Untimely Initiation of Whole Cow Milk, Stunting, and Related Factors in South Gondar, Ethiopia.

Introduction: Despite being an excellent source of essential nutrients, whole cow's milk poses risks for young children. This is mainly due to its association with adverse effects, including growth inhibition, delayed brain and motor development, and increased morbidity and mortality. The current study aimed to evaluate the occurrence of untimely introduction of whole cow milk, stunting and related factors among children below the age of 5 years. Methods: A community-centered survey was implemented on 806 mother-child matches. Expressive statistics such as frequency, magnitude, mean and standard deviation were computed. Multivariable logistic regression was done to discover independent determinants of the dependent variables. A p-value of <0.05 was used to affirm significant association. Results: From the survey participant children 311 (39.2%) of them were stunted. About 453 (57.1%) of children were fed whole cow milk earlier than the age of one year. Mothers who are able to read and write were 49% less likely to initiate cow milk earlier than the age of one year with AOR = 0.51, 95% CI 0.33-0.78. Not attending the growth monitoring and promotion service is a risk for untimely introduction of whole cow milk (AOR = 3.47, 95% CI 2.43-4.94). Children who did not start consuming whole cow milk earlier than the age of one year were 54% less likely to be stunted than those who started consuming whole cow milk before the age of one year (AOR = 0.46, 95% CI 0.33-0.65). Conclusion: More than half of the study participant children started consuming whole cow milk before the age of one year. Children who did not start consuming whole cow milk early were less likely to be stunted.

Undernutrition and associated factors among older adults in Ethiopia: systematic review and meta-analysis.

OBJECTIVE: Undernutrition contributes to decreased physical and cognitive functional status, higher healthcare consumption, premature institutionalisation and increased mortality. So, the objective of this study was to determine the pooled prevalence and factors associated with undernutrition among older adults in Ethiopia. DESIGN: Systematic review and meta-analysis was used. Articles that presented original data on undernutrition using body mass index (BMI) were included. We made an inclusive literature search from PubMed, Medline and Google Scholar. The I2 test was used to examine the heterogeneity of the studies considered in this meta-analysis. Stata software V.14 and METANDI command were used. SETTING: Studies conducted in Ethiopia were included. PARTICIPANTS: Eight independent studies were eligible and enrolled for final analysis. OUTCOME: Prevalence and determinants of undernutrition. A selection of publications, data extraction and reported results for the review was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: A total of eight unique studies were enrolled for final analysis. The pooled prevalence of undernutrition was 20.53% (95% CI 17.39% to 23.67%). The study revealed that males had lesser odds of being undernutrition with AOR 0.17 (95% CI 0.15 to 0.20). Older adults in the age range of 65-74 years were less likely to be undernourished as compared with those whose age was above 85 years with Adjusted Odds Ratio (AOR) 022 (95% CI 0.22 to 0.25). Older adults who were depressed had higher odds of undernutrition as compared with their counterparts with AOR 1.27 (95% CI 1.19 to 1.37). However, older adults from households with poor wealth indexes were two times more likely to be undernourished as compared with those who were from rich households. CONCLUSION: The burden of undernutrition in Ethiopia is significant. The limitation of the current study was that all included studies were observational, mainly cross-sectional.

Knowledge, attitude, acceptance, and practice of COVID-19 vaccination and associated factors complemented with constructs of health belief model among the general public in South Gondar, Ethiopia: A community-based study.

