Geocoding police collision report data from California: a comprehensive approach

Background

Breast cancer in females and prostate cancer in males are two of the most common cancers in the United States, and the literature suggests that they share similar features. However, it is unknown whether the occurrence of these two cancers at the county level in the United States is correlated. We analyzed Caucasian age-adjusted county level average annual incidence rates for breast and prostate cancers from the National Cancer Institute and State Cancer Registries to determine whether there was a spatial correlation between the two conditions and whether the two cancers had similar spatial patterns.

Results

There was a significant correlation between breast and prostate cancers by county (r = 0.332, p < 0.001). This relationship was more pronounced when we performed a geographically-weighted regression (GWR) analysis (r = 0.552) adjusting for county unemployment rates. There was variation in the parameter estimates derived with the GWR; however, the majority of the estimates indicted a positive association. The strongest relationship between breast and prostate cancer was in the eastern parts of the Midwest and South, and the Southeastern U.S. We also observed a north-south pattern for both cancers with our cluster analyses. Clusters of counties with high cancer incidence rates were more frequently found in the North and clusters of counties with low incidence rates were predominantly in the South.

Conclusion

Our analyses suggest breast and prostate cancers cluster spatially. This finding corroborates other studies that have found these two cancers share similar risk factors. The north-south distribution observed for both cancers warrants further research to determine what is driving this spatial pattern.     

A quantile regression approach to re-investigate the relationship between sleep duration and body mass index in Taiwan

Objective

Previous studies on the relationship between sleep duration and body mass index (BMI) have shown inconsistent results by using estimation strategies within the framework of ordinary least squares (OLS). This study examined the relationship between sleep duration and BMI by using quantile regression to account for the potential heterogeneous effect of sleep duration on BMI in different BMI categories.

Methods

The data of 2,392 adults were from the 2005 Panel Study of Family Dynamics in Taiwan. The dependent variable was BMI of the respondents. Both OLS and quantile regression models were used for comparison.

Results

The OLS model does not show significant relationship, while the quantile regression model shows a U-shaped relationship between sleep duration and BMI beyond the 90th percentile in men (BMI?=?28.69) and an inverse U-shaped relationship at the 30th percentile of BMI in women (BMI?=?21.37).

Conclusions

Quantile regression can provide information that may be masked by OLS in analyzing the relationship between sleep duration and BMI. Sleep modification with the aim to obtain the optimal sleep duration may help to reduce BMI in obese men.     

Studying relationships between environment and malaria incidence in Camopi (French Guiana) through the objective selection of buffer-based landscape characterisations

Background

Many sub-Saharan countries are confronted with persistently high levels of infant mortality because of the impact of a range of biological and social determinants. In particular, infant mortality has increased in sub-Saharan Africa in recent decades due to the HIV/AIDS epidemic. The geographic distribution of health problems and their relationship to potential risk factors can be invaluable for cost effective intervention planning. The objective of this paper is to determine and map the spatial nature of infant mortality in South Africa at a sub district level in order to inform policy intervention. In particular, the paper identifies and maps high risk clusters of infant mortality, as well as examines the impact of a range of determinants on infant mortality. A Bayesian approach is used to quantify the spatial risk of infant mortality, as well as significant associations (given spatial correlation between neighbouring areas) between infant mortality and a range of determinants. The most attributable determinants in each sub-district are calculated based on a combination of prevalence and model risk factor coefficient estimates. This integrated small area approach can be adapted and applied in other high burden settings to assist intervention planning and targeting.

Results

Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.

Conclusions

This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.     

Compulsory drug detention center experiences among a community-based sample of injection drug users in Bangkok, Thailand

Background

Despite Thailand's official reclassification of drug users as "patients" deserving care and not "criminals," the Thai government has continued to rely heavily on punitive responses to drug use such as "boot camp"-style compulsory "treatment" centers. There is very little research on experiences with compulsory treatment centers among people who use drugs. The work reported here is a first step toward filling that gap.

