Intervención educativa basada en metodologías B-learning para mejorar las citologías cervicales: experiencias de enfermeras / Intervenção educacional através do B-learning para melhorar a citologia cervical: experiências de enfermeiras / Educational intervention through B-learning to improve cervical cytology: experiences of nurses

Resumen Objetivo analizar las experiencias de enfermeras en la toma de las citologías cervicales y otros factores organizacionales durante una intervención educativa asistida por metodologías B-learning. Método estudio cualitativo realizado en San Luis Potosí, México. Participaron 15 enfermeras. La recolección de datos se hizo a través de entrevistas semiestructuradas con base en una sistematización de experiencias. Para el análisis de la información se utilizó el programa Taguette y como referente teórico las metodologías B-learning. Resultados se identificaron debilidades en factores relacionados con la accesibilidad de las usuarias al servicio, insumos, infraestructura, bioseguridad, capacitación del personal de salud, entrega de resultados a las pacientes y conocimiento del programa por parte de las usuarias. Conclusiones e implicaciones para la práctica el cáncer cervical es un problema de salud pública. La citología cervical es la prueba de tamizaje más utilizada; sin embargo, existen limitantes en la calidad, por lo que se proponen acciones para mejorar los conocimientos y habilidades del personal de enfermería que tiene como función la toma. La intervención educativa fue efectiva para fomentar el aprendizaje integral sobre la toma de las citologías cervicales y permitió al personal de enfermería compartir sus experiencias.

Resumo Objetivo analisar as experiências das enfermeiras na realização de esfregaços cervicais e outros fatores organizacionais durante uma intervenção educacional assistida por metodologias de b-learning. Método estudo qualitativo realizado em San Luis Potosí, México. Participaram 15 enfermeiras. A coleta de dados foi feita por meio de entrevistas semiestruturadas a partir de uma sistematização de experiências. Para a análise das informações, utilizou-se o programa Taguette e metodologias de b-learning como referencial teórico. Resultados foram identificadas fragilidades em fatores relacionados com a acessibilidade dos usuários ao serviço, insumos, infraestrutura, biossegurança, capacitação da equipe de saúde, entrega de resultados aos pacientes e conhecimento do programa pelos usuários. Conclusões e implicações para a prática o câncer do colo do útero é um problema de saúde pública. A citologia cervical é o teste de triagem mais utilizado; no entanto, existem limitações na qualidade, por isso são propostas ações para aprimorar os conhecimentos e habilidades das enfermeiras que estejam desempenhando essa função. A intervenção educacional foi eficaz para promover o aprendizado integral sobre a realização do esfregaço cervical e permitiu que as enfermeiras compartilhassem suas experiências.

Abstract Objective to analyze the nursing staff's experiences in taking cervical smears and other organizational factors during an educational intervention assisted by B-learning methodologies. Method a qualitative study was carried out in San Luis Potosí, Mexico, with 15 nurses. Data collection was done through semi-structured interviews based on a systematization of experiences. The Taguette program and B-learning methodologies as theoretical references were used to analyze the information. Results weaknesses were identified in factors related to the accessibility of users to the service, supplies, infrastructure, biosafety, training of health personnel, delivery of results to patients, and knowledge of the program by the users. Conclusions and implications for practice cervical cancer is a public health problem. Cervical cytology is the most widely used screening test; however, there are limitations in quality, so actions are proposed to improve the knowledge and skills of the nursing staff in their functions. The educational intervention effectively promoted comprehensive learning about taking cervical smears and allowed the nursing staff to share their experiences.

Midwives' practices related to cervical cancer screening during pregnancy: A vignette-based study.

OBJECTIVE: To describe midwives' practices related to cervical cancer screening and women's eligibility for screening during pregnancy. STUDY DESIGN: Cross-sectional vignette-based study of French midwives during February-May 2018. MAIN OUTCOME MEASURES: Participants were asked to complete an internet-based questionnaire: a clinical case-vignette about a woman eligible for cervical cancer screening during pregnancy and a short self-administered questionnaire. RESULTS: We obtained 273 complete questionnaires from eligible midwives. Of those responding, 15% reported that they never screened for cervical cancer during pregnancy, 63.7% did so for women 25 years or older, and 51% adhered to the recommended intervals between tests. Overall, 110 (40%) midwives adhered to the complete screening protocol (age at initiation and interval). In this clinical case vignette of a woman meeting the criteria for screening, only 29% of midwives reported they would perform a Pap test at 25 weeks of gestation, while 91% would at 10 weeks. CONCLUSION: Midwives' practices of cervical cancer screening and their determination of women's eligibility during pregnancy vary, especially according to gestational age; Nevertheless, pregnancy is an appropriate time to screen women who meet the criteria for cervical cancer screening, especially if they are not receiving regular gynaecological care.

