Green dialysate and gallbladder perforation in a peritoneal dialysis patients: a case report and literature review.

BACKGROUND: Gallbladder perforation is a rare but lethal condition and its diagnosis is usually difficult and delayed. Frequently, gallbladder rupture is associated with cholecystitis, but spontaneous perforation was ever described. However, spontaneous rupture of gallbladder has never been reported in patients underwent peritoneal dialysis. CASE PRESENTATION: We report a 62-year-old man who presented with abdominal pain for 2 days to clinic. Peritoneal dialysis-related peritonitis was diagnosed initially. It was followed by spontaneous gallbladder perforation with greenish dialysate. The patient was managed successfully by antibiotic treatment and primary closure of gallbladder perforation with external drainage. He recovered from this critical condition and stayed on dialysis. CONCLUSIONS: Early diagnosis and timely surgical intervention yields a good prognosis in PD patients with gallbladder perforation. Surgical intervention and antibiotic treatment are the mainstay of treatment. Both of them should take place promptly.

Fabrication of Bi­Sb­Te Thermoelectric by Cold-Pressed Sintering for Motorcycle Exhaust.

This study was conducted on the Bi­Sb­Te thermoelectric material which is cold-pressed Sintering under 750 Mpa to make square thermoelectric pairs with size 8.2 mm × 8.2 mm and thicknesses 0.8 mm and 1.5 mm. The zone melting method was used to acquire P-type thermoelectric material Bi0.4Sb1.6Te3 and N-type thermoelectric material Bi2Te2.5Se0.5. At temperature 383 K, the measured Seebeck coefficient of Bi0.4Sb1.6Te3 is 222 µV/K, and its thermoelectric figure of merit ZT is 1.35. At temperature 400 K, the measured Seebeck coefficient of Bi2Te2.5Se0.5 is 210 µV/K, and its thermoelectric figure of merit ZT is 1.13. Using Solder paste Sn42Bi58 and copper electrode plate are in series connection with 16 pieces of P/N thermoelectric material to form thermoelectric modules. The thermoelectric module is actually pasted on the motorcycle waste heat source to be evaluated the performance, making the cold-end temperature dissipation heat can enhance the temperature difference between it so as to increase the output power. Increasing the leg thickness of thermoelectric module and making the about 35 °C temperature-difference of those can obviously enhance the performance of in terms of its voltage, its thermoelectric figure of merit ZT and output power of the thermoelectric modules.

The efficacy of a self-management programme for people with diabetes, after a special training programme for healthcare workers in Taiwan: a quasi-experimental design.

AIMS AND OBJECTIVIES: To analyse the efficacy of improving disease management after implementing a self-management programme for people with type 2 diabetes administered by healthcare workers who have received special training. BACKGROUND: The needs for diabetic care include increased training for healthcare providers to enhance their confidence and skills in managing patients, both physically and mentally. DESIGN: Quasi-experimental design. METHODS: This study recruited participants from outpatient clinics in 10 hospitals in Taiwan. In 2010, purposive sampling was used to recruit 228 participants from two medical centres, five regional hospitals and three district hospitals. Participants were enrolled in a 'diabetes self-management programme' (watching patient videos, reading a diabetes self-care handbook, participating in four consultation courses of diabetes self-efficacy improvement, telephone follow-up and positive reinforcement). Efficacy analysis of post-test diabetes outcome variables of the experimental group was carried out. Sex, age and pretest score were used as the control variables for ancova test. RESULTS: Patients in the experimental group had significant improvement in body mass index (p < 0·01), waistline circumference (p < 0·001), haemoglobin A1C levels (p < 0·001), degrees of anxiety and depression (p < 0·001), self-efficacy (p < 0·001) and levels of self-care (p < 0·001). CONCLUSION: Self-efficacy of people with diabetes can be effectively improved by planned implementation of a 'diabetes self-management programme' by trained healthcare workers. RELEVANCE TO CLINICAL PRACTICE: The diabetes care professionals are provided the self-management programme to strengthen the awareness and importance of self-management in diabetes care.

