Cancer Mortality In Taiwan Research Articles

Synthesized Age-Period-Cohort Prediction Method: Application to Lung Cancer Mortality in Taiwan.

Age-period-cohort analysis involves three temporal factors: age (the length of time from birth to diagnosis), period (the calendar time of diagnosis), and cohort (the calendar time of birth). The application of age-period-cohort analysis in disease forecasting can help researchers and health authorities anticipate future disease burden. In this study, a synthesized age-period-cohort prediction method was proposed based on four assumptions: (i) no single model can dominate as the most accurate prediction model in all forecasting scenarios, (ii) historical trends will not continue indefinitely, (iii) a model with the most accurate forecast for the training data will also be appropriate for forecasting future data, and (iv) a model dominated the stochastic temporal change will be the best-selected model with the robust forecasting. An ensemble of age-period-cohort prediction models was constructed and Monte Carlo cross-validation was performed to evaluate forecasting accuracy of these models. Data on lung cancer mortality from 1996 to 2015 in Taiwan were used and projected to the year 2035 to illustrate the method. The actual lung cancer mortality rates from 2016 to 2020 were then used to verify the forecasting accuracy.

Nationwide mammographic screening and breast cancer mortality in Taiwan: an interrupted time-series analysis.

In Taiwan, breast cancer is the third leading cause of cancer death in women. A nationwide screening program with biennial mammography for women aged 40-69 in Taiwan was implemented since July 2004, but the impact on breast cancer mortality has not been investigated. The interrupted time-series analysis was used to estimate the impact of mammographic screening on temporal trends of breast cancer mortality and to calculate the level of temporal changes due to the mammographic screening. The annual average percentage changes of the age-standardized breast cancer mortality rates for all women aged 40-69 were 1.06% from 1991 to 2004 (before mammographic screening) and 0.33-0.34% from 2005 to 2019 (after mammographic screening). For all women aged 40-69, the results of interrupted time-series analysis showed that the increasing trends of breast cancer mortality were all attenuated after the implementation of mammographic screening. An estimation of 2114 women prevented from death of breast cancer may be attributable to screening. For women aged 40-44, 55-59, 60-64 and 65-69, the percentage changes in mortality rates were - 12.1% (- 5.1 to - 19.6%), - 20.8% (- 16.5 to - 25.2%), - 12.8% (- 8.5 to - 17.3%) and - 13.0% (- 7.9 to - 18.3%), respectively, after screening. For women aged 45-49 and 50-54, the reduction of deaths and mortality rates of breast cancer were a little. This study revealed that the nationwide screening program with biennial mammography may be associated with the attenuation of breast cancer mortality trends in women aged 40-69 in Taiwan.

Combined Effects of Chronic PM2.5 Exposure and Habitual Physical Activity on Cancer Mortality: A Longitudinal Cohort Study

BACKGROUND AND AIM: Physical activity (PA) may increase the inhalation and deposition of air pollutants, possibly reducing its beneficial effects. We thus examined the combined effects of chronic exposure to fine particle matter (PM2.5) and habitual PA on the risk of cancer mortality in Taiwan. METHODS: A total of 384,128 adults (≥18 years) with 842,384 medical examinations were recruited between 2001 and 2016. All participants were followed up until May 31, 2019. Vital data were obtained from the National Death Registry of Taiwan. Ambient PM2.5 exposure was estimated using a satellite-based spatiotemporal model. Information on habitual PA was collected using a standard self-administered questionnaire. The time-dependent Cox regression model was used to evaluate the combined effects. RESULTS:Higher habitual PA was associated with lower risk of cancer mortality, whereas higher PM2.5 exposure was associated with higher risk of cancer mortality. The inverse associations of habitual PA with cancer mortality were not modified by chronic exposure to PM2.5. Compared to the participants with inactive-low-PA and high-PM2.5, those with high-PA and low-PM2.5 exhibited a 35% lower risk of cancer mortality [95% confidence interval (CI): 28%-42%]. CONCLUSIONS:Increased PA and reduced PM2.5 exposure are associated with lower risk of cancer mortality. Habitual PA reduces the risk of cancer mortality regardless of the levels of chronic PM2.5 exposure. Our results indicate that habitual PA is a suitable health promotion strategy even for people residing in relatively polluted regions. KEYWORDS: Particulate matter, Long-term exposure, cancer mortality

