A Phase III Safety and Efficacy Study of L-Glutamine to Treat Sickle Cell Disease or Sickle βo-thalassemia

• Sponsor: Emmaus Medical, Inc. (Industry)
• Overall Status: Completed
• CT.gov ID: NCT01179217
• Collaborator: (none)
• Enrollment: 230
• Locations: 31
• Arms: 2
• Duration (Months): 46
• Patients Per Site: 7.4
• Patients Per Site Per Month: 0.2

Study Details

Study Description

Brief Summary

The purpose of this research is to evaluate the effects of L-glutamine as a therapy for Sickle Cell Anemia or Sickle ß0 Thalassemia as evaluated by the number of occurrences of sickle cell crises.

Condition or Disease	Intervention/Treatment	Phase
Sickle Cell Anemia; Sickle ß0-Thalassemia	Drug: L-glutamine; Drug: Placebo	Phase 3

Detailed Description

Primary objective:

To evaluate the efficacy of oral L-glutamine as a therapy for sickle cell anemia and sickle ß0-thalassemia as evaluated by the number of occurrences of sickle cell crises.

Secondary objectives:

To assess the effect of oral L-glutamine on: (a) frequency of hospitalizations for sickle cell pain; (b) frequency of emergency room/medical facility visits for sickle cell pain; and (c) hematological parameters (hemoglobin, hematocrit, and reticulocyte count); and to assess the safety of L-glutamine as a therapy for sickle cell anemia as evaluated by adverse events, laboratory parameters, and vital signs.

Methodology:

This was a 2:1 randomized, double-blind, placebo-controlled, parallel-group, multicenter study in patients with sickle cell anemia and sickle ß0-thalassemia who were at least 5 years old. Informed consent was obtained up to four weeks prior to Week 0 (Baseline). Screening procedures were performed anytime between the date of consent and Week 0, as long as all eligibility criteria had been confirmed prior to Week 0. At Week 0, patients were randomized (to L-glutamine or placebo) and underwent 48 weeks of treatment (orally BID), with dose calculated according to patient weight. Patient clinic visits occurred every 4 weeks, and phone calls took place between visits to monitor compliance. After 48 weeks of treatment, the dose was tapered to 0 within 3 weeks. A final evaluation visit occurred 2 weeks after last dose for a total of 53 weeks on study.

Study Design

• Study Type: Interventional
• Actual Enrollment: 230 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
• Primary Purpose: Treatment
• Official Title: A PHASE III, PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, PARALLEL-GROUP, MULTICENTER STUDY OF L GLUTAMINE THERAPY FOR SICKLE CELL ANEMIA AND SICKLE ß0-THALASSEMIA
• Study Start Date: May 1, 2010
• Actual Primary Completion Date: Mar 1, 2014
• Actual Study Completion Date: Mar 1, 2014

Arms and Interventions

Arm	Intervention/Treatment
Experimental: L-glutamine Patients will be randomized to receive investigational product, L-Glutamine.	Drug: L-glutamine; 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.; Other Names: oral L-glutamine
Placebo Comparator: 100% maltodextrin Patients will be randomized to receive Placebo.	Drug: Placebo; 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.; Other Names: Maltodextrin

Outcome Measures

Primary Outcome Measures

1. The Number of Occurrences of Sickle Cell Crises [48 weeks]

   The number of occurrences of protocol-defined sickle cell crises that occur from Week 0 to Week 48 will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.

Secondary Outcome Measures

1. The Number of Hospitalizations for Sickle Cell Pain [48 weeks]

   The number of hospitalizations that occur from Week 0 to Week 48, will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.

2. The Number of Emergency Room/Medical Facility Visits for Sickle Cell Pain [48 weeks]

   The number of emergency room visits or medical facility visits that occur from Week 0 to Week 48, will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.

3. The Effect of Oral -L-glutamine on Hematological Parameters [Baseline, Week 4, 24 and 48]

   To assess the effect of oral L-glutamine on hematological parameters (hemoglobin), Change from Baseline will be reported at Weeks 4, 24 and 48.

4. The Effect of Oral L-glutamine on Vital Signs [Baseline, Week 4, 24, and 48]

   To assess the effect of oral L-glutamine on Vital signs (systolic and diastolic blood pressure). Change from Baseline will be reported at Weeks 4, 24, and 48.

