Clinical Supervision Research Articles

Regaining control over opioid use? The potential application of auricular transcutaneous vagus nerve stimulation to improve opioid treatment in China.

Opioid use disorder (OUD) is a critical problem in China and is accompanied by depression and deficits in cognitive control. In China, the most successful intervention for OUD is the community drug rehabilitation where methadone maintenance treatment (MMT) plays a key role. Even though methadone for the treatment of OUD can be helpful, it can cause severe somatic side-effects, which limit its effectivity. Even worse, it can have detrimental effects on cognitive control, which is crucial to regain control over drug intake. Here, we consider the potential use of auricular transcutaneous vagus nerve stimulation (atVNS) as an addition to MMT for opioid withdrawal treatment. Compared to other non-invasive brain stimulation methods, atVNS also targets the locus coeruleus (LC) important for noradrenaline (NA) synthesis. NA is an essential neurotransmitter impacted in opioid withdrawal and also critically involved in cognitive control processes. Its ADD-ON to MMT might be a useful mean to improve mood and enhance cognitive control processes impacted in OUD. We discuss the translational advantages of atVNS in China such as the cultural acceptance of the modality of treatment similar to electroacupuncture. Additionally, the wearability of the ear electrode and at-home self-administration without intense medical supervision makes of atVNS a useful tool to enhance clinical and cognitive outcomes especially in everyday life situation. We discuss how atVNS can be integrated in tele-medical health approaches allowing that innovative treatments can widely be disseminated and continued even in situations of restricted medical access.

H - 62 Current State of the Practice of Clinical Neuropsychology in Bolivia.

The present study aimed to determine the current state of the practice of clinical neuropsychology in Bolivia. This is a descriptive and cross-sectional study. The sample consisted of 72 professionals working in the field of neuropsychology in Bolivia. The information was collected through an online questionnaire that included 70 questions about the participants' professional training, professional practice, research, teaching, and perceived barriers to the profession's development, among other factors. Approximately 76% of participants reported receiving postgraduate neuropsychology training. Their training was rated as very good (34.8%) and good (23.9%). Conversely, their clinical supervision was rated very good (24.3%) and good (33.3%). The participants indicated that their professional practice is conducted mainly in private settings (72.2%). Also, they mentioned that the most assessed disorders were learning disabilities (93.5%), intellectual disabilities (90%), and ADHD (87.5%). Similarly, the more frequent conditions rehabilitated were learning disabilities (23.6%), ADHD (20%), and depression (20.85%). Only 41.5% of the participants reported conducting research. A smaller proportion of professionals (31.5%) taught neuropsychology courses. Neuropsychology is a relatively new field of work in Bolivia. For this reason, the participants considered that to enhance the quality of this specialty in Bolivia, new graduate programs in neuropsychology must be developed, more standardized tests validated, and more job positions created, especially in public institutions. Additionally, a professional organization that regulates the standards of this field needs to be established.

Multifocal motor neuropathy. A clinical case and literature review

Multifocal motor neuropathy is a rare motor neuron disease characterised by a progressive, gradual loss of muscle strength, although sensory functions are preserved. The worldwide frequency of this disease is estimated at 1 person per 100,000 people. MMN is diagnosed when there are characteristic clinical signs, electroneuromyography test results support the clinical findings, and other possible diagnoses are excluded. To prove the progressive course of the disease, the patient must be under long-term medical supervision, since the deteriorating state of the patient may imitate other diseases affecting the motor neuron, such as amyotrophic lateral sclerosis, chronic inflammatory demyelinating polyneuropathy, spinal muscular atrophy, and other.We present the clinical case of a 71-year-old patient who presented to the Neurology Department of the Hospital of Lithuanian University of Health Sciences Kauno Klinikos. She complained of pain in her right hip and progressing weakness of the right foot which had lasted for a year. After laboratory tests, long-term supervision, and exclusion of other diagnoses, the patient was diagnosed with an atypical type of multifocal motor neuropathy responsive to treatment with intravenous immunoglobulin.