Geographical variations of socioeconomic status and prostate cancer mortality in Taiwan

A population-wide study was conducted to determine the association between area-level socioeconomic status and prostate cancer mortality in Taiwan. Age-period-cohort analysis was performed to adjust the time-trend variation. The area-level socioeconomic factors included proportion with a higher education, average income tax, population density, and clinical workload. After adjustment for time-trend variations in age, period, and cohort, prostate cancer mortality was significantly lower in the groups with the highest higher education proportion (rate ratio 0.88; 95% Confidence Intervals 0.83-0.93), average income tax (RR 0.90; 95% CIs 0.86-0.94), and population density (RR 0.88; 95% CI 0.83-0.93). When all variables were incorporated into one model, the rate ratio of prostate cancer mortality was 0.92 (95% CIs 0.88-0.97) in the region with the highest average income tax level compared with that with the lowest level, but differences in the other socioeconomic factors were not significant. This study revealed a significantly lower prostate cancer mortality rate in areas with a high higher education proportion, average income tax level, and population density compared with areas of low socioeconomic status in Taiwan.

Long-term exposure to ambient fine particles and gastrointestinal cancer mortality in Taiwan: A cohort study

BackgroundInformation on the association between long-term exposure to PM2.5 and gastrointestinal cancer mortality is scarce. ObjectivesThis study investigated the association between long-term exposure to PM2.5 and deaths from gastrointestinal cancer and its subtypes in adults in Taiwan. MethodsA total of 385,650 Taiwanese adults (≥18 years old) jointed a standard medical examination program between 2001 and 2014 and were followed up until 2016. Their vital data were obtained from the National Death Registry maintained by the Ministry of Health and Welfare in Taiwan. We estimated the ambient PM2.5 concentration at individual’s address utilising a satellite-based spatiotemporal model at a resolution of 1 km2. Cox proportional hazard regression model was used to investigate the associations between ambient PM2.5 and deaths from gastrointestinal, stomach, colorectal and liver cancers. ResultsWe found that each 10 µg/m3 increase in PM2.5 was associated with an increased hazard risk (HR) of 1.09 (95% confidence interval (CI): 1.03–1.16) and 1.13 (95%CI: 1.02–1.24) in deaths from gastrointestinal and liver cancers, respectively. The association between PM2.5 and death from colorectal cancer was marginally statistically significant [HR: 1.13 (95%CI: 1.00–1.26)]. We did not find significant associations between PM2.5 and mortality from stomach cancer. ConclusionsLong-term exposure to ambient PM2.5 was associated with an increased risk of deaths from gastrointestinal cancers, liver cancer and also potentially colorectal cancer. Air pollution control strategies are necessary to reduce the burden of gastrointestinal cancer.

Effect of nationwide screening program on colorectal cancer mortality in Taiwan: a controlled interrupted time series analysis.

To reduce colorectal cancer morbidity and mortality in Taiwan, a nationwide screening program with fecal immunochemical test was implemented from January 2004. This study evaluated the influence of this screening program through the controlled interrupted time series analysis. The controlled interrupted time series analysis was performed using the Poisson regression model with simple linear spline function adjusted for 5-year age-groups and the birth cohort. A sensitivity analysis was performed to re-estimate the effect of the screening program. The expected age-adjusted colorectal cancer mortality rates (by setting the effect of the screening program to zero) for both genders were close to the observed rates during 2004-2013 and were dramatically higher than the observed rates thereafter. The average annual percent changes in colorectal cancer mortality revealed an increasing trend for the age-groups 0-49 and ≥ 75years and a decreasing trend for the age-groups 50-69 and 70-74years for 2014-2017. Compared with 1991-2003, the adjusted mortality rate ratios were 0.93 (0.86-1.00) and 1.07 (1.00-1.15) in 2014-2017 for the screening and control groups. Regarding the percent changes, reductions of 7.49% between 1991-2003 and 2014-2017 and 14.76% between the control and screening groups were observed. The nationwide screening program effectively reduced colorectal cancer mortality. Including individuals aged 70-74years into the target population of the screening program as well as including medical centers and clinics in the program to promote the screening test effectively reduced colorectal cancer mortality.