5. The Effect of Oral L-glutamine on Hematological Parameters [Baseline, Week 4, 24 and 48]

   To assess the effect of oral L-glutamine on hematological parameters (hematocrit), Change from Baseline will be reported at Weeks 4, 24 and 48.

6. The Effect of Oral L-glutamine on Hematological Parameters [Baseline, Week 4, 24 and 48]

   To assess the effect of oral L-glutamine on hematological parameters (reticulocyte count), Change from Baseline will be reported at Weeks 4, 24 and 48.

7. The Effect of Oral L-glutamine on Vital Signs [Baseline, Week 4, Week 24 and Week 48]

   To assess the effect of oral L-glutamine on Vital signs (pulse rate). Change from Baseline will be reported at Weeks 4, 24, and 48.

8. Effect of Oral L-glutamine on Vital Signs [Baseline, Week 4, Week 24 and Week 48]

   To assess the effect of oral L-glutamine on Vital signs (temperature). Change from Baseline will be reported at Weeks 4, 24, and 48.

9. The Effect of Oral L-glutamine on Vital Signs [Baseline, Week 4, Week 24 and Week 48]

   To assess the effect of oral L-glutamine on Vital signs (respiration). Change from Baseline will be reported at Weeks 4, 24, and 48.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 5 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Patient is at least five years of age.

• Patient has been diagnosed with sickle cell anemia or sickle ß°-thalassemia (documented by hemoglobin electrophoresis).

• Patient has had at least two documented episodes of sickle cell crises within 12 months of the screening visit.

• If the patient has been treated with an anti-sickling agent within three months of the screening visit, the therapy must have been continuous for at least three months with the intent to continue for the duration of the study.

• Patient or the patient's legally authorized representative has given written informed consent.

• If the patient is a female of child-bearing potential, she agrees to avoid pregnancy during the study and is willing and agrees to practice a recognized form of birth control during the course of the study (e.g. barrier, birth control pills, abstinence).

Exclusion Criteria:

• Patient has a significant medical condition that required hospitalization (other than sickle cell crisis) within two months of the screening visit.

• Patient has prothrombin time INR > 2.0.

• Patient has serum albumin < 3.0 g/dl.

• Patient has received any blood products within three weeks of the Screening Visit.

• Patient has uncontrolled liver disease or renal insufficiency.

• Patient is pregnant or lactating or has the intention of becoming pregnant during the study (if female and of child-bearing potential).

• Patient is currently taking or has been treated with any form of glutamine supplement within 30 days of the screening visit.

• Patient has been treated with an experimental anti-sickling medication/ treatment within 30 days of the screening visit (with the exception of hydroxyurea in pediatric patients).

• Patient is currently taking or has been treated with an investigational drug within 30 days of the screening visit (with the exception of hydroxyurea in pediatric patients).

• Patient is currently enrolled in an investigational drug or device study and/or has participated in such a study within 30 days of the screening visit.

