Analysis of national empirical data on the characteristics and trends of injury among Taiwan's victims of hospitalized child abuse between 1997 and 2009.

OBJECTIVE: To investigate the characteristics and trends of injury among hospitalized child abuse children younger than 18 years between 1997 and 2009. METHODS: We selected hospitalized child abuse cases from the Taiwan's National Health Insurance (NHI) Database in accordance with ICD-9-CM 995.5x or E967.x. RESULTS: There were 1,212 victims of hospitalized child abuse during the research period, including 735 boys and 477 girls. The victims were most frequently inflicted by the father or stepfather, and the most common injury was intracranial damage; besides, the victims most commonly sought treatment in medical centers. Infants younger than 1 year accounted for the highest percentage of hospitalized victims. Although there were no apparent trends in the overall hospitalization rate of the child abuse victims over the 13-year period, the rate of abuse among girls increased gradually over the years. CONCLUSIONS: The medical staff in hospitals should provide appropriate treatment to the victims and contact relevant organizations to intervene; moreover, government agencies should formulate effective control measures to develop a safe growth environment for children.

A nationwide, population-based, long-term follow-up study of repeated self-harm in Taiwan.

BACKGROUND: Previous follow-up studies of repeated self-harm show that the cumulative risk of repeated self-harm within one year is 5.7%-15%, with females at greatest risk. However, relatively few studies have focused on the Far East. The objective of this study was to calculate the cumulative risk of repeated self-harm over different lengths of follow-up time (3 months, 6 months, and 1-8 years), to determine factors influencing repeated self-harm and to explore the interaction between gender and self-harm methods. METHODS: We used self-harm patient who hospitalized due to first-time self-harm between 2000 and 2007 from 1,230 hospitals in Taiwan. Hospitalization for repeated self-harm among members of this cohort was tracked after 3 months, 6 months, and 1-8 years. Tracking continued until December 31, 2008. We analyzed the cumulative risk and risk factors of repeated self-harm by using negative binomial regression. RESULTS: Of the 39,875 individual study samples, 3,388 individuals (8.50%) were found to have repeatedly self-harmed. The cumulative risk of repeated self-harm within three months was 7.19% and within one year was 8%. Within 8 years, it was 8.70%. Females were more likely to repeatedly self-harm than males (RR = 1.21, 95% CI = 1.15-1.76). The main method of self-harm was solid or liquid substances (RR = 1.88, 95% CI = 1.23-2.04) or cutting or piercing (RR = 1.36, 95% CI = 1.02-1.82), and in patients with psychiatric disorders were more likely to self-harm (RR = 1.61, 95% CI = 1.48-1.75). CONCLUSIONS: The key time for intervention for repeated self-harm is within three months. Appropriate prevention programs should be developed based on gender differences.

[Community health building: the safe community promotion experience].

Safety and health promotion at the community level involves special concerns and approaches. A community may develop into a safe community or healthy city depending on the focus of relevant promotion efforts. Neither area nor population size should be factors affecting an initial decision to start safe community or healthy city programs. However, one should consider the diversity of issues that may have the potential impact on people with different gender and age or on different environments and situations, and whether a planned program is sustainable. While safe communities and healthy cities may be linked to international networks, the qualifications for joining such networks differ. The Healthy City Alliance emphasizes outcome measures and the International Safe Community Network emphasizes the appropriateness of sustainability mechanisms. While Taiwan communities are eligible for designation as international safe communities, they may are eligible for associate membership only in the Healthy City Alliance. The author has the following recommendations with regard to sustainability in community health building in Taiwan: 1) The relevant infrastructure must involve both public and private sectors; 2) The community should try to receive financial support from diverse sources; 3) involve significant numbers of active volunteers; and 4) charge local health centers with data collection and analysis responsibilities.

Thoughts of social distancing experiences affect food intake and hypothetical binge eating: Implications for people in home quarantine during COVID-19.