Ursolic acid induces apoptosis and autophagy in oral cancer cells

Oral squamous cell carcinoma (OSCC) is the fifth common cause of cancer mortality in Taiwan with high incidence and recurrence and needs new therapeutic strategies. In this study, ursolic acid (UA), a triterpenoid, was examined the antitumor potency in OSCC cells. Our results showed that UA inhibited the proliferation of OSCC cells in a dose- and time-dependent manner in both Ca922 and SCC2095 oral cancer cells. UA induced caspase-dependent apoptosis accompanied with the modulation of various biological biomarkers including downregulating Akt/mTOR/NF-κB signaling, ERK, and p38. In addition, UA inhibited angiogenesis as evidenced by abrogation of migration/invasion and blocking MMP-2 secretion in Ca922 cells. Interestingly, UA induced autophagy in OSCC cells, as manifested by LC3B-II conversion and increased p62 expression and accumulation of autophagosomes. Inhibition by autophagy inhibitor enhanced UA-mediated apoptosis in Ca922 cells. The experiment provides a rationale for using triterpenoid in the treatment of OSCC.

Trends in regional cancer mortality in Taiwan 1992–2014

BackgroundAlthough the cancer mortality rate in Taiwan has been declining in recent years, no study has yet reported any regional differences in cancer mortality rates in Taiwan. We hypothesized that regional cancer mortality rates in Taiwan, an ethnically homogeneous society, exhibited no significant variations. MethodsWe investigated the trends in Taiwan regional cancer mortality between 1992 and 2014. We analyzed regional age-standardized cancer mortality rates for lung, liver, colon, stomach, oral, breast, and prostate cancers using the Taiwan Longitudinal Health Insurance Database and Demographic Database. Furthermore, we applied Joinpoint regression analysis to evaluate the trends across different regions. ResultsThere are clear regional variations in mortality rates for liver, stomach, and oral cancers, but not for lung, colon, breast, and prostate cancers. The regional death rates of oral cancer, especially for eastern Taiwan, not only elevate the fastest (APC = 14.78% per year, P < 0.001) but also show the largest disparities between men and women. Regional death rates for stomach cancer, which declined most rapidly, are converging in both general and gender groups. Liver cancer is the only one with regional variations whose trends do not all go in the same direction. We also demonstrated that northern Taiwan has significant regional advantages with respect to cancer mortality. ConclusionsSome but not all cancers in Taiwan show regional disparities. Liver, stomach, and oral cancers in Taiwan exhibit clear regional variations in mortality rates. In particular, the regional variations in oral cancer mortality rates are consistent with those in alcohol consumption.

Spatial Analysis of Ambient PM2.5 Exposure and Bladder Cancer Mortality in Taiwan.

Fine particulate matter (PM2.5) is an air pollutant that is receiving intense regulatory attention in Taiwan. In previous studies, the effect of air pollution on bladder cancer has been explored. This study was conducted to elucidate the effect of atmospheric PM2.5 and other local risk factors on bladder cancer mortality based on available 13-year mortality data. Geographically weighted regression (GWR) was applied to estimate and interpret the spatial variability of the relationships between bladder cancer mortality and ambient PM2.5 concentrations, and other variables were covariates used to adjust for the effect of PM2.5. After applying a GWR model, the concentration of ambient PM2.5 showed a positive correlation with bladder cancer mortality in males in northern Taiwan and females in most of the townships in Taiwan. This is the first time PM2.5 has been identified as a risk factor for bladder cancer based on the statistical evidence provided by GWR analysis.

Refined-mapping of the novel TSG within the 17q24.3 chromosomal region in non-small cell lung cancer samples.