• There are factors that would, in the judgment of the investigator, make it difficult for the patient to comply with the requirements of the study.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of South Alabama Medical Center	Mobile	Alabama	United States	36617
2	Phoenix Children's Hospital Center for Cancer and Blood Disorders	Phoenix	Arizona	United States	85016
3	Kaiser Permanente	Inglewood	California	United States	90301
4	Children's Hospital & Research Center at Oakland	Oakland	California	United States	94609
5	Children's Hospital of Orange County	Orange	California	United States	92868
6	Harbor-UCLA Medical Center	Torrance	California	United States	90509
7	University of Denver School of Medicine Sickle Cell Treatment & Research Center	Aurora	Colorado	United States	80045
8	Howard University Hospital & Howard University	Washington	District of Columbia	United States	20060
9	University of Florida	Gainesville	Florida	United States	32610-0296
10	All Children's Hospital	Saint Petersburg	Florida	United States	33701
11	Children's Healthcare of Atlanta at Egleston/Emory University	Atlanta	Georgia	United States	30322
12	University of Illinois at Chicago	Chicago	Illinois	United States	60612
13	University of Louisville School of Medicine	Louisville	Kentucky	United States	40202
14	Sickle Cell Center of S. Louisiana, Tulane University School of Medicine	New Orleans	Louisiana	United States	70112
15	Johns Hopkins University	Baltimore	Maryland	United States	21205
16	Boston University Medical Center	Boston	Massachusetts	United States	02118
17	Children's Hospital of Michigan	Detroit	Michigan	United States	48201
18	University of Mississippi Medical Center	Jackson	Mississippi	United States	39216
19	Children's Mercy Hospitals and Clinics	Kansas City	Missouri	United States	64108
20	Children's Specialty Center of Nevada	Las Vegas	Nevada	United States	89109
21	Comprehensive Cancer Center of Nevada	Las Vegas	Nevada	United States	89109
22	Cooper University Hospital	Camden	New Jersey	United States	08103
23	Bronx Lebanon Hospital	Bronx	New York	United States	11203
24	The Brooklyn Hospital Center	Brooklyn	New York	United States	11201
25	SUNY - Downstate Medical Center	Brooklyn	New York	United States	11203
26	Brookdale University Hospital and Medical Center	Brooklyn	New York	United States	11212
27	New York Methodist Hospital - SC/Thalassemia Program	Brooklyn	New York	United States	11215
28	Interfaith Medical Center	Brooklyn	New York	United States	11238
29	Presbyterian Blume Pediatric Hematology-Oncology Clinic	Charlotte	North Carolina	United States	28204
30	University of Tennessee Cancer Institute	Memphis	Tennessee	United States	38104
31	Virginia Commonwealth University	Richmond	Virginia	United States	23298-0306

Sponsors and Collaborators

• Emmaus Medical, Inc.

Investigators

• Study Director: Yutaka Niihara, MD, MPH, Chairman and CEO

Study Documents (Full-Text)

None provided.

More Information

Publications

None provided.

• Responsible Party: Emmaus Medical, Inc.
• ClinicalTrials.gov Identifier: NCT01179217
• Other Study ID Numbers: GLUSCC09-01
• First Posted: Aug 11, 2010
• Last Update Posted: Aug 19, 2020
• Last Verified: Jul 1, 2017

• Individual Participant Data (IPD) Sharing Statement: No
• Plan to Share IPD: No
• Keywords provided by Emmaus Medical, Inc.: Sickle Cell Anemia; Sickle Cell Pain Crises; Painful Crises; Sickle Cell Pain; Vaso-occlusive Crises
• Additional relevant MeSH terms: Anemia; Thalassemia; Anemia, Sickle Cell

Study Results

Participant Flow

Arm/Group Title	L-glutamine	Placebo
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo (100% maltodextrin): 0.3 g/kg of placebo will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Period Title: Overall Study
STARTED	152	78
COMPLETED	97	59
NOT COMPLETED	55	19

Baseline Characteristics

Arm/Group Title	L-glutamine	Placebo	Total
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.	Total of all reporting groups
Overall Participants	152	78	230
Age (Count of Participants)
<=18 years	75 49.3%	43 55.1%	118 51.3%
Between 18 and 65 years	77 50.7%	35 44.9%	112 48.7%
>=65 years	0 0%	0 0%	0 0%
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	22.4 (12.32)	21.4 (12.42)	22.0 (12.33)
Sex: Female, Male (Count of Participants)
Female	79 52%	45 57.7%	124 53.9%
Male	73 48%	33 42.3%	106 46.1%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	0 0%	0 0%	0 0%
Asian	0 0%	0 0%	0 0%
Native Hawaiian or Other Pacific Islander	0 0%	0 0%	0 0%
Black or African American	144 94.7%	73 93.6%	217 94.3%
White	0 0%	0 0%	0 0%
More than one race	0 0%	0 0%	0 0%
Unknown or Not Reported	8 5.3%	5 6.4%	13 5.7%
Diagnosis (Count of Participants)
Sickle Cell Anemia	136 89.5%	71 91%	207 90%
Sickle Beta plus Thalassemia	2 1.3%	0 0%	2 0.9%
Sickle Beta zero Thalassemia	14 9.2%	7 9%	21 9.1%