Impact of Applying a Learning Strategy to Improve the Sample Quality in Cervical Screening in Nursing Staff in Social Service.

OBJECTIVES: The study sought to assess the impact of applying a learning strategy to improve the quality of sample collection during cervical screening by students from the Nursing Degree Program doing social service. METHODS: This was a longitudinal, quasi-experimental study with the participation of 23 interns from the Nursing Degree Program at a public university from San Luis Potosí, Mexico. The work assessed knowledge of practical skills in taking cervical cytology tests and the quality of samples before and after applying a learning strategy that included 10 h of theoretical training and 22 h of practices on themes related to sample collection in cervical screening. RESULTS: A statistically significant difference was obtained in improved knowledge (t = -12.8 p<0.001) and practical skills (t = -8.86 p<0.001) after the intervention. The increased percentage of suitable samples from 30.43% to 82.60% was attributed to the application of the learning strategy in the pre- and post-intervention phases (p<0.001). CONCLUSIONS: Training is effective to improve knowledge and practical skills to collect samples in cervical screening, as well as the quality of the samples for their interpretation.

HPV vaccination: effects on cervical screening.

Uptake of cervical screening has declined slightly since the 1990s, and is generally lower among young women than older women. Although the human papillomavirus vaccination programme is successful, some girls are still not being vaccinated. In addition, the programme may have a negative impact on the uptake of cervical screening, as young women may not realise they are still vulnerable to cervical cancer after vaccination. Nurses should encourage girls and young women to take up both HPV vaccination and cervical screening.

Effectiveness of nursing interventions to increase pap smear test screening.

The purpose of this study was to determine the effect of a three-stage nursing intervention to increase Turkish women's participation in Pap smear testing. Knowledge and beliefs about cervical cancer screening and barriers to Pap smears also were explored. In a quasi-experimental study in a target population of 2,500 women, 237 completed pre-test measures to inform the intervention, and an educational brochure was distributed to all 2,500. As a result, 510 women (20.4%) accepted free Pap smears. Of the remaining 1,990 women, 417 were randomly selected for telephone interviews, 302 participated, and 158 of these (52.3%) participated in free Pap smear testing. Of the 144 who did not have Pap smears after participating in telephone interviews, 54 were then interviewed face-to-face, and 20 (37.0%) decided to accept free Pap smears. A total of 668 women had accepted free Pap smears by the end of the intervention period.

Mulheres histerectomizadas e preventivo ginecológico: vivências de enfermeiras / Women submitted to the hysterectomy and gynecological preventive: experiences of nurses

Com o objetivo de conhecer a vivência da enfermeira na realização do Exame Papanicolaou em mulheres histerectomizadas e como essas profissionais fazem a abordagem às mulheres durante o exame preventivo. Trata-se de uma pesquisa qualitativa, utilizando a análise compreensiva. Foram entrevistadas nove enfermeiras que atuam em Unidades Básicas de Saúde, no mês de março de 2008. A análise compreensiva desvelou que as enfermeiras receberam pouca ou nenhuma orientação e que se norteiam pelas experiências vivenciadas. Consideramos que a carência de orientações e treinamentos quanto às especificidades do atendimento às mulheres histerectomizadas, interfere na prática e na qualidade da assistência às mulheres.

Program logic: a framework for health program design and evaluation - the Pap nurse in general practice program.