Methods

We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs (IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression was used to identify factors independently associated with a history of compulsory treatment experience.

Results

In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses, compulsory drug detention experience was positively associated with current spending on drugs per day (adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and no difference in intensity of drug use was observed between those with and without a history of compulsory detention.

Conclusion

These findings raise concerns about the current approach to compulsory drug detention in Thailand. Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use, although additional research is needed to determine the precise impact of exposure to this form of detention on future drug use. More broadly, compulsory "treatment" based on a penal approach is not consistent with scientific evidence on addressing drug addiction and should be phased out in favor of evidence-based interventions.     

Quality of life of childbearing age women and its associated factors: an application of seemingly unrelated regression (SUR) models

Purpose

This article is a report of using seemingly unrelated regression (SUR) models to examine the determinants of different dimensions of quality of life (QoL) among childbearing age women. There are a limited number of studies on QoL and its associated factors among women in developing countries such as Iran. Therefore, more attention should be focused on identifying these issues.

Methods

We administered the Persian’s abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to 1,067 married women aged between 15 and 49 years. The women were chosen via a multistage research design from the rural region of Shiraz, the center of Fars Province in Iran in 2008. Clinical and socio-demographic characteristics as well as their reproductive health-related characteristics were investigated. To identify associated factors of QoL dimensions, ordinary least squares (OLS) regression and SUR were used and their findings were compared.

Results

The WHOQOL-BREF showed acceptable consistency (Cronbach’s alpha range: 0.62–0.75 across domains). Lower age, absence of long-term illness, economic status satisfaction, higher level of education, lower number of pregnancies, and higher body mass index were important associated factors of different dimensions of the QoL among these women. The estimated parameters for these factors were in close agreement in both OLS and SUR estimation methods. However, the SUR estimator provided the higher precision of the estimates than the OLS estimator, as the parameters obtained by SUR are characterized by lower standard errors. Women’s age, income satisfaction, and level of education were common for all domains.

Conclusions

This study presents a novel approach to simultaneously predict QoL domains using the SUR estimators and the results are relevant for implementing objective QoL. SUR estimators performed consistently better than the OLS estimators, since SUR takes the correlation between error terms into account. Thus, the SUR method could be a useful methodology for predicting QoL domains.     

Mapping utility scores from the Barthel index

Purpose

It is not always possible to collect utility-based outcome data, like EQ-5D, needed for conducting economic evaluations in populations of older people. Sometimes, information on other non-utility outcome measures may have been collected. This paper examines the possibility of mapping the EQ-5D from a non-utility-based outcome, the Barthel index.

Methods

Data for 1,189 UK intermediate care patients were used. Ordinary least squares (OLS), censored least absolute deviations (CLAD) estimator and multinomial logistic (ML) models were used. The mean absolute error (MAE) and root-mean-squared error (RMSE) were used to estimate the predictive accuracy of eight regression models. Validation of primary models was carried out on random samples of data collected at admission and discharge.

Results

Models where the EQ-5D was entered as a continuous dependent variable and Barthel dimensions used as explanatory variables performed better. CLAD performed best on MAE and OLS on the RMSE, while the ML performed the worst on both measures. The CLAD predicted EQ-5D scores that matched the observed values more closely than the OLS.

Conclusions

It is possible to reasonably predict that the EQ-5D from the Barthel using regression methods and the CLAD model (4) is recommended.     

Mapping the Oxford hip score onto the EQ-5D utility index

Purpose

To assess different mapping methods for the estimation of a group’s mean EQ-5D score based on responses to the Oxford hip score (OHS) questionnaire.

Methods

Four models were considered: a) linear regression using total OHS as a continuous regressor; b) linear regression employing responses to the twelve OHS questions as categorical predictors; c) two-part approach combining logistic and linear regression; and d) response mapping. The models were internally validated on the estimation data set, which included OHS and EQ-5D scores for total hip replacements, both before and six months after procedure for 1,759 operations. An external validation was also performed.

