A Low-Cost Wearable Device to Estimate Body Temperature Based on Wrist Temperature.

The remote monitoring of vital signs and healthcare provision has become an urgent necessity due to the impact of the COVID-19 pandemic on the world. Blood oxygen level, heart rate, and body temperature data are crucial for managing the disease and ensuring timely medical care. This study proposes a low-cost wearable device employing non-contact sensors to monitor, process, and visualize critical variables, focusing on body temperature measurement as a key health indicator. The wearable device developed offers a non-invasive and continuous method to gather wrist and forehead temperature data. However, since there is a discrepancy between wrist and actual forehead temperature, this study incorporates statistical methods and machine learning to estimate the core forehead temperature from the wrist. This research collects 2130 samples from 30 volunteers, and both the statistical least squares method and machine learning via linear regression are applied to analyze these data. It is observed that all models achieve a significant fit, but the third-degree polynomial model stands out in both approaches. It achieves an R2 value of 0.9769 in the statistical analysis and 0.9791 in machine learning.

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus.

INTRODUCTION: Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. METHODS: This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. RESULTS: Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. CONCLUSION: We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. HIGHLIGHTS: Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

Utilizing Community Based Participatory Research Methods in Black/African American and Hispanic/Latinx Communities in the US: The CDC Minority HIV Research Initiative (MARI-Round 4).

The Centers for Disease Control and Prevention Minority HIV Research Initiative (MARI) funded 8 investigators in 2016 to develop HIV prevention and treatment interventions in highly affected communities. We describe MARI studies who used community-based participatory research methods to inform the development of interventions in Black/African American and Hispanic/Latinx communities focused on sexual minority men (SMM) or heterosexual populations. Each study implemented best practice strategies for engaging with communities, informing recruitment strategies, navigating through the impacts of COVID-19, and disseminating findings. Best practice strategies common to all MARI studies included establishing community advisory boards, engaging community members in all stages of HIV research, and integrating technology to sustain interventions during the COVID-19 pandemic. Implementing community-informed approaches is crucial to intervention uptake and long-term sustainability in communities of color. MARI investigators' research studies provide a framework for developing effective programs tailored to reducing HIV-related racial/ethnic disparities.

Provider perceptions of availability, accessibility, and adequacy of health and behavioral services for Latino immigrants in Philadelphia: a qualitative study.

OBJECTIVE: Latino populations in the United States are disproportionately affected by substance use, HIV/AIDS, violence, and mental health issues (SAVAME). A growing body of evidence demonstrates the syndemic nature of SAVAME and the need for integrated strategies to reduce their impact. This study sought to understand the network of SAVAME services for Latino immigrants in Philadelphia to inform future interventions for SAVAME prevention and mitigation. METHODOLOGY: Key informant interviews (N = 30) were conducted with providers working in Latino-serving organizations providing SAVAME services. Interviews were analyzed using thematic coding and grounded theory. RESULTS: Latino-serving providers perceived a large need for, and important limitations in the availability, accessibility, and adequacy of SAVAME services for Latino immigrants. Gaps were seen as especially acute for mental health and substance use services, partly because of insufficient funding for these services. Latino immigrants' lack of health insurance, immigration status, limited English proficiency (LEP), stigma surrounding SAVAME issues, and limited knowledge of available services were identified as significant barriers preventing access to services. Providers noted that scarcity of well-trained, culturally competent, and ethnically concordant providers reduced the adequacy of SAVAME services for Latino immigrant clients. The small size, low levels of infrastructure, and limited capacity were reported as additional factors limiting the ability of many Latino-serving organizations to adopt a syndemic approach in the prevention and treatment of SAVAME services. CONCLUSIONS: The results call for changes in the structure of funding streams and communitywide strategies to foster collaboration across SAVAME providers working with Latino immigrant clients.

Analysis of Network Characteristics to Assess Community Capacity of Latino-Serving Organizations in Philadelphia.

