The experience of the rigid lockdown in the dental emergency room and urgency care during COVID-19 pandemic: a transnational multicenter observational study.

OBJECTIVE: The COVID-19 pandemic had a major impact on our lives all over the world. Changes have occurred in daily life as well as in all medical services. The aim of the present study was to evaluate the emergency accesses in four universities' emergency services during the lockdown period from March to June 2020 during the COVID-19 pandemic. SUBJECTS AND METHODS: A cross-sectional study was carried out on 44,787 patients to evaluate the emergency services of university centers. The medical data of Medical Emergency Service Data (MESD) were assessed by five independent operators considering the epidemiological findings for statistics methods. RESULTS: A lower level of emergency access was reported in March-July compared to the pre-COVID period. The epidemiological data confirmed that female pathologies were more frequent compared to male patients. A fluctuation for almost all urgent healthcare centers was detected, showing one/two peaks per year during the years 2017-2019. The COVID-19 pandemic period did not influence the variety of pathology detected. CONCLUSIONS: After the lockdown period, the emergency services slowly increased in cases. The pre-COVID period showed an overlapping of the most frequent pathologies compared to the post-COVID period: periodontitis (Bari and Tirana), dental fractures (Bari and Bucharest), odontogenic abscess (Bari, Cluj and Tirana).

Stabilized zirconia ceramics for dental applications.

The research is aiming to obtain at room temperature a new ceramic material containing partially stabilized zirconia with different oxides after sintering used for dental and other technological purposes. Our research proposes a new method based on the use of stabilized zirconia with other oxides to obtain optimized dental material with a lower cost price and / or improved properties to allow wider use of these products to an increased number of patients in dental offices. X-ray diffraction, SEM analysis. FTIR spectroscopy, UVVis and density measurements were accomplished for the three ceramic systems. The correlation between the microstructure and the spectroscopic properties of zirconium stabilized by FTIR spectroscopy, UV-Vis helps understanding the mechanisms associated with the formation of high (tetragonal and / or cubic) temperature zirconia. Along with the simple, less costly preparation method and high purity of the ceramic products our study offers a highly desirable product for technological applications.

Acute Bacterial Gastroenteritis as a Healthcare-Associated Infection in Pediatrics.

Despite the fact that acute gastroenteritis can be prevented, the disease still affects children, especially under the age of two. The increased levels of pediatric mortality in most developing regions make diarrheal diseases one of the most common causes of death in the children under the age of 5. The purpose of the study was to describe the cases of acute gastroenteritis reported as healthcare-associated infections in a pediatric hospital deserving the north-eastern urban and rural regions of Romania. MATERIAL AND METHODS: A descriptive study was conducted on a group of 615 cases with acute bacterial gastroenteritis as healthcare-associated infections (HAIs), reported in "Sf. Maria" Emergency Hospital for Children, Iași, between 2012 and 2016. RESULTS: Most cases of acute bacterial gastroenteritis were registered in 2015 (154 cases-25.04%), and the lowest in 2012 (12.84%). Male gender prevailed in almost all years of study, with no statistical significance (p≥0.05). Gastroenteritis with Campylobacter was most commonly reported in pediatric wards, especially in infants of 0-1 years old and children aged of 2-6 years. Cases of HAIs with Salmonella spp were also frequent. CONCLUSIONS: A competent management of HAIs especially as acute gastroenteritis in an emergency hospital for children from a region that includes developing rural areas, should be the most important issue for professionals involved in surveillance and control strategies, as well as clinicians, epidemiologist and microbiologist, in order to prevent HAIs burden occurrence and avoid antimicrobial resistance.

REDUCE CHILD MORTALITY AS A MILLENNIUM DEVELOPMENI GOAL IN ROMANIA.

