Authorship gender among articles about artificial intelligence in breast imaging.

RATIONALE AND OBJECTIVES: The purpose of this study is to investigate the variance of women authors, specifically first and senior authorship among peer-reviewed artificial intelligence-related articles with a specific focus in breast imaging. MATERIALS AND METHODS: A strategic search was conducted in July 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to capture all existing and publicly available peer-reviewed articles intersecting AI and breast imaging. Primary outcomes were first and senior authors' gender, which were assigned with the aid of an emailed self-declaration survey. Secondary outcomes included country of article, journal impact factor, and year of publication. Comparisons were made using logistic regression models and analysis of variances. RESULTS: 115 studies were included in the analysis. Women authors represented 35.7% (41/115) and 37.4% (43/115) of first and senior authors, respectively. Logistic regression modelling showed a significant increase in women senior authors over time but no changes in women first authors. Impact factor was not associated with female authorship and certain countries had women authorship reach over 50%. CONCLUSION: This study demonstrates that there is a significant authorship gender gap in artificial intelligence breast imaging research. An increasing temporal trend of senior authors in breast imaging AI-related research is a promising prognosis for more women voices in this field. Further study needs to be done to understand the reasons behind this gap and any potential implications.

Regional variation in accessibility of automated external defibrillators in British Columbia.

OBJECTIVES: Bystander-applied Automated External Defibrillators (AED) improve outcomes for out-of-hospital cardiac arrest. AED placement is often driven by private enterprise or non-for-profit agencies, which may result in inequitable access. We sought to compare AED availability between four regions in British Columbia (BC). METHODS: We identified AEDs (confirmed to be operational) and emergency medical system (EMS)-treated out-of-hospital cardiac arrests (OHCA) from provincial registries. We compared AED availability between BC's four most populous regions. The primary outcome was the total regional weekly accessible AED-hours per 100,000 population. We also examined: AEDs per 100,000 population and per km2, the ratio of AEDs to OHCA, and the distance from each OHCA to the closest AED. RESULTS: From provincial registries, we included 879 AEDs from BC's four most populous regions, where 9333 EMS-treated OHCA occurred over a 5-year period. The most common AED location types were stores, public community centres, and office buildings. Ten percent of AEDs were accessible for all hours. Weekly accessible AED-hours/100,000 population in the four regions were: 3845, 1734, 1594, and 1299. AEDs/100,000 population ranged from 22 to 48, and AEDs/km2 ranged from 0.0048 to 0.20. The number of OHCAs per AED per year ranged from 1.1 to 2.8. The median OHCA-to-closest AED distance ranged from 503 (IQR 244, 947) to 925 (IQR 455, 1501) metres. The regional mean accessibility of individual AEDs ranged between 59 and 79 h per week. CONCLUSION: BC's four most populous regions demonstrate substantial variability in AED accessibility. Further benefit could be derived from AEDs if placed in locations accessible all hours. Our data may encourage community planning efforts to use data-based strategies to systematically place AEDs in optimal locations with strategies to maximize accessibility.