Lung cancer is a leading cause of cancer mortality in Taiwan. It has been previously demonstrated that alterations to tumor suppressor genes (TSGs) are involved in the multi-step carcinogenesis process that results in the development of human cancer, including lung cancer. Both copies of the TSG must be inactivated for their function to be lost. As a result, it is important to search for the genomic regions that potentially contain TSGs and to investigate the etiological association of lung cancer with the allelic deletion of various candidate TSGs. Previous genome-wide loss of heterozygosity (LOH) data has demonstrated that the chromosome region at 17q24.3 was a novel and frequent LOH region that was associated with non-small-cell lung cancer (NSCLC). In the present study, refined mapping using 9 additional microsatellite markers was performed targeting chromosome 17q24.3 by polymerase chain reaction (PCR)-LOH analysis. The allelic loss pattern across 48 available tumors indicates that the minimal deletion region was located between markers D17S1882 and D17S2193 and spanned a distance of approximately 2.7 Mb, reaching 65% LOH at locus D17S1816. A putative gene, LOC51321 (AMZ2), was postulated to be the deletion target on 17q24.3 based on the findings from these NSCLC samples. Reverse transcription-PCR (RT-PCR) expression analysis indicated reduced expression of LOC51321 in 54% (7/13) of the NSCLC cell lines tested and 36% (19/53) of the NSCLC tumor tissue samples analyzed. In CL1-5-F4 cells, low mRNA and protein expression of LOC51321 were associated with the promoter hypermethylation, as determined by RT-PCR, western blotting and methylation-specific PCR assays. In addition, treatment with 5-Aza-deoxycytosine successfully restored mRNA expression by de-methylating the putative promoter region in CL1-5-F4 cells that lacked LOC51321 expression, but did harbor the relevant methylated promoter. These findings indicate that LOC51321 may be involved in lung tumorigenesis.

Mortality of breast cancer in Taiwan, 1971–2010: Temporal changes and an age–period–cohort analysis

The current paper describes the age, period and cohort effects on breast cancer mortality in Taiwan. Female breast cancer mortality data were collected from the Taiwan death registries for 1971–2010. The annual percentage changes, age- standardised mortality rates (ASMR) and age–period–cohort model were calculated. The mortality rates increased with advancing age groups when fixing the period. The percentage change in the breast cancer mortality rate increased from 54.79% at aged 20–44 years, to 149.78% in those aged 45–64 years (between 1971–75 and 2006–10). The mortality rates in the 45–64 age group increased steadily from 1971 to 1975 and 2006–10. The 1951 birth cohorts (actual birth cohort; 1947–55) showed peak mortalities in both the 50–54 and 45–49 age groups. We found that the 1951 birth cohorts had the greatest mortality risk from breast cancer. This might be attributed to the DDT that was used in large amounts to prevent deaths from malaria in Taiwan. However, future researches require DDT data to evaluate the association between breast cancer and DDT use.

Arsenic in drinking and lung cancer mortality in Taiwan

The association between exposure to arsenic in drinking water and lung cancer has been observed in some epidemiology studies, but dose–response data are limited. To assess the dose–response relationship and identify hot spots, we analyzed the national death registry data of Taiwan from 1971 to 2000. We adopted data on 311 townships gathered by a nationwide survey of drinking water and divided arsenic levels into three groups: below 0.05mg/L, 0.05–0.35mg/L, and above 0.35mg/L. Using the direct standardization method to adjust for the effects of age, we calculated the standardized mortality rates of lung cancer in both genders and evaluated their associations with arsenic levels. We also used the geographical information system to identify the hot spots. During the 30-year study period, we identified 64,954 male and 27,039 female lung cancer deaths in the study townships. We found significant increases in lung cancer mortality associated with arsenic levels above 0.35mg/L in both genders, but the increases associated with levels between 0.05 and 0.35mg/L were statistically significant in men only. Using both 0.05 and 0.35mg/L as the cut-offs, we found most of the hot spots were in the southwestern coast and northeastern areas, but the southwestern coast area had some hot spots where the percentages of high risk population were higher than any hot spots in the northeastern area.