SAT168 Cholecalciferol - Cause Of Hypoglycemia In Patients With Insulin Dependent Diabetes Mellitus

Abstract Disclosure: S. Kalinchenko: None. L. Vorslov: None. T. Sviderskaya: None. S. Timofeeva: None. O. Samburskaya: None. Hypoglycemia is a dangerous complication in patients with diabetes mellitus receiving insulin drugs. We found a previously undescribed cause of hypoglycemia caused by prescription of cholecalciferol. Materials and Methods. Five patients (ages 6, 14, 28, 37, and 45 years) with medically subcompensated insulin-dependent diabetes mellitus (HbA1c > 7%) with vitamin D deficiency (25(OH)D < 30 ng/mL) were under observation. To compensate for vitamin D deficiency, cholecalciferol preparations were prescribed in individually selected doses (2,000 to 20,000 IU), considering age and weight. Findings. As a result of using cholecalciferol (without changing diet and physical activity level) all patients had episodes of hypoglycemia at different terms of treatment - from one to two weeks (younger patients 6 and 14 years old) to 6-8 months (patients of older age groups 28, 37 and 45), which were recorded by the continuous glucose monitoring system FreeStyle Libre: glucose level less than 3.0 mmol/L was accompanied by associated symptoms (tremor, tachycardia, cold clammy sweats, and intense hunger), which necessitated a reduction in the dose of insulin drugs. Interpretation. Vitamin D deficiency is a pandemic of modern society. Overweight, obesity, arterial hypertension, metabolic syndrome, and diabetes mellitus are the clinical manifestations of vitamin D deficiency. Vitamin D regulates the expression of over 5,000 genes, and compensating for its deficiency not only increases the number of insulin receptors, but also increases their sensitivity, leveling out insulin resistance and preventing its development. On achieving an adequate vitamin D level (25(OH)D not less than 65 ng/ml and parathormone levels closer to the lower limit of normal ranges of 16-25 ng/ml) against the background of reduced or completely discontinued insulin drugs, glycated hemoglobin in the blood was determined after three months and its values were within the reference values in all five patients (HbA1c not more than 5.6%). Conclusion. In patients with diabetes receiving insulin therapy, correction of vitamin D deficiency should be accompanied by daily glucose monitoring and under strict medical supervision, with dose adjustment of insulin drugs to prevent the development of hypoglycemia. Presentation: Saturday, June 17, 2023

Trust-wide clinical neuropsychology peer supervision group: A service evaluation

This paper reports an evaluation of a monthly Trust-wide Clinical Neuropsychology peer supervision group set up in 2021 to respond to requests from clinicians for informal case discussions, whilst also providing group supervision for team members undertaking specialist Clinical Neuropsychology training. This evaluation was conducted to review how the group was received by attendees and facilitators, identify improvements, and address barriers to attendance. Group-specific questionnaires were completed by four facilitators and 21 participants. The findings suggested the group met its aims, and is consistent with many of the service and Trust aims and values. The majority of responses suggest the group has several benefits such as facilitating a space for reflection and exploring complex cases collaboratively. Both facilitators and participants felt their clinical practice was enhanced.

Self-Management in Allergic Rhinitis: Strategies, Outcomes and Integration into Clinical Care.

Allergic rhinitis (AR) is a common disease, characterized by typical symptoms and type 2 inflammation. Standard treatment is usually effective and safe, and most medications are available as over-the-counter (OTC). Therefore, AR patients, mostly at the AR onset or if symptoms are mild, prefer to manage symptoms themselves. However, self-management could be associated with problems, including inadequate control or medication abuse. Therefore, this paper aimed at presenting and discussing this issue. Ideally, self-management should be conducted under medical supervision. In this regard, telemedicine could represent a valuable tool for implementing self-management. Visual analog scale (VAS) is a perfect parameter to measure symptom severity, medications use, and AR control. In addition, VAS is easily monitored over time. Presently, a mobile application allows to AR patients of self-managing themselves. Therefore, mobile healthcare may supply fundamental support in communication and decision-making. In this regard, VAS represents the best tool to monitor symptoms' severity and control over time. Finally, pharmacological and non-pharmacological remedies are numerous and effective but should be used wisely.

The Aperta type of neural tube defect: The relevant experience in a local community with the diversity of the presentation.