BACKGROND AND RATIONALE: Social distance regulations have been suggested as one of the best ways to control and prevent the spread of COVID-19. Social connection and food are intertwined because both have played critical evolutionary roles in human survival. We tested whether the substitutability hypothesis in human motivation applies here in that cues signaling scarcity in one domain (e.g., social connection) might enhance the desire to acquire resources in another domain (e.g., food). METHODS: We recruited 140 adults from Kaohsiung City (the largest city in southern Taiwan) to participate in a laboratory experiment. Participants were randomly assigned to receive either social distancing or neutral primes via an emotional-event recollection technique. The amount of ice cream eaten during a taste test and the self-reported likelihood of binge eating served as the dependent measures. RESULTS: We found that, compared with controls, participants primed with social distancing consumed more ice cream in a taste test and reported a greater likelihood that they would engage in binge eating if they were placed in home quarantine. CONCLUSIONS: We may be the first to provide experimental evidence that social distancing can enhance the desire for food. The link between social distancing and the desire for food is pertinent to understanding how strongly social distance regulations may influence weight gain. Our findings have far-reaching implications for weight control under social distance regulations for prevention and control of COVID-19.

An unintended consequence of social distance regulations: COVID-19 social distancing promotes the desire for money.

Social distance regulations have been widely adopted during the global COVID-19 pandemic. From an evolutionary perspective, social connection and money are interchangeable subsistence resources for human survival. The substitutability principle of human motivation posits that scarcity in one domain (e.g., social connection) could motivate people to acquire or maintain resources in another domain (e.g., money). Two experiments were conducted to test the possibility that COVID-19 social distancing enhances the desire for money. Results showed that compared with controls, participants receiving social distancing primes (via recollection of experiences of social distancing or a Chinese glossary-search task) offered less money in the dictator game, showed lower willingness towards charitable donation (Experiment 1; N = 102), donated less money to a student fund, and rated money as having more importance (Experiment 2; N = 140). Our findings have far-reaching implications for financial decisions, charitable donations, and prosociality during and after the COVID-19 pandemic.

Postformal thinking and creativity among late adolescents: a post-Piagetian approach.

This study investigated the relationship between cognitive development levels and creative performance among late adolescents from a post-Piagetian perspective. Participants were 386 college students, ranging in age from 19 to 26 years. The Social Paradigm Belief Scale was employed to measure the three cognitive styles of late adolescence: formal, relativistic, and dialectical thinking. The Divergent Thinking Test (DTT) was used to measure creative performance. Dialectical and relativistic thinking were positively correlated with creative performance, whereas formal thinking was negatively correlated. Planned contrasts revealed that postformal thinkers scored higher than formal thinkers in all dimensions of creativity, and additional MANOVA analysis exhibited a similar pattern. Multiple discriminant analysis showed that the linear combination of the six dimensions of creativity recognized in the DTT discriminated between formal and postformal thinkers, which supported our findings about the relationship between postformal thinking and creativity. Future research directions and implications for creativity pedagogy are discussed.

Marginal leakage of different temporary restorations in standardized complex endodontic access preparations.

This study compared the marginal leakage of temporary restorations using Cavit, IRM, zinc phosphate cement (ZPC), and copper bands cemented with ZPC. Standardized complex endodontic access preparations were made in 176 extracted human molars. The teeth were divided into six groups, including positive and negative controls. A Universal matrix system was placed over each tooth before restoration, except in the copper band group, in which teeth were restored with ZPC after copper band cementation. Marginal leakage was evaluated with a binocular microscope after the teeth were immersed in artificial saliva, colored with 2% methylene blue and buffered to neutral pH, at 37 degrees C for various time intervals after thermal cycling. In the experimental groups, the differences in the leakage scores of the Cavit group and the other groups were very marked. The Cavit group presented the least marginal leakage, irrespective of time, whereas more than half the specimens from the IRM, ZPC, and copper band groups displayed severe leakage from day 1.

Autogenous fat injection for glottic insufficiency: analysis of 101 cases and correlation with patients' self-assessment.

