Lower Mental Quality Of Life Research Articles

An Internet-Based Study Examining the Factors Associated with the Physical and Mental Health Quality of Life of LGBT Cancer Survivors.

The purpose of this study was to examine factors associated with the quality of life of lesbian, gay, bisexual, and transgender (LGBT) cancer survivors. Data were collected via a nationally advertised online short-form health survey. Factors associated with lower physical quality of life included younger age at diagnosis, cancer type, medical co-morbidities, being overweight or obese, recurrence, and current cancer treatment. Lower mental quality of life was associated with younger age, smoking, lower perceived quality of care, lower perceived support, and higher cancer-related worry. Findings highlight a need for health promotion interventions specifically for LGBT cancer survivors.

The impact of primary Sjögren's syndrome on female sexual function.

Prevalence of vaginal dryness and dyspareunia is high in women with primary SS (pSS). Our aim was to compare sexual function and sexual distress in women with pSS with healthy controls, as well as to assess parameters that are associated with sexual dysfunction and distress in pSS. Forty-six women fulfilling the American-European Consensus Group criteria for pSS [mean age 46.3 years (s.d. 10.5)] and 43 age-matched healthy controls were included. Participants completed self-administered questionnaires, namely the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), Multidimensional Fatigue Inventory (MFI), Hospital Anxiety and Depression Scale (HADS), Maudsley Marital Questionnaire (MMQ) and RAND 36-item Health Survey (RAND-36). In addition, the European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI) and Patient Reported Index (ESSPRI) were recorded in patients. Women with pSS had impaired sexual function compared with healthy controls (median FSFI 20.6 vs 30.3, P < 0.001), as reflected by significantly lower scores in the domains of desire, arousal, orgasm, lubrication and pain. Furthermore, pSS patients experienced more sexual distress (median FSDS 7 vs 4, P < 0.05) and were sexually active less frequently than controls (76% vs 93%, P < 0.05). Sexual dysfunction correlated significantly with patient-reported symptoms of pSS (ESSPRI), symptoms of fatigue (MFI), depressive symptoms (HADS), relationship dissatisfaction (MMQ) and lower mental quality of life (RAND-36), but not with systemic disease activity (ESSDAI). Women with pSS have impaired sexual function and more sexual distress compared with healthy controls. Sexual function and distress are influenced by vaginal dryness and patient-reported symptoms of pSS as well as psychosocial factors.

Dysfunctional illness perception and illness behaviour associated with high somatic symptom severity and low quality of life in general hospital outpatients in China

ObjectiveIn primary care populations in Western countries, high somatic symptom severity (SSS) and low quality of life (QoL) are associated with adverse psychobehavioural characteristics. This study assessed the relationship between SSS, QoL and psychobehavioural characteristics in Chinese general hospital outpatients. MethodsThis multicentre cross-sectional study enrolled 404 patients from 10 outpatient departments, including Neurology, Gastroenterology, Traditional Chinese Medicine [TCM] and Psychosomatic Medicine departments, in Beijing, Shanghai, Chengdu and Kunming. A structured interview was used to assess the cognitive, affective and behavioural features associated with somatic complaints, independent of their origin. Several standard instruments were used to assess SSS, emotional distress and health-related QoL. Patients who reported low SSS (PHQ-15<10, n=203, SOM−) were compared to patients who reported high SSS (PHQ-15≥10, n=201, SOM+). ResultsAs compared to SOM− patients, SOM+ patients showed significantly more frequently adverse psychobehavioural characteristics in all questions of the interview. In hierarchical linear regression analyses adjusted for anxiety, depression, gender and medical conditions (SSS additionally for doctor visits), high SSS was significantly associated with “catastrophising” and “illness vulnerability”; low physical QoL was associated with “avoidance of physical activities” and “disuse of body parts”; low mental QoL was associated with “need for immediate medical help.” ConclusionIn accordance with the results from Western countries, high SSS was associated with negative illness and self-perception, low physical QoL with avoidance behaviour, and low mental QoL with reassurance seeking in Chinese general hospital outpatients.

