Demonstration of the validity of the SF-36 for measurement of the temporal recovery of quality of life outcomes in burns survivors

Objective

Outcome assessment after burn is complex. Determination of quality of life is often measured using the Burns Specific Health Scale (BSHS), a validated tool in the burn population. The SF-36 is a generic quality of life questionnaire that is validated for numerous populations, but not in burns. The aim of the study was to examine the validity of SF-36, using the BSHS as a reference.

Methods

280 burn patients were recruited at Royal Perth Hospital. Each completed SF-36 and BSHS-B at regular intervals to 2 years after burn. Regression modelling was used to assess the temporal validity and the relative sensitivity of the measures.

Results

SF-36 domains and BSHS-B demonstrated significant associations at all time points (r = 0.37–0.76, p < 0.002). In the months after burn, SF-36 domains: role physical; bodily pain; social function and role emotional outperformed BSHS-B total score and domain scores. Greater measurement sensitivity was demonstrated in all SF-36 summary and subscales measures (except General Health) when compared to BSHS-B and sub-domains.

Conclusion

This study demonstrated SF-36 as a valid measure of recovery of quality of life in the burn patient population. The data suggests that SF-36 components were more sensitive to change than the BSHS-B from ∼1 month after injury.     

Biological markers of stress in pediatric acute burn injury

Background

Burns and their associated wound care procedures evoke significant stress and anxiety, particularly for children. Little is known about the body's physiological stress reactions throughout the stages of re-epithelialization following an acute burn injury. Previously, serum and urinary cortisol have been used to measure stress in burn patients, however these measures are not suitable for a pediatric burn outpatient setting.

Aim

To assess the sensitivity of salivary cortisol and sAA in detecting stress during acute burn wound care procedures and to investigate the body's physiological stress reactions throughout burn re-epithelialization.

Methods

Seventy-seven participants aged four to thirteen years who presented with an acute burn injury to the burn center at the Royal Children's Hospital, Brisbane, Australia, were recruited between August 2011 and August 2012.

Results

Both biomarkers were responsive to the stress of burn wound care procedures. sAA levels were on average 50.2 U/ml higher (p < 0.001) at 10 min post-dressing removal compared to baseline levels. Salivary cortisol levels showed a blunted effect with average levels at ten minutes post dressing removal decreasing by 0.54 nmol/L (p < 0.001) compared to baseline levels. sAA levels were associated with pain (p = 0.021), no medication (p = 0.047) and Child Trauma Screening Questionnaire scores at three months post re-epithelialization (p = 0.008). Similarly, salivary cortisol was associated with no medication (p < 0.001), pain scores (p = 0.045) and total body surface area of the burn (p = 0.010).

Conclusion

Factors which support the use of sAA over salivary cortisol to assess stress during morning acute burn wound care procedures include; sensitivity, morning clinic times relative to cortisol's diurnal peaks, and relative cost.     

Grip strength dynamometry: Reliability and validity for adults with upper limb burns

Background

Upper limb (UL) burns can result in significant loss of strength and physical function. The aim of this study was to establish the reliability and validity of grip strength dynamometry (GSD) for measuring burn-affected UL strength over time.

Methods

A retrospective sample of adult participants (n = 89) with UL burns was obtained from Royal Perth Hospital. Data were compiled from assessments conducted at discharge, one, three, six and 12 months afer burn. Within-session reliability and validity was examined through multivariable analyses.

Results

GSD demonstrated within-session reliability for all investigated timepoints (ICC's ≥ 0.87, p < 0.0005.) Criterion validity was confirmed with GSD and QuickDASH being significantly associated in both right (b = 0.17, p = 0.002) and left (b = 0.14, p = 0.002) hands. Construct validity was demonstrated through significant association of GSD values with location of burn (p < 0.35); time after burn (p < 0.012); surgical intervention (p = 0.003) and burn size (p < 0.05).

Conclusion

This study demonstrates that grip strength dynamometry is a reliable and valid outcome measure for measuring burn-affected UL strength from one month to one year after burn.     

