Whole-Genome Sequencing Reveals Diversity of Carbapenem-Resistant Pseudomonas aeruginosa Collected through CDC's Emerging Infections Program, United States, 2016-2018.

The CDC's Emerging Infections Program (EIP) conducted population- and laboratory-based surveillance of US carbapenem-resistant Pseudomonas aeruginosa (CRPA) from 2016 through 2018. To characterize the pathotype, 1,019 isolates collected through this project underwent antimicrobial susceptibility testing and whole-genome sequencing. Sequenced genomes were classified using the seven-gene multilocus sequence typing (MLST) scheme and a core genome (cg)MLST scheme was used to determine phylogeny. Both chromosomal and horizontally transmitted mechanisms of carbapenem resistance were assessed. There were 336 sequence types (STs) among the 1,019 sequenced genomes, and the genomes varied by an average of 84.7% of the cgMLST alleles used. Mutations associated with dysfunction of the porin OprD were found in 888 (87.1%) of the genomes and were correlated with carbapenem resistance, and a machine learning model incorporating hundreds of genetic variations among the chromosomal mechanisms of resistance was able to classify resistant genomes. While only 7 (0.1%) isolates harbored carbapenemase genes, 66 (6.5%) had acquired non-carbapenemase ß-lactamase genes, and these were more likely to have OprD dysfunction and be resistant to all carbapenems tested. The genetic diversity demonstrates that the pathotype includes a variety of strains, and clones previously identified as high-risk make up only a minority of CRPA strains in the United States. The increased carbapenem resistance in isolates with acquired non-carbapenemase ß-lactamase genes suggests that horizontally transmitted mechanisms aside from carbapenemases themselves may be important drivers of the spread of carbapenem resistance in P. aeruginosa.

Characteristics of Adults Aged 18-49 Years Without Underlying Conditions Hospitalized With Laboratory-Confirmed Coronavirus Disease 2019 in the United States: COVID-NET-March-August 2020.

Among 513 adults aged 18-49 years without underlying medical conditions hospitalized with coronavirus disease 2019 (COVID-19) during March 2020-August 2020, 22% were admitted to an intensive care unit, 10% required mechanical ventilation, and 3 patients died (0.6%). These data demonstrate that healthy younger adults can develop severe COVID-19.

Carbapenem-Resistant Pseudomonas aeruginosa at US Emerging Infections Program Sites, 2015.

Pseudomonas aeruginosa is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. During July-October 2015 in the United States, we piloted laboratory-based surveillance for carbapenem-resistant P. aeruginosa (CRPA) at sentinel facilities in Georgia, New Mexico, Oregon, and Tennessee, and population-based surveillance in Monroe County, NY. An incident case was the first P. aeruginosa isolate resistant to antipseudomonal carbapenems from a patient in a 30-day period from any source except the nares, rectum or perirectal area, or feces. We found 294 incident cases among 274 patients. Cases were most commonly identified from respiratory sites (120/294; 40.8%) and urine (111/294; 37.8%); most (223/280; 79.6%) occurred in patients with healthcare facility inpatient stays in the prior year. Genes encoding carbapenemases were identified in 3 (2.3%) of 129 isolates tested. The burden of CRPA was high at facilities under surveillance, but carbapenemase-producing CRPA were rare.

Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals.

BACKGROUND: A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care-associated infection. We repeated the survey in 2015 to assess changes in the prevalence of health care-associated infections during a period of national attention to the prevention of such infections. METHODS: At Emerging Infections Program sites in 10 states, we recruited up to 25 hospitals in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected 1 day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of health care-associated infections. We compared the percentages of patients with health care-associated infections and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of health care-associated infections. RESULTS: In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had health care-associated infections in 2015 (394 patients [3.2%; 95% confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0%; 95% CI, 3.7 to 4.4]) (P<0.001), largely owing to reductions in the prevalence of surgical-site and urinary tract infections. Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile [now Clostridioides difficile]), and surgical-site infections were the most common health care-associated infections. Patients' risk of having a health care-associated infection was 16% lower in 2015 than in 2011 (risk ratio, 0.84; 95% CI, 0.74 to 0.95; P=0.005), after adjustment for age, presence of devices, days from admission to survey, and status of being in a large hospital. CONCLUSIONS: The prevalence of health care-associated infections was lower in 2015 than in 2011. To continue to make progress in the prevention of such infections, prevention strategies against C. difficile infection and pneumonia should be augmented. (Funded by the Centers for Disease Control and Prevention.).