AB0517 Impaired Sexual Function in Women with Primary SjÖGren's Syndrome

BackgroundPrimary Sjögren's syndrome (pSS) is a chronic and disabling disease, characterized by sicca symptoms of the eyes and mouth as well as fatigue. Besides these well-known symptoms, multiple studies have...

Cross-sectional survey of workload and burnout among Japanese physicians working in stroke care: the nationwide survey of acute stroke care capacity for proper designation of comprehensive stroke center in Japan (J-ASPECT) study.

Burnout is common among physicians and affects the quality of care. We aimed to determine the prevalence of burnout among Japanese physicians working in stroke care and evaluate personal and professional characteristics associated with burnout. A cross-sectional design was used to develop and distribute a survey to 11 211 physicians. Physician burnout was assessed using the Maslach Burnout Inventory General Survey. The predictors of burnout and the relationships among them were identified by multivariable logistic regression analysis. A total of 2724 (25.3%) physicians returned the surveys. After excluding those who were not working in stroke care or did not complete the survey appropriately, 2564 surveys were analyzed. Analysis of the participants' scores revealed that 41.1% were burned out. Multivariable analysis indicated that number of hours worked per week is positively associated with burnout. Hours slept per night, day-offs per week, years of experience, as well as income, are inversely associated with burnout. Short Form 36 mental health subscale was also inversely associated with burnout. The primary risk factors for burnout are heavy workload, short sleep duration, relatively little experience, and low mental quality of life. Prospective research is required to confirm these findings and develop programs for preventing burnout.

Ability of the Physician Well-Being Index to Identify Residents in Distress

Resident well-being impacts competence, professionalism, career satisfaction, and the quality of care delivered to patients. We established normative scores and reported evidence of relationship between the Physician Well-Being Index (PWBI) score to other variables and consequence validity for the PWBI in a national sample of residents, and evaluated the performance of the index after substituting the original fatigue item with an item not associated with driving a car. We conducted a cross-sectional survey study of a national sample of 20 475 residents. The survey included the PWBI, instruments assessing mental quality of life (QOL) and fatigue, and items on recent suicidal ideation and medical error. Fisher exact test or Wilcoxon/2-sample t test procedures were used with a 5% type I error rate and a 2-sided alternative. Of 7560 residents who opened the e-mail to participate in the study, 1701 (22.5%) completed the survey. Residents with low mental QOL, high fatigue, or recent suicidal ideation were more likely to endorse each of the PWBI items and a greater number of total items (all P < .001). At a threshold score of ≥ 5, the PWBI's specificity for identifying residents with low mental QOL, high fatigue, or recent suicidal ideation was 83.6%. PWBI score also stratified residents' self-reported medical errors. The PWBI performed similarly using either fatigue item. The 7-item PWBI appears to be a useful screening index to identify residents whose degree of distress may negatively impact the quality of care they deliver.

Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea

ObjectivesOur study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms. MethodsOur population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2years apart (baseline, time 1, and time 2). ResultsAmong individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors. ConclusionsIn particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

Assessment of subjective and motor fatigue in Polio survivors, attending a Postpolio clinic, comparison with healthy controls and an exploration of clinical correlates

Purpose: Polio survivors experience declining mobility, pain and fatigue. The extent of motor fatigue and its impact on mobility and quality of life, in addition to other commonly reported impairments requires evaluation. Methods: An observational, case–control, cross-sectional design was used to assess 30 Polio survivors and 30 age- and sex-matched controls. Muscle strength and motor fatigue were assessed using fixed dynamometry. Fatigue, pain and quality of life were assessed using the Piper Fatigue Scale, the Fatigue Severity Scale, visual analogue scales and the RAND Short Form-36, respectively. An 8-min walking test, including physiological cost index (PCI), evaluated mobility. Results: A significant difference in motor fatigue was identified only in hand grip (p = 0.03). Polio survivors were significantly weaker (p < 0.001) and more fatigued (p < 0.001) than controls. Motor fatigue was not related to subjective fatigue, mobility or quality of life. Muscle strength predicted mobility. Pain and fatigue were associated with lower mental quality of life, while PCI was associated with physical quality of life. Conclusion: Motor fatigue has been identified in Polio survivors but was only significantly different in hand grip, using this approach. Pain, fatigue and elevated energy cost of walking negatively influenced quality of life. Motor fatigue was unrelated to subjective fatigue, mobility or quality of life.