Modernized standards in burns management: A comparative study in Komfo Anokye Teaching Hospital,Kumasi, Ghana

Background

Management of burns patients before May 2009 was very difficult at the Komfo Anokye Teaching Hospital (KATH).

Aim

To compile burns patients’ information in the new Burns Intensive Care Unit (BICU), analyze it and draw comparisons to information from the old BICU at KATH.

Methods

This retrospective study involves data from May 2007 to April 2009 (Group 1 – old BICU) and May 2009 to April 2011 (Group 2 – new BICU). The parameters of burn patients recorded included: record of admission, gender, age, aetiology of injury, Total Burns Surface Area (TBSA), the patients’ treatment regime and record of discharge/death. This information was analyzed with SPSS version 18.0.

Results

The total number of patients in the study was 511; Group 1 constituted 47.36% (n = 242) patients; males (n = 307, 61%) outnumbering females (n = 204, 39%). The overall mean, median and interquartile range (IQR) ages of the patients were 12.4 ± 2; 9.5 and 18.0 years respectively. The main aetiology of burns in Group 1 was flame burns (n = 115, 47.5%) and for Group 2 was scald (n = 151, 56.1%). The median TBSA recorded for Groups 1 and 2 were 32% and 41% respectively. A mortality rate of 19.1% (n = 46) and 12.7% (n = 34) were recorded for Groups 1 and 2 respectively which was statistically significant (p < 0.05). We found no differences for age and TBSA (P = 0.7168 and P = 0.8020 respectively). A Chi Square analysis for gender and aetiology of burn revealed no significant difference between Groups 1 and 2. A risk factor analysis for mortality within the Groups (using multiple regression analysis) identified only aetiology of burn in Group 1 to be a factor (P = 0.044).

Conclusion

This comparative study reveals that a significant difference in mortality was recorded for both groups. The mortality difference does not appear to be due to socio-demographic features. This study may demonstrate that modernized and advanced equipment with the adequate personnel play an essential role in burn management in low income countries such as Ghana.     

Polish adaptation and validation of Burn Specific Health Scale – Brief

Background

The Burn Specific Health Scale – Brief is a well-described, specific tool to assess health condition (quality of life) of burnt patients. This project was aimed at creating a Polish adaptation and validation of the Burn Specific Health Scale – Brief.

Method

Adaptation of the tool was performed in two stages. The first stage involved translation, back translation, evaluation by a panel of judges and a pre-test of the tool. The second stage consisted of surveying 202 burned patients. Those data were used to conduct a psychometric analysis. Reliability was checked by determining the Cronbach's α internal consistency coefficient and conducting the test–retest procedure (ICC). Content validity was evaluated by a panel of judges. Criterion validity was determined using SF-36. Construct validity was determined using known-groups validation.

Results

Reliability of the tool, determined using the internal consistency coefficient (Cronbach's α = 0.94) and the test–retest procedure (ICC = 0.89), proved to be high. Criterion validity, determined using the relationship of results of comparable BSHS-B and SF-36 subscales, obtained a satisfactory level with a correlation of r = 0.55–0.89 (p < 0.01). Analysis of inter-group differences showed that patients who stayed at a hospital for more than 10 days (p = 0.002), patients after surgical intervention (p = 0.018), patients with a burn larger than 19% of the TBSA (p = 0.01) and patients with 3rd degree burns (p = 0.001) have much poorer results than the rest of the subjects.

Discussion

The Polish version of BSHS-B is a reliable and valid tool for assessing quality of life of burned patients. It may be used to plan the burn treatment process and evaluate its outcomes.     

Enhancing the clinical utility of the Burn Specific Health Scale-Brief: Not just for major burns

Introduction

Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice.

Aim

This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients.

Method

BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzedCronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B.

Results

Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p < 0.001, p < 0.001, p = 0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p < 0.001).

Discussion

The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns.

Conclusion

The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

In the media: Burns as a method of assault

Aim

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns.