Outcome Measures

1. Primary Outcome

Title	The Number of Occurrences of Sickle Cell Crises
Description	The number of occurrences of protocol-defined sickle cell crises that occur from Week 0 to Week 48 will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.
Time Frame	48 weeks

Outcome Measure Data

Analysis Population Description

Intent-to-Treat Population - Included all patients who were randomized and dispensed study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. 100% maltodextrin: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	152	78
Median (Full Range) [Number of crises]	3	4

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	L-glutamine, 100% Maltodextrin
	Comments
	Type of Statistical Test	Superiority or Other (legacy)
	Comments
Statistical Test of Hypothesis	p-Value	0.0052
	Comments	The primary analysis was analyzed using a CMH analysis of the number of SCCs using modified ridit scores. P-value (controlling for region and HU use) The null hypothesis of the final analysis was performed at the 0.045 significance level.
	Method	Cochran-Mantel-Haenszel
	Comments
Method of Estimation	Estimation Parameter	Wilcoxon rank-sum test
	Estimated Value	0.5
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

2. Secondary Outcome

Title	The Number of Hospitalizations for Sickle Cell Pain
Description	The number of hospitalizations that occur from Week 0 to Week 48, will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.
Time Frame	48 weeks

Outcome Measure Data

Analysis Population Description

Intent-to-Treat Population - Included all patients who were randomized and dispensed study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. 100% maltodextrin: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	152	78
Median (Full Range) [Number of hospitalizations]	2	3

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	L-glutamine, 100% Maltodextrin
	Comments
	Type of Statistical Test	Superiority or Other (legacy)
	Comments
Statistical Test of Hypothesis	p-Value	0.0045
	Comments
	Method	Cochran-Mantel-Haenszel
	Comments

3. Secondary Outcome

Title	The Number of Emergency Room/Medical Facility Visits for Sickle Cell Pain
Description	The number of emergency room visits or medical facility visits that occur from Week 0 to Week 48, will be used to evaluate the efficacy of oral L-glutamine as a treatment for sickle cell anemia and beta-0 thalassemia.
Time Frame	48 weeks

Outcome Measure Data

Analysis Population Description

Intent-to-Treat Population - Included all patients who were randomized and dispensed study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. 100% maltodextrin: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	152	78
Median (Full Range) [Number of ER visits]	1	1

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	L-glutamine, 100% Maltodextrin
	Comments
	Type of Statistical Test	Superiority or Other (legacy)
	Comments
Statistical Test of Hypothesis	p-Value	0.0888
	Comments
	Method	Cochran-Mantel-Haenszel
	Comments

4. Secondary Outcome

Title	The Effect of Oral -L-glutamine on Hematological Parameters
Description	To assess the effect of oral L-glutamine on hematological parameters (hemoglobin), Change from Baseline will be reported at Weeks 4, 24 and 48.
Time Frame	Baseline, Week 4, 24 and 48

Outcome Measure Data

Analysis Population Description

Safety population - The safety population included all patients who received at least 1 dose of study medication.

Arm/Group Title	L-glutamine	Placebo
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo (100% maltodextrin): 0.3 g/kg of placebo will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Hemoglobin at Baseline	8.82 (1.43)	8.71 (1.17)
Change in Hemoglobin at week 4	0.04 (0.84)	0.23 (0.71)
Change in Hemoglobin at Week 24	-0.17 (1.01)	-0.12 (1.24)
Change in Hemoglobin at Week 48	-0.12 (0.95)	-0.12 (0.96)

5. Secondary Outcome

Title	The Effect of Oral L-glutamine on Vital Signs
Description	To assess the effect of oral L-glutamine on Vital signs (systolic and diastolic blood pressure). Change from Baseline will be reported at Weeks 4, 24, and 48.
Time Frame	Baseline, Week 4, 24, and 48

Outcome Measure Data

Analysis Population Description

Safety Population which includes all patients that took at least one dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Systolic blood pressure at Baseline	111.3 (11.20)	114.6 (14.16)
Change Systolic blood pressure at Week 4	0.5 (11.19)	-0.2 (10.68)
Change in Systolic blood pressure at Week 24	1.1 (10.78)	0.5 (14.23)
Change in Systolic blood pressure at Week 48	2.2 (10.78)	2.6 (15.70)
Diastolic blood pressure at Baseline	64.8 (8.61)	66.2 (9.75)
Change in Diastolic blood pressure at Week 4	-0.7 (9.08)	0.3 (10.29)
Change in Diastolic blood pressure at Week 24	-0.7 (8.40)	0.6 (12.44)
Change in Diastolic blood pressure at Week 48	0.4 (8.71)	2.0 (9.96)