Latino immigrants are disproportionately impacted by substance use, HIV/AIDS, domestic violence, and mental health (SAVAME). The burden of these syndemic conditions is influenced by limited access to health and social services to prevent and treat these conditions. The syndemic nature of these factors necessitates an integrated, coordinated approach to address them simultaneously. We analyzed characteristics of Latino-serving organizations in Philadelphia, PA, that provide SAVAME-related health and/or social services, and their interorganizational collaborations to meet the needs of Philadelphia's Latino communities. We surveyed Latino-serving organizations (N=43) identified through existing resource directories and key informants. Network analyses identified patterns and density of collaborative ties (i.e., referrals, administrative, or planning/advocacy) across organizations and characterized these ties by type of service. Density (expressed as percent of all possible ties) revealed a higher referral rate (40%) than administrative (29%) or planning (26%) coordination. Network sociograms display clusters of providers by geography. Examination of bonding (within-group) ties revealed comparable perceptions of high value among both South/Center Philadelphia (57%) and in North Philadelphia providers (56%), but bridging (between-group) ties suggest lower levels of high-value perceptions (24%). No evident clustering by type of service based on syndemic factor was observed. Density of bridging across types of providers was highest for referrals (38%) followed by planning (23%) and administrative coordination (20%). Interventions to promote collaboration between providers should focus on facilitating administrative and planning collaborations that leverage existing capacity of the network. Given the syndemic nature of these conditions, greater collaboration between providers of complementing SAVAME services is imperative.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research.

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

Examining the impact of medical legal partnerships in improving outcomes on the HIV care continuum: rationale, design and methods.

BACKGROUND: Over the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams' capacity to address social and environmental threats to patients' health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV. METHODS: This on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping. DISCUSSION: The proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience.

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP's utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

The Assets and Challenges of Formerly Incarcerated Latino Men's Social Support Networks in Promoting Healthy Behaviors.

After being exposed to high-risk environments in correctional facilities, formerly incarcerated Latino men (FILM) encounter new risks upon reentering their community of residence including drug use and sexual risk behaviors. Families and close social support networks are critical in potentially mitigating the stressors and risks associated with reentry and reducing the likelihood of recidivism. We conducted a study to examine the material and cognitive assets that familial networks can use to provide support to FILM to engage in health-promoting practices. This analysis is based on linear and logistic regression modeling of cross-sectional data collected through a computer-administered survey with dyads of FILM (ages 18-49, who had been in jail or prison within the past 5 years) and their nominated social network (n = 130 dyads). We found that both male and female social supports (MSS and FSS) have significantly higher levels of structural resources (education and employment) than FILM. Though FSS reported higher self-efficacy on health-promoting practices than FILM, contrary to what we predicted, FILM and FSS/MSS reported similar levels of mental health and behavioral risks. Our results suggest a number of limitations in designing family-based intervention strategies, but they also provided insight into the specificities needed to enhance the social support networks of FILM.

Open Relationships, Nonconsensual Nonmonogamy, and Monogamy Among U.S. Adults: Findings from the 2012 National Survey of Sexual Health and Behavior.

People in open and other consensually nonmonogamous partnerships have been historically underserved by researchers and providers. Many studies group such partnerships together with nonconsensual nonmonogamy (NCNM) under the banner of "concurrent sexual partnerships." Discrimination from service providers poses a substantial barrier to care. Responding to such concerns, this investigation explored sociodemographic correlates with open relationships and associations between relationship structure and sexual risk, HIV/STI testing, and relationship satisfaction in a nationally representative probability sample. Data were drawn from the 2012 National Survey of Sexual Health and Behavior (n = 2270). We used multinomial logistic regression to identify correlates with relationship structure, and linear and logistic regression to investigate associations between relationship structure and testing, condom use, and relationship satisfaction. Eighty-nine percent of participants reported monogamy, 4% reported open relationships, and 8% reported NCNM. Males, gay/lesbian individuals, bisexual individuals, and those who identified as "Other, Non-Hispanic" were more likely to report open relationships. Bisexual individuals and Black, Non-Hispanic participants were more likely to report NCNM; older participants were less likely to do so. Participants in open relationships reported more frequent condom use for anal intercourse and lower relationship satisfaction than monogamous participants. NCNM participants reported more HIV testing and lower satisfaction. Identities, experiences, and behaviors within open and other consensually nonmonogamous populations should be regarded as unique and diverse, rather than conflated with those common to other relationship structures. There is a need for greater awareness of diverse relationship structures among researchers and providers, and incorporation of related content into educational programming.