The correlations of sexual activity, sleep problems, emotional distress, attachment styles with quality of life: comparison between gynaecological cancer survivors and noncancer women

To compare quality of life and its related factors, which include sexual activity, sleep problems, depression, anxiety and attachment styles in close relationships, between gynaecological cancer survivors and noncancer women. The majority of studies focus on examining the relationships between the late-treatment side effects and quality of life in gynaecological cancer survivors. As a result, there is insufficient information about what are the correlations between psychosocial factors and quality of life in gynaecological cancer survivors. Cross-sectional study. The quality of life of the 85 gynaecological cancer patients who had completed active treatments for at least sixmonths was compared with the 85 age-matched women without cancer history. Measures included SF-12 Health Surveys, Medical Outcomes Study Sleep Scale, Beck Depression Inventory-II, State-Trait Anxiety Inventory, Sexual Activity Questionnaire and Experiences in Close Relationships-Revised. There were no significant differences in the quality of life between gynaecological cancer survivors and noncancer women. However, higher attachment-related anxiety in close relationship was the main factor associated with the lower physical quality of life in the gynaecological cancer survivor group. In contrast, older ages were correlated with lower physical quality of life in noncancer women. Anxiety level was the main factor associated with lower mental quality of life for both groups. Different from noncancer women, the psychosocial factor of insecure attachment in close relationships was the main factor associated with physical quality of life for gynaecological cancer survivors. Anxiety status was the common factor correlated with mental quality of life for cancer and noncancer women. Developing psychosocial interventions focusing on secure attachment in close relationships and anxiety management could improve physical and mental components of quality of life among gynaecological cancer survivors.

Should We Still Focus That Much on Cardiovascular Mortality in End Stage Renal Disease Patients? The CONvective TRAnsport STudy

BackgroundWe studied the distribution of causes of death in the CONTRAST cohort and compared the proportion of cardiovascular deaths with other populations to answer the question whether cardiovascular mortality is still the principal cause of death in end stage renal disease. In addition, we compared patients who died from the three most common death causes. Finally, we aimed to study factors related to dialysis withdrawal.MethodsWe used data from CONTRAST, a randomized controlled trial in 714 chronic hemodialysis patients comparing the effects of online hemodiafiltration versus low-flux hemodialysis. Causes of death were adjudicated. The distribution of causes of death was compared to that of the Dutch dialysis registry and of the Dutch general population.ResultsIn CONTRAST, 231 patients died on treatment. 32% died from cardiovascular disease, 22% due to infection and 23% because of dialysis withdrawal. These proportions were similar to those in the Dutch dialysis registry and the proportional cardiovascular mortality was similar to that of the Dutch general population. cardiovascular death was more common in patients <60 years. Patients who withdrew were older, had more co-morbidity and a lower mental quality of life at baseline. Patients who withdrew had much co-morbidity. 46% died within 5 days after the last dialysis session.ConclusionsAlthough the absolute risk of death is much higher, the proportion of cardiovascular deaths in a prevalent end stage renal disease population is similar to that of the general population. In older hemodialysis patients cardiovascular and non-cardiovascular death risk are equally important. Particularly the registration of dialysis withdrawal deserves attention. These findings may be partly limited to the Dutch population.