A series of birth defects known as neural tube defects (NTDs) appear when the neural tube fails to fully or partially close during fetal development. In nations without folic acid supplementation, their incidence ranges from 0.5 to 2 per 1,000 births. The purpose of our study is to estimate the prevalence of NTDs and define the workup for newborn infants with an open neural tube in Al-Qadissiyah, Iraq. This 18-year descriptive retrospective analysis included all babies with NTD diagnoses at the Maternity and Child Teaching Hospital in Al-Qadissiyah Governorate, Iraq. Over the research period, 187 cases of NTDs were evaluated. NTDs presented a male predominance and an incidence rate of 9.4 per 1,000 births, with spina bifida (67.9%), encephalocele (24.02%), and anencephaly (8.02%) being the most prevalent defects. The typical gestational age was 36±5, whereas the typical maternal age was 30±5. It should be noted that 29.9% of women did not take folic acid supplements during the first trimester, while one-third of moms did not benefit from medical supervision during pregnancy. In 65.2% of instances, an antenatal diagnosis was made, and cesarean section was the mode of delivery in 87,8% of cases. Other than that, 64.7% of women lived in low socioeconomic conditions, and 67.9% were from rural areas. The relevance of reinforcing and maximizing folic acid measures throughout the periconceptional phase is emphasized by the fact that NTDs require high intensity and advanced care.

80.5 Self-Disclosure of Personal Trauma Experiences During Medical Training and Supervision

80.5 Self-Disclosure of Personal Trauma Experiences During Medical Training and Supervision

Health and medical rescue service supervision centre

The profession of firefighter working on the rescue and emergency care involves many skills and requirements. The Health Sub-Directorate's supervisory division oversees the activities of these agents in partnership with the Operations, Forecasting and Prevention Division. A firefighter nurse is present on the site and watches over the 250 to 350 daily interventions.

80.2 Self-Disclosure of Transgender Identity in Medical Training and Supervision

80.2 Self-Disclosure of Transgender Identity in Medical Training and Supervision

Establishing a novel partnership model to deploy health services for children with autism in a low-resource setting - experience from Sri Lanka.

Sri Lanka is representative of challenges faced by low-income and middle-income countries, including the rise in the prevalence of autism and the lack of sufficient autism-specific services in the state sectors. The experience in establishing a Center to provide services for children with autism in Northern Sri Lanka is described. Funding and resourcing were accessed through an innovative partnership-based public/non-governmental organisation/charity model, where service-based outcomes were the main objectives. This model, incorporating state institutions, local and international charity organisations, and volunteers, devised a bespoke approach to care provision using the available resources under the clinical supervision of a consultant psychiatrist and the administrative purview of the Regional Director of Health Services. The evolution of this Center into a Learning Health System is described, reflecting how a minimalistic partnership approach focused on the integration of existing organisations and services could be a feasible model for the delivery of high-quality healthcare in low-resource settings.

Curriculum evaluation innovation in realizing superior madrasa in Ma Wahab Chasbullah Bahrul Ulum Tambakberas Jombang Indonesia

This research departs from the research context that the curriculum is the core of the field of education and influences all educational activities. With the development of education now, every educational institution must have innovation, especially in curriculum management, so that education will continue to develop and exist in facing the challenges of the times. Madrasah Aliyah Unggulan Wahab Chasbullah Bahrul 'Ulum Tambakberas also uses an integrated curriculum by combining the national curriculum with the pesantren curriculum. This cannot be separated from the innovation that continues to be carried out, especially in curriculum management. The focus of this research is curriculum evaluation innovation in creating superior madrasa. This research uses a qualitative type of phenomenological approach, and the methods are interviews, observation and documentation. The data analysis used is data collection, data condensation, and conclusion. This research is expected to contribute to the study and development of theory in managing Islamic educational institutions, especially curriculum management innovation in creating superior madrasa. The results of this study are curriculum evaluation innovations carried out by madrasah heads through evaluating educators/educational staff and students. The evaluation uses Google Forms, clinical supervision, continuous reviews with teachers, and madrasah self-evaluation (EDM). The assessment is carried out on students through tests and non-tests such as observations, tests, practices, and mentoring students who excel or have problems.

Exploring the Relationship Between Components of Professional Identity for Counselors

The present study of 1,218 counselors used a correlational research design to explore the relationship between components of professional identity for counselors. The study explored relationships between factors of practice setting, years of experience, compassion, demographics, and overall professional identity. The study included provisionally and fully licensed counselors. Counselors in full-time practice reported a significantly higher sense of professional identity as compared with counselors in part-time practice. Further, highly experienced counselors reported significantly higher strength of professional identity as compared with novice counselors. However, no significant group differences were found based on counselor work setting, licensure type, and gender identity. Type of practice, years of experience, and compassion emerged as the best predictors of counselor professional identity. Implications for clinical supervision and burnout prevention to support strong professional identity for counselors are discussed.