Bidirectional referral system between National Taiwan University Hospital medical center and Zhongxiao Branch community hospital of Taipei City Hospital: focus on patient satisfaction.

The policy of bidirectional referral between National Taiwan University Hospital and Taipei City Hospital has been launched due to the over-crowding of the emergency department at National Taiwan University Hospital. This research aims to evaluate patient satisfaction with the bidirectional referral. Sixty-six patients have been referred from the emergency department of National Taiwan University Hospital to Taipei City Hospital, Zhongxiao campus from April 2015 to December 2017. The selection criteria of the subjects for bidirectional referral include the management of patients classified as triage classification 2 or 3. Exclusion criteria are as follows: incomplete patient records and patients who chose hospice care. Sixty-six patients completed the questionnaires. Multivariate regression was used to evaluate the determinants of overall satisfaction scores of the bidirectional referral. The two overall satisfaction scores of patients were high (> 7). Three independent variables, (1) overall satisfaction scores of medical care at Taipei City Hospital, Zhongxiao campus, (2) waiting times for examination, treatment, and test, and (3) a positive question regarding quality improvement of delivered care for patients and family explained 69.3% adjusted variability of the overall satisfaction scores of bidirectional referrals. Therefore, the policy of bidirectional referrals and direct admission into the wards of Taipei City Hospital, Zhongxiao campus, from the emergency department of National Taiwan University Hospital met the criteria for patient satisfaction and public accountability.

Impaired microvascular flow motion in subclinical diabetic feet with sudomotor dysfunction.

Impaired cutaneous blood flow and sweating dysfunction might be among the earliest manifestations of diabetic autonomic neuropathy. This study assessed the pathophysiological basis underlying skin vasomotion changes and their relation with progressive sudomotor dysfunction and other autonomic and somatic measures in subclinical diabetic feet. Laser Doppler skin perfusion was assessed on 68 diabetic and 25 control subjects. The low-frequency vasomotion was transformed into three frequency intervals 0.0095-0.021, 0.021-0.052 and 0.052-0.145 Hz, respectively, for the investigation of endothelial, neurogenic and myogenic effects on microcirculatory alterations. The diabetic patients were categorized into three groups by increasing severity of sudomotor dysfunction: SSR+ (sympathetic skin response present; 27 patients), SSR- (SSR absent; 23 patients) and at-risk (SSR absent and of preulcerative cracked skin; 18 patients). All diabetic patients underwent nerve conduction and cardiovascular autonomic studies. The total spectral and endothelial activity was significantly decreased only in the at-risk group. The SSR- group had lower neurogenic vasomotion than the SSR+ group (p<0.05). Although no statistical difference was noted between any group in absolute myogenic spectrum, the SSR- group had higher normalized myogenic activity than the SSR+ group (p<0.01). The larger drop in orthostatic pressure was paralleled by a reduction in the myogenic amplitude (r=-0.33, p<0.01). These results suggested that early impairment of low-frequency flow motion correlated closely with the presence of sudomotor dysfunction of subclinical feet mainly in neurogenic and endothelial components. Impaired systemic vascular tone as manifested by orthostatic hypotension was proportional to the degree of myogenic dysregulation in diabetic patients.

Analysis of the electron transport properties in dye-sensitized solar cells using highly ordered TiO2 nanotubes and TiO2 nanoparticles.

This study uses TiO2 nanoparticles and highly ordered anatase TiO2 nanotubes (AOTnt) as thin film photoanodes for dye-sensitized solar cells (DSSCs). DSSCs are assembled by single-layer and double-layer films of photoanodes and their electron transfer performance is compared. TiO2 nanoparticles were fabricated by the sol-gel method, and AOTnts were grown on titanium foil. This study uses TiO2 nanoparticles or AOTnts to prepare single-layer photoanodes and TiO2 nanoparticles coated on an AOTnt film to fabricate double-layer photoanodes. These three different photoanodes are soaked in dye and assembled into DSSCs, and their open-loop voltage recession, electrochemical impedance, lifetime, life cycle, and effective diffusion coefficient are measured. Electron transfer efficiency of the photoanodes and light harvesting efficiency are further analyzed. The results show that the electron transfer efficiency, open-loop voltage recession, lifetime, life cycle, and effective diffusion coefficient of the DSSCs assembled using double-layer photoanodes (AOTnt-TiO2) are superior to those of single-layer photoanodes (TiO2 or AOTnt).