6. Secondary Outcome

Title	The Effect of Oral L-glutamine on Hematological Parameters
Description	To assess the effect of oral L-glutamine on hematological parameters (hematocrit), Change from Baseline will be reported at Weeks 4, 24 and 48.
Time Frame	Baseline, Week 4, 24 and 48

Outcome Measure Data

Analysis Population Description

Safety population - The safety population included all patients who received at least 1 dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Hematocrit at Baseline	27.67 (4.40)	27.53 (3.61)
Change in Hematocrit at Week 4	0.16 (2.77)	0.75 (2.52)
Change in Hematocrit Week 24	-0.26 (3.42)	-0.15 (4.13)
Change in Hematocrit at Week 48	0.16 (3.27)	0.11 (3.19)

7. Secondary Outcome

Title	The Effect of Oral L-glutamine on Hematological Parameters
Description	To assess the effect of oral L-glutamine on hematological parameters (reticulocyte count), Change from Baseline will be reported at Weeks 4, 24 and 48.
Time Frame	Baseline, Week 4, 24 and 48

Outcome Measure Data

Analysis Population Description

Safety population - The safety population included all patients who received at least 1 dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Reticulocyte (Abs)	283.62 (129.49)	295.03 (140.10)
Change in Reticulocyte (Abs) at Week 4	-9.28 (104.88)	-23.09 (160.41)
Change in Reticulocyte (Abs) at Week 24	7.94 (111.85)	-1.93 (137.65)
Change in Reticulocyte (Abs) at Week 48	50.89 (112.93)	26.27 (140.65)

8. Secondary Outcome

Title	The Effect of Oral L-glutamine on Vital Signs
Description	To assess the effect of oral L-glutamine on Vital signs (pulse rate). Change from Baseline will be reported at Weeks 4, 24, and 48.
Time Frame	Baseline, Week 4, Week 24 and Week 48

Outcome Measure Data

Analysis Population Description

Safety Population which includes all patients that took at least one dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Pulse Rate (bpm) at Baseline	85.6 (13.15)	88.5 (14.07)
Change in Pulse Rate (bpm) at Week 4	-0.1 (12.07)	-0.4 (14.96)
Change in Pulse Rate (bpm) at Week 24	3.0 (14.58)	-1.5 (15.05)
Change in Pulse Rate (bpm) at 48	1.1 (14.74)	0.2 (15.33)

9. Secondary Outcome

Title	Effect of Oral L-glutamine on Vital Signs
Description	To assess the effect of oral L-glutamine on Vital signs (temperature). Change from Baseline will be reported at Weeks 4, 24, and 48.
Time Frame	Baseline, Week 4, Week 24 and Week 48

Outcome Measure Data

Analysis Population Description

Safety Population which includes all patients that took at least one dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Temperature at Baseline	36.85 (0.387)	36.83 (0.403)
Change in Temperature at Week 4	-0.06 (0.436)	-0.02 (0.540)
Change in Temperature at Week 24	-0.05 (0.469)	0.03 (0.510)
Change in Temperature at Week 48	-0.09 (0.442)	0.05 (0.521)

10. Secondary Outcome

Title	The Effect of Oral L-glutamine on Vital Signs
Description	To assess the effect of oral L-glutamine on Vital signs (respiration). Change from Baseline will be reported at Weeks 4, 24, and 48.
Time Frame	Baseline, Week 4, Week 24 and Week 48

Outcome Measure Data

Analysis Population Description

Safety Population which includes all patients that took at least one dose of study medication.

