Community-based education: An effective policy for earthquake preparedness in Iran: Empirical study.

BACKGROUND: As natural or man-made shocks, disasters are sudden events that require emergency and fundamental measures. The need to be prepared for disasters has become clearer than ever worldwide. This study aimed to investigate the effect of earthquake preparedness training using the face-to-face or cascade method in rural households living in Juybar County (Iran) in 2018. METHODS AND MATERIAL: Following an experimental design with a pretest and posttest, the study was performed on married women aged 10-49 living in Kurdkolay village of Juybar county (n = 372). Participants were randomly categorized into two groups of training (n = 95) and face-to-face cascade method (n = 95). Data were collected using the Disaster Preparedness Assessment Index, comprising demographic and education sections. Data were collected using the disaster preparedness assessment index and analyzed using SPSS version 24. RESULTS: The findings indicated improved preparedness in all five dimensions in both groups. There was a significant difference between the study groups immediately and one week after the intervention (P < 0.05); i.e. a higher impact for the face-to-face cascade method. Meanwhile, both groups presented a similar level of preparedness 90 days after receiving the intervention (P > 0.05). CONCLUSIONS: The face-to-face cascade method was more effective in the short term, while no difference was found in the long term. Crisis managers and policymakers should choose their preferred method based on available facilities, human resources, and context to increase preparedness against earthquakes. Mothers play a vital role in educating and nurturing their children. It is suggested to conduct educational programs at the community level using the most appropriate methods that are chosen based on the best evidence.

A comparative study of the curriculum in master degree of medical education in Iran and some selected countries.

BACKGROUND: When training efficient human resources for the health system, it is necessary to train appropriate student teaching and assessment methods and necessary skills for educational planning and evaluation. Therefore, studies and efforts to train human resources in the field of Iranian medical education have begun since 1994. The aim of the present study is a comparative study of the curriculum in master's degree of medical education in Iran and some selected countries. METHODS: This is applied, descriptive and comparative research. Data were collected by electronic search on the website of the selected universities. Each of these selected educational curricula, the newest curriculum of the studied universities at the time of the present research, was translated into fluent Persian and studied in detail. The model used in the present study is the famous Polish Bereday model. A quota sampling method was used and universities were selected at a 1:10 ratio from each classified area. Institutions that offered master's degrees in medical education were chosen in each region using the World Health Organization (WHO) classification based on QS World University Rankings (2020). The data collection instrument was a researcher-made checklist, which was used to extract the relevant data available on the website of selected universities. This checklist consisted of eight items, which included course title, course length, mission, vision, goals, admission process, teaching methods (online, In-person, and both), educational strategies, teaching methods, and student assessment. These eight items were compared at selected universities. RESULTS: The samples included seven selected universities including Kebangsaan University in Asia, the University of Toronto in Canada, the University of Michigan in America, the University of Bern and Imperial College in Europe, Monash University in Australia, and Iranian universities. Student admission in Iran is carried out through a centralized exam; therefore, most faculties do not have the option to select students and criteria for student selection. The course length in all universities is between 1-3 years (depending on part-time/full-time) and most of the studied universities offer this field as modular degree courses. CONCLUSIONS: The characteristics of the curriculum for the master's degree of medical education in Iran and selected countries showed the differences and similarities of this course among the top universities of different continents. Unlike other countries, the curriculum for a master's degree in medical education in Iran is offered in a centralized manner in eight universities of Tehran, Shahid Beheshti, Iran, Isfahan, Shiraz, Tabriz, Kerman, and Mashhad.

Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation.

IMPORTANCE: Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described. OBJECTIVE: To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region. DESIGN: We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition. SETTING: 2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: All members of surveyed households during five interviews over a two-year period. INTERVENTION: Start of insurance coverage expansion under the ACA. MAIN OUTCOMES: Health insurance status. RESULTS: On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001). CONCLUSION AND RELEVANCE: The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

Comparing the effect of traditional and role-play training methods on nursing students' performance and satisfaction in the principles of patient education course.