Introduction: Understanding the epidemiological dynamics of disease control, as well as the effectiveness, compliance, and success of the vaccination program requires an understanding of the local population's knowledge, attitude, and practice regarding the Corona Virus Disease of 2019 (COVID-19) vaccine. Thus, the objective of this study was to assess knowledge, attitude, and practice toward COVID-19 vaccination and associated factors among the general public. Methods: A cross-sectional study was conducted in the South Gondar Zone, among residents above the age of 18 years. The study used objective measures and the constructs of the Health Belief Model. Binary logistic regression was used and the result of the final model was presented in terms of adjusted odds ratio (AOR) and 95% confidence intervals (CI), and statistical significance was taken and considered at a P-value < 0.05. Results: The study was conducted on 1,111 study participants. The mean age is 30.83 ± 7.106. About 575 (51.8%) of the respondents have good knowledge about the COVID-19 vaccination and 43.4% have a positive attitude toward COVID-19 vaccination. About 361 (32.5%) of the respondents were willing to take the vaccine if it is available and 113 (10.2%) of them were vaccinated. Participants with a positive attitude and good knowledge, those with a secondary level of education AOR = 5.70, 95% CI (2.60-12.60), those with a monthly income of >2,000 birr AOR = 6.30, 95% CI (2.50-15.60), those having a television (TV), and those who use Facebook AOR = 17.70, 95% CI (10.10-30.90) had a higher level of acceptance of COVID-19 vaccination. The Health Belief Model's constructs of perceived susceptibility AOR = 1.53, 95% CI (1.26-1.85), perceived benefit AOR = 1.49, 95% CI (1.28-1.75), and cues to action AOR = 0.54, 95% CI (0.45-0.65) were all linked to COVID-19 vaccine acceptability. Conclusion: The level of acceptance of COVID-19 vaccination is much lower. Having a positive attitude score and good knowledge score, level of education, monthly income, presence of TV, the use of Facebook, and knowing the means of transmission of COVID-19 increase the level of acceptance of COVID-19 vaccination.

Determinants of undernutrition among older adults in South Gondar Zone, Ethiopia: a community-based study.

OBJECTIVES: The objectives of this study were to assess the prevalence and determinants of undernutrition among older adults aged 65 years in the south Gondar Zone, Ethiopia, in 2020. DESIGN: A community-based cross-sectional study. SETTING: The study was conducted from 1 October to 15 December 2020, in the South Gondar Zone, Ethiopia. Study participants were selected by systematic random sampling. A pretested and structured questionnaire adapted from different literature was used to collect data. Anthropometric measurements were taken following the standard procedure. PARTICIPANTS: A total of 290 older adults aged greater than or equal to 65 years of age were included in the study. DATA ANALYSIS: Descriptive and summary statistics were employed. Multiple logistic regression was fitted to identify determinants of undernutrition. ORs and their 95% CIs were computed to determine the level of significance. OUTCOME MEASURES: Undernutrition was assessed by using Body Mass Index and Mini Nutritional Assessment (MNA) tool. RESULTS: The prevalence of undernutrition was 27.6% (95% CI 22.4 to 32.8), and 2.1% (95% CI 0.7 to 3.8) of the study participants were overweight. Based on the MNA tool, 29.7% (95% CI 24.5 to 35.2) of the study participants were undernourished and 61.7% (95% CI 55.5 to 67.2) were at risk of undernourishment. Rural residence adjusted OR (aOR)=10.3 (95% CI 3.6 to 29.4), inability to read and write aOR=3.5 (95% CI 1.6 to 7.6), decrease in food intake aOR=13.5 (95% CI 6.1 to 29.5) and household monthly income of less than US$35.6 aOR=4.3 (95% CI 1.9 to 9.4) were significantly and independently associated with undernutrition. CONCLUSION: The level of undernutrition among older adults in the study area was high, making it an important public health burden. The determinants of undernutrition were a place of residence, educational status, food intake and monthly income.

Knowledge, Attitude, and Practice of Healthcare Providers Toward Novel Coronavirus 19 During the First Months of the Pandemic: A Systematic Review.

Introduction: Coronavirus disease (COVID-19) is a highly contagious viral infection that has spread to every corner of the world. Lack of knowledge among healthcare providers (HCPs) about diseases such as COVID-19 may delay the diagnosis, disease spread, and produce poor infection control practices. Hence, this systematic review aimed to summarize the knowledge, attitudes, and practices (KAP) of HCPs toward COVID-19 during the first months of the pandemic. Methods: A systematic review was conducted according the PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42020191742). A relevant article search was performed on EMBASE, PubMed, CINAHL, Scopus, and the Google Scholar database. The methodological quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. The median percentage of HCPs with good KAP was computed. Results: Twenty studies involving 12,072 HCPs were included in the review process. Median percentages of 75.8% (IQR: 69.3-87.7%), 74.6% (IQR: 54.4-74.6), and 79.8% (IQR: 67.0-79.8%) of HCPs had good knowledge, and positive attitude and practice, respectively. Although the reported risk factors were inconsistent among studies, age, gender, level of education, experience, infection prevention training, and sources of information were associated with knowledge of HCPs. In addition, being elderly, having a high level of education, absence of chronic illness, and good knowledge and practice were significantly associated with the attitude of HCPs. Further, types of profession, experience, age, level of education, use of personnel protective equipment, and gender were significantly associated with the practice of HCPs. Conclusions: Approximately, three-fourths of HCPs had good knowledge, attitudes, and practices toward COVID-19 during the first months of the pandemic, although the percentage of HCPs was inconsistent in different study settings. In addition, associated factors of KAP were inconsistent among studies; hence, stake holders should target locally identified risk factors to design relevant education packages and infection prevention training to halt the rapid transmission of COVID-19. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020191742, identifier: CRD42020191742.