In this paper, program logic will be used to 'map out' the planning, development and evaluation of the general practice Pap nurse program in the Australian general practice arena. The incorporation of program logic into the evaluative process supports a greater appreciation of the theoretical assumptions and external influences that underpin general practice Pap nurse activity. The creation of a program logic model is a conscious strategy that results an explicit understanding of the challenges ahead, the resources available and time frames for outcomes. Program logic also enables a recognition that all players in the general practice arena need to be acknowledged by policy makers, bureaucrats and program designers when addressing through policy, issues relating to equity and accessibility of health initiatives. Logic modelling allows decision makers to consider the complexities of causal associations when developing health care proposals and programs. It enables the Pap nurse in general practice program to be represented diagrammatically by linking outcomes (short, medium and long term) with both the program activities and program assumptions. The research methodology used in the evaluation of the Pap nurse in general practice program includes a descriptive study design and the incorporation of program logic, with a retrospective analysis of Australian data from 2001 to 2009. For the purposes of gaining both empirical and contextual data for this paper, a data set analysis and literature review was performed. The application of program logic as an evaluative tool for analysis of the Pap PN incentive program facilitates a greater understanding of complex general practice activity triggers, and also allows this greater understanding to be incorporated into policy to facilitate Pap PN activity, increase general practice cervical smear and ultimately decrease burden of disease.

Resultados de citologia oncótica em uma regional de saúde no período de 2007-2008 / Oncotic cytology results in a health center in the period of 2007-2008 / Resultados de colpocitología oncótica en una regional de salud en el periodo de 2007-2008

A citologia oncótica é um exame de rastreamento capaz de detectar o câncer cérvico-uterino na fase inicial. Este estudo retrospectivo teve como objetivo descrever a frequência dos resultados dos exames de citologia oncótica coletados nos anos de 2007 e 2008 em 16 municípios pertencentes ao Departamento Regional de Saúde VIII/São Paulo, por meio dos dados do Sistema de Informação do Câncer do Colo do Útero. Foi realizada análise descritiva de 28.066 e 27.044 exames coletados nos anos de 2007 e 2008, respectivamente, destes 62,3% em 2007 e 59,5% em 2008 estavam dentro dos limites de normalidade. As alterações em células epiteliais escamosas representaram 0,2% e, 0,4% dos resultados em 2007 e 2008, e as alterações em células epiteliais glandulares 0,2% em 2007 e 2008. Neste contexto, percebe-se que as porcentagens de microbiologia e de atipias celulares encontradas nesta pesquisa estão aquém dos resultados apresentados por outras pesquisas em diferentes regiões do país.

The oncotic cytology is a tracking test which can detect early cervical cancer. This retrospective study aimed to describe the frequency of the results of oncotic cytology exam collected in the years 2007 and 2008 in 16 municipalities belonging to the Regional Health Department VIII/São Paulo, using data from the Information System for Uterine Cervical Cancer. A descriptive analysis of 28,066 and 27,044 tests collected in the years 2007 and 2008, respectively, of these 62.3% in 2007 and 59.5% in 2008 were within normal limits. The changes in flaky epithelial cells represented 0.2% and 0.4% of results the in 2007 and 2008, and changes in glandular epithelial cells by 0.2% in 2007 and 2008. In this context, it is noticed that the percentages of microbiology and of atypical cells found in this study fall short of the results presented by other studies in different regions of the country.

La colpocitología oncótica es un examen de rastreo capaz de detectar el cáncer de cuello uterino precoz. Este estudio retrospectivo planteó como objetivo describir la frecuencia de los resultados de las pruebas de colpocitología oncótica recolectadas en los años 2007 y 2008 en 16 municipios pertenecientes al Departamento Regional de Salud VIII / São Paulo, a través de datos del Sistema de Información de Cáncer de Cuello Uterino. Se realizó un análisis descriptivo de 28.066 y 27.044 pruebas recolectadas en los años 2007 y 2008, respectivamente, de éstas 62,3% en 2007 y 59,5% en 2008 estaban dentro de los límites de normalidad. Las alteraciones en células epiteliales escamosas representaron 0,2% y, 0,4% de los resultados en 2007 y 2008, y las alteraciones en células epiteliales glandulares 0,2% en 2007 y 2008. En este contexto, se percibe que los porcentajes de microbiología y de anormalidades de atipias celulares encontrados en esta investigación aparecen en inferior grado tocante a los resultados presentados por otras pesquisas en diferentes regiones del país.

Personal influences that affect motivation in pap smear testing among African American women.

