Portuguese Health Research Articles

Uncontrolled chronic pain: can a pain consultation in primary care be a solution?

Chronic pain is one of the most frequent medical problems in Portuguese primary health care. These patients significantly show poorer functioning capabilities and quality of life than the general population. The importance of improving the quality of life in patients suffering from chronic pain is paramount, and a holistic approach must be implemented. However, proper pain evaluation and management may be time-consuming in a routine primary health care consultation. Given the significant impact of this disease, we initiated a dedicated consultation for patients with chronic pain in our primary health care unit. A complete evaluation is performed, and, among other questionaries, the Brief Pain Inventory is applied to evaluate pain impact on functioning at the first appointment and re-evaluated after six months of follow-up. In the first six months, 31 patients with uncontrolled pain were referred by their family physicians to this consultation. Non-pharmacological strategies were strongly recommended alongside pharmacological therapies. Although this consultation is relatively recent, our patients with longer follow-ups showed improvement in both maximum and minimum pain levels and substantial improvement in all the measured interferences in the Brief Pain Inventory. Even though there is literature that thoroughly describes the impact of pain on patients’ quality of life, there is much to be done to change this problem. Since family physicians know their patients and their contexts well, they are in a privileged position to manage this problem, and a specific pain consultation in primary health care can be one of the best services for managing pain.

HiCorr: an influenza surveillance model using over-the-counter sales from community pharmacies

Abstract Background In large-scale community transmission, such as seasonal influenza, monitoring geographic trends and estimating the transmission intensity are critical to support public health decision-making. Previous studies have successfully used sales data from over-the-counter (OTC) products in community pharmacies to detect and monitor different epidemiological outbreaks, developing surveillance systems that are able to anticipate the load on primary care services and hospitals by up to 3 weeks. Methods The subset of OTC products sold in Portuguese community pharmacies was selected by correlating sales data to primary care attendance in previous flu seasons. This data pertained to daily coded episodes of influenza-like-illness (International Classification of Primary Care, 2nd Edition, code R80) in the Portuguese health cluster Oeste Sul. By fitting a moving epidemic method to historical sales data and then applying it to daily collected sales data, the developed index was used to anticipate the relative load to the primary care system as well as the start and the peak of epidemic activity for the current flu season. Results were compared to the public health data available on respiratory infections in Portugal. Results The model pinpointed the onset of the 2023-2024 flu epidemic in week 47 and its peak in week 52. The index curve showed a high correlation with the data published by the Portuguese national health service, with no time lag. However, the availability of consolidated public data was delayed, on average, by approximately two weeks. Discussion and conclusions Data from community pharmacies significantly enhance the early detection of seasonal flu trends, while reflecting population distribution. This underscores their invaluable contribution to public health assessments and the potential for improving the timeliness and accuracy of seasonal flu surveillance. Key messages • Community pharmacy data significantly enhance the early detection of seasonal flu trends. • Real world sales data maybe useful to support epidemic surveillance in public health.

Barriers and facilitators of evidence-based practice in the Portuguese context: perceptions of formal nursing leaders.

Formal nursing leaders play an important role in promoting and sustaining evidence-based practice (EBP) in the clinical context, particularly by creating a conducive environment for change and increasing clinicians' awareness of the positive results of EBP. However, nursing leaders encounter both barriers and facilitators in their work; therefore, it is important to understand their perceptions on this topic. The objective of this study was to understand the perceptions of formal nursing leaders about barriers and facilitators for EBP. A descriptive exploratory study with a qualitative approach was conducted. A convenience sample was obtained, consisting of formal nursing leaders from three Portuguese health care institutions. Data were collected through semi-structured interviews. Content analysis was conducted using MAXQDA Analytic Pro 2022 software. Seventeen formal nursing leaders were interviewed. Five categories of EBP barriers were identified: (1) scarce resources and inefficient resource management; (2) non-conducive organizational culture; (3) distance between academia and the clinical context; (4) demotivation; and (5) resistance to change. Seven categories of EBP facilitators were identified: (1) availability of resources and efficient resource management; (2) conducive organizational culture; (3) partnerships between academia and the clinical context; (4) motivation and commitment; (5) leadership; (6) organization that regulates professional practice; and (7) multidisciplinary meetings. This study identified barriers and facilitators for EBP through the perceptions of formal nursing leaders. Collaborative multidisciplinary efforts by leaders, direct care professionals, academics, and researchers should be conducted to overcome barriers and strengthen facilitators for EBP. http://links.lww.com/IJEBH/A242.

