The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender surgery.

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males.

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

The anatomy of abdominal flap phalloplasty for transgender surgery.

Abdominal flap phalloplasty is surgical construction of a neophallus using a pedicled abdominal flap for patients transitioning female to male, for males whose penis is congenitally absent, or lost from trauma. It is an option for trans men whose goals do not require urethroplasty or vaginectomy but would like a phallus suitable for male gender appearance. A prosthesis can be placed for penetrative sexual capability. Surgical text descriptions were enhanced by creation of new anatomic illustrations. Anatomy of donor site and surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. Significant structures of the donor site of the abdominal flap include the superficial external pudendal artery and ilioinguinal nerve that provide the blood supply and sensory innervation to the base of the flap, respectively. As a pedicled phalloplasty procedure, microsurgical anastomosis is not needed. Patients can expect to have tactile sensation but not innate rigidity. The dorsal nerve of clitoris (and sometimes the clitoris itself) is preserved to provide erogenous sensation. Abdominal flap phalloplasty makes it possible to maintain the natural blood supply and innervation to the neophallus. The neophallus created by abdominal flap phalloplasty has the advantage of homogeneous skin color and texture from contiguous skin. Grafting leaves a less stigmatizing horizontal scar running from one side of the pelvis to the other along the lower abdomen. The anatomy of the abdominal flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:181-186, 2018. © 2017 Wiley Periodicals, Inc.

Neovaginal Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application.

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc.

Perceptions of the living dead: An assessment of knowledge and opinions about whole body donation, its process, and willingness to become cadaveric donors in Pennsylvania.

Despite the many important uses for human cadavers, there is a relative shortage of bodies donated to the scientific community in the United States of America. The purpose of this study was to determine the community's perceptions regarding whole body donation and their willingness to become donors. Moreover, we aimed to investigate people's understanding of the process of whole body donation, and examine their opinions regarding its importance. Individuals in Erie, Pennsylvania were surveyed. Data were collected via a questionnaire, which was offered to friends and family members of patients in the waiting area of the UPMC Hamot Surgery Center. All participants were residents of Erie County. The questionnaire was designed to evaluate knowledge and opinions about whole body donation. A total of 123 people completed the survey. We found people were willing to become whole body donors and understood the importance of this giving act, but lacked understanding about the registration process and the use of donated bodies. Participants revealed the belief that they have the right to decide what is to be done with their bodies after death, but did not indicate specific negative repercussions of becoming whole body donors. In conclusion, our findings indicate that the shortage of cadaveric donors could be due to lack of understanding about whole body donation and the registration process.

Prehospital mass-casualty triage training-written versus moulage scenarios: how much do EMS providers retain?

INTRODUCTION: The aim of this study was to assess the effectiveness of written and moulage scenarios using video instruction for mass-casualty triage by evaluating skill retention at six months post intervention. METHODS: Prehospital personnel were instructed in the START method of mass-casualty triage using a video. Moulage and written testing were completed by each participant immediately after instruction and at six months post instruction. RESULTS: There was a significant decrease in performance between initial and six-month testing, indicating skill decay and loss of retention of triage skills after an extended nonuse period. There were no statistically significant differences between written and moulage testing results at either initial testing or at six months. Prior skill level did not influence test performance on the type of testing conducted or long-term retention of triage skills. CONCLUSION: These data confirm the skill deterioration associated with an infrequently used triage method. Further research to more precisely define triage criteria, as well as the ability to apply the criteria in a clinical setting and to rapidly identify patients at risk for morbidity/mortality is needed.

Flipped Classroom With Artificial Intelligence: Educational Effectiveness of Combining Voice-Over Presentations and AI.