Pharmacological Evaluation of Antipyretic and Antioxidant Activities of 80% Methanol Root Extract and Derived Solvent Fraction of Echinops kebericho M. (Asteraceae) in Mice Model.

BACKGROUND: Toxicity and untoward effects are very ostensible in most standard drugs including antipyretic agents. Searching for conceivable antipyretic drugs with minimal toxicities and side effects from traditional plants is a growing concern to date. Echinops kebericho M. (Asteraceae) is one of the most prominent traditional medicinal plants, which is frequently testified for its traditionally claimed uses of treating fever and different infectious and noninfectious disorders by traditional healers in Ethiopian folk medicine. However, this plant has not been scientifically assessed for its traditionally claimed uses. This study therefore is aimed at investigating the antipyretic and antioxidant activities of 80% methanol root extract and the derived solvent fraction of Echinops kebericho M. in mouse models. METHODS: Successive solvent maceration with increased polarity was used as the method of extractions, and chloroform, ethyl acetate, methanol, and water were used as solvents. After extraction, the crude extract and its derived solvent fractions were assessed for their antipyretic activities using yeast-induced pyrexia while, the antioxidant activities were measured in vitro using the diphenyl-2-picrylhydrazyl (DPPH) assay method. Both the extract and solvent fractions were evaluated at the doses of 100, 200, and 400 mg/kg for its antipyretic activities, and the antioxidant activity was evaluated at the doses of 50, 100, 200, 400, 600, 800, and 1000 mg/kg. The positive control group was treated with standard drug (ASA 100 mg/kg), while normal saline-receiving groups were assigned as negative control. RESULT: E. kebericho crude extract along with its derived solvent fractions showed statistically significant (p < 0.05, 0.01, and 0.001) temperature reduction activities. The maximum percentage of temperature reduction was observed by the highest dose (400 mg/kg) of the crude extract. The aqueous fraction also showed significantly (p < 0.05 and 0.01) higher temperature reduction than those of ethyl acetate and chloroform fractions. The free radical scavenging activities of the crude extract were also significantly high at the maximum dose, and the aqueous fraction showed the significantly highest antioxidant activity. CONCLUSION: In general, the data obtained from the present study clarified that the extract possessed significant antipyretic and antioxidant activities, upholding the traditionally claimed use of the plant.

Household Level Drug Utilization and Associated Factors in South Gondar Zone, North Western Ethiopia.

INTRODUCTION: Inappropriate drug utilization may reduce the best possible benefits of drug therapy, and patients may not be cured, they may be exposed to toxicity, and medications may be wasted. The aim of this study is to assess household-level drug utilization practices and their associated factors. METHODS: A cross-sectional community-based study was conducted from January 15 to March 15, 2020. In total, 847 households selected by stratified multistage sampling were visited. Bivariate and multivariable analyses for association were carried out using a binary logistic regression model. The statistical significance of an association was confirmed at p<0.05. RESULTS: Of the total 847 households, 378 (44.6%) were found to store drugs at home at the time of datacollection. In the 371 households that allowed observation of the drugs stored, a mean of 2.51 (SD=1.68) drugs per household was found; 40.2% of stored medicines were not in use at the time of the study. The prevalences of medication hoarding, sharing, and allopathic self-medication were 20.4%, 26.3%, and 43.8%, respectively. Higher monthly income and the presence of a child aged under 5 years were significantly associated with drug hoarding. The presence of an elderly person aged above 65 years and the presence of a family member with chronic illness were significantly associated with drug hoarding and sharing. Families with higher educational status were less likely to hoard and share medicines. The presence of stored drugs at home was significantly associated with the practice of self-medication. CONCLUSION: A high prevalence of inappropriate drug utilization was observed. Factors such as the presence of a family member with chronic illness, elderly people, and children under 5, higher income, and the presence of stored drugs were significantly associated with inappropriate drug utilization. Families of higher educational status were less likely to hoard and share medicines.