CONCLUSIONS: Our data confirm that fat injection (FI) is a safe, useful, thorough and experience-dependent procedure. It should be considered as a potential treatment protocol for patients with vocal fold atrophy (VFA) and sulcus vergeture (SVER). To increase the chances of excellent phonatory results for sulcus vocalis (SV) patients, our recommended surgical option is FI with fascia transplantation. OBJECTIVE: To investigate prognostic factors in patients with glottic insufficiency following FI. MATERIAL AND METHODS: The study sample comprised 101 patients treated for VFA (n=31), SVER (n=41) and SV (n=29). A retrospective analysis was performed by means of patient self-assessments, employing multiple logistic regressions for the four independent factors of age, gender, diagnosis and time-frame of surgery. RESULTS: The mean follow-up time was 16.8 months (range 5-38 months). Immediate complications included hematoma of the donor site in two patients and fat extrusion at the injection site in three. The results of treatment were "excellent" in 48.4% (15/31) of VFA cases, 43.9% (18/41) of SVER cases and 20.7% (6/29) of SV cases, with 19.4% (6/31), 24.4% (10/41) and 55.2% (16/29), respectively reporting improvement and 32.3% (10/31), 31.7% (13/41) and 24.1% (7/29), respectively reporting no improvement. Disease type was determined to have a significant bearing (p=0.025) on treatment effectiveness and patients operated on most recently were shown to have a 4.3-times greater chance of achieving successful results (p<0.01). Multiple logistic regression analysis indicated that VFA and SVER sufferers (as compared to those with SV) and men (as opposed to women) were more likely to achieve an "excellent" result: 3.4, 3.3 and 3.6 times, respectively.

Readiness of hospital nurses for disaster responses in Taiwan: A cross-sectional study.

BACKGROUND: Because patients in disaster areas require the most critical care, mobilising hospital nurses has become a pivotal strategy. Given the importance of disaster nursing training programmes, understanding how well prepared hospital nurses are to provide disaster care is vital. OBJECTIVES: This paper analyses the perceived readiness of hospital nurses for a disaster response and the factors influencing their report for work outside the hospital environment. DESIGN: A cross-sectional research design was used. SETTINGS: This study was conducted at a military hospital in Taiwan. PARTICIPANTS: A sample of 311 registered nurses participated in this study. METHODS: Data were collected on readiness for disaster responses using a 40-item researcher-designed, self-administered questionnaire found to have satisfactory reliability and validity. The questionnaire has four domains: personal preparation (16 items), self-protection (11 items), emergency response (6 items), and clinical management (7 items). Data were analysed using descriptive statistics, independent t-tests and generalised linear models. RESULTS: The majority of hospital nurses demonstrated poor readiness for disaster responses. Scores on the four domains were most associated with nurses' disaster-related training, experience in disaster response and emergency/intensive care experience. CONCLUSIONS: Our results indicate that disaster-related training should be included in undergraduate programmes and continuing education courses to help hospital nurses recognise and improve their own readiness for disaster responses outside the hospital environment. Future research is needed to improve hospital nurses' disaster-response readiness in Taiwan and other countries.

Clinical predictors of difficult laryngeal exposure.

PURPOSE: Although difficult laryngeal exposure (DLE) is a common problem encountered after procedures using a rigid laryngoscope, to date, no anticipatory physical indicators have been formally noted as reliable predictors of DLE. The purpose of this paper is to identify useful and reliable indicators by which to predict, with acceptable accuracy, the occurrence of DLE following rigid laryngoscopy. STUDY DESIGN: Fifty-six patients, each of whom had undergone a rigid laryngoscope procedure, were classified as belonging to either the DLE group (n = 19) or the control group (n = 37) for purposes of this prospective study. METHODS: All patients were given a physical examination, which encompassed the following nine measures: age, sex, modified Mallampati index (MMI), body mass index (BMI), hyoid-mental distance (HMD), thyroid-mental distance (TMD), thyroid-mandible angle (TMA), horizontal thyroid distance (HTD), and vertical thyroid distance (VTD). Stepwise regression was employed on patient data to identify those with DLE. RESULTS The ages of patients in the DLE group ranged from 35 to 79 years, with a mean of 51.3 years. Among the nine variables, we found sex (P =.045, odds ratio = 69.159) and TMA (P =.004, odds ratio = 1.510) to be "reliable" DLE predictors. Using these two variables, 94.6% of study case patients could have been correctly classified preoperatively. Based on our comparison of case results, we found that a TMA value greater than 120 degrees in men and 130 degrees in women indicates a strong likelihood of DLE. CONCLUSIONS TMA is a sensitive, reliable, and useful predictor of DLE in both men and women. The combination of sex and TMA provide important initial clinical indicators that can alert a clinician regarding DLE probability.

Fat augmentation following microsurgical removal of the vocal nodules.