BACKGROUND: Education is considered as one of the most important well-known roles of nurses, which is based on the patients' needs and awareness level. Thus, training the skill to nursing students is highly prioritized. The present study aimed to compare traditional and role-play training methods on nursing students' performance and satisfaction in the principles of patient education course. MATERIALS AND METHODS: The present quasi-empirical study was conducted in 2019 among 36 fourth-semester nursing students at the School of Nursing in Borujen branch. In this regard, the students were randomly divided into experimental (n = 18) and control (n = 18) groups and trained through role-play and traditional methods, respectively. The data were collected using demographic questionnaire, training method satisfaction form, and student performance evaluation checklist (30 items), among which the two last ones were researcher made. Then, data were analyzed by SPSS software version 19 and using descriptive and analytical statistical tests such as Chi-square and Mann-Whitney. RESULTS: The results demonstrated a statistically significant difference (P < 0.05) between the mean score of students' satisfaction with teaching method in the control (17.15 ± 0.89) and experimental groups (19.03 ± 1.49), as well as between that of their performance in the control and experimental groups (115.31 ± 2.07 and 118.28 ± 3.59, respectively). CONCLUSION: Based on the results, role-play training method affected nursing students' performance in the principles of patient education course higher. Thus, using the method in training students and in-service training for nursing personnel is recommended to education planners and nursing education authorities for improving the skill.

Impact of social problem-solving training on critical thinking and decision making of nursing students.

BACKGROUND: The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students' critical thinking and decision-making. METHODS: This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental (n = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient. RESULTS: The finding indicated that the social problem-solving course positively affected the student' social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group (P < 0.05), but this result was not observed in the control group (P > 0.05). CONCLUSIONS: The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

Geographic variations in specialty distribution and specialty-related mortality.

Using data from the Centers for Disease Control and Centers for Medicare and Medicaid Services, we analyzed the relationship between specialty physician location and specialty-specific mortality rates for diagnoses where access to specialty expertise could plausibly reduce death rates. After adjustment for demographic and health indicators, counties with the highest quartile specialty physician density had lower mortality rates compared to counties with the lowest quartile. The observed association in endocrinology, infectious disease, and neurology was 10.7, 2.9 and 7.2 fewer deaths per 100,000 residents, respectively. There is an inverse correlation between the distribution of select specialties and population-level mortality.

Transition to Virtual Learning During the Coronavirus Disease-2019 Crisis in Iran: Opportunity Or Challenge?

COVID-19 is a respiratory disease that can spread from one person to person. This virus is a novel coronavirus that was first identified during an investigation into an outbreak in Wuhan, China. Iran's novel coronavirus cases reached 17,361 on 17 March, while death toll reached approximately 1,135. Its first death was officially announced on 20 February 2020 in Qom. The 2019 coronavirus pandemic has affected educational systems around the world, Also in Iran, and led to the closure of face to face courses in schools and universities. Therefore, virtual education can be seen as a turning point in education of these days in Iran.

Differences in the Complexity of Office Visits by Physician Specialty: NAMCS 2013-2016.

BACKGROUND: Specialty-to-specialty variation in use of outpatient evaluation and management service codes could lead to important differences in reimbursement among specialties. OBJECTIVE: To compare the complexity of visits to physicians whose incomes are largely dependent on evaluation and management services to the complexity of visits to physicians whose incomes are largely dependent on procedures. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 53,670 established patient outpatient visits reported by physicians in the National Ambulatory Medical Care Survey (NAMCS) from 2013 to 2016. We defined high complexity visits as those with an above average number of diagnoses (> 2) and/or medications (> 3) listed We based our comparison on time intervals corresponding to typical outpatient evaluation and management times as defined by the Current Procedural Terminology Manual and specialty utilization of evaluation and management codes based on 2015 Medicare payments. MAIN OUTCOME AND MEASURES: Proportion of complex visits by specialty category. KEY RESULTS: We found significant differences in the content of similar-length office visits provided by different specialties. For level 4 established outpatient visits (99214), the percentage involving high diagnostic complexity ranged from 62% for internal medicine, 52% for family medicine/general practice, and 41% for neurology (specialties whose incomes are largely dependent on evaluation and management codes), to 34% for dermatology, 42% for ophthalmology, and 25% for orthopedic surgery (specialties whose incomes are more dependent on procedure codes) (p value of the difference < 0.001). High medication complexity was found in the following proportions of visits: internal medicine 56%, family medicine/general practice 49%, and neurology 43%, as compared with dermatology 33%, ophthalmology 30%, and orthopedic surgery 30% (p value of the difference < 0.001). CONCLUSION: Within the same duration visits, specialties whose incomes depend more on evaluation and management codes on average addressed more clinical issues and managed more medications than specialties whose incomes are more dependent on procedures.