AIM: To assess the efforts made in Romania towards achieving the Goal 4 from MDGs--Reduce Child Mortality. MATERIALS AND METHODS: A descriptive study about the deaths among Romanian children under five, between 2002 and 2015, from the perspective of the MDGs. To help track progress toward this commitment, following specific targets and indicators were developed: Target 1-Halve the mortality rate in children aged 1-4 years between 2002-2015; Target 2--Reduce infant mortality by 40% between 2002 and 2015; Target 3--Eliminate measles by 2007. The comparison allows establish the status (achieved or not) for each target. RESULTS: From 2002, the under-five mortality rate recorded a continuous descendent trend till now (20.8 to 10.3 under five deaths per 1000 inhabitants in 2013). The infant mortality rates declined from 17.3 to 8.5 deaths per 1,000 live births (2002-2013). Eliminating measles by 2007--was achieved one year later, because of the measles epidemic in 2005 and 2006. High vaccination rates have been maintained, with the proportion of children 1 year old vaccinated against measles reaching and being maintained at between 94-98%. CONCLUSIONS: Substantial progress has been made in Romania, in achieving the Millennium Development Goal no. 4. All the three targets were achieved. However, infant mortality still remains above the average of European Union (4 infant deaths per 1,000 live-births).

Surveillance Seasonal Program. Antibiotic Resistance of Pathogenic Agents Isolated From Children With Acute Gastroenteritis, in a Region of North-East Romania.

The acute gastroenteritis is a population health problem, frequently met everywhere in the world. In Romania, for certain etiologies the reporting is compulsory. Also, these infections are reported in the TESSy system, too (The European Surveillance System). In this context, antibiotics therapy and antibiotics resistance have a particular importance. The study aim was to assess the prevalence of bacterial pathogens involved in the etiology of acute gastroenteritis (AGE) on the Iasi County, Romania and the surrounding areas and the determination of the profile of resistance to the antibiotics for the identified agents. Material and methods: 72 strains of isolated and identified bacterial agents involved in the acute gastroenteritis (AGE) in the case of children (0-14 years), with the exception of the Campylobacter spp., in the municipality of Iasi and its surrounding areas were studied in 2012, during the surveillance period of AGE (May to October). Results: The most frequent has been the Salmonella spp. (63.9%) from which the S. enterica Thyphimurium in 21 cases (29.2%) and S. enteritidis in 7 cases (9.7%), followed by E. coli (20.8%) from which E. coli O:127 in 3 cases (4.2%), Shigella sonnei S (13.9%) and Yersinia enterocolitica (1.4%). In the case of the children from the group of 0-1 year, the Salmonella enterica Thyphimurium has been the pathogenic agent most frequently encountered (6 cases ­ 29.2%), followed by Salmonella Colindale, S. enteritidis, Shigella sonnei S, E. coli O:127 registered with a frequency of 5.6%. The antibiotic resistance rates are high in the case of ampicillin (43.1%), tetracycline (31.9%), amoxicillin ­ clavulanic acid (26.4%), trimethoprim/ sulfametoxazole (22.2%), sulfonamides (11.1%). Conclusions: The antibiotic resistance rates are high in the case of ampicillin, tetracycline, amoxicillin ­ clavulanic acid, trimethoprim/ sulfametoxazole, sulfonamides.

Patterns of Road Traffic Accident in North-East Romania.

Romania is ranked first among mortality road traffic accidents in Europe. The aim of our study was to evaluate some statistical patterns of population group who unfortunately was admitted at an emergency hospital of Iasi, a large city in the North East of the country. Material and Methods: The study was performed on 1623 patients admitted in the Emergency Room ("Sf. Spiridon" Emergency Hospital of Iasi, Romania) suffering from road traffic accidents, during 2009 and 2013. Results: The prevalence of 19-45 age group cases represented more than 50% of all patients, with a high significance (p<0.05), and men were involved more frequently (69.69%) than women (30.31%); most of the patients were injured while driving an automobile; 6 PM was the "rush" hour (6.4%), Monday was the "black" week day (16.02% of total cases), September the "harvest" time (12.7%), and Summer the "hottest" season (48.49%). Conclusions: The "B plan" is imperative to be implemented in Romania, including better roads, better vehicles, better legislation, and better teens' education, in order to avoid road traffic accidents.

Cold stress protein RBM3 responds to temperature change in an ultra-sensitive manner in young neurons.

Extremely mild hypothermia to 36.0 °C is not thought to appreciably differ clinically from 37.0 °C. However, it is possible that 36.0 °C stimulates highly sensitive hypothermic signaling mechanism(s) and alters biochemistry. To the best of our knowledge, no such ultra-sensitive pathway/mechanisms have been described. Here we show that cold stress protein RNA binding motif 3 (RBM3) increases in neuron and astrocyte cultures maintained at 33 °C or 36 °C for 24 or 48 h, compared to 37 °C controls. Neurons cultured at 36 °C also had increased global protein synthesis (GPS). Finally, we found that melatonin or fibroblast growth factor 21 (FGF21) augmented RBM3 upregulation in young neurons cooled to 36 °C. Our results show that a 1 °C reduction in temperature can induce pleiotropic biochemical changes by upregulating GPS in neurons which may be mediated by RBM3 and that this process can be pharmacologically mimicked and enhanced with melatonin or FGF21.