Results

All models estimated the mean EQ-5D score within 0.005 of an observed health-state utility estimate, ordinary least squares (OLS) continuous being the most accurate and OLS categorical the most consistent. Age, gender and deprivation did not improve the models. More accurate estimations at the individual level were achieved for higher scores of observed OHS and EQ-5D.

Conclusion

Based on these results, when EQ-5D scores are not available, answers to the OHS questionnaire can be used to estimate a group’s mean EQ-5D with a high degree of accuracy.     

Spatially explicit multi-criteria decision analysis for managing vector-borne diseases

Background

This study investigates the impact of tubewell user density on cholera and shigellosis events in Matlab, Bangladesh between 2002 and 2004. Household-level demographic, health, and water infrastructure data were incorporated into a local geographic information systems (GIS) database. Geographically-weighted regression (GWR) models were constructed to identify spatial variation of relationships across the study area. Zero-inflated negative binomial regression models were run to simultaneously measure the likelihood of increased magnitude of disease events and the likelihood of zero cholera or shigellosis events. The aim of this study was to examine the effect of tubewell density on both the occurrence of diarrheal disease and the magnitude of diarrheal disease incidence.

Results

In Matlab, households with greater tubewell density were more likely to report zero cholera or shigellosis events. Results for both cholera and shigellosis GWR models suggest that tubewell density effects are spatially stationary and the use of non-spatial statistical methods is appropriate.

Conclusions

Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh. Our findings demonstrate the importance of tubewell installation and access to groundwater in reducing diarrheal disease events in the developing world.     

The role of nurses and midwives in polio eradication and measles control activities: a survey in Sudan and Zambia

Background

The mandatory interprofessional education programme at Gunma University was initiated in 1999. This paper is a statistical evaluation of the programme from 1999 to 2007.

Methods

A questionnaire of 10 items to assess the achievement levels of the programme, which was developed independently of other assessment systems published previously, was distributed, as well as two or three open-ended questions to be answered at the end of each annual module. A multivariate analysis of variance model was used, and the factor analysis of the responses was performed with varimax rotation.

Results

Over all, 1418 respondents of a possible 1629 students completed the survey, for a total response rate of 87.1%. Cronbach's alpha of 10 items was 0.793, revealing high internal consistency. Our original questionnaire was categorized into four subscales as follows: "Role and responsibilities", "Teamwork and collaboration", "Structure and function of training facilities", and "Professional identity". Students in the Department of Occupational Therapy reached a relatively lower level of achievement. In the replies to the open-ended questions, requests for the participation of the medical students were repeated throughout the evaluation period.

Conclusion

The present four subscales measure "understanding", and may take into account the development of interprofessional education programmes with clinical training in various facilities. The content and quality of clinical training subjects may be remarkably dependent on training facilities, suggesting the importance of full consultation mechanisms in the local network with the relevant educational institutes for medicine, health care and welfare.     

Analyzing spatial aggregation error in statistical models of late-stage cancer risk: a Monte Carlo simulation approach

Purpose

This paper examines the effect of spatial aggregation error on statistical estimates of the association between spatial access to health care and late-stage cancer.

Methods

Monte Carlo simulation was used to disaggregate cancer cases for two Illinois counties from zip code to census block in proportion to the age-race composition of the block population. After the disaggregation, a hierarchical logistic model was estimated examining the relationship between late-stage breast cancer and risk factors including travel distance to mammography, at both the zip code and census block levels. Model coefficients were compared between the two levels to assess the impact of spatial aggregation error.

Results

We found that spatial aggregation error influences the coefficients of regression-type models at the zip code level, and this impact is highly dependent on the study area. In one study area (Kane County), block-level coefficients were very similar to those estimated on the basis of zip code data; whereas in the other study area (Peoria County), the two sets of coefficients differed substantially raising the possibility of drawing inaccurate inferences about the association between distance to mammography and late-stage cancer risk.