Trends of geographic distribution of general practitioners in the public health sector of Iran.

BACKGROUND: Proper distribution of general practitioners (GPs) is one of the challenges in all health systems. This study aimed to investigate geographical distribution of GPs in public health sector in Iran between 2010 and 2016. METHODS: The study is a descriptive-cross-sectional study. The population of provinces was extracted from Iran's National Statistic Center, while information on GPs was gathered from deputy of statistic and information technology in Ministry of Health and Medical Education. Data analysis was carried out using descriptive statistics, Gini coefficient (GC), and by drawing geographical distribution map of GPs. Data analysis was performed by excel 2013, Stata V.14, and Arc GIS software. RESULTS: The results of calculating the number of GPs per 100,000 population in Iran showed that, in year 2010, Chaharmahal and Bakhtiari Province had the highest (10.39) and Alborz Province had the lowest (0.66) number of per capita GPs. The highest number of GPs per 100,000 population among Iran's provinces belonged to Chaharmahal and Bakhtiari (8.97), while the lowest belonged to Tehran (0.28) in year 2016. The GC was 0.31 in year 2010 and 0.283 for 2011. The lowest GC belonged to year 2012 (GC = 0.272), while the largest coefficient belonged to year 2016 (0.356). CONCLUSIONS: According to the results of this study, the distribution of GPs in public health sector of Iran in between 2010 and 2016 showed inequality. Therefore, along with increasing the number of GPs working in public health sector, it is necessary to pay attention to their distribution. Further studies are needed to investigate inequality of GPs within and between the provinces.

Introducing an attractive method for total biomimetic creation of a synthetic biodegradable bioactive bone scaffold based on statistical experimental design.

A new total biomimetic technique based on both the water uptake and degradation processes is introduced in this study to provide an interesting procedure to fabricate a bioactive and biodegradable synthetic scaffold, which has a good mechanical and structural properties. The optimization of effective parameters to scaffold fabrication was done by response surface methodology/central composite design (CCD). With this method, a synthetic scaffold was fabricated which has a uniform and open-interconnected porous structure with the largest pore size of 100-200µm. The obtained compressive ultimate strength of ~35MPa and compression modulus of 58MPa are similar to some of the trabecular bone. The pore morphology, size, and distribution of the scaffold were characterized using a scanning electron microscope and mercury porosimeter. Fourier transform infrared spectroscopy, EDAX and X-ray diffraction analyses were used to determine the chemical composition, Ca/P element ratio of mineralized microparticles, and the crystal structure of the scaffolds, respectively. The optimum biodegradable synthetic scaffold based on its raw materials of polypropylene fumarate, hydroxyethyl methacrylate and nano bioactive glass (PPF/HEMA/nanoBG) as 70/30wt/wt%, 20wt%, and 1.5wt/wt% (PHB.732/1.5) with desired porosity, pore size, and geometry were created by 4weeks immersion in SBF. This scaffold showed considerable biocompatibility in the ranging from 86 to 101% for the indirect and direct contact tests and good osteoblast cell attachment when studied with the bone-like cells.

Effects of problem-solving skill training on emotional intelligence of nursing students: An experimental study.

BACKGROUND: Nursing students are generally trained to acquire the knowledge, skills, and approaches required for solving problems and contradictions in life and at work. In fact, problem-solving skills are the core of effective nursing activities. Therefore, the aim of this study is to evaluate the effectiveness of problem-solving training on the promotion of emotional intelligence in nursing students. MATERIALS AND METHODS: This interventional case-control study used a pretest-posttest design. All senior nursing students (n = 43) attending the seventh semester of their undergraduate studies at Hazrat Fatemeh School of Nursing and Midwifery of Shiraz University of Medical Sciences were recruited in the present study. The participants were randomly allocated to either the intervention group (n = 20) or the control group (n = 23). The collected data were analyzed with SPSS software version 16. RESULTS: While the mean standardized scores of Emotional Quotient Inventory of the two groups were not significantly different before the intervention, the scores were significantly higher in the intervention group both immediately and 2 months after the intervention. Comparison of the standardized emotional intelligence scores revealed the intervention group to have significantly higher mean scores immediately and 2 months after the intervention compared to baseline scores (105.87 ± 9.82 and 109.44 ± 9.56 vs. 101.22 ± 10.93; P < 0.001). Such significant differences were absent in the control group. CONCLUSION: Using the results of this research in nursing education, it is possible to improve the level of nurses' knowledge and personal skills and to increase the level of services and increase the satisfaction of the clients.