Disparities in the access to primary healthcare in rural areas from the county of Iasi - Romania.

AIM: To identify the factors that may conduct to various forms of social exclusion of the population from the primary healthcare and to analyze health disparities as population-specific differences in the access to primary healthcare in rural compared to urban residence areas from Iasi, the second biggest county, situated in the North--East region of Romania. MATERIALS AND METHODS: This research is a type of inquiry-based opinion survey of the access to primary healthcare in rural compared to urban areas of the county of Iasi. Data were collected by face-to-face interviews. There were taken into account the socioeconomic status (education level in the adult population, employment status, family income, household size) and two temporal variables (the interval of time spent to arrive at the primary healthcare office as a marker for the geographical access and the waiting time for a consultation). The study group consisted of two samples, from rural and urban area, each of 150 patients, all ages, randomly selected, who were waiting at the family doctor's practice. RESULTS: The study has identified disparities related to a poor economic status assessed through the employed status ("not working" 15% in urban and of 20% in rural).The income calculated per member of family and divided in terciles has recorded significant differences for "high" (36.7% urban and 14.7% rural) and "low", respectively (14.6% urban and 56.6% rural). High household size with more than five members represented 22.6% of the total subjects in rural and 15.3% in urban areas. The assessment of the education level in the adult population (> 18 years) revealed that in the rural areas more than a half (56%) of the sample is placed in the category primary and secondary incomplete, whereas the value for secondary complete and postsecondary was 37.3%. The proportion of respondents in the urban areas who have post-secondary education is five times higher than those in rural areas (15.4% vs. 2.7%). The reduced geographical access assessed as the interval of time spent to arrive at the primary healthcare office revealed, on average, 25 minutes in urban versus 75 minutes in rural areas. CONCLUSIONS: The research outcomes highlight the fact that the population living in rural communities from the county of Iasi, are disadvantaged in accessing the primary health services, with negative consequences on the health status.

Epidemiological assessments on incidence of acute gastroenteritis in 0-14 aged children, in the Iasi County, Romania, between 2009-2012.

UNLABELLED: The study aim was to assess the epidemiological potential of acute gastroenteritis (AGE) in children between 2009 and 2012. MATERIAL AND METHODS: We studied two groups; first, a lot of 7237 cases (group A) recorded in the Iasi County through passive surveillance system, reported monthly by the network of primary health care, the assisted outpatients, respectively, those reported by hospitals. The second group (group B) was composed of 4191 hospitalized cases reported also in the passive surveillance system m by telephone, weekly, during only June/end of May to October/beginning of November. Structural peculiarities of the two groups are due to different reporting methodology, so that they were analyzed separately. RESULTS: AGE cases come from urban or rural areas in relatively stable proportions and slightly increased in rural areas compared to urban. The distribution by sex of cases from the group B is maintained at the same shape from one year to another, with a slight predominance in males. The best represented age group in every studied was 0-3 (54.3% of all cases), followed by children between 5 and 10 years with 17.5%). Laboratory investigations have enabled the etiologic diagnosis for hospitalized cases, which ranged from 15.3 to 17.5%, with the exception of 2009 when the diagnosis was noted for almost half of the discharged patients (47.5%). CONCLUSIONS: AGE remains a public health problem in the Iasi County and Romania also, by affecting all age groups, but especially children under 3, an insufficient knowledge of the etiology, and economic losses insufficiently evaluated.

Using ArcGIS software in the pre-hospital emergency medical system.

