Address Ethical Issues Research Articles

A conjunctural analysis of the origins of ‘embedded ELSI’ in U.S. genomic medicine

ABSTRACT Calls to identify, explore, and address ethical and social issues as part of the design and implementation of scientific research are now widespread. One way of doing so is through an embedded approach, where ethical, legal, and social implications (ELSI) researchers are situated within larger scientific research studies. We trace the emergence of the ‘embedded ELSI’ approach to integration alongside the development of genomic medicine. In particular, we conduct a conjunctural analysis that draws attention to contests and struggles over the forms and meanings of good science – in this case, genomics – and the role(s) of ELSI scholars and researchers in producing good science. We demonstrate that the embedded ELSI approach emerged from these contests, which left ELSI research and interventions constrained – institutionally, topically, and methodologically. We end by calling for an opening up of embedded approaches to integration so that they might better meet calls for justice and equity in the present conjuncture.

EVOLUTION OF ARTIFICIAL INTELLIGENCE IN ANESTHESIA AND ITS PATH FORWARD

Artificial intelligence (AI) has brought a paradigm shift in patient management in the modern healthcare industry. This narrative literature review aims to explore the evolution of AI in the field of anesthesia and discuss its potential path forward. The increased demand for personalized care, smart decision-making tools, precision in practice, and growth in telemedicine, particularly in the realm of perioperative care, has brought AI to the forefront. By examining the existing research and applications of AI in anesthesia, this review seeks to provide insights into the current state of AI technology, its applications, implications for practicing clinicians, and the challenges and limitations that need to be addressed for its successful integration into perioperative care. This review encourages interdisciplinary teamwork between anesthesiologists, technologists, engineers, and technicians to simplify the complexities of AI implementation, address ethical issues, mitigate risks, and ensure safe perioperative care.

The Promising Role of Artificial Intelligence in Navigating Lung Cancer Prognosis

Incorporating AI in lung cancer management is a disruptive innovation that has improved diagnosis accuracy, prognosis prediction and treatment modalities. In this literature review, we seek to identify the role of artificial intelligence (AI) and machine learning (ML) in lung cancer detection, diagnosis and treatment between 2010 and 2023. A total of 55 studies were selected systematically from databases such as IEEE Xplore, Scopus and PubMed via a PRISMA-based approach. The analysis reveals that artificial intelligence (AI) techniques, specifically convolutional neural networks (CNNs) and natural language processing (NLP), highly improve the precision of initial detection and imaging of lung cancer. Also, CNN distinguishes between benign and malignant nodules, thus aiding early diagnosis and reducing unnecessary biopsies. On the other hand, NLP is utilized to extract relevant clinical information from electronic health records and unstructured medical texts, thereby enhancing the understanding of patient histories and improving treatment planning. Sensitive and specific scores usually higher than standard techniques characterize these technologies. Results show that traditional statistical approaches couldn’t match AI models whose predictive accuracies are outstanding while providing better care to patients through personalised treatment plans. Furthermore, multi-omics data analysis for personalised treatment planning and clinical decision-making optimisation via Clinical Decision Support Systems (CDSS) powered by AI are some ways artificial intelligence has exhibited its potential in this area. Given this, future studies should aim to fine-tune AI algorithms, improve data integration, and address ethical issues promoting responsible use of AI technologies in clinical practice settings. Despite these advances, data quality, model interpretability, and integration into clinical workflows persist. This review demonstrates the demand for continued research and collaboration from different disciplines so that the complete possibilities of AI in fighting lung cancer may be realised.

Analyzing socioscientific issues-based instruction studies focusing on character and value development: A systematic review

ABSTRACT The increase in ecological problems and social and moral conflicts has brought character and value education to the agenda in the 21st century. Socioscientific issues (SSI) that concern society and address ethical and moral issues are recommended as appropriate content to develop character and values within science education. In this systematic review, we investigate the trends and differences of SSI-based instruction studies that aim to develop character and values. Based on the analysis of 12 related articles, we found that SSI-based instructions focus on ecological worldview, socioscientific accountability, and social and moral compassion. We also cover instructional activities, assessment, time spent, and content. This research will guide researchers and practitioners to develop SSI-based instructions particularly for character and value development and explore new areas of SSI-based research by recognizing the gaps in this field.