ABSTRAIT: OBJECTIFS: Les défibrillateurs externes automatisés (DEA) appliqués par les témoins améliorent les résultats en cas d'arrêt cardiaque hors hôpital. Le placement des DEA est souvent dirigé par une entreprise privée ou des organismes sans but lucratif, ce qui peut entraîner un accès inéquitable. Nous avons cherché à comparer la disponibilité des DEA entre quatre régions de la Colombie-Britannique. MéTHODES: Nous avons identifié les DEA (dont la mise en service a été confirmée) et les SMU (système médical d'urgence) traités par arrêt cardiaque hors hôpital (AHC) dans les registres provinciaux. Nous avons comparé la disponibilité des DEA entre les quatre régions les plus peuplées de la Colombie-Britannique. Le résultat principal était le nombre total d'heures de DEA accessibles hebdomadaires par région pour 100000 habitants. Nous avons également examiné : les DEA par 100000 habitants et par km2, le rapport entre les DEA et l'AHCA, et la distance entre chaque AHCA et le DEA le plus proche. RéSULTATS: À partir des registres provinciaux, nous avons inclus 879 DEA des quatre régions les plus peuplées de la Colombie-Britannique, où 9333 OHCA traités par les SMU se sont produits sur une période de 5 ans. Les types de DEA les plus courants étaient les magasins, les centres communautaires publics et les immeubles de bureaux. Dix pour cent des DEA étaient accessibles toutes les heures. La population hebdomadaire accessible en heures AED/100000 habitants dans les quatre régions était de 3845, 1734, 1594 et 1299. Le nombre de DEA/100 000 habitants variait de 22 à 48, et le nombre de DEA/km2 variait de 0,018 à 0,018. Le nombre de CASO par DEA par année variait de 1,1 à 2,8. La distance médiane entre le DEA OHCA et le DEA le plus proche variait de 503 mètres (IQR 244, 947) à 925 mètres (IQR 455, 1501). L'accessibilité moyenne régionale des DEA individuels variait entre 59 et 79 heures par semaine. CONCLUSION: Les quatre régions les plus populeuses de la Colombie-Britannique présentent une variabilité importante de l'accessibilité aux DEA. D'autres avantages pourraient découler des DEA s'ils sont placés dans des endroits accessibles toutes les heures. Nos données peuvent encourager les efforts de planification communautaire à utiliser des stratégies fondées sur les données pour placer systématiquement les DEA dans des endroits optimaux avec des stratégies pour maximiser l'accessibilité.

The Emotional Impact and Coping Mechanisms Following Adverse Patient Events Among Canadian Vascular Surgeons and Trainees.

BACKGROUND: This study's objective is to evaluate the emotional experiences, coping mechanisms, and support resources for Canadian vascular surgeons and trainees following an adverse patient event or near miss. METHODS: This is a cross-sectional survey study of all Canadian Society for Vascular Surgery (CSVS) members from October to November 2021. We collected data on participant experiences with adverse events, their emotional responses, the coping mechanisms used, and their perceptions on available support resources. RESULTS: The survey was sent to 233 CSVS members yielding 66 responses. The majority (77%) of respondents had experiences with adverse event causing serious patient harm. The most common negative experience following an adverse event included feelings of negativity towards oneself, general distress, and anxiety about potential for future errors. The most common coping mechanism was seeking advice from a mentor or close colleague. Peers (82%) and senior colleagues (59%) were the most preferred sources of support. Most of the respondents would reach out to a mentor if they had 1, but 30% reported no mentor or close colleague for support. CONCLUSION: Adverse patient events and near misses have serious negative impact on the lives of Canadian vascular surgeons and trainees. Peers and senior colleagues are the most desired source for support, but this is not universally available. Organized efforts are needed to bring awareness in our vascular surgery community on the ubiquitous nature and detrimental effects of adverse events.

Disability, an often-overlooked aspect of equity, diversity, and inclusion among radiology departments in Canada and the United States.

PURPOSE: Despite nearly a quarter of Canadians and Americans reported to be living with a disability, persons with disabilities continue to face both physical and cultural barriers with respect to careers in medicine. Equity, diversity, and inclusion (EDI) statements can act as a first step in deconstruction of these cultural barriers. However, when compared to other EDI initiatives focused on gender, race, and ethnicity, persons with disabilities receive little attention. METHODS: We conducted a cross-sectional analysis of all radiology residency program websites in Canada and the United States (US). Data was collected from each radiology department website including the presence or absence of an EDI statement or page; if present, we determined whether mention was made of persons with disabilities. RESULTS: We reviewed the websites of 16 Canadian and 181 US radiology residency programs. Seven (44%) Canadian institutions had an EDI statement, with one (14%) mentioning persons with disabilities. In the US, 103 (57%) institutions had an EDI statement, with 42 (41%) mentioning persons with disabilities. CONCLUSIONS: There were a significant proportion of radiology residency programs without EDI statements on their websites and an even smaller proportion that acknowledged persons with disabilities. An institution's public commitment to EDI, and specifically to patients and providers with disabilities, is central to implementing inclusive change going forward.

Hepatic Hilar Nerve Block for Adjunctive Analgesia during Percutaneous Thermal Ablation of Hepatic Tumors: A Retrospective Analysis.