Donor/recipient origin of lung cancer after lung transplantation by DNA short tandem repeat analysis.

Lung cancer is more common in posttransplant recipients than in the general population. The objective of this study was to examine the chimerism donor/recipient cell origin of graft cancer in recipients of lung transplant. A retrospective chart review was conducted at Foch Hospital for all lung transplantations from 1989 to 2020. Short tandem repeat PCR (STR-PCR) analysis, the gold standard technique for chimerism quantification, was used to determine the donor/recipient cell origin of lung cancers in transplant patients. Fourteen (1.4%) of the 1,026 patients were found to have graft lung cancer after lung transplantation, and one developed two different lung tumors in the same lobe. Among the 15 lung tumors, 10 (67%) presented with adenocarcinoma, four (27%) with squamous cell carcinoma and one with small cell lung cancer. STR analysis showed that the origin of the cancer was the donor in 10 patients (71%), the recipient in three patients (21%), and was undetermined in one patient. Median time to diagnosis was 62 months. The prevalence of lung cancer in lung transplant recipients is very low. However, the results of our study showed heterogeneity of genetic alterations, with 21% being of recipient origin. Our results highlight the importance of donor selection and medical supervision after lung transplantation.

Barriers and facilitators to mental health promotion for Mexican immigrants in the U.S. through the Ventanillas de Salud program.

Mental health promotion and screenings are recommended as part of standard preventive care. Mexican immigrants in the U.S. are at high risk for mental health illness especially after the COVID-19 pandemic, however access to mental health prevention for this population has been limited, which results in important implementation and equity gaps. The Ventanilla de Salud (VDS) program provides preventive services through Mexican consulates in the U.S. The objective of this study was to assess capability, opportunity, and motivation for promotores to implement mental health programming through the VDS, leveraging early experiences of ongoing mental health prevention efforts. This was a qualitative study using the Capability, Opportunity, and Motivation for Behavior Change model (COM-B). We conducted 9 focus groups with 40 VDS promotores and 6 semi-structured interviews with program stakeholders. Data were analyzed using inductive and deductive coding. We found high levels of interest from the leadership, partners, and promotores to provide mental health services through the VDS. Early implementation of a mental health strategy that included training sessions for promotores and mental health promotion, screenings and referrals for VDS users was ongoing. We identified facilitators and barriers that could affect capability, opportunity, and motivation to provide mental health services. Facilitators included promotores' extensive knowledge about the importance of mental health, promotores service mindset and commitment to provide services to VDS users, and general support from the VDS network and partners. Barriers included promotores' turnover, need for additional economic compensation, burnout, competing priorities, and lack of mental health professionals to provide clinical services or supervision. Additional investments are recommended to support promotores' well-being. The main lesson learned from this study was that investing in VDS promotores' training, resources, and well-being is key to their capability, opportunity and motivation to provide mental health services for Mexican immigrants in the US. Results from this study can be applied to improve the ongoing VDS mental health strategy and increase its impact on the mental health of Mexican immigrants.

Improving Teacher Performance Through Academic Supervision Activities at Madrasah Ibtidaiyah Nurul Huda Krembangan Surabaya

This study aims to find a model of madrasa principal academic supervision that improves teacher performance. The location of this research is at Madrasah Ibtidaiyah Nurul Huda Krembangan, Surabaya. There were four respondents to the research. Collecting research data using in-depth interview techniques, observation, and documentation. The research data was then analyzed using data reduction and triangulation techniques. The results of this study found: 1) Implementation of academic supervision by the head of Madrasah Ibtidaiyah Nurul Huda Krembangan Surabaya is carried out every year at the beginning of the new school year, then divided into two stages, namely the first semester and the second semester. The stages of implementation of academic supervision are divided into three, namely: a) planning of academic supervision; b) implementation of academic supervision; and c) evaluation and follow-up of the results of the implementation of academic supervision. 2) There are three approaches used by madrasa heads: a) a directive approach; b) a non-directive approach; and c) a collaborative approach. The supervision model used is the artistic supervision model. The application of academic supervision using these models and approaches has implications for improving the performance of teaching staff at Madrasah Ibtidaiyah Nurul Huda Krembangan Surabaya. Teachers became more diligent in preparing everything related to learning activities and became more disciplined in carrying out their duties at the madrasah. This study recommends further research on the academic and clinical supervision of all teachers at Madrasah Ibtidaiyah Nurul Huda Krembangan Surabaya.