Inspired anatomy education: Might God be relevant?

Anatomy education is essential for developing healthcare professionals, and discussion continues about factors that impact and improve the anatomy learning environment. Neglected in this discussion is a consideration of the diverse religious assumptions and beliefs that college students bring to anatomy learning. Surveys of religion among United States college students indicate that many identify as religious and Christian. This viewpoint commentary summarizes main elements of Christian theology and anthropology, discusses the holistic and positive view of the body presented in Christian scripture, and outlines how these Christian beliefs inform and impact student preparation for anatomy education and human body dissection, address ethical issues in body donation, and support professionalism for future career practice.

Academic machine learning researchers' ethical perspectives on algorithm development for health care: a qualitative study.

We set out to describe academic machine learning (ML) researchers' ethical considerations regarding the development of ML tools intended for use in clinical care. We conducted in-depth, semistructured interviews with a sample of ML researchers in medicine (N = 10) as part of a larger study investigating stakeholders' ethical considerations in the translation of ML tools in medicine. We used a qualitative descriptive design, applying conventional qualitative content analysis in order to allow participant perspectives to emerge directly from the data. Every participant viewed their algorithm development work as holding ethical significance. While participants shared positive attitudes toward continued ML innovation, they described concerns related to data sampling and labeling (eg, limitations to mitigating bias; ensuring the validity and integrity of data), and algorithm training and testing (eg, selecting quantitative targets; assessing reproducibility). Participants perceived a need to increase interdisciplinary training across stakeholders and to envision more coordinated and embedded approaches to addressing ethics issues. Participants described key areas where increased support for ethics may be needed; technical challenges affecting clinical acceptability; and standards related to scientific integrity, beneficence, and justice that may be higher in medicine compared to other industries engaged in ML innovation. Our results help shed light on the perspectives of ML researchers in medicine regarding the range of ethical issues they encounter or anticipate in their work, including areas where more attention may be needed to support the successful development and integration of medical ML tools.

Challenging social media threats using collective well-being-aware recommendation algorithms and an educational virtual companion.

Social media have become an integral part of our lives, expanding our interlinking capabilities to new levels. There is plenty to be said about their positive effects. On the other hand, however, some serious negative implications of social media have been repeatedly highlighted in recent years, pointing at various threats to society and its more vulnerable members, such as teenagers, in particular, ranging from much-discussed problems such as digital addiction and polarization to manipulative influences of algorithms and further to more teenager-specific issues (e.g., body stereotyping). The impact of social media-both at an individual and societal level-is characterized by the complex interplay between the users' interactions and the intelligent components of the platform. Thus, users' understanding of social media mechanisms plays a determinant role. We thus propose a theoretical framework based on an adaptive "Social Media Virtual Companion" for educating and supporting an entire community, teenage students, to interact in social media environments in order to achieve desirable conditions, defined in terms of a community-specific and participatory designed measure of Collective Well-Being (CWB). This Companion combines automatic processing with expert intervention and guidance. The virtual Companion will be powered by a Recommender System (CWB-RS) that will optimize a CWB metric instead of engagement or platform profit, which currently largely drives recommender systems thereby disregarding any societal collateral effect. CWB-RS will optimize CWB both in the short term by balancing the level of social media threats the users are exposed to, and in the long term by adopting an Intelligent Tutor System role and enabling adaptive and personalized sequencing of playful learning activities. We put an emphasis on experts and educators in the educationally managed social media community of the Companion. They play five key roles: (a) use the Companion in classroom-based educational activities; (b) guide the definition of the CWB; (c) provide a hierarchical structure of learning strategies, objectives and activities that will support and contain the adaptive sequencing algorithms of the CWB-RS based on hierarchical reinforcement learning; (d) act as moderators of direct conflicts between the members of the community; and, finally, (e) monitor and address ethical and educational issues that are beyond the intelligent agent's competence and control. This framework offers a possible approach to understanding how to design social media systems and embedded educational interventions that favor a more healthy and positive society. Preliminary results on the performance of the Companion's components and studies of the educational and psychological underlying principles are presented.