OBJECTIVES: Autogenous fat augmentation has been used as a treatment for glottic insufficiency. However, no information is available on the effectiveness of fat injection in patients with vocal nodules or recurrent vocal nodules after surgery. STUDY DESIGN: The retrospective study reviews the efficiency of fat injection after surgery in patients with vocal nodules (n = 18) and recurrent vocal nodules (n = 5). METHODS: The perceptual acoustic, phonatory function, and video laryngostroboscopic data were evaluated before and after surgery in 23 patients. RESULTS: Mean follow-up time was 7.5 months. Nineteen patients had excellent results. Two patients had improvement, and no change was observed in two patients. Phonatory function showed significant improvement in shimmer, harmonic-to-noiseratio (P <.05), maximum phonation time, grade, roughness, and breathiness (P <.001). Video laryngostroboscopic rating showed significant improvement in linearity of the vocal fold edge, amplitude of vocal fold vibration, and excursion of the mucosal wave (P <.001). Less improvement was observed in recurrent vocal nodules than in nonrecurrent vocal nodules. CONCLUSIONS: Fat injection is an effective autogenous implant and may be considered as an option in management of patients with vocal nodules after surgery. Recurrence of nodules is a problem, but the procedure may be repeated.

A longitudinal study of risk factors for motorcycle crashes among junior college students in Taiwan.

A cohort of 4729 junior college students in an urban and a rural area in Taiwan was followed up for a period of 20 months. Students' characteristics, including riding exposures, as well as human, vehicular, and environmental factors were collected using one initial and three follow-up questionnaires. The Anderson-Gill (AG) multiplicative intensity model was used to determine the risk of a motorcycle crash over time while also allowing for the modeling of multiple events. The average response rate for the four assessments was 92%. The adjusted relative hazard (RH) for students living in the rural as opposed to the urban area for crashes was 1.67 at the beginning of the study but decreased to 0.66 by the end. Past motorcycle crash history, number of riding days, average riding distance, risk-taking level, alcohol consumption, and traffic violations were all significantly associated with an increased risk of being involved in a crash. Conversely, increasing age, riding experience, and automobile licensure were related to a decreased risk of crashing. Furthermore, helmet use was not independently related to the risk of crashing. In conclusion, a high-risk group predisposed to involvement in a motorcycle crash, including both non-injury and injury-related crashes, can be identified using selected risk factors for crash prevention among young riders.

Epidemiology of hospitalized burns patients in Taiwan.

Previous studies based on either single hospital data or sampling of specific groups of hospitalized burns victims in Taiwan have provided only minimal epidemiological information. The study is designed to provide additional data on the epidemiology of hospitalized burns patients in Taiwan. Data were obtained from the Burn Injury Information System (BIIS), which brings together information supplied by 34 contracted hospitals. The study time course spanned a 2-year period from July 1997 to June 1999. Patient characteristics (age, sex, education level, etc.), causes and severity of injuries, and medical care measures were explored. A total of 4741 patients were registered with BIIS over the study period. The majority of hospitalized patients (67%) were male. The age distribution of burns patients showed peaks occurring at the age groups of 0-5 and 35-44 years. Over the time course of a day, burn injuries occurred more frequently from 10:00 to 12:00 h and 16:00 to 18:00 h. Injuries suspected as the result of suicide, homicide or child abuse accounted for 4.8% of hospitalized cases. More than 48% of the burns occurred in the home. The leading type of burn injury was scalding, followed by naked flame, explosion, electrical burns, and chemical burns due to caustic or corrosive substances. The mean percent total body surface area (%TBSA) for adults was 19%, and for young children was 12%. The average length of hospital stay was 18 days. In conclusion, children under 5 years and adults between 35 and 44 years of age are two high-risk groups for burn injuries. Corresponding to meal preparation time, hot substances such as boiling water, hot soup, etc. are the most common agents responsible for scalds. Prevention programs for reducing the risk of burn injuries during cooking and eating are required, especially for parents with young children.

Combination of fascia transplantation and fat injection into the vocal fold for sulcus vocalis: long-term results.

