*** - The **ADOS** is a semi-structured, standardized assessment considered the **gold standard** for diagnosing **Autism Spectrum Disorder (ASD)** through direct observation of social communication and repetitive behaviors. - This child's presentation, including **social communication deficits**, **restricted interests**, **insistence on routine**, and **avoidance of eye contact**, strongly indicates ASD, necessitating a specialized diagnostic tool like the ADOS. *Conners' Rating Scale* - This scale is primarily used for assessing symptoms of **Attention Deficit Hyperactivity Disorder (ADHD)**, focusing on inattention, hyperactivity, and impulsivity. - It does not specifically evaluate the **social communication impairments** and **restricted, repetitive patterns of behavior** that are central to an ASD diagnosis. *Strengths and Difficulties Questionnaire (SDQ)* - The **SDQ** is a brief **screening tool** for identifying general emotional and behavioral difficulties, such as hyperactivity or peer problems, in children. - It is not a comprehensive **diagnostic instrument** for **Autism Spectrum Disorder** and lacks the specific criteria needed for a definitive ASD diagnosis. *Griffiths Mental Development Scales* - These scales are designed to assess the **developmental level** of infants and young children across various domains like motor, personal-social, and language skills. - While useful for identifying **developmental delays**, they do not specifically target or provide diagnostic information for the **social communication deficits** and **repetitive behaviors** characteristic of ASD. *Child Behaviour Checklist (CBCL)* - The **CBCL** is a broad **parent-report questionnaire** used to identify a wide range of emotional and behavioral problems, such as anxiety, depression, or aggression. - It provides a general behavioral profile but is not a specific diagnostic tool for **Autism Spectrum Disorder**, as it doesn't focus on the unique core features of ASD.
Question 148: A 15-month-old girl is reviewed in the developmental clinic. She can walk holding onto furniture but cannot walk independently. She can say 3 words with meaning and can build a tower of 2 cubes. She can drink from a cup with help but cannot use a spoon. Her hearing and vision screening tests are normal. What is the most appropriate management?
- A. Reassure parents that development is within normal limits for age
- B. Refer to paediatric physiotherapy for assessment of gross motor skills (Correct Answer)
- C. Arrange urgent neuroimaging to exclude intracranial pathology
- D. Refer to speech and language therapy for language delay
- E. Request chromosomal microarray for suspected genetic syndrome
Explanation: ***Refer to paediatric physiotherapy for assessment of gross motor skills*** - The child exhibits an isolated **gross motor delay**, as she is still **cruising** at 15 months but should ideally be taking **independent steps** by this age. - Professional assessment is required to rule out underlying issues like **hypotonia** or **mild cerebral palsy** and to initiate **early intervention**. *Reassure parents that development is within normal limits for age* - While the upper limit for independent walking is **18 months**, the lack of progress from **cruising** at 15 months warrants an investigation rather than just reassurance. - **Passive observation** is inappropriate when a child is at the extreme end of the normal range for reaching a major milestone. *Arrange urgent neuroimaging to exclude intracranial pathology* - There are no **focal neurological deficits**, symptoms of **increased intracranial pressure**, or macrocephaly to justify **urgent neuroimaging**. - Neuroimaging is not a first-line investigation for **isolated motor delay** in the absence of red flags like **regression** of milestones. *Refer to speech and language therapy for language delay* - Her language skills are **age-appropriate**, as saying **3 words with meaning** is a milestone typically achieved between 12 and 15 months. - **Speech and language therapy** is reserved for children who do not meet verbal milestones or fail **hearing screenings**, which were normal here. *Request chromosomal microarray for suspected genetic syndrome* - Genetic testing is generally reserved for cases of **global developmental delay** or children with **dysmorphic features**, neither of which are present. - Her fine motor, social, and language domains are within **normal limits**, making a single-domain motor delay less likely to be part of a **genetic syndrome**.
Question 149: A 2-year-old boy attends the emergency department with his mother. She reports he fell down three stairs yesterday. On examination, he has a 3cm bruise on his right cheek, appears withdrawn, and becomes upset when approached. His mother states he has always bruised easily. A full blood count, clotting screen, and von Willebrand factor assay are all normal. What is the most appropriate next step in management?