BACKGROUND: Most theorists and medical educators agree that a curriculum rich in active learning (AL) strategies, such as a flipped classroom, is superior to passive listening to promote better retention and application of new knowledge. Although AL multimodal teaching strategies have been considered the most effective, including online virtual teaching, voice-over pre-recorded lectures, and, more recently, the addition of artificial intelligence (AI), data on the effectiveness of these methods in medical education is scarce. The present educational research study examined the effectiveness of voice-over-style lectures and AI in facilitating learning outcomes as assessed by test scores after participating in basic science lectures in a medical school setting. METHODS: Participating students were divided equally into two educational strategy groups: slide decks only traditional way (PPT) or PPT plus AI (PPT+AI) platform (edYOU; Los Angeles, CA, USA). The PPT+AI group comprised the PPT with narration and real-time interaction with an AI being personalized, which leverages natural language processing to tailor customized conversations to each student's current knowledge. Students in the two groups were asked to participate in a formative quiz (not reflective of their academic evaluations) to answer questions relevant to voice-over lectures (PPT and PPT+AI). The statistical strategy for conducting quiz item analysis included item difficulty, item discrimination, and point-biserial correlation R. A student's T-test was conducted to compare the two strategies' effectiveness via test scores. A priori, an alpha level of 0.05 was considered significant. RESULTS:  Data are presented as mean ± s.e.m.; Cohen's d. A total of 42 (n=21 in each group) students participated in the study. Students using PPT+AI obtained statistically significant (P <0.043; d = .54) higher quiz scores under challenging questions and less time spent in lectures (54.1 ± 14.3 hrs.) in the PPT+AI group (P <0.001; d = 1.17) compared with the PPT group.  Conclusions: The PPT+AI strategy could be the difference between a pass and a fail, as the PPT+AI strategy is particularly efficient in improving difficult question test scores. At the same time, students may learn the material in less time (efficiency). Research on the application of AI as part of educational strategies for improving satirized test scores, including boards, is warranted. The present study is part of the necessary early steps to better understand the impact of AI as an educational strategy for improving educational outcomes.

Learning in Stereo: The Relationship Between Spatial Ability and 3D Digital Anatomy Models.

Three-dimensional (3D) digital anatomical models show potential to demonstrate complex anatomical relationships; however, the literature is inconsistent as to whether they are effective in improving the anatomy performance, particularly for students with low spatial visualization ability (Vz). This study investigated the educational effectiveness of a 3D stereoscopic model of the pelvis, and the relationship between learning with 3D models and Vz. It was hypothesized that participants learning with a 3D pelvis model would outperform participants learning with a two-dimensional (2D) visualization or cadaveric specimen on a spatial anatomy test, particularly when comparing those with low Vz. Participants (n = 64) were stratified into three experimental groups, who each attended a learning session with either a 3D stereoscopic model (n = 21), 2D visualization (n = 21), or cadaveric specimen (n = 22) of the pelvis. Medical and pre-medical student participants completed a multiple-choice pre-test and post-test during their respective learning session, and a long-term retention (LTR) test 2 months later. Results showed no difference in anatomy test improvement or LTR performance between the experimental groups. A simple linear regression analysis showed that within the 3D group, participants with high Vz tended to retain more than those with low Vz on the LTR test (R2  = 0.31, P = 0.01). The low Vz participants may be cognitively overloaded by the complex spatial cues from the 3D stereoscopic model. Results of this study should inform resource selection and curriculum design for health professional students, with attention to the impact of Vz on learning.

Assessing the Knowledge of the Osteopathic Profession in New York City's Eastern European Communities.

Background According to the decennial Osteopathic Survey of Healthcare in America, the osteopathic profession has been steadily gaining recognition in the United States, particularly among the White/Caucasian demographic. This, however, does not take into account immigrant European communities that, while racially classified as White/Caucasian, may be unexposed to osteopathic physicians (DOs) in their home country and may be reticent to osteopathic manipulative medicine. Data on non-English-speaking communities are limited and can mask the need for further outreach. This study aimed to identify literature in osteopathic outreach to minority communities and assess osteopathic awareness in New York City's Eastern European communities. Secondary objectives include characterization of potential barriers in hindering access to osteopathic medicine, and, by extension, other minority groups. Methodology An anonymous survey prepared in Russian and English was used to gather demographics, education level, healthcare habits, and knowledge of the osteopathic profession. To provide a clinical scenario, a health habit question regarding low back pain (LBP) was provided to participants. Participants over the age of 18 were randomly selected from high density Eastern European areas at two separate time points. Statistical analysis was performed using R to evaluate independence between questions using chi-square tests. Results A total of 150 surveys met the inclusion criteria, with 71 males and 79 females, an age range of 18-92, and a median age of 62. On comparing demographics, education level, and healthcare habits, only English proficiency showed statistical significance (p = 0.039) in determining recognition of the osteopathic profession. Overall, 60% (n = 94) stated that they have heard of osteopathic medicine and knew what a DO physician does. However, only 35% (n = 53) would see a DO for LBP, with 50% (n = 77) seeing a physical therapist. Conclusions Compared to research examining osteopathic awareness in ethnic minority communities, the Russian community in New York appears to have greater recognition of the osteopathic profession. This, however, does not translate into a clinical scenario as more participants were more likely to see a physical therapist. While this difference can be attributed to numerous factors, it stands without doubt that greater osteopathic outreach and data collection needs to be performed in minority communities.