Diabetes, insulin use, smoking, and pancreatic cancer mortality in Taiwan

The aim of the study was to evaluate the link between diabetes and pancreatic cancer (PC) mortality and the joint effect of smoking and insulin use on PC mortality. A total of 39,988 men and 46,909 women with type 2 diabetes, aged ≥25 years and recruited in 1995-1998, were followed to 2006 for PC mortality. Age-sex-specific mortality rate ratios for diabetic patients versus the general population were calculated. Cox regression was used to evaluate hazard ratios for PC mortality for covariates including age, sex, diabetes duration, body mass index, smoking, insulin use, and area of residence. The interaction and joint effect of smoking and insulin use were also evaluated. A total of 89 men and 63 women died of PC. The mortality rate ratios (95 % CI) showed a significantly higher risk in diabetic patients with a magnitude most remarkable at the youngest age: 1.51 (1.15, 1.98), 2.02 (1.35, 3.03), and 8.36 (5.39, 12.98) for ≥65, 55-64, and 25-54 years old, respectively, for men; and 1.16 (0.84, 1.59), 2.12 (1.39, 3.23) and 3.33 (1.14, 9.68), respectively, for women. In multivariable Cox regression analysis, only age was significantly predictive for PC mortality. Although smoking and insulin use might be associated with a 50 % higher risk when analyzed as individual risk factors, they did not reach statistical significance. The interaction term of smoking and insulin use was also not statistically significant in additional modeling. However, smoking and insulin use jointly increased the risk with an adjusted hazard ratio (95 % CI) of 3.04 (1.37, 6.73) when compared to patients who did not smoke and did not use insulin. Diabetic patients have a significantly higher risk of PC mortality. In patients with type 2 diabetes, smoking and insulin use may jointly increase the risk by threefold.

CN2 How Early-Stage Non-Persistence and Non-Adherence to Adjuvant Hormonal Therapy Associated With Postmenopausal Breast Cancer Mortality in Taiwan

Y1, Lee C1, Wang J2, Chen P1 1National Taiwan University, Taipei, Taiwan, 2National Cheng Kung University College of Medicine, Tainan, Taiwan OBJECTIVES: Statins have potential protective effects against cancers but no studies have focused on patients with chronic hepatitis B virus (HBV) infection. The purpose of this study was to investigate the association between the use of statins in HBV-infected patients and the risk of hepatocellular carcinoma (HCC). METHODS: We conducted a population-based cohort study from the Taiwan National Health Insurance Research Database. A total of 33,413 HBV-infected patients were included as the study cohort. Each subject was individually tracked from 1997 to 2008 to identify incident cases of HCC since 1999. Subsequent use of statin, other lower-lipid agents, aspirin, and angiotensin-converting enzyme inhibitors were identified. Cox proportional hazard regressions were employed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between the use of statins and the occurrence of HCC in the HBV-infected cohort. RESULTS: There were 1,021 HCC cases from the HBV cohort during follow-up periods of 328,946 person-years; the overall incidence rates were 310.4 cases per 100,000 person-years, respectively. There was a dose–response relationship between statin use and the risk of HCC in the HBV cohort. The adjusted HRs were 0.66 (95% CI, 0.44–0.99), 0.41 (95% CI, 0.27–0.61), and 0.34 (95% CI, 0.18–0.67) for statin use 28-90, 91-365, and 365 cumulative defined daily doses (cDDD), respectively, relative to no statin use ( 28 cDDD). CONCLUSIONS: Statin use may reduce the risk for HCC in HBV-infected patients in a dose-dependent manner. Further mechanistic research is needed.

Spatiotemporal trends in oral cancer mortality and potential risks associated with heavy metal content in Taiwan soil.

Central and Eastern Taiwan have alarmingly high oral cancer (OC) mortality rates, however, the effect of lifestyle factors such as betel chewing cannot fully explain the observed high-risk. Elevated concentrations of heavy metals in the soil reflect somewhat the levels of exposure to the human body, which may promote cancer development in local residents. This study assesses the space-time distribution of OC mortality in Taiwan, and its association with prime factors leading to soil heavy metal content. The current research obtained OC mortality data from the Atlas of Cancer Mortality in Taiwan, 1972–2001, and derived soil heavy metals content data from a nationwide survey carried out by ROCEPA in 1985. The exploratory data analyses showed that OC mortality rates in both genders had high spatial autocorrelation (Moran’s I = 0.6716 and 0.6318 for males and females). Factor analyses revealed three common factors (CFs) representing the major pattern of soil pollution in Taiwan. The results for Spatial Lag Models (SLM) showed that CF1 (Cr, Cu, Ni, and Zn) was most spatially related to male OC mortality which implicates that some metals in CF1 might play as promoters in OC etiology.