Methods

Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients.

Results

Assault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p = 0.025) and concomitant fractures or dislocations (46% vs. 2%), p = 0.011).

Conclusions

While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.     

Mental disorders among acute burn patients

Objective

To investigate mental disorders among acute hospitalized burn patients.

Method

Consecutive acute adult burn patients (n = 107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

Results

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q = 6.40, df = 1, p = 0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q = 13.00, df = 1, p < 0.001) in acute care.

Conclusions

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.     

Involving burn survivors in agenda setting on burn research: An added value?

Background and aim

The role of burn survivors in burn research is usually restricted to being objects of study and beneficiaries of research results, while decision-making on research is traditionally the domain of a small group of experts, mainly scientists. In this article we compare the research priorities of burn survivors and professionals and investigate to what extent it is possible to come to a joint research agenda.

Methodology

The project followed the Dialogue Model for research agenda setting. Initially burn survivors and professionals were consulted separately and group-specific lists of research priorities were established, using a literature survey, exploratory interviews (n = 10), focus groups (n = 58), a questionnaire (n = 224) and Delphi rounds (n = 12). Subsequently, in a dialogue meeting burn survivors and professionals presented and discussed their priorities, developed one integrated list, and prioritized the 15 most important topics on this list.

Results

Considerable overlap was observed between the research priorities of burn survivors and professionals, particularly with respect to biomedical and clinical research on wound healing and scar management. However, differences were also observed, e.g. treatment of itching and oedema on scars and donor places.

Conclusion

The model proved useful in eliciting research priorities from both professionals and burn survivors, and in stimulating a meaningful dialogue between these groups. The involvement of burn survivors identified burn research areas that are currently not the focus of research in The Netherlands.     

Factors associated with duration of hospitalization and outcome in burns patients: A cross sectional study from Government Tertiary Care Hospital in Karachi,Pakistan

Objective

Burns are important contributors toward mortality in trauma related injuries in Karachi, Pakistan. The aim of the present study was to delineate the factors contributing to the duration of hospitalization and mortality in such patients.

Methods

We performed a single center retrospective study of patients admitted during a 2 year period (January 2009 till December 2010) in Burns Center, Karachi. Patients with incomplete record were excluded. Variables included were age and gender of the patient, the percent total body surface area (%TBSA) burn, the cause of the burn and the body parts affected along with the micro-organisms isolated from the burn wounds. The relationship of these variables with the duration of hospitalization and the outcome of patients was assessed by means of Pearson Chi Square test in SPSS version 14.

Results

Mean age of patients was 26.64 years (±13.430). More males (56.6%) were admitted than females (43.4%), giving a male to female ratio of 1.3:1. Mean percent total body surface area (%TBSA) burnt and mortality were 24.69% and 26.38% respectively with both having higher values in females (p < 0.001). Males had a mean longer duration of hospitalization compared to females (35.94 days vs. 27.63 days). The most common micro-organism colonizing the wounds was found to be Staphylococcus aureus. Factors significantly (p < 0.05) associated with increased duration of hospitalization and mortality include the age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt.

Conclusion

The relationship of age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt are important factors in determining the duration of hospitalization of the patients and whether the patients will survive or succumb to injuries.     

Acute burn induced coagulopathy

Background

Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC).

Methods

Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC.

Results

On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p = 0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p = 0.0013, r = 0.292) and serum lactate (p = 0.0013, r = 0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11–10.56).

Conclusion

In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.     

Laser Doppler Imaging prediction of burn wound outcome in children: Is it possible before 48 h?

Background

Laser Doppler Imaging (LDI) assists in prediction burn wound outcome. Previous data has validated this technique in children between 48 and 72 h after burn.

Aim

To evaluate the ability of Laser Doppler Imaging (LDI) to predict burn wound outcome in paediatric patients prior to and after 48 h from the time of injury.