Depressive Symptoms, Pain, and Quality of Life among Patients with Nonalcohol-Related Chronic Pancreatitis

Objective. The present study was conducted to determine if depressive symptoms were associated with variability in pain perception and quality of life among patients with nonalcohol-related chronic pancreatitis. Methods. The research design was cross-sectional, and self-report data was collected from 692 patients with nonalcohol-related, intractable pancreatitis. The mean age of the sample was 52.6 (SD = 14.7); 41% of the sample were male. Participants completed the MOS SF12 Quality of Life Measure, the Center for Epidemiological Studies 10-item Depression Scale (CESD), and a numeric rating scale measure of “pain on average” from the Brief Pain Inventory. Results. Depressive symptoms were significantly related to participants' reports of increased pain and decreased quality of life. The mean CESD score of the sample was 10.6 (SD = 6.5) and 52% of the sample scored above the clinical cutoff for the presence of significant depressive symptomology. Patients scoring above the clinical cutoff on the depression screening measure rated their pain as significantly higher than those below the cutoff (P < 0.0001) and had significantly lower physical quality of life (P < 0.0001) and lower mental quality of life (P < 0.0001). Conclusion. Although causality cannot be determined based on cross-sectional, correlational data, findings suggest that among patients with nonalcoholic pancreatitis, the presence of depressive symptoms is common and may be a risk factor associated with increased pain and decreased quality of life. Thus, routine screening for depressive symptomology among patients with nonalcoholic pancreatitis may be warranted.

Avoiding Burnout

To evaluate the health habits, routine medical care practices, and personal wellness strategies of American surgeons and explore associations with burnout and quality of life (QOL). Burnout and low mental QOL are common among US surgeons and seem to adversely affect quality of care, job satisfaction, career longevity, and risk of suicide. The self-care strategies and personal wellness promotion practices used by surgeons to deal with the stress of practice are not well explored. Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. The survey included self-assessment of health habits, routine medical care practices, and personal wellness strategies and standardized assessments of burnout and QOL. Of 7197 participating surgeons, 3911 (55.0%) participated in aerobic exercise and 2611 (36.3%) in muscle strengthening activities, in a pattern consistent with the Centers for Disease Control and Prevention recommendations. The overall and physical QOL scores were superior for surgeons' following the Centers for Disease Control and Prevention recommendations (all P < 0.0001). A total of 3311 (46.2%) participating surgeons had seen their primary care provider in the last 12 months. Surgeons who had seen their primary care provider in the last 12 months were more likely to be up to date with all age-appropriate health care screening and had superior overall and physical QOL scores (all P < 0.0001). Ratings of the importance of 16 personal wellness promotion strategies differed for surgeons without burnout (all P < 0.0001). On multivariate analysis, surgeons placing greater emphasis on finding meaning in work, focusing on what is important in life, maintaining a positive outlook, and embracing a philosophy that stresses work/life balance were less likely to be burned out (all P < 0.0001). Although many factors associated with lower risk of burnout were also associated with achieving a high overall QOL, notable differences were observed, indicating surgeons' need to employ a broader repertoire of wellness promotion practices if they desire to move beyond neutral and achieve high well-being. This study identifies specific measures surgeons can take to decrease burnout and improve their personal and professional QOL.

Oncologist Burnout: Causes, Consequences, and Responses

Although the practice of oncology can be extremely rewarding, it is also one of the most demanding and stressful areas of medicine. Oncologists are faced with life and death decisions on a daily basis, administer incredibly toxic therapies with narrow therapeutic windows, must keep up with the rapid pace of scientific and treatment advances, and continually walk a fine line between providing palliation and administering treatments that lead to excess toxicity. Personal distress precipitated by such work-related stress may manifest in a variety of ways including depression, anxiety, fatigue, and low mental quality of life. Burnout also seems to be one of the most common manifestations of distress among physicians, with studies suggesting a prevalence of 35% among medical oncologists, 38% among radiation oncologists, and 28% to 36% among surgical oncologists. Substantial evidence suggests that burnout can impact quality of care in a variety of ways and has potentially profound personal implications for physicians including suicidal ideation. In this review, we examine the causes, consequences, and personal ramifications of oncologist burnout and explore the steps oncologists can take to promote personal well-being and professional satisfaction.