Carbapenem-Nonsusceptible Acinetobacter baumannii, 8 US Metropolitan Areas, 2012-2015.

In healthcare settings, Acinetobacter spp. bacteria commonly demonstrate antimicrobial resistance, making them a major treatment challenge. Nearly half of Acinetobacter organisms from clinical cultures in the United States are nonsusceptible to carbapenem antimicrobial drugs. During 2012-2015, we conducted laboratory- and population-based surveillance in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee to determine the incidence of carbapenem-nonsusceptible A. baumannii cultured from urine or normally sterile sites and to describe the demographic and clinical characteristics of patients and cases. We identified 621 cases in 537 patients; crude annual incidence was 1.2 cases/100,000 persons. Among 598 cases for which complete data were available, 528 (88.3%) occurred among patients with exposure to a healthcare facility during the preceding year; 506 (84.6%) patients had an indwelling device. Although incidence was lower than for other healthcare-associated pathogens, cases were associated with substantial illness and death.

Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study.

BACKGROUND: An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. METHODS: We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. RESULTS: Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. CONCLUSIONS: Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.

Impact of Prompt Influenza Antiviral Treatment on Extended Care Needs After Influenza Hospitalization Among Community-Dwelling Older Adults.

BACKGROUND: Patients hospitalized with influenza may require extended care on discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥ 65 years hospitalized with influenza. METHODS: We used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility on hospital discharge. We focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤ 4 days) or late (>4 days) in reference to date of illness onset. RESULTS: Among 6593 community-dwelling adults aged ≥ 65 years hospitalized for influenza, 18% required extended care at discharge. The need for care increased with age and neurologic disorders, intensive care unit admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤ 2 or >2 days from illness onset (adjusted odds ratio, 0.38 [95% confidence interval {CI}, .17-.85] and 0.75 [.56-.97], respectively). Early treatment was also independently associated with reduction in length of stay for those hospitalized ≤ 2 days from illness onset (adjusted hazard ratio, 1.81; 95% CI, 1.43-2.30) or >2 days (1.30; 1.20-1.40). CONCLUSIONS: Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.

Pneumonia among adults hospitalized with laboratory-confirmed seasonal influenza virus infection-United States, 2005-2008.

BACKGROUND: Influenza and pneumonia combined are the leading causes of death due to infectious diseases in the United States. We describe factors associated with pneumonia among adults hospitalized with influenza. METHODS: Through the Emerging Infections Program, we identified adults ≥ 18 years, who were hospitalized with laboratory-confirmed influenza during October 2005 through April 2008, and had a chest radiograph (CXR) performed. Pneumonia was defined as the presence of a CXR infiltrate and either an ICD-9-CM code or discharge summary diagnosis of pneumonia. RESULTS: Among 4,765 adults hospitalized with influenza, 1392 (29 %) had pneumonia. In multivariable analysis, factors associated with pneumonia included: age ≥ 75 years, adjusted odds ratio (AOR) 1.27 (95 % confidence interval 1.10-1.46), white race AOR 1.24 (1.03-1.49), nursing home residence AOR 1.37 (1.14-1.66), chronic lung disease AOR 1.37 (1.18-1.59), immunosuppression AOR 1.45 (1.19-1.78), and asthma AOR 0.76 (0.62-0.92). Patients with pneumonia were significantly more likely to require intensive care unit (ICU) admission (27 % vs. 10 %), mechanical ventilation (18 % vs. 5 %), and to die (9 % vs. 2 %). CONCLUSIONS: Pneumonia was present in nearly one-third of adults hospitalized with influenza and was associated with ICU admission and death. Among patients hospitalized with influenza, older patients and those with certain underlying conditions are more likely to have pneumonia. Pneumonia is common among adults hospitalized with influenza and should be evaluated and treated promptly.

Estimating influenza disease burden from population-based surveillance data in the United States.