Effects of Vitamin D on COVID-19 Infection and Prognosis: A Systematic Review.

INTRODUCTION: Vitamin D status is related to risks of influenza and respiratory tract infections. Vitamin D has direct antiviral effects primarily against enveloped viruses, and coronavirus is an enveloped virus. The 2019 coronavirus disease had a high mortality rate and impacted the whole population of the planet, with severe acute respiratory syndrome the principal cause of death. Vitamin D can adequately modulate and regulate the immune and oxidative response to infection with COVID-19. The goal of this systematic review was thus to summarize and decide if there were a link between vitamin D status and COVID-19 infection and prognosis. METHODS: The protocol of this study is documented in the Prospero database and can be accessed with the protocol number CRD42020201283. PubMed and Google Scholar were used for a literature search from August 2020 to September 2020. We restricted the year of publication of reviewed articles to 2019-2020, and the selected language was English. Studies that used secondary data, feedback, or analysis of reviews were removed. To assess the standard of studies included, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method was used. RESULTS: Of the nine studies reviewed, seven (77.8%) showed that COVID-19 infection, prognosis, and mortality were correlated with vitamin D status. CONCLUSION: Most of the articles reviewed showed that blood vitamin D status can determine the risk of being infected with COVID-19, seriousness of COVID-19, and mortality from COVID-19. Therefore, maintaining appropriate levels of Vitamin D through supplementation or natural methods, eg, sunlight on the skin, is recommended for the public to be able to cope with the pandemic.

Prevalence and Determinants of Stunting, Wasting, and Underweight Among School-Age Children Aged 6-12 Years in South Gondar Zone, Ethiopia.

BACKGROUND: Underweight, wasting, and stunting are the commonest nutritional disorders among children, especially in developing countries. The aim of this study was to assess the prevalence and determinant factors of underweight, wasting, and stunting among school-age children in 2019. METHODS: A cross-sectional study was conducted in the five special districts of South Gondar Zone, among 314 school-age children. WHO AnthroPlus software was used to build Z-scores from anthropometric measurement. The data were analyzed by SPSS Version 20. The degrees of association were assessed using adjusted odds ratio (AOR) and 95% confidence interval during multivariable logistic regression. A P-value less than 0.05 was considered to be statistically significant. RESULTS: Of the total study participants, 232 (77.3%) were from public schools. The mean±standard deviation (SD) of height of children was 132.9±9.8 cm, and the mean±SD weight of children was 27.7±5.8 kg. The prevalence of stunting, wasting, and underweight was 11%, 6.3%, and 11.4%, respectively. Students who ate their breakfast rarely were 8-times more likely to be underweight than those who ate their breakfast always (AOR=7.9, 95% CI=4.8-14.8). Those who were sick in the past 2 weeks were more likely to be underweight than their counterparts (AOR=7.3, 95% CI=2.8-14.4). Those who never consume milk or milk products were 6.5 (AOR=6.5, 95% CI=1.7-23) times more likely to be stunted than those who consumed this always. Sickness in the past 2 weeks prior to data collection was significantly associated with thinness (AOR=6 0.9, 95% CI=4.1-10.1). CONCLUSION: The overall prevalence of wasting, stunting, and underweight was a mild public health problem in the study area.

Minimum Acceptable Diet and Associated Factors Among HIV-Exposed Children Aged 6-24 Months in Debre Tabor Town, Ethiopia.