Nurses' Awareness about Principles of Airway Suctioning.

INTRODUCTION: Airway suctioning is one of the most common interventions for patients with respiratory disorders and having adequate knowledge in implementing this technique is quite crucial for nurses. AIM: To assess the nurses' awareness about principles of airway suctioning. MATERIALS AND METHODS: This study was a cross-sectional study done on 85 staff nurses' in Vali-Asr hospital. Sampling was based on census data collection. A researcher made questionnaire was used for assessment of nurses' awareness about the principles of airway suctioning. The validity and reliability (Cronbach's alpha=0.78) of the questionnaire have been examined and proved. The level of nurses' awareness about airway suctioning was measured based on the questionnaire that includes demographic and specialty information in the form of eight questions of 3-selection-item. The maximum and minimum score of knowledge ranged between 0-8. The data obtained was statistically analysed using SPSS software Version 16.0 and was analysed using descriptive statistics and Pearson correlation coefficient. RESULTS: The results reveal that the nurses' awareness about principles of airway suctioning was average. There was a significant association between knowledge and gender of nurses (p<0.05) which reveals that the awareness of women about the principles of airway suctioning was more than men. CONCLUSION: The results indicate that nurses' awareness of airway suctioning technique was in an average state. Considering the importance of this technique and the effects this technique has on the patients' haemodynamic status, we recommend in-service courses.

Influence of Training about Carcinogenic Effects of Hookah Smoking on the Awareness, Attitude, and Performance of Women

Background: Wrong attitudes and beliefs about the less carcinogenic effects of hookah smoking comparing to cigarette, easy availability, low cost, and other factors have caused that the usage of hookah smoking increase a lot in our country. Objective: This study has been done with the purpose of examining the influence of education about carcinogenic effects of hookah smoking on the awareness, attitude, and performance of women who refer to the healthcare and medical treatment centers. Materials and Methods: At this semi experimental study, 60 women who refer to the medical and hygienic centers of Bushehr were placed in 3 educational groups based on simple accidental sampling. The tool for data collection was a questionnaire including demographic features, awareness, attitude, and performance measurement. Results: according to the results, the amount of awareness in the majority (48%) of participants about carcinogenic effects of hookah smoking was in an average level. 100% of the participants had the awareness of over 33.1% and their attitude toward hookah smoking was 100% positive that after the intervention it was reported 5%. The participants' performance in hookah smoking before the intervention was only 25% desirable that after the intervention it was reported 73.3%. The results of Kolmogorov­Smirnov test also showed that the distribution of awareness, attitude, and performance was quite normal. Conclusion: according to the results, it's the society's basic need to warn people about carcinogenic effects of hookah smoking by increasing people's awareness through media, holding training courses, showing movies, and training booklets.

Comparison of Direct and Indirect Methods of Teaching Breast Self-Examination ­ Influence on Knowledge and Attitudes of Iranian Nursing and Midwifery Personnel

Background: Breast cancer is the most common cancer in women. Monthly breast self-examination (BSE) has been presented as one of the best screening methods available. The aim of this study was to compare effects of both direct and indirect methods of teaching of BSE on knowledge and attitudes of nursing and midwifery personnel. Materials and Methods: The present study was performed on 89 nursing and midwifery personnel in Valiasr hospital of Borujen city. Participants were randomly divided into a direct and an indirect training group. Researcher-designed BSE knowledge and attitude and demographic information questionnaires were used for data collection. Results: Before the education intervention, the mean levels of knowledge and attitude were 9.82±2.79 and 56.5±6.21 in the direct training group and 9.59±2.71 and 54.5±4.51 in the indirect training group; after the intervention, they reached 19.2±0.96 and 62.9±4.21, and 11.0±2.58 and 59.0±3.44, respectively. The difference in the mean levels of knowledge and attitude were significantly higher in the direct training group post intervention (P<0.05). Conclusion: It appears that educational planners and hospital personnel education officials should seek to teach aspects of crucial health behavior to female personnel using cooperative and direct training methods.