Probable mechanisms of needling therapies for myofascial pain control.

Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia cannot be explained by any single mechanism. There are several principles for selection of acupoints based on the TCM principles: "Ah-Shi" point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.

Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies.

Objective. The purpose of this pilot study is to investigate the effectiveness of the percutaneous soft tissue release for the treatment of recurrent myofascial pain in the forearm due to recurrent lateral epicondylitis. Methods. Six patients with chronic recurrent pain in the forearm with myofascial trigger points (MTrPs) due to chronic lateral epicondylitis were treated with percutaneous soft tissue release of Lin's technique. Pain intensity (measured with a numerical pain rating scale), pressure pain threshold (measured with a pressure algometer), and grasping strength (measured with a hand dynamometer) were assessed before, immediately after, and 3 months and 12 months after the treatment. Results. For every individual case, the pain intensity was significantly reduced (P < 0.01) and the pressure pain threshold and the grasping strength were significantly increased (P < 0.01) immediately after the treatment. This significant effectiveness lasts for at least one year. Conclusions. It is suggested that percutaneous soft tissue release can be used for treating chronic recurrent lateral epicondylitis to avoid recurrence, if other treatment, such as oral anti-inflammatory medicine, physical therapy, or local steroid injection, cannot control the recurrent pain.

Remote subcutaneous needling to suppress the irritability of myofascial trigger spots: an experimental study in rabbits.

Objective. To obtain electrophysiological effects of Fu's subcutaneous needling (FSN) on needling distance by assessment of endplate noise (EPN) recorded from the myofascial trigger spots (MTrSs) in rabbit skeletal muscle. Method. Eighteen New Zealand rabbits weighing 2.5-3.0 kg were randomly divided into two groups as follows: proximal needling (PN) group and distal needling (DN) group. The needling procedure followed the instructions described by the inventor of FSN, including needling insertion and swaying movement. The amplitudes of EPN on the MTrS region of BF muscle were recorded as an index of MTrS irritability. Random sampling of EPN tracings were taken for further analyses before, during, and after FSN treatment. Results. In PN and DN groups, the trends of EPN amplitude alterations were similar at conditions before, during, and after FSN treatment. The degree of reduction in the EPN amplitude in PN group was significantly higher than that in DN group. There were no significant changes in EPN amplitudes in the MTrS of contralateral BF without FSN intervention either in DN or PN group. Conclusion. The irritability of proximal MTrSs could be modulated after ipsilateral FSNs. The placement of FSN may affect the effectiveness of suppression of irritability of MTrSs.

Mechanical pain sensitivity of deep tissues in children--possible development of myofascial trigger points in children.

BACKGROUND: It is still unclear when latent myofascial trigger points (MTrPs) develop during early life. This study is designed to investigate the mechanical pain sensitivity of deep tissues in children in order to see the possible timing of the development of latent MTrPs and attachment trigger points (A-TrPs) in school children. METHODS: Five hundreds and five healthy school children (age 4- 11 years) were investigated. A pressure algometer was used to measure the pressure pain threshold (PPT) at three different sites in the brachioradialis muscle: the lateral epicondyle at elbow (site A, assumed to be the A-TrP site), the mid-point of the muscle belly (site B, assumed to be the MTrP site), and the muscle-tendon junction as a control site (site C). RESULTS: The results showed that, for all children in this study, the mean PPT values was significantly lower (p < 0.05) at the assumed A-TrP site (site A) than at the other two sites, and was significantly lower (p < 0.05) at the assumed MTrP site (site B) than at the control site (site C). These findings are consistent if the data is analyzed for different genders, different dominant sides, and different activity levels. CONCLUSIONS: It is concluded that a child had increased sensitivity at the tendon attachment site and the muscle belly (endplate zone) after age of 4 years. Therefore, it is likely that a child may develop an A-Trp and a latent MTrP at the brachioradialis muscle after the age of 4 years. The changes in sensitivity, or the development for these trigger points, may not be related to the activity level of children aged 7-11 years. Further investigation is still required to identify the exact timing of the initial occurrence of a-Trps and latent MTrPs.