Conclusions

Spatial aggregation error can significantly affect the coefficient values and inferences drawn from statistical models of the association between cancer outcomes and spatial and non-spatial variables. Relying on data at the zip code level may lead to inaccurate findings on health risk factors.     

The fraction of disability pensions attributable to smoking and obesity. Results from a 15-year follow-up study

Objective

The aim of this study was to estimate the fraction of permanent disability pensions among the working population in Denmark that can be attributed to differences in health behaviour.

Methods

A total of 8,287 employees were interviewed regarding health behaviour, work environment and general health. They were followed in a national register on granted disability pensions. Cox regression analysis was performed, and attributable fractions were calculated.

Results

The analysis showed a 48% and 79% risk increase for female heavy and moderate smokers, respectively (attributable fraction 19.7%), and a 74% risk increase for BMI?<?18.5 (attributable fraction 6.1%). Male heavy smokers had a 67% excess risk of disability pension (attributable fraction 15.7%).

Conclusions

Smoking was an independent disability pension predictor regardless of age, work environment factors and baseline general health status. Workplace-based smoking cessation could substantially decrease permanent disability retirement from work.     

A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009

Background

It is important to identify and quantify the factors that affect gender differences in high-risk drinking (HRD), from both an academic and a policy perspective. However, little is currently known about them. This study examines these factors and estimates the percentage contribution each makes to gender differences in HRD.

Methods

This study analyzed information on 23,587 adults obtained from the Korea National Health and Nutrition Surveys of 1998, 2001, and 2005. It found that the prevalence of HRD was about 5 times higher among men (0.37) than women (0.08). Using a decomposition approach extended from the Oaxaca-Blinder method, we decomposed the gender difference in HRD to an "overall composition effect" (contributions due to gender differences in the distribution of observed socio-economic characteristics), and an "overall HRD-tendency effect" (contributions due to gender differences in tendencies in HRD for individuals who share socio-economic characteristics).

Results

The HRD-tendency effect accounted for 96% of the gender difference in HRD in South Korea, whereas gender differences in observed socio-economic characteristics explained just 4% of the difference. Notably, the gender-specific HRD-tendency effect accounts for 90% of the gender difference in HRD.

Conclusion

We came to a finding that gender-specific HRD tendency is the greatest contributor to gender differences in HRD. Therefore, to effective reduce HRD, it will be necessary to understand gender differences in socioeconomic characteristics between men and women but also take notice of such differences in sociocultural settings as they experience. And it will be also required to prepare any gender-differentiated intervention strategy for men and women.     

Percent body fat, fractures and risk of osteoporosis in women

Objectives

Globally, in an aging population, osteoporosis and fractures are emerging as major public health problems; accessible and affordable recognition, prevention and treatment strategies are needed. Percent body fat is known to be associated with bone mineral density and fractures. This paper uses an innovative, virtually cost-free method to estimate percent body fat from age, height and weight, and assesses its validity by examining the association between percent body fat and fractures among women 39 and older.

Design

An epidemiologic study.

Participants

3940 college alumnae, median age 53.6, participated by responding to a mailed questionnaire covering medical history, behavioral factors, birth date, weight and height.

Statistical methods

T-tests, chi-square and multivariable logistic regression.

Measurements

Percent body fat estimated from age, weight, height and gender.

Results

Associations of fractures with percent body fat are expressed as odds ratios: for osteoporotic (wrist, hip and/or x-ray confirmed vertebral), the adjusted OR = 2.41, 95% CI (1.65, 3.54), P<0.0001; for wrist fractures, the adjusted OR = 2.56, 95% CI (1.65, 3.96), P<0.0001; for x-ray confirmed vertebral fractures the adjusted OR = 4.69, 95% CI (2.05, 10.77), P=0.0003).; and for non-osteoporotic, he adjusted OR= 1.00, 95% CI (0.76 1.32), P=0.999.