Anaerobic ammonium oxidation linked to sulfate and ferric iron reduction fuels nitrogen loss in marine sediments.

Availability of fixed nitrogen is a pivotal driver on primary productivity in the oceans, thus the identification of key processes triggering nitrogen losses from these ecosystems is of major importance as they affect ecosystems function and consequently global biogeochemical cycles. Denitrification and anaerobic ammonium oxidation coupled to nitrite reduction (Anammox) are the only identified marine sinks for fixed nitrogen. The present study provides evidence indicating that anaerobic ammonium oxidation coupled to the reduction of sulfate, the most abundant electron acceptor present in the oceans, prevails in marine sediments. Tracer analysis with 15N-ammonium revealed that this microbial process, here introduced as Sulfammox, accounts for up to 5 µg 15N2 produced g-1 day-1 in sediments collected from the eastern tropical North Pacific coast. Raman and X-ray diffraction spectroscopies revealed that elemental sulfur and sphalerite (ZnFeS) were produced, besides free sulfide, during the course of Sulfammox. Anaerobic ammonium oxidation linked to Fe(III) reduction (Feammox) was also observed in the same marine sediments accounting for up to 2 µg 15N2 produced g-1 day-1. Taxonomic characterization, based on 16S rRNA gene sequencing, of marine sediments performing the Sulfammox and Feammox processes revealed the microbial members potentially involved. These novel nitrogen sinks may significantly fuel nitrogen loss in marine environments. These findings suggest that the interconnections among the oceanic biogeochemical cycles of N, S and Fe are much more complex than previously considered.

Long-term health outcomes of childhood sexual abuse and peer sexual contact among an urban sample of behaviourally bisexual Latino men.

While previous research indicates high rates of childhood sexual abuse among Latino men who have sex with men, few studies have examined the long-term health outcomes of childhood sexual abuse specifically among behaviourally bisexual Latino men. In a sample of 148 behaviourally bisexual Latino men in New York City, we examined associations between childhood sexual abuse and multiple dimensions of adult health: sexual risk behaviours; sexually transmitted infections incidence; polydrug use; depressive symptoms; and perceived stress. We compared outcomes between those with histories of childhood sexual abuse, those reporting peer sexual contact prior to age 13 and those with no sexual contact prior to age 13. Over one-fifth (22.3%) reported a history of childhood sexual abuse, which was significantly associated with engaging in receptive condomless anal intercourse (aOR = 3.59, p < .01, SE = 2.0), high perceived stress (aOR = 2.48, p < .06, SE = 1.13) and clinically significant depressive symptoms (aOR = 2.7, p < .05, SE = 1.25). Across all variables, peer sexual contact did not impact these outcomes, underscoring a key distinction between abusive and non-abusive early sexual experiences. We recommend that sexual abuse prevention policies and programmes better engage Latino youth, and that practitioners serving this population across diverse areas of practice incorporate childhood sexual abuse screening and culturally appropriate treatment and care into practice.

Child Sexual Abuse and Adult Mental Health, Sexual Risk Behaviors, and Drinking Patterns Among Latino Men Who Have Sex With Men.

One in five Latino men who have sex with men has experienced child sexual abuse. Although concerning in itself, child sexual abuse may increase an individuals' likelihood of depression and risk-taking in adult life, including engagement in HIV risk behaviors and alcohol and substance use. It is therefore urgent that researchers and practitioners better understand the long-term effects of child sexual abuse. We utilized logistic and linear regression to assess associations between child sexual abuse (operationalized as forced or coerced sexual activity before age 17) and depression, sexual behaviors, and drinking patterns in a sample of 176 adult Latino men who have sex with men from New York City. Over one-fifth (22%) of participants reported child sexual abuse. In multivariable models, participants with histories of child sexual abuse were significantly more likely than participants without such histories to screen for clinically significant depressive symptoms and heavy drinking and reported more anal sex acts, male sexual partners, and incidents of condomless anal intercourse in the previous three months. These findings confirm a high prevalence of child sexual abuse among Latino men who have sex with men and associations between child sexual abuse and adulthood depressive symptoms, high-risk alcohol consumption, and sexual risk behaviors. We recommend that providers who serve Latino men who have sex with men incorporate child sexual abuse screenings into mental health, HIV prevention, and substance use treatment programs, utilizing approaches that are inclusive of resilience.