Effect of SARS CoV2-Neutralizing Monoclonal Antibody on Hospitalization and Mortality in Long-Term Care Facility Residents.

To measure the association between intravenous administration of monoclonal antibody bamlanivimab (LY-CoV555) to long-term care facility (LTCF) residents recently diagnosed with pre-symptomatic, mild-to-moderate COVID-19 and are considered high risk for disease progression with mortality, hospitalization, and adverse effects. A retrospective analysis of LTCF residents with confirmed COVID-19, pre-symptomatic, mild to moderate disease, who were treated with bamlanivimab (LY-CoV555) were compared to similar LTCF residents who did not receive monoclonal antibody treatment. Dependent variables investigated included mortality and hospitalization as primary outcomes with adverse effects as the secondary outcome. A total of 107 residents from three LTCFs were diagnosed with pre-symptomatic, mild-to-moderate COVID-19 between November 1, 2020, and December 31, 2020. Of the 107 study participants, 44 residents provided consent to treatment, of which 39 received a single intravenous infusion of neutralizing monoclonal antibody, bamlanivimab 700mg, early in the disease, and 5 received an incomplete dose. Of the 39 residents who received the full dose of bamlanivimab, 5 (12.8%) were admitted to the hospital and 4 (10.3%) died. Conversely, of the 63 residents who did not receive the monoclonal antibody, 26 (41.3 %) were admitted to the hospital and 18 (28.6%) died. Relative risk for hospitalization and death were statistically significantly lower for those residents who received the full bamlanivimab treatment. No serious adverse effects were documented on any patient. Intravenous administration of monoclonal antibody bamlanivimab (LY-CoV555) to LTCF residents recently diagnosed with pre-symptomatic, mild to moderate COVID-19 was significantly associated with reduced mortality and hospitalization. The monoclonal antibody was well-tolerated.

The Role of Barriers and Community-Based Education in Compliance to Regular Eye Exams in New York City's Harlem Community.

Background The American Optometric Association (AOA) recommends adults between the ages of 18 to 65 have an eye exam every two years while older individuals or those who utilize vision correction should have yearly exams. Previous vision screenings throughout New York City's Harlem community determined that 60% warranted referral to an ophthalmologist.  Objective As delayed vision screening could potentially leave a sight-threatening condition undiagnosed for many years, the objective of this study was to identify barriers to regular eye examinations. Methods A voluntary anonymous survey was verbally administered and recorded at free medical student-run vision screenings throughout multiple Harlem community health fairs. Data gathered included demographics, insurance coverage, comfort with an eye exam, and knowledge associated with an ophthalmologist eye exam. As a strategy to curtail the frequency of non-compliance to regular eye examinations, all participants were then educated about knowledge of ocular examinations and assured about uncertainties. Comfort levels were remeasured after education to determine the effectiveness and impact of community-based education. Results One hundred surveys fit the inclusion criteria. Of the participants with suboptimal knowledge of an eye exam (n=41), 32% were more comfortable after education and assurance versus 3% of the optimal knowledge participants (n=59). Of the participants with non-compliance to regular eye exams (n=39), 41% had suboptimal knowledge and 23% were more comfortable after education versus 33% and 10% of the compliant participants (n=61), respectively. Participants with suboptimal knowledge were 20.9% more likely to be noncompliant with regular eye examinations and at the same time, 18.1% more likely to have increased comfort after education and assurance than those with optimal knowledge. Of the participants without medical insurance (n=15), 67% were noncompliant with regular eye examinations and 60% had suboptimal knowledge versus 34% and 38% of the insured participants (n=85), respectively. Participants with medical insurance were 23.8% more likely to be compliant with regular eye examinations than those without medical insurance. Conclusion Measured perceptions of ophthalmology in New York City's Harlem community solidifies a lack of education as a clear barrier against proper vision care. Lack of health insurance coverage also contributed to decreased participation in regular eye examinations but to a lesser extent than education. These results suggest that empowering people through education can significantly improve compliance with regularly scheduled eye exams, thus improving the overall visual health of this minority-rich community.