Conclusion

The findings are consistent with methods using DXA and/or other technologies that show percent body fat is associated with fractures of the wrist and vertebrae. Identification of risk factors is necessary for the prevention and treatment of osteoporosis and osteoporotic fractures. Estimation of percent body fat from age, height and weight may be a valid, cost-saving, and costeffective alternative tool for screening and assessing risk of osteoporosis in settings where Dual x-ray absorptiometry (DXA) or other radiological techniques are too costly or unavailable.     

Measuring the geographic coverage of methadone maintenance programme in Hong Kong by using geographic information system (GIS)

Background

Rural-urban disparities in health and healthcare are often attributed to differences in geographic access to care and health seeking behavior. Less is known about the differences between rural locations in health care seeking and outcomes. This study examines how commuting patterns in different rural areas are associated with perforated appendicitis.

Results

Controlling for age, sex, insurance type, comorbid conditions, socioeconomic status, appendectomy rates, hospital type, and hospital location, we found that patient residence in a rural ZIP code with significant levels of commuting to metropolitan areas was associated with higher risk of perforation compared to residence in rural areas with commuting to smaller urban clusters. The former group was more likely to seek care in an urbanized area, and was more likely to receive care in a Children's Hospital.

Conclusion

To our knowledge, this is the first study to differentiate rural dwellers with respect to outcomes associated with appendicitis as opposed to simply comparing "rural" to "urban". Risk of perforated appendicitis associated with commuting patterns is larger than that posed by several individual indicators including some age-sex cohort effects. Future studies linking the activity spaces of rural dwellers to individual patterns of seeking care will further our understanding of perforated appendicitis and ambulatory care sensitive conditions in general.     

Distance saturation product predicts health–related quality of life among sarcoidosis patients

Background

Quality of life (QOL) is an important measure in the management of Irritable Bowel Syndrome (IBS). Controversy exists in the findings of studies evaluating QOL in IBS subtypes, and little is known about this issue in Iranian patients. Determination of the factors affecting QOL in IBS patients may influence treatment outcomes. The aims of this study are to: 1) compare QOL between subtypes in a sample of Iranian IBS patients, 2) determine the factors associated with QOL in IBS.

Methods

This cross sectional study included two hundred and fifty IBS patients with the mean age (± standard deviation) of 31.62 (± 11.93) years that were referred to outpatient gastroenterology clinic. IBS patients were diagnosed based on Rome-3 criteria by a gastroenterologist, and then they were categorized into three subtypes according to the predominant type of bowel habit. The "QOL specific for IBS", "Stait-trait anxiety inventory", and "Beck depression inventory-2" questioners were used to evaluate QOL, anxiety, and depression symptoms, respectively.

Results

The mean QOL scores in IBS mixed subtype (71.7 ± 25.57), constipation predominant subtype (80.28 ± 25.57), and diarrhea predominant subtype (76.43 ± 19.13) were not different. (P value: 0.05) In multivariate linear regression analysis, anxiety symptom scores were inversely correlated with QOL scores. [Standardized beta: -0.43, (95% confidence interval: -0.70, -0.39), P value: < 0.01]

Conclusion

It seems reasonable to manage anxiety symptoms properly in IBS patients since this might increase their QOL.     

There is no age limit for methadone: a retrospective cohort study

Background

Excessive alcohol consumption in underage people is a rising phenomenon. A major proportion of the disease burden and deaths of young people in developed nations is attributable to alcohol abuse. The aim of this study was to investigate social, demographic and environmental factors that may raise the risk of Saturday night drinking and binge drinking among Italian school students.

Methods

The study was conducted on a sample of 845 Italian underage school students, by means of an anonymous, self-test questionnaire. Multivariate logistic regression was applied to identify independent risk factors for alcohol drinking and binge drinking. Ordered logistic regression was used to identify independent risk factors for harmful drinking patterns.

Results

The independent variables that confer a higher risk of drinking in underage students are older age classes, male sex, returning home after midnight, belonging to a group with little respect for the rules, or to a group where young people are not seen as leaders. The higher the perception of alcohol consumption by the group, the higher the risk. Spending time in bars or discos coincides with a two-fold or four-fold increase, respectively, in the risk of alcohol consumption.