PURPOSE: To determine whether hepatic hilar nerve block techniques reduce analgesic and sedation requirements during percutaneous image-guided thermal ablation of hepatic tumors. MATERIALS AND METHODS: A single-center retrospective cohort analysis was performed of 177 patients (median age, 67 years; range, 33-86 years) who underwent percutaneous image-guided thermal ablation of liver tumors. All patients were treated utilizing local anesthetic and moderate sedation between November 2018 and November 2021 at a tertiary level hospital, with or without the administration of a hepatic hilar nerve block. Univariable and multivariable linear regression analyses were performed to determine the relationship between the administration of the hilar nerve block and fentanyl and midazolam dosages. RESULTS: A total of 114 (64%) patients received a hilar nerve block in addition to procedural sedation, and 63 (36%) patients received procedural sedation alone. There were no significant differences in the baseline demographic and tumor characteristics between the cohorts. The procedure duration was longer in the hilar block cohort than in the unblocked cohort (median, 95 vs 82 minutes; P = .0012). The technical success rate (98% in both the cohorts, P = .93) and adverse event rate (11% vs 3%, P = .14) were not significantly different between the cohorts. After adjusting for patient and tumor characteristics, ablation modality, and procedure and ablation durations, hilar nerve blocks were associated with lower fentanyl (-18.4%, P = .0045) and midazolam (-22.7%, P = .0007) dosages. CONCLUSIONS: Hepatic hilar nerve blocks significantly decrease the fentanyl and midazolam requirements during thermal ablation of hepatic tumors, without a significant change in the technical success or adverse event rates.

Female Authorship Trends Among Articles About Artificial Intelligence in North American Radiology Journals.

Purpose: To examine trends in female authorship of peer-reviewed North American radiology articles centred around artificial intelligence (AI). Method: A bibliographic search was conducted for all AI-related articles published in four North American radiology journals. Collected data included the genders of the first and last (senior) authors, year and country. We compared the trends of female authorship using Pearson chi-square, Fisher exact tests and logistic regression models. Results: 453 articles met the inclusion criteria. Among these, 107 (22.3%) had a female first author and 97 (27.3%) had a female senior author. Female first authors were over three times more likely to publish with a female senior author. Among the four journals, the CARJ had the highest proportion of female senior authors at 45.5%. The only significant temporal trend identified was an increase over the years in female senior authors in Radiology. Twenty-four countries contributed to the included articles, with the largest contributors being the United States (n = 290) and Canada (n = 30). Of the countries contributing more than 15 articles, there were none with above 50% female authorship. Conclusions: Female authors are underrepresented in AI-related radiology literature. However, there has been an encouraging recent increase in female authorship in AI-related radiology articles trending towards significance. There is a great opportunity to improve female representation in AI with intentional mentorship and recruitment. We urge more platforms for female voices in radiology as AI becomes increasingly integrated into the radiology community.

Percutaneous proximal axillary artery versus femoral artery access for endovascular interventions.

OBJECTIVE: The primary objective of this study is to describe and illustrate the technique of ultrasound-guided percutaneous proximal axillary artery (PAA) access, and secondarily to evaluate the versatility and safety of this approach in peripheral, visceral, and aortic endovascular interventions. METHODS: This is a single-center retrospective review of all peripheral, visceral, and aortic endovascular cases using percutaneous PAA access from February 2019 to March 2021 compared with a sample of an equivalent number of consecutive cases completed via percutaneous common femoral artery (CFA) access during the same time period. Access entry success, minor and major access site complications within 30 days, major adverse events within 30 days, demographics, and procedural details were analyzed using standard statistical analyses. RESULTS: A total of 115 accesses-59 PAA and 56 CFA-were reviewed during the study period. Group demographics were not significantly different. Access entry success was achieved in 58 (98.3%) and 56 (100%) of PAA and CFA accesses, respectively, with no statistically significant difference. There were no significant differences in minor access-site complications (13.6% vs 5.4%; P = .21) major access site complications (3.4% vs 7.1%; P = .43), or major adverse events (6.8% vs 5.4%). between the PAA and CFA groups. With respect to versatility, PAA cases had a significantly greater mean number of vessels intervened on per procedure compared with CFA access (2.59 ± 1.31 vs 1.95 ± 0.98; P < .01). A wide range of target vessels were intervened on in both groups. PAA cases had significantly more bilateral lower leg interventions (28.8% vs 12.5%; P = .04). PAA access had a significantly longer mean procedure time (103.2 minutes vs 58.63 minutes; P < .001) and fluoroscopy time (18.21 minutes vs 12.87 minutes; P = .02). CONCLUSIONS: The PAA is a feasible, versatile, and safe percutaneous access option for endovascular intervention. The in-line trajectory from this site facilitates visceral, renal, aortic, and bilateral lower extremity interventions with ease. Outcomes, complications, and major adverse events are similar to those of conventional CFA access in the short term.