Effectiveness of a community-based health promotion program targeting people with hypertension and high cholesterol.

The purpose of this study was to evaluate the effectiveness of a community-based health promotion program targeting people with hypertension and high cholesterol. A pre-experimental study was conducted. A total of 60 residents were recruited to participate. Participants were assessed at baseline and at a 6 month follow up at a regional hospital in northern Taiwan. The questionnaires used for data collection consisted of an assessment of self-efficacy, self-care activities, health outcomes, and physical fitness. Several teaching resources were used, including a DVD, a self-care booklet, group support (exercise and counseling sessions), and telephone follow up. A significant decrease in waist circumference (t = 2.20, P = 0.03) and high density lipoprotein-cholesterol level (t = 4.71, P < 0.00) was found at follow up. Moreover, the level of physical fitness activity, and sit-ups specifically (t = 3.10, P < 0.00), was increased. Participants also showed significant increases between baseline and 6 month follow up in their efficacy expectation score (t = -5.81, P < 0.00), outcome expectation scores (t = -4.76, P < 0.00) and self-care behavior scores (t = -2.78, P = 0.007). The community-based health promotion program is an effective means of helping people with hypertension and high cholesterol and should be instituted regularly and evaluated in clinical practice.

Experimental analysis of nanomechanics of spherical titanium oxide nanooils in reducing friction.

This work explores the nanomechanics of sphere titanium oxide nanooils in reducing friction between two pieces of cast iron. A friction test is performed using an ATE-77 Reciprocal Tribological Tester made by Cameron-Plint Tribology Limited, England. The friction between two pieces of cast iron was determined 25-135 degrees C using home-made titanium oxide nanooils. In elastohydrodynamic lubrication (EHL), the lubricant is subjected to enormous pressures, there is considerable local heating, and the assumption of constant viscosity no longer holds up. The derivation of the governing equations for elastohydrodynamic lubrication, the pressure and temperature dependence of viscosity is recognized after the lubrication thin film approximation has been made. The viscosity of the nanooils consistently exceeded that of the paraffin oil enlarging the partial EHL area with a complete lubricating film between two move iron surfaces. The spherical geometry of TiO2 nanoparticles caused them to act as a rolling medium when the machine parts move which is in the solid friction area. Because they provide a rolling function, spherical titanium oxide nanoparticles have feasible tribological and lubrication applications in the mechanical industry to reduce noise, vibration and friction wear.

Serial ultrasonographic findings of plantar fasciitis after treatment with botulinum toxin a: a case study.

Plantar fasciitis is a common cause of heel pain and is the result of a degenerative process of the plantar fascia at its calcaneal attachment. A case study of a preliminary experience with local injections of botulinum toxin A (BTX-A) for the treatment of chronic plantar fasciitis in a 43-year-old woman is presented. We injected the patient with 70 units of BTX-A (0.7mL) in 2 divided doses: 40 units (0.4mL) in the tender region of the heel, and 30 units (0.3mL) in the most tender point of the foot arch. Visual analog scale (VAS) and pressure pain threshold (PPT) were measured to evaluate the efficacy of BTX-A injections. Real-time, high-resolution ultrasonographic findings of the plantar fascia after BTX-A injections were also used for serial follow-ups. After BTX-A injection, decreased VAS values were reported and increased PPT was observed. In ultrasonographic studies, the thickness of the plantar fascia and the hypoechogenicity of the fascia were reduced. Decreased plantar fascia thickness was observed on the first and third week after BTX-A injections. The findings were compatible with the changes in pain assessed by VAS and PPT. Ultrasonographic findings also indicated a progressive decrease in the thickness of the underlying muscle belly. Ultrasonography seems to be a valuable, noninvasive diagnostic tool for the evaluation of plantar fasciitis treated with BTX-A injections. It can offer objective measurements of therapeutic effects and is feasible for serial follow-ups.