The effectiveness of a formal curriculum in teaching mass casualty management.

OBJECTIVE: To improve knowledge, skills, and confidence in mass casualty management through design and im-plementation of a formal educational curriculum. DESIGN: Observational study using a mixed-methods formal educational training curriculum. SETTING: Rural Emergency Medical Services (EMS) system in Pennsylvania. Subjects/participants: Convenience sample of 141 licensed EMS providers. INTERVENTIONS: Formal educational curriculum using a computerized mass casualty scenario, lectures, hands-on skill stations, post-intervention participant satisfaction survey, knowledge retention at three- and six-month post curriculum. RESULTS: The formal curriculum resulted in an improvement in scene size-up, incident command system (ICS) set-up, and medical management of 12 percent, 27 percent, and 26 percent, respectively. Average scores on the written component evaluating mass casualty incident (MCI) management and knowledge of test patient triage were 84 percent and 74 percent, respectively. Knowledge recall at three- and six-month post-training was highly retained as test scores were generally unchanged from the time of the educational session. Course and instructor evaluations by participants reflected a high degree of satisfaction (scoring five on a five-point Likert scale). CONCLUSIONS: The formal curriculum was effective in improving the knowledge, skills, and confidence of mass casualty management. Although traditional educational methods tend to show decreases in long-term knowledge retention, the mixed active learning strategies used in this curriculum resulted in high level retention since short and long-term test scores were similar and unchanged over time. Additionally, this curriculum was perceived by participants as highly satisfactory toward their knowledge and skill development.

Perceptions of the osteopathic profession in New York City's Chinese Communities.

Objective: The purpose of this study was to assess knowledge of and barriers to osteopathic medicine in Chinese immigrant communities in New York City (NYC). Design: A cross-sectional study was designed in which a culturally appropriate survey in Chinese and English versions was administered anonymously to measure immigrant perceptions and knowledge of osteopathic medicine. Setting: Data collection occurred in the municipal delineations for the Chinatown neighbourhood within the New York, New York borough of Manhattan. Participants: Community members were selected using convenience sampling from high-density areas to participate. Information gathered from the survey included demographics, education level, healthcare habits and knowledge of the osteopathic profession. Results: 120 surveys were conducted with 68 males and 52 females, with an average age=40. Respondents in the age range of 18-29 years, those with fluent English-language proficiency, and participants with graduate-level education status demonstrated a higher proportion of knowledge of osteopathic manipulative medicine and osteopathic physicians (doctors of osteopathic medicine) among the study variables. Conclusion: Compared with research on the general US population, a general lack of knowledge of osteopathic medicine exists within NYC's Chinese immigrant community. Although this difference may be ascribed to linguistics and ethnosociological factors, greater outreach and education is needed in urban minority communities to make immigrants aware of all healthcare resources available during the current shortage of US primary care physicians.

Anatomy of learning: instructional design principles for the anatomical sciences.

Teaching anatomy is becoming increasingly challenging due to the progressive evolution of university teaching missions, student populations, medical and undergraduate curricula, coupled with a paucity of empirically tested evidence-based instructional practices in the anatomical and medical education literature. As a mechanism to confront these pedagogical challenges, recent advances in educational psychology are analyzed for developing a framework to guide educational reform efforts. Extensive research in educational psychology over the last 100 years has resulted in four major theories on human learning that have facilitated a paradigm shift from teacher-centered to learner-centered classrooms and are described here in temporal order of development: behavioral theory, information processing theory, metacognitive theory, and social constructivist theory. Each theory is analyzed in detail and is used to construct instructional design principles for enhancing anatomical education research and practice. An example of a cognitively based learning environment for an undergraduate anatomy course is presented. Preliminary results suggest that intentionally drawing on different theories of learning when making instructional decisions gave students the learning support they needed to be successful and nearly doubled the course's student retention rate over a 3-year period.

Reduction in unavailable-for-response episodes in a private emergency medical services agency.