Annual estimates of the influenza disease burden provide information to evaluate programs and allocate resources. We used a multiplier method with routine population-based surveillance data on influenza hospitalization in the United States to correct for under-reporting and estimate the burden of influenza for seasons after the 2009 pandemic. Five sites of the Influenza Hospitalization Surveillance Network (FluSurv-NET) collected data on the frequency and sensitivity of influenza testing during two seasons to estimate under-detection. Population-based rates of influenza-associated hospitalization and Intensive Care Unit admission from 2010-2013 were extrapolated to the U.S. population from FluSurv-NET and corrected for under-detection. Influenza deaths were calculated using a ratio of deaths to hospitalizations. We estimated that influenza-related hospitalizations were under-detected during 2010-11 by a factor of 2.1 (95%CI 1.7-2.9) for age < 18 years, 3.1 (2.4-4.5) for ages 18-64 years, and 5.2 (95%CI 3.8-8.3) for age 65+. Results were similar in 2011-12. Extrapolated estimates for 3 seasons from 2010-2013 included: 114,192-624,435 hospitalizations, 18,491-95,390 ICU admissions, and 4,915-27,174 deaths per year; 54-70% of hospitalizations and 71-85% of deaths occurred among adults aged 65+. Influenza causes a substantial disease burden in the U.S. that varies by age and season. Periodic estimation of multipliers across multiple sites and age groups improves our understanding of influenza detection in sentinel surveillance systems. Adjusting surveillance data using a multiplier method is a relatively simple means to estimate the impact of influenza and the subsequent value of interventions to prevent influenza.

Complications among adults hospitalized with influenza: a comparison of seasonal influenza and the 2009 H1N1 pandemic.

BACKGROUND: Persons with influenza can develop complications that result in hospitalization and death. These are most commonly respiratory related, but cardiovascular or neurologic complications or exacerbations of underlying chronic medical conditions may also occur. Patterns of complications observed during pandemics may differ from typical influenza seasons, and characterizing variations in influenza-related complications can provide a better understanding of the impact of pandemics and guide appropriate clinical management and planning for the future. METHODS: Using a population-based surveillance system, we compared clinical complications using International Classification of Diseases, Ninth Revision (ICD-9) discharge diagnosis codes in adults hospitalized with seasonal influenza (n = 5270) or 2009 pandemic influenza A(H1N1) (H1N1pdm09; n = 4962). RESULTS: Adults hospitalized with H1N1pdm09 were younger (median age, 47 years) than those with seasonal influenza (median age, 68 years; P < .01), and differed in the frequency of certain underlying medical conditions. Whereas there was similar risk for many influenza-associated complications, after controlling for age and type of underlying medical condition, adults hospitalized with H1N1pdm09 were more likely to have lower respiratory tract complications, shock/sepsis, and organ failure than those with seasonal influenza. They were also more likely to be admitted to the intensive care unit, require mechanical ventilation, or die. Young adults, in particular, had 2-4 times the risk of severe outcomes from H1N1pdm09 than persons of the same ages with seasonal influenza. CONCLUSIONS: Although H1N1pdm09 was thought of as a relatively mild pandemic, these data highlight the impact of the 2009 pandemic on the risk of severe influenza, especially among younger adults, and the impact this virus may continue to have.

Comparing clinical characteristics between hospitalized adults with laboratory-confirmed influenza A and B virus infection.

We challenge the notion that influenza B is milder than influenza A by finding similar clinical characteristics between hospitalized adult influenza-cases. Among patients treated with oseltamivir, length of stay and mortality did not differ by type of virus infection.

The burden of influenza hospitalizations in infants from 2003 to 2012, United States.

BACKGROUND: Little information is available describing the epidemiology and clinical characteristics of those <12 months hospitalized with influenza, particularly at a population level. METHODS: We used population-based, laboratory-confirmed influenza hospitalization surveillance data from 2003 to 2012 seasons to describe the impact of influenza by age category (<3, 3 to <6 and 6 to <12 months). Logistic regression was used to explore risk factors for intensive care unit (ICU) admission. Adjusted age-specific, influenza-associated hospitalization rates were calculated and applied to the number of US infants to estimate national numbers of hospitalizations. RESULTS: Influenza was associated with an annual average of 6514 infant hospitalizations (range 1842-12,502). Hospitalization rates among infants <3 months were substantially higher than the rate in older infants. Most hospitalizations occurred in otherwise healthy infants (75%) among whom up to 10% were admitted to the ICU and up to 4% had respiratory failure. These proportions were 2-3 times higher in infants with high risk conditions. Infants <6 months were 40% more likely to be admitted to the ICU than older infants. Lung disease (adjusted odds ratio 1.80; 95% confidence interval 1.22-2.67), cardiovascular disease (adjusted odds ratio: 4.16; 95% confidence interval: 2.65-6.53), and neuromuscular disorder (adjusted odds ratio: 2.99; 95% confidence interval: 1.87-4.78) were risk factors for ICU admission among all infants. CONCLUSIONS: The impact of influenza on infants, particularly those very young or with high risk conditions, underscores the importance of influenza vaccination, especially among pregnant women and those in contact with young infants not eligible for vaccination.