Electromagnetic shielding effectiveness of thin film with composite carbon nanotubes and stainless steel fibers.

Using the polymer blending method, conductive materials and waterborne polyurethane (WPU) were mixed to fabricate conductive composite films for application in electromagnetic shielding. First, nitric acid was used to purify the multi-walled carbon nanotubes (MWCNT). Second, sodium dodecyl sulfate (SDS) was utilized to disperse the carbon nanotubes, and then they were mixed with 8 microm diameter and 2 mm long stainless steel fibers (SSF) in the WPU by the polymer blending method. Finally, the thickness of 0.25 mm of conductive composite film was fabricated by means of coating. According to the ASTM D4935-99 standard, a coaxial transmission line was used to measure the electromagnetic shielding effectiveness (EMSE) of conductive composite film within the range of 50 MHz approximately 3.0 GHz. Moreover, the influence of the prior and posterior dispersion of carbon nanotubes dispersed on electromagnetic shielding was dealt with in the paper. Results demonstrated that the conductive composite film, within 50 MHz approximately 3.0 GHz, fabricated by the 15 wt% of the multi-walled carbon nanotubes and 30 wt% of the stainless steel fibers can achieve the maximum of the electromagnetic shielding effectiveness, 34.86 dB, and its shielding effect, 99.9%.

Fabrication and characterization of photoelectrode thin films with different morphologies of TiO2 nanoparticles for dye-sensitized solar cells.

This study deals with the fabrication of three different morphologies of TiO2 nanoparticles to fabricate two-layer photoelectrode thin film for dye-sensitized solar cells (DSSC). The four different TiO2 morphologies are titania nanotubes (Tnt), TiO2 nanoparticles (H220), TiO2 nanoparticle (SP) and commercial DP-25 nanoparticles (P-25). To prepare the thin films of the photoelectrodes, the first layer is coated by H220 TiO2 nanoparticles, and the second is coated by 3 kinds of materials optimally proportionally mixed - P25, SP and Tnt. The photoelectric conversion efficiency of DSSCs with photoelectrodes fabricated using H220 reached 6.31%. Finally, the TiO2 nanaomaterials with four different morphologies were used to prepare a two layer photoelectrode with the structure of H220/P25-Tnt-SP which was combined with a Pt counter electrode to assemble DSSCs. These DSSCs had photoelectric conversion efficiencies of as high as 7.47%.

Thermoelectric properties of Sb2Te3 thin films by electron beam evaporation.

This study applies the thermoelectric grains of Sb2Te3 on conductive glass to evaporate Sb2Te3 thin films by the electron beam evaporation method. Through experimental tests with different evaporation process parameters and film annealing conditions, thin films with better Seebeck coefficient, resistivity (p) and power fact (PF) can be obtained. Experimental results show that when thin films are annealed, their defects can be decreased accordingly, and carrier mobility can be enhanced to further elevate the conductivity of thin films. When the substrate temperature is set at 200 degrees C to fabricate Sb2Te3 thin films by the evaporation process and by annealing at 220 degrees C for 60 minutes, the Seebeck coefficient of Sb2Te3 thin films increase from 87.6 microV/K to 177.7 microV/K; resistivity falls from 6.21 m ohms-cm to 2.53 m ohms-cm and PF can achieve the maximum value of 1.24 10(-3) W/K2 m. Finally, this study attempts to add indium (In) to Sb2Te3 thin films. Indium has been successfully fabricated In3SbTe, thin films. This study also analyzes the effects of In on the thermoelectric properties of In3SbTe2 thin films.

Synthesis and characterization of natural dye and counter electrode thin films with different carbon materials for dye-sensitized solar cells.

This study aims to deal with the film of the counter electrode of dye-sensitized solar cells (DSSCs) and the preparation, structure and characteristics of the extract of natural dye. This study adopts different commercial carbon materials such as black lead, carbon black and self-made TiO2-MWCNT compound nanoparticle as the film of the counter electrodes. Moreover, for the preparation of natural dyes, anthocyanins and chlorophyll dyes are extracted from mulberry and pomegranate respectively. Furthermore, the extracted anthocyanins and chlorophyll are blended into cocktail dye to complete the preparation of natural dye. Results show that the photoelectric conversion efficiency of the single-layer TiO2-MWCNT counter electrode film and the cocktail dye of the DSSCs is 0.462%.