Relationship Factors Associated with Sexual Risk Behavior and High-Risk Alcohol Consumption Among Latino Men Who Have Sex with Men: Challenges and Opportunities to Intervene on HIV Risk.

The HIV epidemic continues to be a major public health concern, affecting communities with varying prevention and treatment needs. In the U.S., Latino men who have sex with men (MSM) bear a disproportionate burden of HIV incidence. While recent studies have highlighted the relevance of relationship factors for HIV transmission among MSM generally, the unique needs and experiences of Latino MSM have received relatively little attention. Consequently, associations between relationship factors and HIV risk among Latino MSM remain unknown. This mixed-method study examined relationship status and dynamics and potential HIV-related risk behaviors among Latino MSM. Quantitative analyses with 240 Latino MSM investigated associations between relationship status and engagement in condomless anal intercourse (CAI). Focus groups with 20 Latino male couples and 10 health service providers explored the impact of relationship dynamics on sexual behaviors, as well as opportunities to intervene on HIV risk. The majority of participants were predominantly Spanish speaking, most screened positive for high-risk alcohol consumption in the past month, more than half engaged in CAI in the past 3 months, and a majority reported multiple sexual partners in this period. Among participants in same-sex relationships (n = 175), approximately half reported multiple partners in the previous 3 months and more than two-thirds reported CAI in this time period. Being in a same-sex relationship was positively associated with high-risk alcohol consumption and being age 30 or older and negatively associated with having multiple partners. Moreover, being in a same-sex relationship significantly increased the likelihood that participants would report engaging in CAI. Qualitative analyses identified themes related to relationship dynamics and sexual behavior, as well as opportunities to intervene on HIV risk. Despite the challenges encountered by Latino male couples, most participants expressed commitment to and support for their partners. As such, prevention efforts involving Latino male couples must address relationship dynamics and the role they play in sexual health, including safer sex practices.

"The Pleasure Is Better as I've Gotten Older": Sexual Health, Sexuality, and Sexual Risk Behaviors Among Older Women Living With HIV.

There is limited research examining the sexual health and well-being of older women living with HIV (OWLH). Most studies focus on sexual dysfunction, leaving aside the richer context of sexuality and sexual health, including the effect of age-related psychosocial and interpersonal changes on sexual health behaviors. Guided by the integrative biopsychosocial model and the sexual health model, this study explored the importance of sex and sexuality among OWLH to identify their sexual health and HIV prevention needs for program planning. A purposive sample (n = 50) of OWLH was selected from a parent study (n = 2052). We conducted 8 focus groups and 41 in-depth interviews with 50 African American and Latina OWLH aged 50-69 years old in three U.S. cities. The triangulation approach was used to synthesize the data. Six salient themes emerged: sexual pleasure changes due to age, sexual freedom as women age, the role of relationships in sexual pleasure, changes in sexual ability and sexual health needs, sexual risk behaviors, and ageist assumptions about older women's sexuality. We found that sexual pleasure and the need for intimacy continue to be important for OWLH, but that changing sexual abilities and sexual health needs, such as the reduction of sexual desire, as well as increased painful intercourse due to menopause-associated vaginal drying, were persistent barriers to sexual fulfillment and satisfaction. Particular interpersonal dynamics, including low perceptions of the risk of HIV transmission as related to gender, viral suppression, and habitual condomless sex with long-term partners without HIV transmission have resulted in abandoning safer sex practices with serodiscordant partners. These findings suggest that HIV prevention for OWLH should focus on how sexual function and satisfaction intersect with sexual risk. HIV prevention for OWLH should promote ways to maintain satisfying and safe sex lives among aging women.

Latino men who have sex with transgender women: the influence of heteronormativity, homonegativity and transphobia on gender and sexual scripts.