Hospital-onset influenza hospitalizations--United States, 2010-2011.

BACKGROUND: Seasonal influenza is responsible for more than 200,000 hospitalizations each year in the United States. Although hospital-onset (HO) influenza contributes to morbidity and mortality among these patients, little is known about its overall epidemiology. OBJECTIVE: We describe patients with HO influenza in the United States during the 2010-2011 influenza season and compare them with community-onset (CO) cases to better understand factors associated with illness. METHODS: We identified laboratory-confirmed, influenza-related hospitalizations using the Influenza Hospitalization Surveillance Network (FluSurv-NET), a network that conducts population-based surveillance in 16 states. CO cases had laboratory confirmation ≤ 3 days after hospital admission; HO cases had laboratory confirmation > 3 days after admission. RESULTS: We identified 172 (2.8%) HO cases among a total of 6,171 influenza-positive hospitalizations. HO and CO cases did not differ by age (P = .22), sex (P = .29), or race (P = .25). Chronic medical conditions were more common in HO cases (89%) compared with CO cases (78%) (P < .01), and a greater proportion of HO cases (42%) than CO cases (17%) were admitted to the intensive care unit (P < .01). The median length of stay after influenza diagnosis of HO cases (7.5 days) was greater than that of CO cases (3 days) (P < .01). CONCLUSION: HO cases had greater length of stay and were more likely to be admitted to the intensive care unit or die compared with CO cases. HO influenza may play a role in the clinical outcome of hospitalized patients, particularly among those with chronic medical conditions.

Effect of the 2009 influenza A(H1N1) pandemic on invasive pneumococcal pneumonia.

BACKGROUND: Because pneumococcal pneumonia was prevalent during previous influenza pandemics, we evaluated invasive pneumococcal pneumonia (IPP) rates during the 2009 influenza A(H1N1) pandemic. METHODS: We identified laboratory-confirmed, influenza-associated hospitalizations and IPP cases (pneumococcus isolated from normally sterile sites with discharge diagnoses of pneumonia) using active, population-based surveillance in the United States. We compared IPP rates during peak pandemic months (April 2009-March 2010) to mean IPP rates in nonpandemic years (April 2004-March 2009) and, using Poisson models, to 2006-2008 influenza seasons. RESULTS: Higher IPP rates occurred during the peak pandemic month compared to nonpandemic periods in 5-24 (IPP rate per 10 million: 48 vs 9 (95% confidence interval [CI], 5-13), 25-49 (74 vs 53 [CI, 41-65]), 50-64 (188 vs 114 [CI, 85-143]), and ≥65-year-olds (229 vs 187 [CI, 159-216]). In the models with seasonal influenza rates included, observed IPP rates during the pandemic peak were within the predicted 95% CIs, suggesting this increase was not greater than observed with seasonal influenza. CONCLUSIONS: The recent influenza pandemic likely resulted in an out-of-season IPP peak among persons ≥5 years. The IPP peak's magnitude was similar to that seen during seasonal influenza epidemics.

Increase in rates of hospitalization due to laboratory-confirmed influenza among children and adults during the 2009-10 influenza pandemic.

BACKGROUND: The Emerging Infections Programs (EIP) network has conducted population-based surveillance for hospitalizations due to laboratory-confirmed influenza among children since 2003, with the network expanding in 2005 to include adults. METHODS: From 15 April 2009 through 30 April 2010, the EIP conducted surveillance among 22.1 million people residing in 10 states. Incidence rates per 100 000 population were calculated using US Census Bureau data. Mean historic rates were calculated on the basis of previously published and unpublished EIP data. RESULTS: During the 2009 pandemic of influenza A virus subtype H1N1 infection, rates of hospitalizations due to laboratory-confirmed influenza were 202, 88, 49, 31, 27, 36, 28, and 27 episodes per 100 000 among persons aged <6 months, 6-23 months, 2-4 years, 5-17 years, 18-49 years, 50-64 years, 65-74 years, and ≥75 years, respectively. Comparative mean rates from previous influenza seasons during which EIP conducted surveillance were 153, 53, 20, 6, 4, 8, 20, and 56 episodes per 100 000 among persons aged <6 months, 6-23 months, 2-4 years, 5-17 years, 18-49 years, 50-64 years, 65-74 years, and ≥75 years, respectively. CONCLUSIONS: During the pandemic, rates of hospitalization due to laboratory-confirmed influenza among individuals aged 5-17 years and 18-49 years increased 5-fold and 6-fold, respectively, compared with mean rates from previous influenza seasons. Hospitalization rates for other pediatric and adult age groups increased, compared with mean rates from previous influenza seasons, whereas the rate among individuals aged ≥75 years decreased.