An unusual cause of pericardial effusion: A case report of a hepatic abscess following foreign body migration and duodenal perforation.

INTRODUCTION AND IMPORTANCE: Although foreign bodies are a rare cause of gastrointestinal tract perforation, they may serve as a nidus for hepatic abscess. Abdominal pain is the most common presenting symptom. We present a case of an ingested pen causing duodenal perforation and hepatic abscess several months after initially presenting with a pericardial effusion. CASE PRESENTATION: A 59-year-old female living in an intensive tertiary mental health facility was noted to have an incidental pericardial effusion during work-up for hyponatremia. Seven months later, she developed a new fever and was noted to have interval increase in the pericardial effusion size. This prompted further investigation which finally revealed that an ingested pen had perforated through the first part of the duodenum and caused an abscess in the left lobe of the liver. The pericardial effusion was presumed secondary to local inflammation. Upon discovery of the abscess, the patient underwent successful operative management including abscess drainage, foreign body extraction, and duodenal repair. CLINICAL DISCUSSION: Reports of hepatic abscess from foreign body causing duodenal perforation are rare, with bone fragments and toothpicks the most common foreign bodies implicated. There is one other previously reported case of an ingested pen. Abdominal pain is present in up to 85% of cases, but fever may be the only presenting symptom. CONCLUSION: Foreign body migration causing a hepatic abscess may present non-specifically with unexplained fever or even pericardial effusion. Psychiatric comorbidities may contribute to delays in diagnosis due to difficulties recalling the episode of ingestion.

Cryopreserved venous allograft in the treatment of a mycotic abdominal aortic aneurysm caused by group B Streptococcus.

We report a case of a mycotic abdominal aortic aneurysm caused by invasive group B streptococcus. Given the anatomical suitability with healthy segments of aortoiliac vessels, in situ repair was performed. A cryopreserved femoral vein graft was chosen because of risks of graft reinfection and negated the need for bilateral femoral vein harvest. The patient remained clinically well and the graft patent with no concerns at 6 months of follow-up. A review of literature on group B Streptococcus aortitis was performed.

Gender-Inclusive Fellowship Naming and Equity, Diversity, and Inclusion in Radiology: An Analysis of Radiology Department Websites in Canada and the United States.

Purpose: Transgender and gender non-binary (TGNB) individuals face numerous inequalities in healthcare and there is substantial work to be done in fostering TGNB culturally competent care in radiology. A radiology department's online presence and use of gender-inclusive language are essential in promoting an environment of equity, diversity, and inclusion (EDI). The naming of radiology fellowships and continuing medical education (CME) courses with terminology such as "Women's Imaging" indicates a lack of inclusivity to TGNB patients and providers, which could result in suboptimal patient care. Methods: We conducted a cross-sectional analysis of all institutions in Canada and the United States (US) offering training in Breast Imaging, Women's Imaging, or Breast and Body Imaging. Data was collected from each institution's radiology department website pertaining to fellowship names, EDI involvement, and CME courses. Results: 8 Canadian and 71 US radiology fellowships were identified. 75% of Canadian and 90% of US fellowships had gender-inclusive names. One (12.5%) Canadian and 29 (41%) US institutions had EDI Committees mentioned on their websites. Among institutions publicly displaying CME courses about breast/body or women's imaging, gender-inclusive names were used in only 1 (25%) of the Canadian CME courses, compared to 81% of the US institutions. Conclusions: Most institutions in Canada and the US have gender-inclusive names for their radiology fellowships pertaining to breast and body imaging. However, there is much opportunity to and arguably the responsibility for institutions in both countries to increase the impact and visibility of their EDI efforts through creation of department-specific committees and CME courses.

Bupropion for smoking cessation in adolescents.