Latino men who have sex with transgender women make up an overlooked sector of the population that requires more attention than is currently given in sexuality and gender studies, particularly in regard to their non-commercial, long-term sexual and romantic relationships with transgender women. Sixty-one sexual histories were selected for this qualitative analysis from a larger study on Latino male bisexuality in the New York City metropolitan area. Findings suggest that participants' sexual and gender scripts with transgender women are strongly regulated by heteronormativity. Furthermore, homonegativity and transphobia often intersect in the lived experiences of men who have sex with transgender women, resulting in relationship conflicts over the control of transgender women's bodies, sexual behaviours and gender performance both in public and in private. Findings also suggest that low relationship conflict is more common among men who have sex with transgender women who exhibit diverse sexual roles (being both insertive and receptive during anal sex), or transgress heteronormative scripts through dialogue of desires and/or by embracing transgender women as human beings and not as hyperfeminised objects of desire. Stigma reduction and alternatives to heteronormative interventions are needed to improve relationship dynamics and potentially positively impact on the sexual health and overall wellbeing of Latino men who have sex with transgender women and their transgender partners.

Retention of South African Adolescents in a 54-Month Longitudinal HIV Risk Reduction Trial.

Retention of participants in clinical trials is a central concern of HIV/STI behavioral researchers and research sponsors. This article describes the strategies used for addressing the challenges in retaining South African adolescents for a 54-month longitudinal study. The objective of the South African adolescent health promotion long-term follow-up trial was to test the sustainability of the effects of an HIV/STI risk reduction intervention, "Let Us Protect Our Future," on young adolescents as they aged into middle and late adolescence. Inaccurate contact information, invalid mobile telephone numbers, lack of transportation, transitory family addresses, and family relocation were among the challenges to retaining participants. Despite a significant gap in time of 36 months between the main trial and the long-term follow-up study, 99.2% of 1057 participants were retained. Solutions used for retaining the adolescents are discussed with suggestions offered for retaining adolescents in longitudinal HIV/STI prevention clinical trials in low resource countries.

Correlates of HIV and STI testing among Latino men who have sex with men in New York City.

We assessed the extent to which sociodemographic, personal, and behavioral factors are associated with human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing among a diverse group of Latino men who have sex with men (MSM) in New York City. The triangulation approach was used to synthesize data from 176 MSM who completed an in-person or phone questionnaire about substance use, alcohol consumption, sexual behaviors, and HIV/STI testing history and 40 participants who participated in focus groups. Correlates of testing significant in univariable analyses (p < .05) were entered into multivariable logistic regression models. Over half (57.9%) of study subjects tested for HIV in the previous 12 months and 60.2% tested for STIs in the previous 12 months. Age and education were positively correlated with HIV testing in multivariable analysis. No significant correlates of STI testing were identified. Spanish-speaking only subjects were less likely to get tested for HIV and STI; however, this association was not significant. Our study demonstrates the need for further study of predictors of STI testing as well as the potential role of language barriers and education in routine testing for HIV. Social and behavioral factors may intensify these obstacles. Future research and interventions should address the role of language barriers and perceived issues of immigration status in the decision to get tested.

Adapting the Get Yourself Tested Campaign to Reach Black and Latino Sexual-Minority Youth.

BACKGROUND: Culturally appropriate efforts are needed to increase sexually transmitted disease (STD) testing and care among Black and Latino sexual-minority youth, who are at high risk for STDs. Get Yourself Tested, a national testing campaign, has demonstrated success among youth, but it has yet to be assessed for relevance or impact among this population. METHOD: This effort included (1) formative and materials-testing research through focus groups; (2) adaptation of existing Get Yourself Tested campaign materials to be more inclusive of Black and Latino sexual-minority youth; (3) a 3-month campaign in four venues of New York City, promoting STD testing at events and through mobile testing and online and social media platforms; (4) process evaluation of outreach activities; and (5) an outcome evaluation of testing at select campaign venues, using a preexperimental design. RESULTS: During the 3-month campaign period, the number of STD tests conducted at select campaign venues increased from a comparable 3-month baseline period. Although testing uptake through mobile vans remained low in absolute numbers, the van drew a high-prevalence sample, with positivity rates of 26.9% for chlamydia and 11.5% for gonorrhea. This article documents the process and lessons learned from adapting and implementing a local campaign for Black and Latino sexual-minority youth.