Preditores da qualidade de vida em fumadores e abstinentes

This study aimed to evaluate quality of life, psychological morbidity, nicotine dependence and family coping in smokers and abstinents. 116 smokers and 117 abstinents, from both sexes, participated in the study. All participants answered the following instruments: Socio-Demographic; Medical Outcomes Study Short Form 36 (MOS SF-36); Depresion, Anxiety, Stress Scales (DASS); Fagerstrom Test for Nicotine Dependence (FTND) and Family Crises-Oriented Personal Evaluation Scales (F-COPES). According to the results, in smokers who also have a partner who smokes, high nicotine dependence and psychological morbidity predict less physical quality of life. High psychological morbidity and passive assessment, predict less quality of life. As for abstinents, having chronic respiratory disease, high psychological morbidity and looking for spiritual support predicted poorer quality of physical life. Being female, having chronic respiratory disease and psychological morbidity predicted lower mental quality of life. Hereafter, intervention programs should include partners as well as psychological morbidity and coping strategies in order to increase quality of life.

The problems program directors inherit: medical student distress at the time of graduation

Background: Distress is prevalent among residents and often attributed to rigors of training.Aims: To explore the prevalence of burnout and depression and measured mental quality of life (QOL) among graduating medical students shortly before they began residency.Method: Pooled analysis of data from 1428 fourth year medical students who responded to 1 of 3 multi-institutional studies. Students completed the Maslach Burnout Inventory, PRIME MD, and SF-8 to measure burnout, depression, and low mental QOL (defined as mean mental SF-8 scores ½ a standard deviation below the population norm) and answered demographic items.Results: Shortly before beginning residency, 49% of responding medical students had burnout, 38% endorsed depressive symptoms, and 34% had low mental QOL. While no differences in the prevalence of distress was observed by residency specialty area, there were subtle differences in the manifestation of burnout by specialty. Medical students entering surgical fields had lower mean emotional scores, students entering primary care fields had lower mean depersonalization scores, and students entering non-primary care/non-surgical fields reported the lowest mean personal accomplishment scores (all p ≤ 0.03).Conclusion: Our results indicate a high prevalence of distress among graduating medical students across all specialty disciplines before they even begin residency training.

Efficacy of a Brief Screening Tool to Identify Medical Students in Distress

To determine whether the Medical Student Well-Being Index (MSWBI) can serve as a brief assessment tool to identify medical students in severe psychological distress. The authors used data from 2,248 medical students at seven U.S. medical schools who responded to a 2007 survey to explore the accuracy of the MSWBI in identifying medical students with three outcomes: low mental quality of life (QOL; defined by having a Medical Outcomes Study Short-Form Health Survey mental component summary score ≥1/2 standard deviation below that of the age- and gender-matched population norm), suicidal ideation, or serious thoughts of dropping out. The authors confirmed their analyses using data from a separate sample of 2,682 students evaluated in 2009. Students with low mental QOL, suicidal ideation, or serious thoughts of dropping out were more likely to endorse each individual MSWBI item and a greater number of total items than were students without such distress (all P < .001). The likelihood ratio for low mental QOL among students with MSWBI scores <4 was 0.47 as compared with 4.79 for those with scores ≥4. At an MSWBI threshold score of ≥4, the MSWBI's sensitivity and specificity for identifying students with low mental QOL or recent suicidal ideation/serious thoughts of dropping out were both ≥90%. On multivariable logistic regression, all MSWBI items were independently associated with at least one outcome. The MSWBI is a useful brief screening tool to help identify students with severe distress.