Fat injection and fascia transplantation alone have been used to treat patients with sulcus vocalis. No information is available on the effectiveness of these two procedures used in concert to treat sulcus vocalis. The objectives of this study were to conduct the two procedures together and report the long-term results. This article assesses, retrospectively, the effectiveness of the combination treatment of fascia transplantation and fat injection (FTFI) in patients with sulcus vocalis (n = 22). Perceptual acoustic, phonatory function, and videolaryngostroboscopic data were evaluated before and after FTFI treatment in 18 patients. The mean follow-up time was 16.6 months. Sixteen patients had excellent results, 3 reported improvement, and 3 indicated no change. Phonatory function improved significantly in terms of phonation time, grade, roughness (p < .05), and breathiness (p < .001). The videolaryngostroboscopic rating showed significant improvement in vocal fold vibration amplitude and excursion of the mucosal wave (p < .05). Type 3 sulcus responded better to this treatment than did type 2 (sulcus vergeture). No postoperative complications were noted. The FTFI technique consists of an autogenous implant and delivers positive results. It may be considered as an option for patients with sulcus vocalis. It has been demonstrated to achieve excellent results in a majority of patients and to deliver a better prognosis than fat injection alone. Although resorption of fat and fascia is associated with FTFI, the FTFI procedure may be repeated multiple times.

Clearing microvascular lesions of the true vocal fold with the KTP/532 laser.

Although used for treating vascular malformations, KTP (532 nm) lasers have not been used to treat microvascular lesions of the vocal fold. The efficiency of KTP laser operation in the continuous mode with a 0.4- or 0.6-mm beam (1- to 2-W aim for 3 to 7 seconds delivering a total energy of 3 to 7 J) was studied retrospectively in patients with microvascular lesions of the vocal fold (n = 14). The perceptual acoustic, phonatory function, and videolaryngostroboscopic data were evaluated before and after operation in 10 patients. At follow-up (mean, 7 months), the results were excellent in all patients. Their phonatory function (jitter, shimmer, grade, breathiness, and roughness) significantly improved (p < .01). The videolaryngostroboscopic rating showed significant improvement in the amplitude of vocal fold vibration and excursion of the mucosal wave (p < .05). No postoperative recurrence or complications were noted. The KTP laser operation is a useful, cost-effective, and time-saving procedure and can be considered as an option in management of patients with microvascular lesions of the vocal fold, particularly those with repeated hemorrhages. Because the operation is easy (compared to other surgical methods) and has no major side effects, the prospect of total patient recovery is excellent.

Effects of music therapy on oxygen saturation in premature infants receiving endotracheal suctioning.

The purpose of this study was to investigate how premature infants' oxygen saturation changed in response to music therapy while they were receiving endotracheal suctioning. A convenience sample of 30 premature infants was selected from three neonatal intensive care units. A one-group repeated measures design was adopted for this study. The oxygen saturation of all subjects was first measured while they were receiving endotracheal suctioning during a four-hour control period with regular care. Then, four hours after the control period was completed, an experimental period began in which the music " Transitions " was played. One minute before suctioning, the level of oxygen saturation was measured to provide the baseline data. During a period of 30 minutes after suctioning, the oxygen saturation was recorded every minute to analyze the clinical effects of music therapy. The results showed that premature infants receiving music therapy with endotracheal suctioning had a significantly higher SPO(2); than that when not receiving music therapy (p <.01), and the level of oxygen saturation returned to the baseline level faster than when they did not receive music therapy (p <.01). Accordingly, it is hoped that giving appropriate music therapy as developmental care to premature infants when performing any nursing intervention may enhance not only the quality of nursing care but also quality of the infant's life.

A nation-wide evidence-based data analysis of repeated suicide attempts.

BACKGROUND: Taiwan is a high-risk area for suicide. Repeated suicide attempts are an important factor of suicide mortality. Yet there has been little research on the factors associated with repeated suicidal behavior in Taiwan. AIMS: To explore the characteristics of repeated suicide attempts. METHODS: Data were obtained from the National Health Insurance Research Database for 2005 to 2008. We then classified repeated suicide attempts into single method, two different methods, and three different methods. RESULTS: A total of 1,004 inpatients were admitted to Taiwanese hospitals due to repeated suicide attempts, and the use of a single suicide method constituted the majority of the cases (71%). Risk factors related to repeated suicide attempts included being female, aged 30-39, suicide by poisoning using solid and/or liquid substances, the fall season, living in Northern Taiwan, more psychiatric nature of injury codes (N-codes), seeking medical attention from a psychiatrist, receiving more surgeries or procedures, a longer length of stay in a hospital, coming from a low-income background, and having a serious illness. CONCLUSIONS: Consultation and treatment are particularly crucial for patients with mental illnesses and other concomitant diseases, so that the psychiatric symptoms such as auditory and visual hallucinations can be controlled.