Single nucleotide polymorphisms of the APC gene and colorectal cancer risk: a case-control study in Taiwan

BackgroundColorectal cancer (CRC), which has become especially prevalent in developed countries, is currently the third highest cause of cancer mortality in Taiwan. Mutation of the adenomatous polyposis coli (APC) gene, a tumour suppressor, is thought to be an early event in colorectal tumourigenesis. To date, however, no large-scale screening for APC gene variants in Chinese subjects has been performed. The present study was undertaken to identify APC gene variants that are significantly associated with the occurrence of CRC in Taiwanese subjects.MethodsIn order to compare the genotype distribution of variant sites, the full-length APC genes of 74 healthy individuals and 80 CRC patients were sequenced.ResultsAmong the 154 Taiwanese subjects examined in this study, three new mutations, but no previously reported mutations, were found. One deletion at codon 460 leading to a frameshift and two missense mutations resulting in p.V1125A and p.S1126R substitutions were identified. Additionally, three high risk genotypes associated with three single nucleotide polymorphisms and one low risk genotype at codon 1822 were identified.ConclusionThe findings of this case-control study are consistent with the proposal that Taiwanese subjects differ from other subjects with respect to phenotypic presentation of APC and CRC risk.

Nutrient intakes in relation to cancer mortality in Taiwan

To provide more information on the international variations of nutrient intake in relation to cancer mortality rates, we investigated the association between nutrient intake and common cancer mortality rates in Taiwan by using the ecological design. Cancer mortality rates in Taiwan from 1997-2000 were obtained from the Office of Statistics, Department of Health. The data of nutrient intake were obtained from the third national survey (Nutrition and Health Survey in Taiwan; NAHSIT) (1993–1996). Data was drawn from 7 geographical districts. Stomach, lung, prostate, liver, and colorectal cancer mortality rates in men were attributed to regional variations in the consumption of either lipid, calcium, thiamin, and/or vitamin E; breast and liver cancer mortality rates in women were related to the regional variations in consumption of either lipid, carbohydrate, calcium, or iron. Not all cancer (i.e., esophageal cancer in men and women; stomach, lung, and colorectal cancer in women) mortality rates could be explained by the regional variations in the consumption of nutrients. Time-lag and potential confounders might be considered in the ecological study.

Fluoride in Drinking Water and Cancer Mortality in Taiwan

The possibility that cancer risk is associated with naturally fluoridated water in Taiwan is examined. The 1982–1991 age-adjusted mortality rates for cancer for 10 municipalities whose water supplies contained the highest naturally occurring fluoride concentrations in Taiwan were compared to those rates for 10 matched municipalities with unfluoridated water. The two groups had similar urbanization levels and sociodemographic characteristics. Our study does not support the suggestion that fluoridation of water supplies is associated with an increase in cancer mortality in Taiwan.

Chlorination of Drinking Water and Cancer Mortality in Taiwan

Chlorination has been the major strategy for disinfection of drinking water in Taiwan. An ecologic epidemiological study design was used to examine whether chlorination of drinking water was associated with cancer risks. A “chlorinating municipality” (CHM) was defined as one in which more than 90% of the municipality population was served by the chlorinated water while an “nonchlorinating municipality” (NCHM) was one in which less than 5% of the municipality population was served by chlorinated water. Age-adjusted mortality rates for cancer during 1982–1991 among the 14 CHMs were compared to rates among the 14 matched NCHMs with similar urbanization level and sociodemographic characteristics. The results of this study suggest a positive association between consumption of chlorinating drinking water and cancer of the rectum, lung, bladder, and kidney. Although these findings must be interpreted with caution because of limitations in the ecological study design, their public health significance should not be disregarded because chlorination of water is so widely practiced in Taiwan.

The relationship between population density and cancer mortality in Taiwan.

Many investigators have examined urbanization gradients in cancer rates. The purpose of this report was to identify urban‐rural trends in cancer mortality rates (1982–1991) for municipalities in Taiwan. For this purpose, Taiwan's municipalities were classified as rural, suburban, urban, or metropolitan, using population density as an ordinal indicator of the degree of urbanization. Average annual age‐adjusted, site‐specific cancer mortality rates were calculated for both sexes within each population density group. Significant increasing trends with more urbanization were observed in mortality rates for cancers of the lung, pancreas, and kidney among both males and females, as well as male prostate cancer, and female breast and ovary cancer. In addition, this study revealed a significant rural excess for nonmelanoma skin cancer among both males and females, as well as male non‐Hodgkin's lymphoma, and cancers of the female bone, and female connective tissue. Analytic studies for sites with consistent urban‐rural trends may be fruitful in identifying the aspect of population density, or other unmeasured factors, that contribute to these trends.