INTRODUCTION: Minimum acceptable diet is a composite indicator of minimum dietary diversity and minimum meal frequency. World Health Organization's newborn child feeding and HIV guidelines suggestbeginning complementary nourishments at six months, and breastfeeding for HIV-exposed children. HIV infected mothers may be more sensitive on feeding practices to protect their children from contracting the disease. On the other hand, HIV infection is associated with higher risk food insecurity which may affect feeding practices of children. But in Ethiopia, there is lack of evidence on extent of minimum acceptable diet of HIV-exposed children. Therefore, the objective of this study was to assess minimum acceptable diet and associated factors among HIV-exposed 6-24 months aged children. METHODS: An institution-based cross-sectional study was conducted in health institutions of Debre Tabor town. The study was conducted on 287 mother-child pairs attending antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) at public health facilities. Descriptive statistics like frequency, proportions, mean and standard deviation were computed. Multi-variable logistic regression was run to identify independent predictors of the outcome variable (minimum acceptable diet). A p-value <0.05 was used to declare statistical significance. RESULTS: About 76% (95% CI: 70.8-80.8) and 58.2% (95% CI: 53.0-68.3) children were fed with appropriate meal frequency and recommended dietary diversity, respectively. One hundred (34.8%) (95% CI: 29.3-40.4) of children were fed a minimum acceptable diet and 59.9% (95% CI: 54.0-65.9) of children consumed iron rich or fortified food. Out of the total, 203 (71.0%) (95% CI: 66.1-76.2) of the mothers had good knowledge on minimum dietary diversity and meal frequency feeding practices. In multi-variable logistic regression poor knowledge with AOR = 0.32, 95% CI: 0.17-0.58, maternal workload with AOR = 0.38, 95% CI: 0.19-0.75 and inadequate information about child feeding from health care providers with AOR = 0.46, 95% CI: 0.26-0.81 were statistically significant predictors of minimum acceptable diet. CONCLUSION: The study revealed that the proportion of children who received minimal acceptable diet was lower than that of WHO recommendation for good practice. Knowledge, maternal workload and information related to complementary feeding were associated with low minimum acceptable diet.

Prevalence and Associated Factors of Clinical Vitamin A Deficiency Among Pre-School Children 1-5 Years of Age in Rural Kebeles in Farta District, South Gondar Zone, Ethiopia: A Mixed Methods Study.

BACKGROUND: Globally, pre-school children are the most at-risk population groups for vitamin A deficiency (VAD). The 2009 World Health Organization (WHO) report stated that one-third (190 million) of pre-school children worldwide are deficient in vitamin A. Both clinical and subclinical VAD have been a long-standing problem in developing countries. In Ethiopia, VAD was recognized as a public health problem 4-5 decades before. Since then, researches conducted in other parts of the country still showed varied and high prevalence, which is 2-8 times higher than WHO cut-off points. This community-based study was therefore conducted on pre-school children of rural kebeles in Farta district to determine the prevalence of clinical VAD (Bitot's spot and night blindness) and associated factors. METHODS: A community-based cross-sectional mixed quantitative and qualitative study was conducted. Randomly selected 588 pre-school children participated in the study. The clinical aspect of the study investigated the presence of Bitot's spots on the children's eye with the aid of a magnifying loop and torch. Data on the history of night blindness were obtained from mothers/caregivers by using WHO standard questions. The qualitative study data were obtained via a key informant interview with the mothers/caregivers whose child has clinical VAD. Quantitative data were entered using Epi Data statistical software and analysed by using SPSS version 20 statistical software package. A bivariable logistic regression was employed, and variables that showed significant association with clinical VAD (P < 0.2) were entered a multivariable logistic regression model to identify independent predictors of clinical VAD. RESULTS: The prevalence of Bitot's spot and night blindness was 0.8% and 1.2%, respectively. Pre-school children who were from highland (AOR: 3.71; 95% CI: 1.01-13.68), a mother having antenatal care (ANC) visit during pregnancy of a child (AOR: 8.63; 95% CI: 2.58-28.79), family monthly income (AOR: 8.63; 95% CI: 2.58-28.79) and handwashing frequency were found to be determinants of VAD (p < 0.05). CONCLUSION: Clinical vitamin A deficiency in the study area is of public health concern because the prevalence of Bitot's and night blindness was above the WHO threshold level. Accordingly, effective preventive measures should be designed to reduce VAD prevalence.

Magnitude and determinants of drug therapy problems among type 2 diabetes mellitus patients with hypertension in Ethiopia.