Prediction of Marital Satisfaction Based on Emotional Intelligence in Postmenopausal Women.

OBJECTIVES: This study was coperinducted with the aim of prediction of marital satisfaction based on emotional intelligence for postmenopausal women. METHODS: This cross-sectional study was the descriptive-correlation and with a sample size of 134 people to predict marital satisfaction based on emotional intelligence for postmenopausal women was conducted in the Borujen city. The subjects were selected by convenience sampling. Data collection tools included an emotional intelligence questionnaire (Bar-on) and Enrich marital satisfaction questionnaire. RESULTS: The results of this study showed a significant positive relationship between marital satisfaction and emotional intelligence (P < 0.05, r = 0.25). Also, regression analysis showed that emotional intelligence (ß = 0.31) can predict positively and significantly marital satisfaction. CONCLUSIONS: Due to the positive relationship between emotional intelligence and marital satisfaction, adequacy of emotional intelligence is improved as important structural in marital satisfaction. So it seems that can with measuring emotional intelligence in reinforced marital satisfaction during menopause, done appropriate action.

Comparing Sexual Function and Quality of Life in Polycystic Ovary Syndrome and Healthy Women.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders that is associated with different metabolic, reproductive and psychological consequences. The main aim of this study was to compare the sexual function and quality of life in women with polycystic ovary syndrome and healthy women. MATERIALS AND METHODS: This is a causal-comparative study in which 129 women with polycystic ovary syndrome were qualified as the research group. The control group consisted of 125 healthy women. The sampling method was convenient and was done using Rotterdam criteria. Women of both research and control groups responded to the FSFI and WHOQOL-BREF questionnaires. Data were analyzed with SPSS software using MANOVA. RESULTS: According to findings, all of quality of life subscales except environment domain were significantly lower in research group than healthy group (p < 0.01), but none of sexual function subscales were significantly different between two groups (p > 0.05). CONCLUSION: Women with PCOS in term of some quality of life parameters have lower performance than healthy women. Therefore, it seems to be essential to increase awareness about symptoms and psychological consequences and referring process in order to take advantage of the advisory services.

Influence of physician, patient, and health care system characteristics on the use of outpatient mastectomy.

BACKGROUND: Breast cancer is the 2nd leading cause of cancer deaths among women in the United States. Breast cancer surgeries can be performed on either an inpatient or ambulatory basis. This systematic review of literature on outpatient mastectomy examines what is known about the factors that influence the use of this procedure, existing public policies, and strategies to promote the appropriate use of outpatient mastectomy. METHODS: Factors associated with the utilization of outpatient mastectomy were categorized and discussed under the following headings: "patient level," "physician level," and "system level." RESULTS: Potential contributing factors to the use of outpatient mastectomy at the patient level were race, educational level, comorbid conditions, cancer stage, and health insurance. Contributing factors at the provider level were demographics, surgeon specialty, and whether physician is an American or international graduate. The associated factors at the system level were state policy and legislation and hospital characteristics. CONCLUSIONS: The evidence in the research literature suggests that the use of outpatient mastectomy is a function of interactions between patient and physician characteristics, managed care influences, and the state policies and laws.

Effect of training problem-solving skill on decision-making and critical thinking of personnel at medical emergencies.

BACKGROUND: The aim of this study was to determine the effect of problem-solving training on decision-making skill and critical thinking in emergency medical personnel. MATERIALS AND METHODS: This study is an experimental study that performed in 95 emergency medical personnel in two groups of control (48) and experimental (47). Then, a short problem-solving course based on 8 sessions of 2 h during the term, was performed for the experimental group. Of data gathering was used demographic and researcher made decision-making and California critical thinking skills questionnaires. Data were analyzed using SPSS software. RESULTS: The finding revealed that decision-making and critical thinking score in emergency medical personnel are low and problem-solving course, positively affected the personnel' decision-making skill and critical thinking after the educational program (P < 0.05). CONCLUSIONS: Therefore, this kind of education on problem-solving in various emergency medicine domains such as education, research, and management, is recommended.