AIM: To measure the accessibility to healtcare services in order to reveal their quality and to improve the overall coverage, continuity and other features. MATERIAL AND METHODS: We used the software ESRI Arc GIS 9.3, the Network Analyst function and data provided by Ambulance Service of Iasi (A.S.I.) with emergencies statistics for the first four months of 2012, processed by Microsoft Office Excel 2010. As examples, we chose "St. Maria" Children's Emergency Hospital and "St. Spiridon" Emergency Hospital. RESULTS: ArcGIS Network Analyst finds the best route to get from one location to another or a route that includes multiple locations. Each route is characterized by three stops. The starting point is always the office of Ambulance Service of Iasi (A.S.I.), a second stop at the case address and the third to the hospital unit chosen according to the patient's diagnosis and age. Spatial distribution of emergency cases for the first four months of 2012 in these two examples is one unequable, with higher concentrations in districts located in two areas of the city. CONCLUSIONS: The presented examples highlight the poor coverage of healthcare services for the population of Iasi, Romania, especially the South-West area and its vulnerability in situations of emergency. Implementing such a broad project would lead to more complex analyses that would improve the situation of pre-hospital emergency medical services, with final goal to deserve the population, improve the quality of healthcare and develop the interdisciplinary relationships.

Descriptive study on acute gastroenteritis in 3,883 patients admitted in "sf. Maria" children hospital from Iasi, Romania, between 2008 and 2013.

UNLABELLED: The aim of study was to assess some population characteristics in children of acute gastroenteritis (AGE) admitted in a regional pediatric hospital. MATERIAL AND METHODS: For the present transversal descriptive study we considered a group of subjects hospitalized for AGE in 2008-2013 (2013--only 6 months) in "Sf. Maria" Emergency Hospital for Children Iasi, Romania. Consultations in the Emergency Unit of this hospital did not take into consideration. RESULTS: Number of AGE cases admitted to "St. Maria" Emergency Hospital for Children Iasi between 2008 and 2013 has seen a steady decline. Male subjects are better represented (54.1%); largest age group 1-4 years, with 1,827 cases, immediately followed by group 0-1 year (1789 cases); together, the two-age groups account for 93.1% of admissions for AGE. Distribution of cases by seasons showed balanced values, with higher percentages in summer (29.7%) and spring (25.5%). The number of cases is relatively constant and lower in winter, affecting predominantly younger groups (0-5 years) compared to the summer when cases aged 5 to 14 years were admitted more frequent. Most cases presented at admission vomiting (41.2%) and fever (40.7%); the presence of bacterial flora was identified in 82.2% of stool specimens, and blood in 13.4% of cases. CONCLUSIONS: A higher number of education measures should be implemented in urban and rural areas in order todecrease the contamination with pathogenic agents involved in infectious acute gas- troenteritis in children.

Some observations on the optimization of pre-hospital emergency medical services from the city of Iasi, Romania.

UNLABELLED: In the lasi City, with a population of 825,100 inhabitants, the number of requests for ambulance service has increased steadily for the past 17 years. One of the determining factors could be the development of the primary health care prevention. MATERIAL AND METHODS: We take into study some factors which consider influencing the reorganization of emergency medical systems in the lasi City territory. RESULTS: According to the spatial analyzes, distribution of health units in lasi City is concentrated type, developing in the downtown area, where there is also a high accessibility to health care services. There are some areas with a high population density, have low accessibility to hospital units, due to the presence of spatial network railroad as a spatial barrier, limiting interaction with other areas of the city. CONCLUSIONS: The analysis of optimization concept of Medical Services in a city like lasi is about the challenge to understand the impact of the population health towards the development and organizing the territory, and, interrelated, how we can improve the population health by the best possible organization.

Variables of job satisfaction in medical assistant profession.

AIM: To identify the key favorable issues, showing a high degree of job satisfaction, and also the adverse issues that may affect the work performance among medical assistants. MATERIAL AND METHODS: This research is a type of inquiry-based opinion survey carried out by administering a self-managed, anonymous questionnaire, consisting of five sections with 25 items. The study group included 175 medical assistants from all specialties, working in public hospitals in the city of Iasi, who answered the questionnaires. A number of 167 subjects have responded, the return rate being of 95.4%. The respondents were asked to indicate the amount of agreement or disagreement on a typical five-level Likert scale. RESULTS: The study has identified some positive aspects: positive perception of the medical assistant profession (76.6%); concern about personal growth and career development (86.3%); good rel ationships established with other colleagues (71.2%), and some negative aspects: inappropriate work conditions and equipments (70%); the income compared to the volume of work was perceived by majority as an important source of dissatisfaction (80.8%); willingness to work abroad (53.9%). CONCLUSIONS: The findings of the present research focused on the variables of job satisfaction in the medical assistant profession and should be a real concern for managers, because the job dissatisfaction may affect the employee's productivity.