Methods

A prospective evaluation was performed in 400 children over a 12-month period that presented to our burns clinic. Patients were divided into two groups: those that presented within 48 h of injury (n = 160) and those that presented after 48 h (n = 240). Patients were reviewed until healing had occurred or operative intervention was required.

Results

The median age of the patients was 2.4 years (range 0.1–15.9 years). For patients who presented within 48 h, the sensitivity and specificity of the LDI was 78% and 74% respectively compared to 75% and 85% for those scanned after 48 h. This difference was not statistically significant.

Conclusions

LDI predicted burn wound outcome in children within 48 h of the burn wound. Moderate degrees of movement, infection, whether first aid was administered and type of dressing did not impact on the accuracy of LDI.     

Hypoalbuminemia in the first 24 h of admission is associated with organ dysfunction in burned patients

Objective

Hypoalbuminemia is a common finding in burned patients, but its association with increased morbidity and mortality has not been well established. We assessed whether hypoalbuminemia in the first 24 h of admission is associated with organ dysfunction in patients with severe burns.

Methods

For a two year period (2008–2009), we reviewed the records of burn adult patients with a total body surface area 20% admitted in our unit within the first 24 h of injury. A multiple linear regression analysis was conducted to assess hypoalbuminemia as an independent predictor of organ dysfunction.

Results

56 subjects were analyzed. Multiple linear regression analysis showed that hypoalbuminemia in the first 24 h of admission was an independent predictor of organ dysfunction. Serum albumin concentration ≤30 g/L was associated with a two-fold increase in organ dysfunction [SOFA scores at day 0 (p = 0.005), day 1 (p = 0.005) and first week mean values (p = 0.004)], but not with mortality (p = 0.061).

Conclusion

Hypoalbuminemia is associated with organ dysfunction in burned patients. Unlike unmodifiable predictors such as age, burn surface and inhalation burn, correction of hypoalbuminemia might represent a goal for a future trial in burn patients.     

Lack of precision of burn surface area calculation by UK Armed Forces medical personnel

Objective

Accurate determination of the severity of burn is essential for the care of thermally injured patients. We aimed to examine the accuracy and precision of TBSA calculation performed by specialist military burn care providers and non-specialist but experienced military clinicians.

Methods

Using a single case example with photographic montages and a modified Lund and Browder chart, the two cohorts of clinicians were each given 10 min to map and calculate the case example TBSA involvement. The accuracy and precision of results from the two cohorts were compared to a set standard %TBSA.

Results

The set standard %TBSA involvement was 64.5%. Mean %TBSA mapped by non-specialists (52.53 ± 10.03%) differed significantly from the set standard (p < 0.0001). No difference was observed when comparing results from the burn care providers (65.68 ± 10.29%; p = 0.622). However, when comparing precision of calculation of TBSA burned, there was no evidence of a difference in heterogeneity of results between the two cohorts (F test, p = 0.639; Levene's test, p = 0.448).

Conclusions

These results indicate that experienced military burn care providers overall more accurately assess %TBSA burned than relatively inexperienced clinicians. However, results demonstrate a lack of precision in both groups.     

Epidemiology of burns in the United Arab Emirates: Lessons for prevention

Purpose

To study mechanism, risk factors and outcome of hospitalized burns so as to give recommendations for prevention.

Methods

Burn patients admitted to Al Ain hospital for more than 24 h or who died after arrival were studied over 4 years. Demographics, burn type, location and time of injury, total body burned surface area (TBSA), body region, hospital and ICU stay and outcome were analyzed.

Results

203 patients were studied, 69% were males and 25% were children under 5 years old. The most common location for burn was home. Women were burned more at home (p < 0.0001). 28% of patients were injured at work with more men (p < 0.0001) and non-UAE nationals (p < 0.01). Scalds from water, tea were the major hazard at home, while majority of burns at work were from gas and flame. Burns caused by gas and flame had larger TBSA and longer ICU stay. Six (3%) patients died and nine (4%) were transferred to the specialized burn center.