OBJECTIVE: Increased demand for emergency medical services (EMS), financial constraints, emergency department overcrowding, EMS crews kept in hospital, all result in ambulance unavailability. This study seeks to identify daily temporal patterns for unavailable-for-response episodes, impact of increasing staffing during peak periods, and evaluating the extent of reduction in unavailable-for-response episodes due to temporally precise increases in staffing during critical time periods and the resulting cost/benefit analysis. DESIGN: The authors evaluated all EMS responses during a 7-month time period and recorded all unavailable-for-response episodes. This identified clusters of unavailable-for-response episodes for which incremental staffing changes were implemented. Internal audit of cost/revenues was recorded. SETTING: Midsized private EMS agency in Northwest Pennsylvania. SUBJECTS/PARTICIPANTS: EMS Responders/Agency calls. INTERVENTIONS: Temporally precise increases in staffing during critical time periods/unavailable-for-response episodes. MAIN OUTCOME MEASURE(S): Reduction in unavailable-for-response episodes, cost effectiveness. RESULTS: Evaluating 23,833 EMS responses that occurred during the study period, staffing changes resulted in a 93 percent average reduction and 100 percent maximum reduction in unavailable-for-response episodes and were cost effective, based on evaluation of cost versus revenue, in this EMS agency. CONCLUSIONS: Identification of opportunities for system staffing improvement in a midsized EMS agency demonstrated feasibility and usability of mapping temporal patterns of unavailable-for-response episodes to substantially reduce the number of unavailable-for-response episodes and was cost effective.

Primary structure of the 2-O-methyl-alpha-L-fucose-containing side chain of the pectic polysaccharide, rhamnogalacturonan II.

A 2-O-methylfucosyl-containing heptasaccharide was released from red wine rhamnogalacturonan II (RG-II) by acid hydrolysis of the glycosidic linkage of the aceryl acid residue (AceA) and purified to homogeneity by size-exclusion and high-performance anion-exchange chromatographies. The primary structure of the heptasaccharide was determined by glycosyl-residue and glycosyl-linkage composition analyses, ESIMS, and by 1H and 13C NMR spectroscopy. The NMR data indicated that the pyranose ring of the 2,3-linked L-arabinosyl residue is conformationally flexible. The L-Arap residue was confirmed to be alpha-linked by NMR analysis of a tetraglycosyl-glycerol fragment, [alpha-L-Arap-(1-->4)-beta-D-Galp-(1-->2)-alpha-L-AcefA-(1-->3)-beta-L-Rhap-(1-->3)-Gro], generated by Smith degradation of RG-II. Our data together with the results of a previous study,(1) establish that the 2-O-Me Fuc-containing nonasaccharide side chain of wine RG-II has the structure (Api [triple bond] apiose): [see structure]. Data are presented to show that in Arabidopsis RG-II the predominant 2-O-MeFuc-containing side chain is a mono-O-acetylated heptasaccharide that lacks the non-reducing terminal beta-L-Araf and the alpha-L-Rhap residue attached to the O-3 of Arap, both of which are present on the wine nonasaccharide.

A usability study of users' perceptions toward a multimedia computer-assisted learning tool for neuroanatomy.

This usability study evaluated users' perceptions of a multimedia prototype for a new e-learning tool: Anatomy of the Central Nervous System: A Multimedia Course. Usability testing is a collection of formative evaluation methods that inform the developmental design of e-learning tools to maximize user acceptance, satisfaction, and adoption. Sixty-two study participants piloted the prototype and completed a usability questionnaire designed to measure two usability properties: program need and program applicability. Statistical analyses were used to test the hypothesis that the multimedia prototype was well designed and highly usable, it was perceived as: (1) highly needed across a spectrum of educational contexts, (2) highly applicable in supporting the pedagogical processes of teaching and learning neuroanatomy, and (3) was highly usable by all types of users. Three independent variables represented user differences: level of expertise (faculty vs. student), age, and gender. Analysis of the results supports the research hypotheses that the prototype was designed well for different types of users in various educational contexts and for supporting the pedagogy of neuroanatomy. In addition, the results suggest that the multimedia program will be most useful as a neuroanatomy review tool for health-professions students preparing for licensing or board exams. This study demonstrates the importance of integrating quality properties of usability with principles of human learning during the instructional design process for multimedia products.