- A. Discharge home with safety advice about preventing falls
- B. Arrange outpatient follow-up with a paediatric haematologist
- C. Complete a full skeletal survey and discuss with the safeguarding team (Correct Answer)
- D. Prescribe iron supplementation for possible nutritional deficiency
- E. Reassure the mother and provide written information about normal childhood injuries
Explanation: ***Complete a full skeletal survey and discuss with the safeguarding team*** - Significant clinical red flags including **facial bruising**, **withdrawn behavior**, and an inconsistent history in a young child necessitate a thorough **safeguarding evaluation**. - A **skeletal survey** is mandatory in children under 2 years with suspected **non-accidental injury (NAI)** to identify occult fractures that may indicate chronic physical abuse, especially when bleeding disorders are ruled out. *Discharge home with safety advice about preventing falls* - This is inappropriate because the child's **withdrawn behavior** and bruising on the **cheek** are highly suspicious of abuse rather than a simple accidental fall. - Discharging the child without further investigation would violate **safeguarding protocols** and potentially leave him at risk for further harm. *Arrange outpatient follow-up with a paediatric haematologist* - While the mother claims he bruises easily, the **normal clotting screen**, FBC, and **von Willebrand factor assay** have already ruled out common bleeding disorders. - Delaying the investigation and focusing solely on haematology ignores the acute **clinical indicators of physical abuse** and the need for immediate protection. *Prescribe iron supplementation for possible nutritional deficiency* - **Iron deficiency** does not typically cause isolated, significant facial bruising and would not explain the child's **withdrawn psychological state**. - This approach is a **clinical distraction** that fails to address the high likelihood of non-accidental trauma and the need for a **multi-agency referral**. *Reassure the mother and provide written information about normal childhood injuries* - Bruising on the **face/cheek** is an unusual site for accidental injury in toddlers, who generally sustain bruises on **bony prominences** like knees and shins. - Reassurance is contraindicated here as the **mechanism of injury** (falling down 3 stairs) is often inconsistent with the severity of bruising and the child's fearful behavior.
Question 150: During a safeguarding training session, junior doctors discuss physical abuse patterns. A presentation shows photographs of various injuries in children. Which pattern of bruising would be most specific for non-accidental injury rather than accidental trauma in a mobile toddler?
- A. Bruising over the anterior tibial surfaces bilaterally
- B. A single bruise on the forehead above the eyebrow
- C. Multiple small round bruises on the upper arms in a cluster pattern (Correct Answer)
- D. Bruising over both knees of different ages
- E. A linear bruise on the shin with associated abrasion
Explanation: ***Multiple small round bruises on the upper arms in a cluster pattern***- These are characteristic of **finger-tip bruising** caused by forceful gripping, which is highly specific for **non-accidental injury (NAI)**.- Bruising to **soft tissue areas** like the upper arms, ears, neck, and torso is concerning as these sites are rarely injured during a child's normal activities.*Bruising over the anterior tibial surfaces bilaterally*- These are the most common sites for **accidental bruising** in mobile children due to falls and collisions with low objects.- Presence on **bony prominences** is typically considered normal developmental trauma in mobile toddlers.*A single bruise on the forehead above the eyebrow*- The **forehead** is a very common site for accidental injury in toddlers because it is a prominent bony surface during forward falls.- A **localized, solitary bruise** over a bony prominence is usually consistent with the developmental history of an active walker.*Bruising over both knees of different ages*- Active children frequently sustain **repeated minor impacts** to their knees, which explains why bruises may be observed in various stages of healing.- While multiple bruises can be a red flag, their location on **knees** makes them much more likely to be accidental than NAI.*A linear bruise on the shin with associated abrasion*- This pattern is highly consistent with a child bumping their leg against a **hard surface or edge**, such as a coffee table or stair.- **Abrasions** (scrapes) combined with bruising on the shin are classic markers of everyday accidental trauma in exploring toddlers.
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