Arm/Group Title	L-glutamine	100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.	Patients will be randomized to receive Placebo. Placebo: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
Measure Participants	151	78
Respiration at Baseline	18.9 (3.0)	19.1 (2.34)
Change in Respiration at Week 4	-0.2 (3.01)	-0.2 (2.55)
Change in Respiration at Week 24	-0.7 (3.03)	-0.6 (3.36)
Change in Respiration at Week 48	-0.7 (3.25)	-0.6 (2.94)

Adverse Events

Time Frame	Adverse events data were collected throughout the course of the study (53 weeks or about 1 year).
Adverse Event Reporting Description	The Safety population will include all patients who received at least one dose of study medication.
Arm/Group Title	L-glutamine		100% Maltodextrin
Arm/Group Description	Patients will be randomized to receive investigational product, L-Glutamine. L-glutamine: 0.3 g/kg of L-glutamine will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration. Mixing L-glutamine with soda or highly acidic juices (such as grapefruit juice or lemonade) is not recommended.		Patients will be randomized to receive Placebo. 100% maltodextrin: 0.3 g/kg of placebo (100% maltodextrin) will be administered twice a day orally to each patient for 48 weeks. The dosage will be in increments of 5 grams based on weight. The upper limit for daily dose of study medication will be set at 30 grams. Patients will be given verbal and written instructions for self-administration of the study medication at the Baseline visit. The powder can be mixed with water or most non-heated beverages other than alcohol, or can be mixed with most non-heated foods such as yogurt, applesauce, or cereal for administration.
All Cause Mortality
	L-glutamine		100% Maltodextrin
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	/ (NaN)		/ (NaN)
Serious Adverse Events
	L-glutamine		100% Maltodextrin
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	118/151 (78.1%)		68/78 (87.2%)
Blood and lymphatic system disorders
Acute Chest Syndrome	12/151 (7.9%)		18/78 (23.1%)
Anaemia	1/151 (0.7%)		2/78 (2.6%)
Aplastic anaemia	1/151 (0.7%)		0/78 (0%)
Haemolysis	1/151 (0.7%)		0/78 (0%)
Hypersplenism	2/151 (1.3%)		0/78 (0%)
Leucocytosis	1/151 (0.7%)		0/78 (0%)
Lymphadenopathy	0/151 (0%)		0/78 (0%)
Cardiac disorders
Cardiac Arrest	2/151 (1.3%)		1/78 (1.3%)
Cardiac failure	0/151 (0%)		1/78 (1.3%)
Cardiac failure congestive	0/151 (0%)		1/78 (1.3%)
Congenital, familial and genetic disorders
Sickle cell anaemia with crisis	102/151 (67.5%)		63/78 (80.8%)
Eye disorders
Eye irritation	0/151 (0%)		1/78 (1.3%)
Gastrointestinal disorders
Abdominal pain	3/151 (2%)		3/78 (3.8%)
Abdominal pain upper	1/151 (0.7%)		0/78 (0%)
Constipation	1/151 (0.7%)		1/78 (1.3%)
Gastritis	1/151 (0.7%)		1/78 (1.3%)
Nausea	1/151 (0.7%)		0/78 (0%)
Pancreatic acute	0/151 (0%)		1/78 (1.3%)
Vomiting	2/151 (1.3%)		1/78 (1.3%)
General disorders
Chest pain	5/151 (3.3%)		1/78 (1.3%)
Death	1/151 (0.7%)		0/78 (0%)
Drug withdrawal syndrome	0/151 (0%)		1/78 (1.3%)
Necrosis	0/151 (0%)		1/78 (1.3%)