INTRODUCTION: Type 2 diabetes mellitus patients with hypertension are at high risk of drug therapy problems since they are subject to receive multiple drug therapies due to comorbidities. OBJECTIVES: To determine the magnitude of drug therapy problems and its determinants among Type 2 diabetes mellitus patients with hypertension. METHODS: A cross-sectional study was employed among 423 randomly selected participants based on the inclusion criteria. A structured questionnaire and review of patients' medical record were employed in the data collection. The classification system used by Cipolle was used to classify and evaluate drug therapy problems. Data were analyzed using Statistical Package for the social sciences version 25.0 software. Multivariate logistic regression analysis was used to identify determinants of drug therapy problems with a statistical significance of p ⩽ 0.05. RESULTS: A total of 491 drug therapy problems with a mean of 1.86 ± 0.53 drug therapy problems per patient were identified, and 62.4% (264) of them experienced at least one drug therapy problem. Non-compliance (197, 40.1%), needs of additional drug therapy (119, 24.2%), and dosage too low (91, 18.5%) were the most frequently observed drug therapy problems in the study setting. Anti-diabetic medications (88.4%), statins (44.5%), and aspirin (33.5%) were the most commonly involved drugs in drug therapy problems. The determinants of drug therapy problems were very low family income (adjusted odds ratio = 4.64, p = 0.010), age (45-65 years old) (adjusted odds ratio = 2.55, p = 0.008), presence of comorbidity (adjusted odds ratio = 9.19, p < 0.001), and taking ⩾5 medications (adjusted odds ratio = 2.84, p = 0.001). CONCLUSION: Approximately three out of five patients had one or more drug therapy problems encountered. In this study, the most common types of drug therapy problems were non-compliance, needs additional drug therapy, and dosage too low. Family monthly income, age, comorbidities, and number of medications were the significant determinants of drug therapy problems. Therefore, patient education regarding medication adherence, routine medication review, and strengthening clinical pharmacy services should be promoted.

Clinical pattern and predictors of stroke treatment outcome among hospitalised patients who had a stroke at Felege Hiwot comprehensive specialised hospital, northwest Ethiopia: a retrospective cross-sectional study.

OBJECTIVES: This study aimed to assess the clinical pattern and predictors of stroke treatment outcomes among hospitalised patients in Felege Hiwot comprehensive specialised hospital (FHCSH) in northwest Ethiopia. DESIGN: A retrospective cross-sectional study. SETTING: The study was conducted medical ward of FHCSH. PARTICIPANTS: The medical records of 597 adult patients who had a stroke were included in the study. All adult (≥18 years) patients who had a stroke had been admitted to the medical ward of FHSCH during 2015-2019 were included in the study. However, patients with incomplete medical records (ie, incomplete treatment regimen and the status of the patients after treatment) were excluded in the study. RESULTS: In the present study, 317 (53.1%) were males, and the mean age of the study participants was 61.08±13.76 years. About two-thirds of patients (392, 65.7%) were diagnosed with ischaemic stroke. Regarding clinical pattern, about 203 (34.0%) of patients complained of right-side body weakness and the major comorbid condition identified was hypertension (216, 64.9%). Overall, 276 (46.2%) of them had poor treatment outcomes, and 101 (16.9%) of them died. Patients who cannot read and write (AOR=42.89, 95% CI 13.23 to 111.28, p<0.001), attend primary school (AOR=22.11, 95% CI 6.98 to 55.99, p<0.001) and secondary school (AOR=4.20, 95% CI 1.42 to 12.51, p<0.001), diagnosed with haemorrhagic stroke (AOR=2.68, 95% CI 1.62 to 4.43, p<0.001) and delayed hospital arrival more than 24 hours (AOR=2.92, 95% CI 1.83 to 4.66, p=0.001) were the independent predictors of poor treatment outcome. CONCLUSIONS: Approximately half of the patients who had a stroke had poor treatment outcomes. Ischaemic stroke was the most predominantly diagnosed stroke type. Education status, types of stroke and the median time from onset of symptoms to hospitalisation were the predictors of treatment outcome. Health education should be given to patients regarding clinical symptoms of stroke. In addition, local healthcare providers need to consider the above risk factors while managing stroke.