Conclusions

Safety education for caregivers and close supervision of young children is important to reduce pediatric burns. Occupational safety education of young men could prevent burns caused by gas and flame.     

A meta-analysis of trials using the intention to treat principle for glutamine supplementation in critically ill patients with burn

Background

During critical illness, the demand for glutamine may exceed that which can be mobilized from muscle stores. Infections increase mortality, morbidity, length-of-stay, antibiotic usage and the cost of care. This is a major health care issue.

Methods

RCTs were identified from the electronic databases: the Cochrane Library, MEDLINE, PubMed web of knowledge and hand searching journals. The trials compared the supplementation with glutamine and non-supplementation in burn. Statistical analysis was performed using RevMan5.1 software, from Cochrane Collaboration.

Results

216 papers showed a match, in the keyword search. Upon screening the title, reading the abstract and the entire article, only four RCTs, involving 155 patients, were included. For both the glutamine group and control group, total burn surface area (TBSA) (MD = 2.02, 95% CI −2.17, 6.21, p = 0.34) was similar. Glutamine supplementation was associated with a statistically significant decrease in the number of patients with gram-negative bacteremia (OR 0.27, 95% CI 0.08–0.92, p = 0.04) and hospital mortality (OR = 0.13, 95% CI 0.03, 0.51, p = 0.004), however, no statistical difference was noted between groups, for the other results.

Conclusion

Glutamine supplemented nutrition can be associated with a reduction in mortality in hospital, complications due to gram-negative bacteremia in burn patients. Further larger and better quality trials are required, in order to determine whether any differences are statistically and clinically important.     

Epidemiology of operative burns at Kijabe Hospital from 2006 to 2010: Pilot study of a web-based tool for creation of the Kenya Burn Repository

Introduction

In order to implement effective burn prevention strategies, the WHO has called for improved data collection to better characterize burn injuries in low and middle income countries (LMIC). This study was designed to gather information on burn injury in Kenya and to test a model for such data collection.

Methods

The study was designed as a retrospective case series study utilizing an electronic data collection tool to assess the scope of burn injuries requiring operation at Kijabe Hospital from January 2006 to May 2010. Data were entered into a web-based tool to test its utility as the potential Kenya Burn Repository (KBR).

Results

174 patients were included. The median age was 10 years. There was a male predominance (59% vs. 41%). Findings included that timing of presentation was associated with burn etiology (p = 0.009). Length of stay (LOS) was associated with burn etiology (p < 0.001). Etiology differed depending on the age group, with scald being most prominent in children (p = 0.002).

Conclusions

Burn injuries in Kenya show similarities with other LMIC in etiology and pediatric predominance. Late presentation for care and prolonged LOS are areas for further investigation. The web-based database is an effective tool for data collection and international collaboration.     

Tissue expansion for correction of scars due to burn and other causes: A retrospective comparative study of various complications

Background

Tissue expansion is associated with a relatively high complication rate. The aim of this study was to quantify the complication risk of burn scar patients who underwent tissue expansion in comparison to patients with other indications such as skin tumors. Furthermore it was attempted to compare the complication rates in children and adults.

Methods

A retrospective analysis was performed on 148 expanders implanted in 73 patients during the years 1994–2011. Two patient cohorts (burn scar cohort n = 31 and other indication cohort n = 42) were identified and analyzed.

Results

27 male and 46 female patients with a median age of 21 years were included. No statistically significant difference for complication risk between the burn and other indication cohorts could be found (p = 0.1412). Statistical analyses revealed a higher complication rate (52%) in the lower limb compared to all other anatomic sites (29%) (p = 0.1746). In addition, statistical analyses revealed a significantly higher total complication rate in children younger than 10 years (p = 0.0043). Moreover a greater TBSA was accompanied by a higher complication rate (p = 0.0258).

Conclusion

This set of data suggests that the burn scar patient is at no greater risk to suffer complications from tissue expansion. Other factors like age, TBSA and anatomical site have far more influence on the expander complication rate than the initial indication for tissue expansion.