Oedema peripheral	2/151 (1.3%)		0/78 (0%)
Pain	1/151 (0.7%)		0/78 (0%)
Pyrexia	6/151 (4%)		3/78 (3.8%)
Cholelithiasis	1/151 (0.7%)		0/78 (0%)
Hyperbilirubinaemia	0/151 (0%)		1/78 (1.3%)
Hepatobiliary disorders
Cholecystitis	1/151 (0.7%)		0/78 (0%)
Cholecystitis acute	1/151 (0.7%)		0/78 (0%)
Immune system disorders
Hypersensitivity	0/151 (0%)		1/78 (1.3%)
Infections and infestations
Bronchitis	1/151 (0.7%)		1/78 (1.3%)
Gastroenteritis	0/151 (0%)		2/78 (2.6%)
Gastrointestinal viral infection	1/151 (0.7%)		0/78 (0%)
Influenza	3/151 (2%)		1/78 (1.3%)
Lobar pneumonia	1/151 (0.7%)		0/78 (0%)
Osteomyelitis	1/151 (0.7%)		0/78 (0%)
Osteomyelitis acute	0/151 (0%)		1/78 (1.3%)
Pharnygitis streptococcal	1/151 (0.7%)		1/78 (1.3%)
Pneumonia	3/151 (2%)		8/78 (10.3%)
Sepsis	1/151 (0.7%)		0/78 (0%)
Sinustitis	1/151 (0.7%)		1/78 (1.3%)
Tonsilitis	0/151 (0%)		1/78 (1.3%)
Tooth infection	0/151 (0%)		1/78 (1.3%)
Upper respiratory tract infection	1/151 (0.7%)		0/78 (0%)
Urinary tract infection	0/151 (0%)		1/78 (1.3%)
Injury, poisoning and procedural complications
Complication of device removal	1/151 (0.7%)		0/78 (0%)
Device leakage	0/151 (0%)		1/78 (1.3%)
Device malfunction	2/151 (1.3%)		0/78 (0%)
Device occlusion	0/151 (0%)		1/78 (1.3%)
Fall	1/151 (0.7%)		0/78 (0%)
Haemolytic transfusion reaction	1/151 (0.7%)		0/78 (0%)
Ligament rupture	0/151 (0%)		1/78 (1.3%)
Post-traumatic reaction	1/151 (0.7%)		0/78 (0%)
Traumatic arthropathy	0/151 (0%)		1/78 (1.3%)
Investigations
Blood creatinine increased	0/151 (0%)		1/78 (1.3%)
White blood cell count increased	0/151 (0%)		1/78 (1.3%)
Hyperkalaemia	0/151 (0%)		1/78 (1.3%)
Metabolism and nutrition disorders
Dehydration	2/151 (1.3%)		2/78 (2.6%)
Musculoskeletal and connective tissue disorders
Arthralgia	0/151 (0%)		1/78 (1.3%)
Arthropathy	0/151 (0%)		1/78 (1.3%)
Back pain	3/151 (2%)		1/78 (1.3%)
Bunion	0/151 (0%)		1/78 (1.3%)
Bone infarction	0/151 (0%)		1/78 (1.3%)
Joint effusion	1/151 (0.7%)		0/78 (0%)
Musculoskeletal pain	0/151 (0%)		1/78 (1.3%)
Osteoarthritis	0/151 (0%)		1/78 (1.3%)
Osteonecrosis	0/151 (0%)		1/78 (1.3%)
Pain in extremity	2/151 (1.3%)		0/78 (0%)
Nervous system disorders
Dysarthria	0/151 (0%)		1/78 (1.3%)
Headache	1/151 (0.7%)		1/78 (1.3%)
Migraine	0/151 (0%)		1/78 (1.3%)
Transient ischaemic attack	2/151 (1.3%)		0/78 (0%)
Pregnancy, puerperium and perinatal conditions
Pregnancy	2/151 (1.3%)		2/78 (2.6%)
Psychiatric disorders
Mental status changes	0/151 (0%)		1/78 (1.3%)
Renal and urinary disorders
Haematuria	1/151 (0.7%)		0/78 (0%)
Renal failure acute	1/151 (0.7%)		1/78 (1.3%)
Reproductive system and breast disorders
Priapism	0/151 (0%)		1/78 (1.3%)
Respiratory, thoracic and mediastinal disorders
Asthma	4/151 (2.6%)		0/78 (0%)
Bronchial hyperreactivity	1/151 (0.7%)		0/78 (0%)
Cough	1/151 (0.7%)		0/78 (0%)
Dyspnoea	1/151 (0.7%)		0/78 (0%)
Haemothorax	0/151 (0%)		1/78 (1.3%)
Hypoxia	1/151 (0.7%)		2/78 (2.6%)
Pulmonary embolism	1/151 (0.7%)		1/78 (1.3%)
Respiratory depression	0/151 (0%)		1/78 (1.3%)
Respiratory distress	0/151 (0%)		1/78 (1.3%)