OBJECTIVE: To explore personal influencing factors that contribute to Papanicolaou (Pap smear) testing in African American women who do (routine-use group) and do not (non-routine-use group) obtain routine testing. DESIGN: Qualitative using the interaction model of client health behavior. SETTING: Community programs, homes, and churches. PARTICIPANTS: Twenty four African American women aged 19 to 60. METHODS: Face-to-face interviews. Data were analyzed using a constant comparison approach. RESULTS: Routine-use group was socially influenced to value preventive health care while the non-routine-use group was not. Previous health care experiences with having a Pap smear and pelvic exam were positive for routine-use group and negative for non-routine-use group. Cognitively, both groups believed Pap smears tested for cancer and sexually transmitted diseases. Vulnerability to cervical cancer was thought to run in families; participants believed they were either safe from risk or hoped that the odds were in their favor. In addition, there was a link between avoiding routine preventive care and a trauma history (sexual, physical, medical), eliciting negative perceptions towards Pap smears and pelvic exams. CONCLUSION: Differences and similarities in personal influencing factors associated with cervical cancer screening were found in the two groups. Further research is needed to explore these differences and similarities because they may contribute to the reason that African American women have a greater mortality rate from cervical cancer than White women.

Câncer de colo uterino: realização do exame colpocitológico e mecanismos que ampliam sua adesão / El cáncer de cuello uterino: la realización de la citología vaginal y los mecanismos para aumentar su adhesión / Uterine cervical neoplasms: pap smear screening and mechanisms that increase adherence

Pesquisa estatística descritiva com o objetivo de identificar o perfil e os mecanismos que ampliam a adesão das mulheres na realização do exame colpocitológico no Sistema Único de Saúde. Os sujeitos foram 264 mulheres residentes no município de Rio do Sul, SC, que realizaram o exame colpocitológico em 2007. A coleta de dados ocorreu entre junho e julho de 2008, através de entrevista a partir de um roteiro estruturado contendo perguntas abertas e fechadas. Os dados da pesquisa foram analisados com base em métodos estatísticos. Os resultados mostraram os fatores de risco presentes para o desenvolvimento do câncer de colo uterino. Conclui-se que houve um bom entendimento das mulheres entrevistadas sobre o tema e que a realização do exame colpocitológico possui intuito preventivo. Há necessidade de os profissionais de saúde individualizarem a assistência prestada.

The aim of this descriptive statistical study was to identify patient profiles and mechanisms that increase women’s adherence to Pap smear screening in Brazil’s national health system. The subjects were 264 women resident in Rio do Sul, Santa Catarina State, who had Pap smear tests in 2007. Data was collected between June and July 2008 through structured interviews using a script of open and closed questions. Research data were analyzed statistically. Results show the risk factors present for development of uterine cervical neoplasms. We conclude that the women interviewed understood the issue well and that their intention in having the test was preventive. There is a need for health care professionals to individualize the care they give.

Investigación estadística de carácter descriptivo con el objetivo de identificar el perfil y los mecanismos que aumentan la adhesión de las mujeres para la realización de la citología vaginal en el Sistema Único de Salud. Los sujetos fueron 264 mujeres que viven en el municipio de Rio do Sul, SC, Brasil, que realizaron la prueba de Papanicolaou en 2007. La recopilación de los datos se produjo entre junio y julio de 2008, a través de entrevistas estructuradas con preguntas abiertas y cerradas. Los datos se analizaron con base en métodos estadísticos. Los resultados mostraron los factores de riesgo presentes para el desarrollo del cáncer de cuello uterino. Se concluye que las mujeres entrevistadas comprendieron el tema y que la realización de la citología vaginal tiene un propósito preventivo. Es necesario que los profesionales de la salud individualicen la atención prestada.

Development of a sexual assault evidence collection kit - the need for standardization in Turkey.