[Some risk factors in breast tumour etiology. Observations in Iasi County between 2006 and 2010]. / Cercetari asupra implicarii unor factori de risc în etiologia tumorilor mamare. Observatii în judetul Iasi, în perioada 2006-2010.

THE AIM OF STUDY: To assess some risk factors and their involvement in female breast tumours etiology. MATERIAL AND METHODS: The study was performed on a sample of 67 patients registered with breast tumours, at family phisicians' offices from Iasi, Romania. RESULTS: Some risk factors were defined such as: nuliparity (20.8%) and first pregnancy after age 30 (34.3%); fibrous mastopathy in personal history (73.1% of cases with breast cancer) and breast cancer in siblings of first (8.9%) and second grade (11.9%). Relative to lifestyle, sedentary life was remarked in 59.2% of patients; modification of circadian rhythm in 28.3%, and excesive caffeine consumption in 80.9% of cases. CONCLUSIONS: Further prevention and educational programs on breast tumoural risk factors are needed in Romania, even at female teenage, performed by family physician.

[Comparative clinical-epidemiological assessments of road traffic accidents: emergency room observations in three counties of Moldavia, Romania, during 2005-2010]. / Evaluari clinico-epidemiologice asupra accidentelor rutiere, comparativ, în unitati de primire urgente: observatii în trei judete ale Moldovei, România, în perioada 2005-2010.

AIM: To assess road traffic injuries according to some descriptive parameters. MATERIAL AND METHODS: The study was carried out on a series of 5374 patients admitted to emergency rooms at Iasi (n=3050), Botosani (n=1187), and Vaslui (n=l137), between 2005 and 2010. RESULTS: Most frequently, the patient was a young, male adult, with cranial cerebral trauma, leg fracture, forearm contusion, or polytrauma, presenting to the emergency room most commonly in the month of August, weekends, and interval noon-dawn interval. CONCLUSIONS: The impact of road trauma epidemic would facilitate a better adaptation of the medical staff to case dynamics and increase the efficacy of primary prevention programs.

[Clinical epidemiological assessments on 3521 patients suffering from road traffic injuries, in relation with trauma localisation and severity, assisted in "Sf. Ioan" Emergency Unit, during 2002-2009]. / Evaluari clinico-epidemiologice asupra unui lot de 3521 de pacienti, care au suferit accidente de circulatie in judetul Iasi, in raport cu localizarea si severitatea traumatismelor, asistati in U.P.U. "Sf. Ioan", in perioada 2002-2009.

UNLABELLED: The aim of study was to assess road traffic injuries in relation with their localisation and severity. MATERIAL AND METHODS: A sample of 3521 patients suffering from road traffic injuries and assisted in "Sf. Ioan" Emergency Unit, Iasi, Romania was assess regarding age group, sex and residence area, type of lesions and ther localisation and severity, between 2002-2009. Data were collected using a special epidemiological inquiry and processed using SPSS and MS Excel statistical softs. RESULTS: The incidence of road traffic injuries increased during the last decade, with a report men/women of 1.5, urban and 21-30 age group predominance. The most frequent were leg fractures (16.7%) and thoracal contusions (19.1%), cranial and facial trauma (32.4%), with open injuries (10.5%). CONCLUSIONS: Prevention programmes with a high efficiency at the national level, as well as a concret identification of risk factors with a multidisciplinar approach of road traffic accidents, are needed.

[Assessment of some laboratory, imaging and anatomical-pathological investigations on a lot of 104 patients diagnosed with breast cancer and appear in the list of family doctor from the city of Iasi]. / Evaluari privind unele investigatii de laborator, imagistice si anatomo-patologice pe un lot de 104 paciente diagnosticate cu tumori mamare si inscrise inlista medicului de familie, din municipiul Iasi.