QUESTION: An adolescent who smokes regularly came to my clinic for help quitting. While I am aware that bupropion is a first-line medication for smoking cessation among adults, is it effective and safe for adolescents? ANSWER: Most adolescent smokers in Canada would like to quit, but more than 90% of the attempts are unsuccessful. Bupropion appears to be more effective than other pharmacologic options in improving abstinence among adolescents who smoke in the short term; however, it is not approved by Health Canada for those younger than 18 years. Bupropion has not been associated with an increase in adverse events in smoking cessation trials. More research is needed on the long-term effectiveness and safety of bupropion in this population.

Le bupropion pour cesser de fumer chez les adolescents.

QUESTION: Un fumeur adolescent m'a souvent consulté à la clinique pour me demander de l'aider pour arrêter de fumer. Je sais que le bupropion est un médicament de première intention pour la cessation tabagique, mais est-il efficace et sécuritaire chez les adolescents? RÉPONSE: La plupart des fumeurs adolescents au Canada aimeraient cesser de fumer, mais plus de 90 % des tentatives échouent. Le bupropion semble être plus efficace que les autres options pharmacologiques pour améliorer l'abstinence à court terme chez les adolescents; toutefois, Santé Canada ne l'a pas homologué pour les personnes de moins de 18 ans. Le bupropion n'est pas associé à un plus grand nombre d'événements indésirables dans les essais sur la cessation du tabagisme. Plus de recherches sont nécessaires sur l'efficacité et l'innocuité du bupropion à long terme dans cette population.

Gonadal vein as a bypass conduit for arterial reconstruction during an aortic debranching repair of a paravisceral aortic aneurysm.

We report a case of a hybrid aortic debranching procedure for repair of a paravisceral inflammatory aortic aneurysm. Vein grafts were chosen over prosthetics because of concern for infection as a possible etiology. The gonadal vein was successfully used as a vein graft between the right common iliac artery and the right renal artery before aortic endograft placement.

Recurrent epistaxis in children.

QUESTION: A child came to my clinic complaining of recurrent epistaxis with several episodes occurring every year since he was a toddler. The nosebleeds affect both nostrils, often lasting for an extended period of time and occurring in no apparent seasonal pattern. What interventions are safe and effective for recurrent epistaxis in children, and which patients warrant hematologic testing? ANSWER: Epistaxis affects more than half of children by the time they are 10 years old, with 9% of children reported to have recurrent episodes. Most cases are of benign origin and will not require further workup. For those seeking intervention, nasal mucosal hydration, such as emollient application, or humidification resolves up to 65% of cases, and many novel interventions have shown promise in their respective initial studies. Standardized bleeding questionnaires have demonstrated usefulness in decision making for further coagulation studies, taking into account historical features including frequency, duration, bleeding site, seasonal correlation, and severity.

Épistaxis récurrente chez l'enfant.

QUESTION: Un enfant vient à ma clinique et se plaint d'une épistaxis récurrente, notamment de plusieurs épisodes par année depuis qu'il est tout petit. Les saignements de nez se produisent dans les 2 narines et durent souvent longtemps, sans qu'il y ait de tendances saisonnières apparentes. Quelles sont les interventions sûres et efficaces pour l'épistaxis chez les enfants, et chez quels patients des analyses hématologiques s'imposeraient-elles? RÉPONSE: L'épistaxis se produit chez plus de la moitié des enfants avant qu'ils aient atteint l'âge de 10 ans, et on rapporte que chez 9 % des enfants, les épisodes sont récurrents. Dans la plupart des cas, l'affection est d'origine bénigne et ne nécessitera pas d'investigation plus poussée. Pour ceux qui demandent une intervention, l'hydratation des muqueuses nasales, comme l'application d'émollients ou l'humidification, règle jusqu'à 65 % des cas, et de nombreuses nouvelles interventions se sont révélées prometteuses dans leurs études initiales respectives. Il a été démontré que des questionnaires normalisés sur les saignements sont utiles dans la prise de décisions sur la poursuite d'autres analyses de la coagulation, en tenant compte des caractéristiques historiques comme la fréquence, la durée, le site des saignements, les corrélations saisonnières et la gravité.

Caregivers' Willingness to Accept Expedited Vaccine Research During the COVID-19 Pandemic: A Cross-sectional Survey.