Sexual offences are recognized to be one of the most critical of crimes throughout the world. In Turkey, forcible rapes show, in the sexual crime rates, an increase of approximately 3% every year. It becomes even more critical, when realizing that less than half of all rapes, which are believed to occur, are reported to law enforcement, and of those few assailants who are arrested even fewer are convicted of rape. Often, little or no knowledge of the correct methods of locating, recovering, packaging, and preserving evidence specimens are the causes for compromising the forensic examination in court. This problem occurs when medical personnel are not adequately trained or properly advised in the evidentiary aspects and medical features of treating a victim. The current survey is aimed to increase the awareness of the need of an initial and continuing education by health care policies to cope with increasing professional demands for forensic practice sexual assault cases, to take judicial and social precautions, and medico-legal evidence. To determine the likelihood of obtaining corroborating evidence this paper presents the results of a study referring to this problem. An updated questionnaire has been applied at random to medical personnel, a total of 543 participants, throughout Turkey. Taking certain criteria into consideration the findings revealed a significant deficiency of knowledge regarding medical-legal examination. In comparison, a one-semester course of basic forensic sciences proved to be sufficient to recognize the amount of knowledge required to work as a forensic professional. Based on the results, recommendations are presented in the form of a sexual assault evidence collection kit (SAECK). A kit, which takes into consideration the needs of crime laboratories, law enforcement agencies, medical personnel, and above all the victim. This is the first step in building a responsible and successful evidence collection program that will survive the rigors of courtroom challenge.

Realização do exame preventivo por enfermeiro obstetra: relato de experiência / Realization of preventive examinations by obstetric nurse: an experience report

Trata-se de relato de experiência sobre o exame Papanicolau realizado pelo enfermeiro em uma Unidade de Saúde da grande Natal/RN, tencionando descrever a atuação do mesmo nessa prática. Inicialmente observamos constrangimento das usuárias frente à figura masculina como examinador, superado mediante abordagem técnico-científica do procedimento, empenho pessoal e ético do enfermeiro. A procura e aceitação do serviço têm ocorrido com maior freqüência, fato atribuído à confiança e acessibilidade da usuária ao profissional, reforçando assim seu compromisso dentro das ações básicas de saúde.

Exame de papanicolaou: qualidade do esfregaço realizado por alunos de enfermagem / Papanicolaou test: quality of smear performed by nursing students

O câncer cervical é prevenível ou curável quando detectado precocemente, porém o impacto sobre a morbimortalidade por essa doença depende não só da disponibilidade e cobertura do exame preventivo, como também da qualidade da amostra colhida. A negligência neste último aspecto pode ocasionar resultados falso-negativos e retardar o diagnóstico e o tratamento. O objetivo deste estudo foi avaliar o esfregaço de Papanicolaou realizado por alunos de enfermagem,comparando-o ao material colhido por profissionais. Cento e doze esfregaços foram analisados em um mesmo laboratório, sendo 56 colhidos por alunos e 56 colhidos por profissionais (grupo-controle), nas mesmas Unidades deSaúde e no mesmo período de tempo. A análise constatou um número de amostras insatisfatórias acima do aceitável, porém, no grupo-controle, esse percentual foi significantemente maior do que no grupo em estudo, para as mulheres com 40 anos ou mais. A ausência de representatividade da junção escamo-colunar (JEC) foi a causa prevalente da classificação da amostra como insatisfatória. Os autores recomendam a revisão dos procedimentos de coleta e a repetição desta sempre que a JEC não estiver devidamente representada no esfregaço.

Representações sociais de mulheres amazônidas sobre o exame de papanicolau: implicações para a saúde da mulher / Social Representations of women amazônidas on examination papanicolau: implications for the health of the woman / Representaciones Sociales de mujeres amazônidas sobre el examen papanicolau: implicaciones para la salud de la mujer

Esta pesquisa tem como objetivos descrever as representações sociais de mulheres amazônidas sobre o exame Papanicolau e analisar as implicações desta para o cuidado de si mesmas. Trata-se de um estudo qualitativo-exploratório com o uso da Teoriadas representações sociais. A coleta de dados foi realizada no período de janeiro a dezembro de 2007, com o emprego de duas técnicas: a entrevista semi-estruturada com perguntas abertas e a observação livre. Para a interpretação desses dados foiutilizada a técnica de análise de conteúdo temático. A pesquisa teve como resultado três unidades temáticas, assim denominadas: O exame Papanicolau - um cuidado com a saúde da mulher; Tabus e crenças sobre o exame Papanicolau; e Uma prática de cuidado de si mesma: o exame Papanicolau. No estudo observamos que as mulheres temem muito ter câncer cérvico-uterino e, por esse motivo, representam o exame Papanicolau como uma prática de cuidado de si mesma.