Study protocol: implementing and evaluating a trauma-informed model of care in residential youth treatment for substance use disorders.

Comorbidity between Substance Use Disorders and trauma/post-traumatic stress disorder (PTSD) is common, particularly within residential treatment services. Comorbidity is associated with poorer treatment retention and treatment outcomes. Integrated treatment approaches are increasingly recommended but are still under examined in residential treatment services. This study will implement and evaluate a novel model of trauma-informed care (TIC) in a youth (18-35 years) residential substance use treatment service. A single-armed, phase 1 implementation trial will be conducted in one residential treatment service. The model, co-developed with staff, incorporates: (i) workforce development in TIC through staff training and clinical supervision; adaptions to the service (ii) policies, procedures, and physical settings and (iii) treatment program adaptions (in delivery style and content) to be more trauma-informed; (iv) client screening and feedback for trauma and PTSD at service entry; and (v) the provision of support, referral and/or trauma-focused therapy to those with PTSD. Service outcomes will include adherence to the TIC model and client treatment completion. Client substance use and mental health measures will be collected at service entry, and 1-, 3-, 6- and 12-months follow up. Staff outcomes, including workplace satisfaction, burnout, and fatigue, as well as perceptions and confidence in delivering TIC will be collected at baseline, and at 3-, 6-, 12- and 18-months following training in the model. The sustainability of the delivery of the TIC model of care will be evaluated for 12 months using service and staff outcomes. The study has received ethical approval by the University of Queensland (Approval number: 2020000949). The results will be disseminated through publication in a peer-reviewed scientific journal, presentations at scientific conferences, and distributed via a report and presentations to the partner organization.Clinical trial registration: ACTRN12621000492853.

Etripamil Nasal Spray for Conversion of Repeated Spontaneous Episodes of Paroxysmal Supraventricular Tachycardia During Long-Term Follow-Up: Results From the NODE-302 Study.

Background Self-administration of investigational intranasal L-type calcium channel blocker etripamil during paroxysmal supraventricular tachycardia (PSVT) appeared safe and well-tolerated in the phase 3 NODE-301 (Multi-Centre, Randomized, Double-Blind, Placebo-Controlled, Efficacy, and Safety Study of Etripamil Nasal Spray for the Termination of Spontaneous Episodes of Paroxysmal Supraventricular Tachycardia) trial of adults with sustained atrioventricular nodal-dependent PSVT. The NODE-302 open-label extension further characterized etripamil safety and efficacy. Methods and Results Eligible patients were monitored via self-applied cardiac monitoring system for 5 hours after etripamil self-administration. The primary end point was time-to-conversion of positively adjudicated PSVT to sinus rhythm after etripamil treatment. Probability of conversion to sinus rhythm was reported via Kaplan-Meier plot. Adverse events were based on self-reported symptoms and clinical evaluations. Among 169 patients enrolled, 105 self-administered etripamil ≥1 time for perceived PSVT (median [range], 232 [8-584] days' follow-up). Probability of conversion within 30 minutes of etripamil was 60.2% (median time to conversion, 15.5 minutes) among 188 PSVT episodes (92 patients) positively adjudicated as atrioventricular nodal dependent by independent ECG analysis. Among 40 patients who self-treated 2 episodes, 75% had a significantly consistent response by 30 minutes; 9 did not convert on either episode, and 21 converted on both episodes (χ2=8.09; P=0.0045). Forty-five of 105 patients (42.9%) had ≥1 treatment-emergent adverse event, generally transient and mild-to-moderate, including nasal congestion (14.3%), nasal discomfort (14.3%), or rhinorrhea (12.4%). No serious cardiac safety events were observed within 24 hours of etripamil. Conclusions In this extension study, investigational etripamil nasal spray was well tolerated for self-treating recurrent episodes of PSVT without medical supervision. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635996.