Conclusion

Our findings show that certain environmental and social risk factors are associated with underage drinking. The most important role for preventing young people's exposure to these factors lies with the family, because only parents can exert the necessary control and provide a barrier against potentially harmful situations.     

Schlaganfallprävention: Identifizierung von Präventionspotenzialen durch Bevölkerungssurveys

Background

Community knowledge of stroke risk factors and prevention in Germany is poor. Therefore, the municipal Health Conference of Düsseldorf city, capital of North Rhine-Westphalia, the Public Health authority commissioned the Institute of Public Health NRW (lögd) to carry out a telephone survey. The aim was to assess community knowledge of stroke risk factors and self-reported prevalence of established risk factors.

Methods

The study population was defined as comprising all residents in the city of Düsseldorf of at least 18 years of age (approx. 485,000 people). The sample of 1,318 persons was drawn randomly and the telephone survey was carried out by the CATI Laboratory (Computer Assisted Telephone Interviews) at the Institute of Public Health (lögd, Bielefeld) between 12 October and 17 November 2004. At the same time, the SUZ GmbH (Sozialwissenschaftliches Umfragezentrum) carried out the identical survey in the Turkish language with citizens of Turkish descent (n=310).

Results

The majority of respondents named smoking as a risk factor [46.2%, German sample (GS) 53.1%, Turkish sample (TS) 16.5%], while hypertension was mentioned by 33.9% of participants (GS 37.8%, TS 17.3%). Only one-third of the Turkish respondents could name at least one risk factor, as compared to about 82% of the German participants. Overweight (47.9%) and smoking (31.4%) were the most frequently reported risk factors concerning respondents. The main target groups for stroke prevention are men, “underclass”/lower socio-economic status, elderly people (>65 years) and immigrants of Turkish descent.

Conclusion

The present study demonstrates the need for stroke prevention and information aimed at specific target groups. Since 2003, the regional network “Healthy Lower Rhine” carries out broad prevention campaigns and the city of Düsseldorf, capital of NRW, established a Stroke Information Bureau for community health education. Local surveys play a central part in health planning and prevention on a municipal level.     

Betätigung und Stimme von Erziehern in der Krippe

Background

Preschool-teachers suffer from a higher risk of illness due to specific contributing factors. However prevention programs barely exist. Considering that strain factors for preschool-teachers and daycare providers differ, it is the purpose of this paper to collect contributing factors relating to the occupation and voice of daycare providers featured during a selected strained situation. The ICF is the theoretical foundation for this paper.

Method

A triangulation based on a questionnaire, guideline interviews and a video-based observation was conducted.

Results

Strain factors for all components of the ICF were collected. Interdependency between the factors is noticeable.

Conclusions

Factors like voice load and to lift and carry appear in preschool and daycare. The intensity of those factors may differ. Daycare is a setting of work for occupational therapists and speech and language pathologists.     

Bewegung zur Prävention von Demenz

Background

Dementia diseases pose a global health problem. Recent studies show that physical activity can slow cognitive decline and delay the onset of dementia. In Germany there is a lack of evidence-based physical activity programs for preventing dementia.

Goals

The intervention study GESTALT investigated if and how an evidence-based physical activity program for preventing dementia could be implemented into the daily routines of prevention providers. The focus of this article is on the efficacy of the physical activity program regarding the cognitive and physical performance of the participants (65–75 years), as well as on the increase and retention of physical activity.

Methods

GESTALT included a multimodal exercise program and accompanying telephone support.

Results

GESTALT was successfully implemented by the prevention providers, and was well accepted by the participants. 60?% of the participants were practicing additional physical activity by the time of follow-up. There were improvements in cognitive performance with respect to short-term and working memory. Some participants met only a few risk factors for dementia.

Conclusions

The successful implementation suggests continuation and dissemination of GESTALT. In order to reach more people who have never engaged in physical activity and meet more risk factors for dementia, refined recruitment strategies are needed.