This research has as objective to describe the social representations of women amazônidas on the Papanicolauexamination and to analyze the implications of this for the samecare of itself. One is about a qualitative-exploratório study with the use of the Theory of the social representations. The collection of data was carried through in the period from January through December of 2007, with the use of two techniques: the interviewhalf-structuralized with open questions and the free comment. For the interpretation of these data the technique of analysis of thematic content was used. The research had as a result, three thematic units, thus called: The Papanicolau examination - a carewith the health of the woman; Taboos and beliefs on the Papanicolau examination; and practical One of same care of itself: the Papanicolau examination. In the study we observe that the women are afraid of having uterine neoplasm for this reason, the Papanicolau examination represents a practical care of itself.

Esta investigación tiene como objetivos describir las representaciones sociales de mujeres amazônidas sobre elexamen Papanicolau y analizar las implicaciones de esta para el cuidado de sí misma. Se trata de un estudio cualitativoexploratorio con el uso de la Teoría de las representaciones sociales. La colecta de dados fue realizada en el periodo de enero a diciembre de 2007, con el empleo de dos técnicas: laentrevista semi-estructurada con preguntas abiertas y la observación libre. Para la interpretación de esos dados fue utilizada la técnica de análisis de contenido temático. La investigación tuvo como resultado tres unidades temáticas, así denominadas: El examen Papanicolau - un cuidado con la salud de la mujer; Tabúes y creencias sobre el examen Papanicolau; y el Una práctica de cuidado de sí misma: el examen Papanicolau. En el estudio observamos que las mujeres temen mucho tener cáncer cérvico-uterino y, por ese motivo,representan el examen Papanicolau como una práctica de cuidado de sí misma.

Informational needs and the experiences of women with abnormal Papanicolaou smears.

PURPOSE: To describe the experience of women with abnormal Papanicolaou (Pap) smears with a particular focus on their informational needs. DATA SOURCE: The small purposive sample consisted of 10 demographically diverse women with a history of at least one abnormal Pap smear, who attended one Women's Health outpatient clinic that typically serves a multiethnic, low-income population. Individual 30- to 60-min tape-recorded interviews were conducted, transcribed verbatim, and analyzed according to Colaizzi's eidetic method of phenomenological analysis. A manual categorizing strategy and a computer software (Qualrus, version 2.0) strategy were used for data management and coding. CONCLUSIONS: Six major themes emerged from the data: initial response to the diagnosis; dealing with stigma; seeking information and support; enduring diagnostic and treatment procedures; formulating a concept of disease; and normalizing. The essential structure of the experience of having an abnormal Pap smear in terms of informational needs involved initial anxiety at disclosure, followed by an urgent need for information. Stigma associated with a sexually transmitted disease (STD) and a dearth of information available for male partners were problematic and influenced decisions about disclosure of human papillomavirus (HPV) infection to current or future partners. Misinformation or misunderstanding of available information was common. Information obtained from the Internet was experienced as private and allowed adequate time, but Web sites that grouped HPV with general STD information were confusing and further stigmatizing. Information obtained from healthcare providers was experienced as supportive if facts were accompanied by reassurance and familiar analogies were used. Information from providers was experienced as nonsupportive if too much medical jargon was used, if not enough time was spent to explain the information, if facts were not accompanied by interpersonal concern, or if a patient-provider relationship was not established. IMPLICATIONS FOR PRACTICE: Patient education regarding abnormal Pap smears and HPV should address the concerns of those affected and should use message framing that informs but decreases stigmatization. Women should be offered the option of individualized informative and supportive counseling resources after initial disclosure of an abnormal Pap smear to adequately address concerns such as information for partners, the nature of HPV, an appropriate concept of cancer risk, and reassurance regarding potential effects on sexuality and fertility. Public information forums should address issues specific to high-risk HPV rather than generalization as an STD.

A prospective descriptive study of women attending a colposcopy clinic.

This paper reports the findings of a prospective convenience sample cohort study investigating self-reported purpose of pap smears and worry interference associated with having abnormal pap smear results in women attending a public colposcopy service between 05 April and 19 December 2003. Intrusive thoughts about cancer have been postulated to be associated with dysfunction in women at increased risk of developing breast or ovarian cancer. A study designed questionnaire and the Multidimensional Health Locus of Control was completed by the women whilst waiting to have colposcopy. This study shows that Asian women need to have information about abnormal pap smear results explained well in order to avoid intrusive thoughts and anxiety. It also demonstrates that nurses provide a key role in providing information that leads to less concern and better understanding of the concepts.