Reduced influenza antiviral treatment among children and adults hospitalized with laboratory-confirmed influenza infection in the year after the 2009 pandemic.

Influenza antiviral treatment is recommended for all persons hospitalized with influenza virus infection. During the 2010-2011 influenza season, antiviral treatment of children and adults hospitalized with laboratory-confirmed influenza declined significantly compared with treatment during the 2009 pandemic (children, 56% vs 77%; adults, 77% vs 82%; both P < .01).

Description of antiviral treatment among adults hospitalized with influenza before and during the 2009 pandemic: United States, 2005-2009.

BACKGROUND: The 2009 influenza pandemic led to guidelines emphasizing antiviral treatment for all persons hospitalized with influenza, including pregnant women. We compared antiviral use among adults hospitalized with influenza before and during the pandemic. METHODS: The Emerging Infections Program conducts active population-based surveillance for persons hospitalized with community-acquired, laboratory-confirmed influenza in 10 states. We analyzed data collected via medical record review of patients aged ≥18 years admitted during prepandemic (1 October 2005 through 14 April 2009) and pandemic (15 April 2009 through 31 December 2009) time frames. RESULTS: Of 5943 adults hospitalized with influenza in prepandemic seasons, 3235 (54%) received antiviral treatment, compared with 4055 (82%) of 4966 during the pandemic. Forty-one (22%) of 187 pregnant women received antiviral treatment in prepandemic seasons, compared with 369 (86%) of 430 during the pandemic. Pregnancy was a negative predictor of antiviral treatment before the pandemic (adjusted odds ratio [aOR], 0.24; 95% confidence interval [CI], .16-.35) but was independently associated with treatment during the pandemic (aOR, 1.97; 95% CI, 1.32-2.96). Antiviral treatment among adults hospitalized >2 days after illness onset increased from 43% before the pandemic to 79% during the pandemic (P < .001). CONCLUSIONS: Antiviral treatment of hospitalized adults increased during the pandemic, especially among pregnant women. This suggests that many clinicians followed published guidance to treat hospitalized adults with antiviral agents. However, compliance with antiviral recommendations could be improved.

Comprehensive assessment of sociodemographic and behavioral risk factors for Mycoplasma genitalium infection in women.

BACKGROUND: Neisseria gonorrhoeae and Chlamydia trachomatis are characterized by different risk factors, thus control strategies for each also differ. In contrast, risk factors for Mycoplasma genitalium have not been well characterized. METHODS: Between 2000 and 2006, 1090 women ages 14 to 45 attending the Public Health-Seattle & King County Sexually Transmitted Diseases Clinic in Seattle, WA, underwent clinical examination and computer-assisted survey interview. M. genitalium was detected by transcription mediated amplification from self-obtained vaginal swab specimens. C. trachomatis and N. gonorrhoeae were detected by culture from cervical swab specimens. RESULTS: Prevalent M. genitalium infection was detected in 84 women (7.7%), C. trachomatis in 63 (5.8%), and N. gonorrhoeae in 26 (2.4%). Age <20 and nonwhite race were associated with increased risk for all 3 organisms. In addition, risk for M. genitalium was higher for women with a black partner (adjusted odds ratio [AOR]: 3.4; 95% confidence interval = 1.83-6.29), those never married (AOR: 2.6; 1.08-6.25), using Depo-Provera (AOR: 2.3; 1.19-4.46), and smoking (AOR: 1.7; 1.03-2.83). Drug use, history of STI in the past year, ≤high school education, meeting and having intercourse the same day, anal sex, douching, and hormonal contraception were associated with N. gonorrhoeae or C. trachomatis, but not with M. genitalium. Number of partners was not associated with any of the 3 organisms. CONCLUSIONS: The limited number of risk factors for prevalent infection common to all 3 pathogens suggests that M. genitalium may circulate in different sexual networks than N. gonorrhoeae or C. trachomatis. The predominance of sociodemographic risk factors for M. genitalium, rather than high-risk sexual behaviors, suggests broad-based testing may be the most effective control strategy.