Evaluation of moral sensitivity and moral courage in intensive care nurses in Turkey during the COVID-19 pandemic.

BackgroundDuring the COVID‐19 pandemic, intensive care nurses may experience ethical issues related to fear of transmission, limited resources, and increased workload. Nurses' moral sensitivity and courage may have a role in dealing with these problems.Aim and ObjectiveThe purpose of this study was to assess intensive care nurses' moral sensitivity and moral courage during the COVID‐19 pandemic.DesignDescriptive cross‐sectional survey.MethodsA total of 362 nurses working in the intensive care units of pandemic hospitals in Turkey participated in the study between January and March 2021. Data were obtained using a personal information form, the Moral Sensitivity Questionnaire, and the Nurses' Moral Courage Scale. A link to the online data collection tools was sent to the management of participating institutions, who forwarded it to nurses. Reporting followed the CHERRIES guidelines.ResultsIn this study, the response rate of nurses was 89%. The nurses' total mean moral sensitivity score was 90.70 ± 28.89 and their mean moral courage score was 82.08 ± 13.51. A weak inverse correlation was found between the nurses' moral sensitivity and moral courage scores (r = −.176, p = .001). Total moral sensitivity score differed significantly according to years of Intensive care unit (ICU) experience (p = .007). Total moral courage scores increased significantly with education level (p = .012), years of nursing experience (p = .016), and willingness to work in the ICU (p < .001).ConclusionThe study suggests that nurses working in the intensive care unit during the pandemic had moderate moral sensitivity and high levels of moral courage. Nurses' sociodemographic characteristics and ICU work conditions may affect their moral sensitivity and moral courage.Relevance to Clinical PracticeThe results of this study can help guide efforts to improve moral courage and sensitivity and address ethical issues among ICU nurses.

"This is Not at All Foreseeable from the Outset" - Research Ethics in Qualitative Health Services Research: A Survey of Researchers

Health services research is multidisciplinary and involves the use of a plurality of research methods. Medicine as a discipline serves as an important reference, also in terms of addressing ethics issues in research. At the same time, however, the highly formalized ethical reviews common in medicine, are controversial within the social sciences, especially among qualitative researchers. So far, little is known about which research ethics issues arise in qualitative health services research. In summer 2019, an online survey was conducted among health services researchers on two main topics: a) research ethics issues in qualitative health services research and b) experiences with the ethics review procedures. The questionnaire contained ten open questions; the responses were analyzed for content. The first topic (ethical issues) is addressed within this article. A total of 73 researchers with heterogeneous professional background and an average of more than seven years of work experience in health services research participated in the survey. The following were reported as central research ethics issues: a) legitimacy and anticipation of ethical challenges in the planning of research, b) field access, consent and burdens during data collection, c) anonymization and data protection in data processing, d) data analysis, e) publication of results and data and f) general topics such as central principles and goals of research as well as the role of researchers. The main formats for dealing with these issues were exchange and consultation as well as referring to texts and regulations. On the one hand, the data documents typical central research ethics questions that researchers are confronted with in the context of qualitative health services research; on the other hand, they also point to gaps and less considered topics. A systematizing ethical reflection could take up these findings in order to develop health services research-specific principles and strategies for handling research ethics issues.