The interaction effect between low income and severe illness on the risk of death by suicide after self-harm.

BACKGROUND: Previous Western studies have reported that the prevalence of death by suicide within 1 year after self-harm was 0.5-2%; however, no studies have focused on the Far East. AIMS: To calculate the prevalence of death by suicide after self-harm over different lengths of follow-up time and to determine the predictors of death by suicide after self-harm. METHOD: Our study was based on 3,388 inpatients hospitalized between 2000 and 2007 in any of the 1,230 hospitals in Taiwan. Death by suicide after self-harm among the members of this cohort was tracked after 3 months, 6 months, and 1-8 years. The tracking continued until December 31, 2008. We analyzed the prevalence and risk factors of death by suicide after self-harm using Cox's regression model. RESULTS: Of the 3,388 individuals with a history of self-harm included in the study, 48 (1.4%) died by suicide after self-harm within 3 months and 97 (2.9%) within 1 year. In all, 144 (4.3%) died by suicide after self-harm within 8 years. The predictors of death by suicide were violent methods (such as hanging, drowning, firearms, and jumping), low income, and severe illness. Moreover, an interaction effect was noted between low income and severe illness on the outcome (death by suicide). CONCLUSION: It seems that effective healthcare for individuals who engage in self-harming behavior would benefit from supplementing medical care with social assistance, such as the support of a social worker.

More options lead to more searching and worse choices in finding partners for romantic relationships online: an experimental study.

It is not surprising that the Internet has become a means by which people expand their social networks and form close relationships. Almost every online-dating Web site provides members with search tools. However, do users truly benefit from more complete searches of a large pool of possibilities? The present study, based on the cognitive perspective, examined whether more search options triggered excessive searching, leading to worse choices and poorer selectivity. We argue that more search options lead to less selective processing by reducing users' cognitive resources, distracting them with irrelevant information, and reducing their ability to screen out inferior options. A total of 128 Taiwanese late adolescents and adults with experience in online romantic relationships participated in an experimental study. After entering the characteristics they found desirable in a partner in such a relationship, participants were randomly assigned to receive one of three levels of available profiles. The dependent measures consisted of the number of profiles searched, the average preference difference for all profiles viewed, the preference difference for the chosen profile, and the degree of selectivity. These measures were used to determine whether more attention was devoted to better alternatives and less attention to worse alternatives. The data supported the predictions. Implications and directions for further research are discussed.

Colonic diverticular bleeding with comorbid diseases may need elective colectomy.

BACKGROUND: Colonic diverticular bleeding can usually be managed with conservative treatment. However, in a selected group of patients under conditions of recurrent, persistent bleeding influencing quality of life or causing life-threatening shock, it should be managed with surgery. This is a retrospective study to clarify the risk factors relating to colectomy for colonic diverticular bleeding. METHODS: Between 1997 and 2005, a retrospective chart review of 73 patients with colonic diverticular bleeding was undertaken. Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy. RESULTS: The mean age of the 73 patients was 70 years (range, 22-90 years). Most colonic diverticular bleeding could be managed with conservative treatment (n = 63, 86.3%), and urgent colectomy was performed in ten patients (13.7%). The bleeding site could not be well identified in six of those ten patients and so underwent total abdominal colectomy with ileorectal anastomosis, and the other four underwent right hemicolectomy after a diagnosis of right-sided colon diverticula with bleeding. There were two deaths in the surgical group and one death in the nonsurgical group. The overall mortality rate in the series was 4.11% and 20% among patients undergoing urgent colectomy. Multiple logistic regression analysis showed that the presence of comorbidities and daily maximum blood transfusion requirement were risk factors for urgent colectomy for colonic diverticular bleeding. CONCLUSION: Preoperative comorbid diseases may increase operative risk in urgent surgery, and the outcome is poor. To avoid high mortality and morbidity relating to the urgent colectomy, we suggest that patients of colonic diverticular bleeding with comorbid diseases, especially subgroups of patients with diabetes and gouty arthritis, may need early elective colectomy.