Effects of an osteoarthritis self-management programme.

AIM: The aim of this study was to assess the effectiveness of a self-management programme among osteoarthritis knee sufferers. BACKGROUND: Osteoarthritis of the knee is a major cause of loss of function and is common in the older people. A self-management programme is an effective way to increase arthritis self-efficacy, and helps with mastering self-management practices. METHOD: This study was carried out from January 2008 to December 2008 and included 205 participants, with 114 in the intervention group and 91 in the control group. The 4-week trial was followed by an 8-week follow-up assessment. The outcome measures included assessments of arthritis self-efficacy, pain beliefs, unplanned medical consultations, pain days and disability days using the Mann-Whitney U-test and Friedman test. FINDINGS: At post-intervention, significant differences were found in pain beliefs (P<0·001) and pain days (P<0·004). At 8-week follow-up, there was a significant improvement in arthritis self-efficacy: pain and other symptoms subscales (P<0·001 and 0·049, respectively), pain beliefs (P<0·001) and number of unplanned medical consultations (P<0·010). CONCLUSION: The study supports the hypothesis that a self-management programme enhances arthritis-related self-efficacy and pain beliefs. A decrease in the number of unplanned medical consultations, pain days and disability days suggests that the programme might help reduce healthcare costs. This programme has introduced a significant result about self-efficacy and self-management to a chronic disease population in Taiwan. In short, there were great beneficial effects on self-management among persons who are affected by knee osteoarthritis.

The fabrication and properties of Ag/Ni nanocomposite fluid.

In this article, an arc-submerged nanofluid synthesis system is proposed and developed for Ag/Ni nanocomposite fluid fabrication. In the fabrication process, the positive electrode uses an Ag rod and the negative electrode uses a Ni rod, with the two electrodes processed in the dielectric liquid. The nanocomposite fluid generated by the synthesis system is analyzed by morphological analysis, heat transfer analysis, magnetic analysis and the UV-Vis spectrophotometer optical property analysis. Experimental results show that the Ag/Ni nanocomposite fluid has a very high Zeta potential of 45 mV, so that without dispersant it can remain stabile longer than five months. Testing the Ag/Ni nancomposite fluid magnetism by SQUID, shows that paramagnetism appears in the nanocomposite fluid. Moreover, the Ag/Ni nanocomposite fluid preserves both the nickel's magnetic characteristic and silver's absorption capability to visible light.

Application of TiO2 nanoparticles coated multi-wall carbon nanotube to dye-sensitized solar cells.

This study uses the sol-gel method to prepare TiO2 nanoparticle, and further applies TiO2 nanoparticle coating on the surface of the multi-wall carbon nanotube (MWCNT). As a result, TiO2-CNT composite nanoparticles are prepared to serve as photoelectrode material in dye-sensitized solar cell (DSSC). First, after acid treatment of MWCNT is used to remove impurities. Then, the sol-gel method is employed to prepare TiO2-CNT composite nanopowder. X-ray diffraction (XRD) pattern shows that after the TiO2 in TiO2-CNT composite nanopowder has been thermally treated at 450 degrees C, it can be completely changed to anatase phase. Furthermore, as shown from the SEM image, TiO2 has been successfully coated on CNT. The photoelectrode of DSSC is prepared using the electrophoretic deposition method (EPD) to mix the Degassa P25 TiO2 nanoparticles with TiO2-CNT powder for deposition on the indium tin oxide (ITO) conductive glass. After secondary EPD, a thin film of TiO2/CNTs with thickness 17 microm can be acquired. For the prepared TiO2-CNT composite nanoparticles, since MWCNT can increase the short-circuit current density of DSSC, the light-to-electricity conversion efficiency of DSSC can be effectively increased. Experimental results show that the photoelectric conversion efficiency of DSSC using CNT/TiO2 photoelectrode and N719 dye is increased by 41% from the original 3.45% to 4.87%.