Chinese physicians\u2019 perceptions of palliative care integration for advanced cancer patients: a qualitative analysis at a tertiary hospital in Changsha, China

BackgroundLittle previous research has been conducted outside of major cities in China to examine how physicians currently perceive palliative care, and to identify specific goals for training as palliative care access expands. This study explored physicians’ perceptions of palliative care integration for advanced cancer patients in Changsha, China.MethodsWe conducted semi-structured qualitative interviews with physicians (n = 24) specializing in hematology or oncology at a tertiary hospital.ResultsMost physicians viewed palliative care as equivalent to end-of-life care, while a minority considered it possible to integrate palliative care with active treatment. Almost all physicians maintained separate conversations about palliative care with family members and patients, communicating more directly with family members than with patients about prognosis and goals of care. Physicians described experiencing ethical tension between the desire of family members to protect the patient from knowing they have advanced cancer, and the patient’s “right to decide” about palliative treatment. Physicians varied overall regarding perceptions of the role they should have in discussions about goals of care.ConclusionsAs palliative care access expands in China, medical training should encourage earlier integration of palliative care for advanced cancer, address ethical issues faced by physicians communicating about palliative care, and establish guidance on the role of the physician in discussions about goals of care.

Ethical Challenges in Staffing: The Importance of Building Moral Muscle.

Addressing ethics issues in healthcare is essential to living out an organization's mission, vision, and values. In addition to exacerbating existing ethical dilemmas, the COVID-19 pandemic raised many new and complex questions for leaders and their organizations. Ethical issues related to the workforce require a deliberate and comprehensive consideration of values. The case study scenarios presented here demonstrate examples of common ethical staffing challenges that healthcare leaders have faced, notably the allocation of care providers among COVID-19 patients and the balancing of care quality with staff and patient safety. With access to expert resources and a decision-making framework, leaders can build the moral muscle to meet these challenges and reach ethically justifiable resolutions. These staffing issues highlight the need for increased access to ethics resources for organizational leaders, including moral development support and assistance from experts to resolve complex ethical matters.

PHILOSOPHICAL‐ANTHROPOLOGICAL AND HISTORICAL‐PHILOSOPHICAL FOUNDATIONS OF TRANSHUMANISM IN CONTEMPORARY CULTURE: DESIGN AND DEVELOPMENT OF THE CONCEPT

The issues of formation of transhumanism in cultural philosophy and history of development of conceptual ideas in visual works were considered. In modern philosophical issues, position of transhumanism becomes essential. Ideas of transhumanism are reflected in all areas of digital space. Based on predominantly visual component of this space, we consider philosophical and anthropological ideas and analyze genre features inherent in the means of expression and technological aspects of modern visual culture. Clarification of conceptual foundations of transhumanism and peculiarities of cultural‐anthropological and transdisciplinary approaches to defining the phenomenon of transhumanism helps clarify the issue of transhumanism in historical‐philosophical and philosophical‐anthropological prospective. Conceptual foundations of the direction are based on humanistic historical perspective, and features of the current state of culture depend on the development of technology, nanotechnology, computer engineering, virtualization of cultural space, literary and cinematic experiments in science fiction. To achieve this goal, we turn to modern advances in neurobiology, phenomenology, philosophy of technology and address ethical issues regarding the morality of the individual in new changing conditions and impact of technological advances on public morality. Drawing conclusions on the development of the concept is not only based on ideas of supporters of transhumanism but also on the work of authors who criticize it. Provisions of transhumanism (including historical, philosophical and literary base) affect man's perception of the world around him. And development of technical component of the world and state of digital influence on society actualize interest in further immersion in prospects of the direction. The purpose of the article is to clarify conceptual foundations of transhumanism, features of cultural‐anthropological and transdisciplinary approaches to defining the phenomenon of transhumanism and clarify issues of transhumanism in historical‐philosophical and philosophical‐anthropological prospective.

Artificial Intelligence: An Interprofessional Perspective on Implications for Geriatric Mental Health Research and Care.

Artificial intelligence (AI) in healthcare aims to learn patterns in large multimodal datasets within and across individuals. These patterns may either improve understanding of current clinical status or predict a future outcome. AI holds the potential to revolutionize geriatric mental health care and research by supporting diagnosis, treatment, and clinical decision-making. However, much of this momentum is driven by data and computer scientists and engineers and runs the risk of being disconnected from pragmatic issues in clinical practice. This interprofessional perspective bridges the experiences of clinical scientists and data science. We provide a brief overview of AI with the main focus on possible applications and challenges of using AI-based approaches for research and clinical care in geriatric mental health. We suggest future AI applications in geriatric mental health consider pragmatic considerations of clinical practice, methodological differences between data and clinical science, and address issues of ethics, privacy, and trust.