UNLABELLED: The aim of study was to assess some investigations in female patients with benign and malignant breast diseases. MATERIAL AND METHODS: The study was performed on a sample of 104 patients registered with breast tumors, at family physicians' offices from Iasi, Romania. RESULTS: Impaired glucose tolerance was associated with 34.2% of patient with breast tumors, and hypercholesterolemia with 25.9% of them. Anatomo-pathological assessments included aspiration puncture and biopsy, extemporaneous biopsy, and paraffin-embedded exam. Invasive carcinoma was the most frequent histo-pathological type (42.1%). CONCLUSIONS; Further investigations on tumor markers are needed in all patients with in situ neoplasia and breast carcinomas.

[Retroprospective clinical epidemiological research on two samples of patients suffering from viral hepatitis A, assisted in specified services of Suceava and Botosani counties, between 1996 and 2007]. / Cercetari clinico-epidemiologice retroprospective, pe doua loturi de bolnavi cu hepatita virala A, asistati in serviciile de profil, din judetele Suceava si Botosani, in perioada 1996-2007.

UNLABELLED: Nowadays, researchers from various fields of study and geographical regions continue to pay attention to viral hepatitis A. Due to a resistant virus, with predominant enteral transmission, with endemic epidemic manifestations and a remarkable clinical polymorphism, affecting children especially, hepatitis A does not chronicize, but, in adults, it is responsible for forms with prolonged evolution and severe, sometimes. MATERIAL AND METHODS: Results of clinical epidemiological and laboratory studies carried on a sample of 10321 patients suffering from hepatitis A, from two lots: 5530, Suceava; 4791, Botosani; 5400, males; 4921 females; age from < 1 to = 55. RESULTS: In Suceava County, the hepatitis A incidence had epidemic values in 1996 (229%000) and 1997 (224%000). The most affected age groups, with hospitalized clinical forms, were 5-14 (42.3%) and 15-24 (24.9%). In Botosani County, epidemic peaks registered in 1999 (213%000), and inter-epidemic in the other years. The most affected age group was of 5-14, with 48.9% from all the admitted cases, but 52% from all cases belonged to age groups over 25.

[Retroprospective clinical epidemiological research on leptospirosis cases hospitalised in the Infectious Diseases Clinic of Iasi]. / Cercetari clinico-epidemiologice, retroprospective, asupra cazurilor de leptospiroza, spitalizate in Clinica de Boli Infectioase Iasi, in perioada 1998-2004.

MATERIAL AND METHOD: Analytical assessment was performed for a sample of 499 patients admitted in the Infectious Diseases Clinic of Iasi, in order to highlight some clinical epidemiological and laboratory characteristics. RESULTS: During the third trimester, 45.3% of patients were hospitalized, comparatively with 7.8% during the first trimester, leading to a summer - autumn seasonality. Age groups of 31-60 years registered 57.3%; 90.2% were males, and only 13.2% agricultural workers. Clinical forms and evolution were assessed by testing a number of 10 biological and biochemical indicators. Leptospira icterohaemorrhagiae was the causal agent in 46.1% of cases, followed by L. wolffi (44.3%), L. pomona (4.2%), and l. grippotyphosa (3.4%). Average length of stay of 11-20 days (42.3%) and over 20 (21.4%) represented an indicator of unfavourable medical and socioeconomic involvements due to leptospirosis.

[Multidisciplinary prospective epidemiological research regarding the prevalence of ankylosing spondilytis, comparatively in Romania and Iasi County, between 1990-2006]. / Cercetari epidemiologice, retroprospective, multi- disciplinare, asupra prevalentei cazurilor de spondilita anchilozanta, comparativ in România si judetul Iasi, in perioada 1990-2006.

UNLABELLED: During the period of study, the prevalence of ankylosing spondylitis (AS) cases values varied between 5.65% per hundred thousand in 1994 and 3.96 in 1999. RESULTS: Are close to those obtained in the national research in 1989 (5.29% hundred thousand) and 1997 (6.34% hundred thousand). The sample of 6894 cases registered a prevalence of 28.86% in the 35-44 age groups with a decreasing trend, and 0.07% in = 85 age group. Males' prevalence was of 84.08%, comparatively with females (15.91% from total cases). Difference between residence areas had not statistic significance. In Iasi County, AS prevalence had increased values in all 17 years of study period, greater and often double that those at national level, and also greater than every county from Moldavia and one from the Western Romania. Demographical structure, variations, and those occupational, ecological, economical, educational could explain this situation. CONCLUSION: Ankylosing spondylitis is included among the major problems in order to promote community health, taking into account its clinical epidemiological characteristics.