Quality of life and psychosocial functioning of spouse/partner caregivers before and after liver transplantation

Spouse/partner caregivers of liver transplant (LTx) patients play an important role both before and after transplantation. However, very little research has examined the quality of life (QOL), caregiving strain, and psychological functioning of these caregivers. In this study, we examined these outcomes and their correlates in 86 (49 pre-LTx, 38 post-LTx) spouse/partner caregivers. The physical QOL of caregivers was not impaired, and numerous caregiving benefits were identified (e.g., realizing what is important in life, discovering one's own inner strength, giving emotional support to the patient). However, a relatively high proportion of both pre-LTx and post-LTx caregivers had clinically low mental QOL (29% and 35%, respectively), low life satisfaction (45% and 32%, respectively), and high caregiving strain (59% and 81%, respectively). Both pre- and post-LTx caregivers, particularly women, had more total mood disturbance than a normative sample. Higher caregiving strain was significantly correlated with lower mental QOL, lower life satisfaction, and more mood disturbance. Overall, findings suggest that caregiving strain is prominent through the LTx spectrum. There is a need for prospective research to identify the patterns of caregiver outcomes over time and to examine the benefits of clinical interventions for caregivers.

The burden of mental disorders in primary care

Objectives To describe and compare the prevalence of mental disorders across primary care populations, and estimate their impact on quality of life. Methods Cross-sectional multilevel analysis of a systematic sample of 2539 attendees to eight primary care centres in different regions of Spain, assessed with the WHO Composite International Diagnostic Interview (CIDI 1.1), the Short Form Health Survey (SF-36) quality of life questionnaire and the SF-6D utility index. Results The 12-month prevalence of any mental disorder was 23% (95% confidence interval: 21–24%), 10% had mood, 9% anxiety, 5% organic, 4% somatoform, and 1% alcohol use disorders, with a significant between-centre variability ( P < 0.001). People with mental disorders had one standard deviation lower mental quality of life than the general population. We estimated that 1831 quality-adjusted life-years (QALYs) are lost annually per 100,000 patients due to mental disorders, without considering mortality. Mood disorders have the worst impact with an annual loss of 1124 QALYs per 100,000 patients, excluding mortality (95% confidence interval: 912–1351). Conclusions Prevalence rates were similar to those obtained in international studies using the same diagnostic instrument and, given the significant between-centre variability found, it is recommended that mental health statistics be considered at small area level. Mental disorders, and especially mood disorders, are associated with very poor quality of life and higher scores on disability indexes than other common chronic conditions.

Physicians Married or Partnered to Physicians: A Comparative Study in the American College of Surgeons

Dual-physician relationships are increasingly common. In this study, the authors explore how surgeons in dual-physician relationships differ from other partnered surgeons in their demographics, practice characteristics, family lives, distress, and job satisfaction. In 2008, members of the American College of Surgeons were asked to complete a survey that included questions on burnout, work-home conflict, and career satisfaction. Among 7,905 responding surgeons (a 32% response rate), 7,120 (90%) had a domestic partner (DP). Half (3,471 of 7,120 [48.8%]) of DPs did not work outside the home, 16.4% (1,165) were physicians, and 34.9% (2,484) were working nonphysicians. Surgeons whose DP was a physician were younger, newer to practice, were more likely to delay having children and to believe childrearing had slowed their career advancement, and were less likely to believe that they had enough time for their personal and family life compared with their colleagues whose DP was a working nonphysician or stayed at home (all p < 0.05). Surgeons in dual-physician relationships more often experienced a recent career conflict with their DP and a work-home conflict than surgeons whose DPs were working nonphysicians (all p < 0.0001). Surgeons whose DP is another surgeon face even greater challenges in these areas. Physicians married or partnered to another physician were more likely to have depressive symptoms and low mental quality of life than surgeons whose DP stayed at home (all p < 0.05). Surgeons whose DP stayed at home appear to be more satisfied with their career (p = 0.0006). Surgeons whose DP is another physicians appear to experience greater challenges balancing personal and professional life than surgeons whose DP is a working nonphysicians or whose DP stays at home.

Evaluation of Psychosocial Impact and Quality of Life in BRCA Mutation Family

Sang Ah Han, Sairhee Kim, Eunyoung Kang, Tae-Hyeon Ha, Jeong-Hyun Kim,Eun Joo Yang, Jae-Young Lim, Wonshik Han, Dong-Young Noh and Sung-Won Kim. J Genet Med 2010;7:67-77. https://doi.org/10.5734/JGM.2010.7.1.67