Environmental DNA as Novel Technology: Lessons in Agenda Setting and Framing in News Media.

Simple SummaryIncreasing threats to wildlife have made assessing their populations, health, and adaptation to stressors ever more important. The use of environmental DNA to make these assessments is relatively new and offers many advantages, such as non-lethal sampling. How novel technologies such as these are framed in the news media is critically important because the general public gathers much of its information about scientific developments from the media, and public perceptions can impact use of technology, responses to data derived from its use, and ethical concerns. To date, media constructions of eDNA and perceptions among the general public have not been examined. The current paper begins to address this gap by undertaking an examination of media coverage of eDNA in Canada and the United States for the past approximately twenty years—likely a critical period in shaping understandings of and responses to eDNA. The findings indicate that eDNA is framed as a powerful tool, yet the social concerns that receive the most attention are those where there are financial interests at play, and these interests have to date eclipsed attending to relevant ethical considerations.Environmental DNA (eDNA) is an emerging technology used for understanding ecosystems, environmental change, and stressors. Cellular and extracellular DNA are collected from environmental samples instead of individual wildlife animals, and as such eDNA comes with associated logistical and ethical benefits. It is increasingly being used, yet to date public knowledge and perceptions of eDNA have not been explored. Given that most of the public gathers scientific information from news media sources, this is a logical first place to start. This paper reports on a framing and agenda-setting analysis of news media coverage of eDNA in Canada and the United States from 2000 to 2020. The findings indicate that eDNA is being framed as an emerging and powerful tool, although questions regarding its validity and reliability are raised vis-à-vis identifying the presence of invasive species. Less than half of the news articles analyzed address broader social or ethical issues in relation to eDNA, and the majority focus on the potential financial impacts of eDNA findings on development projects and business interests. The potential ethical advantages of non-lethal sampling methods used via eDNA sampling are not addressed, nor are the potential ethical issues raised by its potential use in bioprospecting, indicating that the current state of agenda setting regarding eDNA in these newspapers is focused on economic impacts, to the exclusion of potential ethical issues. This unfolding news coverage will likely be key to understanding public perceptions of this novel technology.

United States nurses' experiences during the COVID-19 pandemic: A grounded theory.

The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic. The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored. A qualitative study design was used. Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study. The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping. Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses. Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions.

Emerging ethical issues raised by highly portable MRI research in remote and resource-limited international settings

Smaller, more affordable, and more portable MRI brain scanners offer exciting opportunities to address unmet research needs and long-standing health inequities in remote and resource-limited international settings. Field-based neuroimaging research in low- and middle-income countries (LMICs) can improve local capacity to conduct both structural and functional neuroscience studies, expand knowledge of brain injury and neuropsychiatric and neurodevelopmental disorders, and ultimately improve the timeliness and quality of clinical diagnosis and treatment around the globe. Facilitating MRI research in remote settings can also diversify reference databases in neuroscience, improve understanding of brain development and degeneration across the lifespan in diverse populations, and help to create reliable measurements of infant and child development. These deeper understandings can lead to new strategies for collaborating with communities to mitigate and hopefully overcome challenges that negatively impact brain development and quality of life. Despite the potential importance of research using highly portable MRI in remote and resource-limited settings, there is little analysis of the attendant ethical, legal, and social issues (ELSI). To begin addressing this gap, this paper presents findings from the first phase of an envisioned multi-staged and iterative approach for creating ethical and legal guidance in a complex global landscape. Section 1 provides a brief introduction to the emerging technology for field-based MRI research. Section 2 presents our methodology for generating plausible use cases for MRI research in remote and resource-limited settings and identifying associated ELSI issues. Section 3 analyzes core ELSI issues in designing and conducting field-based MRI research in remote, resource-limited settings and offers recommendations. We argue that a guiding principle for field-based MRI research in these contexts should be including local communities and research participants throughout the research process in order to create sustained local value. Section 4 presents a recommended path for the next phase of work that could further adapt these use cases, address ethical and legal issues, and co-develop guidance in partnership with local communities.