Characterizing Malpractice Cases Involving Emergency Department Advanced Practice Providers, Physicians in Training, and Attending Physicians.

To evaluate available characteristics and financial costs of malpractice cases among Advanced Practice Providers (Nurse Practitioners and Physician Assistants), trainees (medical students, residents, fellows) and attending physicians. A retrospective analysis of claims occurring in the emergency department from January 1, 2010 to December 31, 2019 contained in the Candello database. Cases were classified according to the provider type(s) involved: Nurse Practitioner (NP), Physician Assistant (PA), trainee, or cases which did not identify an extender as being substantially involved in the adverse event that resulted in the case ("no extender"). There were 5,854 cases identified with a total gross indemnity paid of $1,007,879,346. Of these cases, 193 (3.3%) involved an NP, 513 (8.8%) involved a PA, 535 (9.1%) involved a trainee, and 4,568 (78.0%) were no extender. Cases where a trainee was involved account for the highest average gross indemnity paid whereas no extender cases are the lowest. NP and PA cases differed by contributing factors compared to no extender cases: Clinical Judgment (NP 89.1% vs no extender 76.8%, p<0.0001; PA 84.6% vs no extender, p < .0001), Documentation (NP 23.3% vs no extender 17.8%, p=0.0489; PA 25.9% vs no extender, p<0.0001) and Supervision (NP 22.3% vs no extender 1.8%, p<0.0001; PA 25.7% vs no extender p < 0.0001). Cases involving NPs and PAs had a lower percentage of high severity cases such as loss of limb or death (NP 45.6% vs no extender 50.2%, p=0.0004; PA 48.3% vs no extender, p < 0.0001). Advanced Practice Providers (APPs) and trainees comprise approximately 21% of malpractice cases and 33% of total gross indemnity paid in this large national emergency department dataset. Understanding differences in characteristics of malpractice claims that occur in emergency care settings can be used to help to mitigate provider risk.

Medical follow-up and long-term survival of patients with cerebrovascular accident: data from the REGION-M registry

Aim. To assess the survival rate of patients after cerebrovascular accident (CVA), depending on the visits to the local outpatient clinic and the type of medical supervision, and in the first year after hospital discharge.Material and methods. The outpatient part of the REGION-M registry included 684 patients assigned to the City Polyclinic № 64 of Moscow, discharged from the F. I. Inozemtsev City Clinical Hospital (Moscow) in the period from January 1, 2012 to April 30, 2017 with a confirmed diagnosis of cerebral stroke/transient ischemic attack.Results. During the first year after the CVA, 451 (65,9%) patients visited the local clinic on their own (group 1), while 166 (24,3%) patients was consulted by house call (group 2), and 67 (9,8%) did not see the physician (group 3). Patients visited by house call were more likely to have prior coronary artery disease and stroke, and the age of men was older than in other groups. Patients who did not see a doctor were less likely to have comorbidities and disabilities, and were less likely to visit the clinic before stroke. The mortality of patients in group 3 was significantly higher throughout the entire follow-up period (55,2%, 70,1% and 77,6% at stages 1, 2 and 3 (p&lt;0,001), respectively) than in group 2 (31,2%, 55,4% (p&lt;0,001)) and group 1 (23,7%, 37,0% and 54,3% (p&lt;0,001)). Mortality of patients in group 1 was lower than group 2 (p&lt;0,05-0,01). The relative risk of death in clinic visitors was 0,450 (95% confidence interval (CI), 0,333-0,608, p&lt;0,0001), while in those visited by a doctor at home — 0,668 (95% CI, 0,482-0,927, p&lt;0,05). In multivariate analysis and adjustment for sex and age (relative risk (RR) of death, 0,08 (95% CI, 0,048-0,133), p&lt;0,0001 and 1,036 (95% CI, 1,031-1,042), p&lt;0,001, respectively), the independent contribution of the factor of clinic visits was preserved. Thus, the RR of death in visitors was 0,996 (95% CI, 0,994-0,999), p&lt;0,001 and 0,998 (95% CI, 0,995-1,0), p&lt;0,05.Conclusion. The lower mortality among those visited the local clinic in the first year after CVA and among those who were visited by a doctor at home, compared with patients who were not observed, confirms the important role of medical supervision in the post-hospital period.