Rhinitis allergic	1/151 (0.7%)		0/78 (0%)
Skin and subcutaneous tissue disorders
Skin ulcer	2/151 (1.3%)		0/78 (0%)
Surgical and medical procedures
Hip arthroplasty	0/151 (0%)		1/78 (1.3%)
Strabismus correction	1/151 (0.7%)		0/78 (0%)
Tonsillectomy	0/151 (0%)		1/78 (1.3%)
Vascular disorders
Deep vein thrombosis	2/151 (1.3%)		0/78 (0%)
Thrombophlebits superficial	1/151 (0.7%)		0/78 (0%)
Other (Not Including Serious) Adverse Events
	L-glutamine		100% Maltodextrin
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	148/151 (98%)		78/78 (100%)
Blood and lymphatic system disorders
Acute chest syndrome	18/151 (11.9%)		21/78 (26.9%)
Leukocytosis	9/151 (6%)		6/78 (7.7%)
Anaemia	7/151 (4.6%)		6/78 (7.7%)
Cardiac disorders
Tachycardia	8/151 (5.3%)		4/78 (5.1%)
Congenital, familial and genetic disorders
Sickle cell anaemia with crisis	123/151 (81.5%)		71/78 (91%)
Eye disorders
Ocular icterus	15/151 (9.9%)		9/78 (11.5%)
Gastrointestinal disorders
Constipation	38/151 (25.2%)		19/78 (24.4%)
Nausea	34/151 (22.5%)		13/78 (16.7%)
Vomiting	22/151 (14.6%)		10/78 (12.8%)
Abdominal pain	18/151 (11.9%)		10/78 (12.8%)
Abdominal pain upper	16/151 (10.6%)		6/78 (7.7%)
Diarrhoea	12/151 (7.9%)		5/78 (6.4%)
General disorders
Pyrexia	33/151 (21.9%)		29/78 (37.2%)
Chest pain	21/151 (13.9%)		7/78 (9%)
Fatigue	9/151 (6%)		1/78 (1.3%)
Oedema peripheral	8/151 (5.3%)		8/78 (10.3%)
Infections and infestations
Upper respiratory tract infection	27/151 (17.9%)		18/78 (23.1%)
Nasopharyngitis	10/151 (6.6%)		6/78 (7.7%)
Urinary tract infection	10/151 (6.6%)		3/78 (3.8%)
Pneumonia	9/151 (6%)		14/78 (17.9%)
Bronchitis	5/151 (3.3%)		4/78 (5.1%)
Gastroenteritis	5/151 (3.3%)		4/78 (5.1%)
Investigations
Hypomanesaemia	6/151 (4%)		4/78 (5.1%)
Metabolism and nutrition disorders
Hypokalaemia	6/151 (4%)		5/78 (6.4%)
Hyperkalaemia	5/151 (3.3%)		4/78 (5.1%)
Musculoskeletal and connective tissue disorders
Pain in extremity	24/151 (15.9%)		6/78 (7.7%)
Back pain	20/151 (13.2%)		5/78 (6.4%)
Arthralgia	19/151 (12.6%)		10/78 (12.8%)
Nervous system disorders
Headache	32/151 (21.2%)		14/78 (17.9%)
Dizziness	8/151 (5.3%)		4/78 (5.1%)
Respiratory, thoracic and mediastinal disorders
Cough	26/151 (17.2%)		14/78 (17.9%)
Nasal congestion	11/151 (7.3%)		5/78 (6.4%)
Oropharnyngeal pain	11/151 (7.3%)		11/78 (14.1%)
Dyspnoea	8/151 (5.3%)		7/78 (9%)
Hypoxia	5/151 (3.3%)		4/78 (5.1%)
Epistaxis	4/151 (2.6%)		6/78 (7.7%)
Skin and subcutaneous tissue disorders
Pruritus	14/151 (9.3%)		11/78 (14.1%)
Rash	3/151 (2%)		14/78 (17.9%)

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

PI agrees that any INFORMATION submitted to it by EMMAUS shall be maintained in secrecy for a period of seven (7) years from each disclosure of INFORMATION. PI will use the up most due diligence to prevent disclosure by it except to its employees, agents, and contractors necessary for evaluation, all of whom shall be bound by similar written obligations of confidentiality, and who agree not to use the INFORMATION for any purpose other than for evaluation purposes.