Tae Wan Kim: Artificial Intelligence in the workplace, through an ethical lens

Artificial intelligence today continues to assimilate into our modern service industry occupations such as business, economics and health care. It is predicted that AI will continue to develop exponentially as a business staple and will follow a similar path to The Internet and Social Media in terms of growth opportunities and also the criticality to business. The concern for many, including Dr. Tae Wan Kim, associate professor of ethics at Carnegie Mellon University, is how the ethics of AI will affect individuals and society. In his recent book review, Machines Like Me, Kim writes on the varied ethical systems potentially used in AI training as he discusses the character development of the text. Whether a deontological approach or a consequentialist approach, AI is only as good as the training and the data provided. In this interview he says that to really address ethics issues in AI, much more funding should be given to moral philosophy and applied ethics.

The dark side of the ‘Moral Machine’ and the fallacy of computational ethical decision-making for autonomous vehicles

ABSTRACT This paper reveals the dangers of the Moral Machine experiment, alerting against both its uses for normative ends, and the whole approach it is built upon to address ethical issues. It explores additional methodological limits of the experiment on top of those already identified by its authors and provides reasons why it is inadequate in supporting ethical and juridical discussions to determine the moral settings for autonomous vehicles. Demonstrating the inner fallacy behind computational social choice methods when applied to ethical decision-making, it also warns against the dangers of computational moral systems, such as the ‘voting-based system’ recently developed out of the Moral Machine’s data. Finally, it discusses the Moral Machine’s ambiguous impact on public opinion; on the one hand, laudable for having successfully raised global awareness with regard to ethical concerns about autonomous vehicles, and on the other hand pernicious, as it has led to a significant narrowing of the spectrum of autonomous vehicle ethics, de facto imposing a strong unidirectional approach, while brushing aside other major moral issues.

A Comparison of Assessment Book Authors’ and Educators’ Perspectives on Ethics Issues in Assessment: A Review Study

Assessment book authors’ perspectives on ethical assessment practices are not necessarily consistent with those of educators. This study’s purpose was to explore similarities and differences between the two perspectives. Researchers presented scenarios of classroom assessment practices to gain insights into educators’ perspectives on ethical issues. Fourteen scenarios that were common across three empirical research articles were selected. Educators had similar opinions on a scenario if 70% or more respondents selected “ethical” or “unethical” on one item. Twenty-five assessment-related books were reviewed to present the authors’ views on the ethicality of classroom assessment practices. The results showed that assessment book authors and educators held similar views on five of the 14 scenarios. Findings might inform the professional development of in-service teachers and the training of pre-service teachers. The results can inform assessment book authors in the future development to address ethics issues in assessment and practitioners in educational technology to consider ethical issues in the process of designing assessment tasks.

First do no harm: An exploration of researchers' ethics of conduct in Big Data behavioral studies.

Research ethics has traditionally been guided by well-established documents such as the Belmont Report and the Declaration of Helsinki. At the same time, the introduction of Big Data methods, that is having a great impact in behavioral research, is raising complex ethical issues that make protection of research participants an increasingly difficult challenge. By conducting 39 semi-structured interviews with academic scholars in both Switzerland and United States, our research aims at exploring the code of ethics and research practices of academic scholars involved in Big Data studies in the fields of psychology and sociology to understand if the principles set by the Belmont Report are still considered relevant in Big Data research. Our study shows how scholars generally find traditional principles to be a suitable guide to perform ethical data research but, at the same time, they recognized and elaborated on the challenges embedded in their practical application. In addition, due to the growing introduction of new actors in scholarly research, such as data holders and owners, it was also questioned whether responsibility to protect research participants should fall solely on investigators. In order to appropriately address ethics issues in Big Data research projects, education in ethics, exchange and dialogue between research teams and scholars from different disciplines should be enhanced. In addition, models of consultancy and shared responsibility between investigators, data owners and review boards should be implemented in order to ensure better protection of research participants.