PURPOSE: This study determined the predictors of caregivers' willingness to accept an accelerated regulatory process for the development of vaccines against coronavirus disease 2019 (COVID-19). METHODS: An international cross-sectional survey was administered to 2557 caregivers of children in 17 pediatric emergency departments (EDs) across 6 countries from March 26, 2020, to June 30, 2020. Caregivers were asked to select 1 of 4 choices with which they most agreed regarding a proposed COVID-19 vaccine-approval process, in addition to questions regarding demographic characteristics, the ED visit, and attitudes about COVID-19. Univariate analyses were conducted using the Mann-Whitney U test for comparing non-normally distributed continuous variables, an independent t test for comparing normally distributed continuous variables, and a χ2 or Fisher exact test for categorical variables. Multivariate logistic regression analysis was used for determining independent factors associated with caregivers' willingness to accept abridged development of a COVID-19 vaccine. A P value of <0.05 was considered significant. FINDINGS: Almost half (1101/2557; 43%) of caregivers reported that they were willing to accept less rigorous testing and postresearch approval of a new COVID-19 vaccine. Independent factors associated with caregivers' willingness to accept expedited COVID-19 vaccine research included having children who were up to date on the vaccination schedule (odds ratio [OR] = 1.72; 95% CI, 1.29-2.31), caregivers' concern about having had COVID-19 themselves at the time of survey completion in the ED (OR = 1.1; 95% CI, 1.05-1.16), and caregivers' intent to have their children vaccinated against COVID-19 if a vaccine were to become available (OR = 1.84; 95% CI, 1.54-2.21). Compared with fathers, mothers completing the survey were less likely to approve of changes in the vaccine-development process (OR = 0.641; 95% CI, 0.529-0.775). IMPLICATIONS: Less than half of caregivers in this worldwide sample were willing to accept abbreviated COVID-19 vaccine testing. As a part of an effort to increase acceptance and uptake of a new vaccine, especially in order to protect children, public health strategies and individual providers should understand caregivers' attitudes toward the approval of a vaccine and consult them appropriately.

Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.

BACKGROUND: More than 100 COVID-19 vaccine candidates are in development since the SARS-CoV-2 genetic sequence was published in January 2020. The uptake of a COVID-19 vaccine among children will be instrumental in limiting the spread of the disease as herd immunity may require vaccine coverage of up to 80% of the population. Prior history of pandemic vaccine coverage was as low as 40% among children in the United States during the 2009 H1N1 influenza pandemic. PURPOSE: To investigate predictors associated with global caregivers' intent to vaccinate their children against COVID-19, when the vaccine becomes available. METHOD: An international cross sectional survey of 1541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries from March 26 to May 31, 2020. RESULTS: 65% (n = 1005) of caregivers reported that they intend to vaccinate their child against COVID-19, once a vaccine is available. A univariate and subsequent multivariate analysis found that increased intended uptake was associated with children that were older, children with no chronic illness, when fathers completed the survey, children up-to-date on their vaccination schedule, recent history of vaccination against influenza, and caregivers concerned their child had COVID-19 at the time of survey completion in the ED. The most common reason reported by caregivers intending to vaccinate was to protect their child (62%), and the most common reason reported by caregivers refusing vaccination was the vaccine's novelty (52%). CONCLUSIONS: The majority of caregivers intend to vaccinate their children against COVID-19, though uptake will likely be associated with specific factors such as child and caregiver demographics and vaccination history. Public health strategies need to address barriers to uptake by providing evidence about an upcoming COVID-19 vaccine's safety and efficacy, highlighting the risks and consequences of infection in children, and educating caregivers on the role of vaccination.

Melatonin for children with autism spectrum disorder.

Question I have several patients with autism spectrum disorder (ASD) who experience difficulties with sleep, affecting the quality of life of both the child and the family. Is melatonin an effective treatment for sleep problems in children with this condition?Answer Autism spectrum disorder is prevalent among children in Canada and globally, with most affected children experiencing troubles with sleep. Behavioural therapy is the first-line treatment for sleep problems in children with ASD, and melatonin has been reported to be effective and safe in this population as an alternative or adjunctive treatment. A new pediatric, prolonged-release formulation of melatonin is not yet available in Canada, but initial studies in Europe have indicated that it is a potentially effective treatment for sleep problems in children with ASD.