Portuguese Health System – Challenges in Times of Genomics

Portuguese Health System – Challenges in Times of Genomics

Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol

Pulmonary rehabilitation (PR) is the bedrock of non-pharmacological treatment for people with COPD. Nonetheless, it is well described in the literature that unless the patient changes his behaviour, the benefits of PR programmes will decline in six to twelve months after finishing the programme. Therefore, maintenance programmes can address the problem of PR programmes’ effect loss over time.Community care units can provide multidisciplinary care in the current Portuguese primary health care context. These units have an interdisciplinary team that aims to develop competencies in COPD patients to self-manage the disease.This study aims to test the effectiveness of a 12-month home-based PR programme (Rehab2Life) compared to usual care through a single-blind randomised controlled trial with two parallel groups. The Rehab2Life programme includes two distinct phases. The first is an 8-week PR programme delivered to both groups, and the second is a PR maintenance programme delivered to the intervention group after the initial eight weeks. The control group receive the usual care and regular appointments. The primary outcome is functional capacity, and secondary outcomes are dyspnea, Health-Related Quality of Life (HRQoL), number of exacerbations, symptoms burden, anxiety and depression symptoms, and physical activity.We expect to observe that the home-based PR programme brings clinically relevant benefits to the participants at the end of the first eight weeks and that, at 12 months after the maintenance phase of the programme, benefits are less dissipated than in the control group. We expect to identify the characteristics of the patients who benefit the most from home-based programmes.The trial was registered on 7 April 2022 at ClinicalTrials.gov (NCT05315505).

Mental Health Acts - Perspectives from Mental Health and Law in Ireland and in Portugal.

Mental health legislation is a cornerstone to ensure that individuals with severe mental illness access proper care and treatment. Each country establishes their own legislation. We aimed to compare the Portuguese and Irish Mental Health Acts (MHAs). We reviewed the respective MHA and the literature. While the definition of mental disorder is similar in general, who, where, when and how one can be detained differ. Judges decide on detentions in Portugal, while consultant psychiatrists may do so in Ireland. Community-based compulsory treatment is possible and used in Portugal while it is not possible in Ireland. Pros and cons of each approach are discussed with a reflection on the protection of human rights. Further theoretical and empirical studies comparing systems in different jurisdictions would be helpful to deepen our understanding of the legislation and guide on how to better serve individuals with severe mental illness.

Primary thromboprophylaxis in cancer outpatients - real-world evidence.

Cancer-associated thrombosis (CAT) is a significant concern among patients with malignant diseases, leading to increased mortality. While current guidelines recommend primary thromboprophylaxis for venous thromboembolism (VTE) in medium-to-high-risk outpatients, this practice remains controversial. A better understanding of primary thromboprophylaxis is crucial, yet there is a lack of Real-World Evidence (RWE) in Portugal. This RWE study aimed to elucidate primary thromboprophylaxis practices among cancer outpatients in Portugal. A five-year observational multicentric study in eight Portuguese health institutions enrolled 124 adult cancer outpatients under primary thromboprophylaxis for VTE. The endpoints were CAT, bleeding, cancer progression and death. High thrombotic risk tumours were prevalent, with 57% (71) of the patients presenting with pancreatic and gastric cancers. Regarding primary thromboprophylaxis, 55% (68) received Low-Molecular-Weight Heparin (LMWH). VTE was presented in 11% (14) of the patients and major bleeding in 2% (2). Vascular compression, elevated D-dimer and previous VTE were significantly associated with VTE occurrence under primary thromboprophylaxis. The Onkotev model was shown to be the best risk assessment model (RAM) in this population (p = 0.007). CAT patients exhibited a lower progression-free survival than non-CAT patients (p = 0.021), while thrombosis did not influence overall survival (p = 0.542). Primary thromboprophylaxis in medium-to-high-risk cancer outpatients is a safe and effective practice in real-world settings. This study is the first Portuguese RWE on primary thromboprophylaxis, highlighting evidence for improving prophylactic strategies in this population.

Fast Healthcare Interoperability Resources-Based Support System for Predicting Delivery Type: Model Development and Evaluation Study.

The escalating prevalence of cesarean delivery globally poses significant health impacts on mothers and newborns. Despite this trend, the underlying reasons for increased cesarean delivery rates, which have risen to 36.3% in Portugal as of 2020, remain unclear. This study delves into these issues within the Portuguese health care context, where national efforts are underway to reduce cesarean delivery occurrences. This paper aims to introduce a machine learning, algorithm-based support system designed to assist clinical teams in identifying potentially unnecessary cesarean deliveries. Key objectives include developing clinical decision support systems for cesarean deliveries using interoperability standards, identifying predictive factors influencing delivery type, assessing the economic impact of implementing this tool, and comparing system outputs with clinicians' decisions. This study used retrospective data collected from 9 public Portuguese hospitals, encompassing maternal and fetal data and delivery methods from 2019 to 2020. We used various machine learning algorithms for model development, with light gradient-boosting machine (LightGBM) selected for deployment due to its efficiency. The model's performance was compared with clinician assessments through questionnaires. Additionally, an economic simulation was conducted to evaluate the financial impact on Portuguese public hospitals. The deployed model, based on LightGBM, achieved an area under the receiver operating characteristic curve of 88%. In the trial deployment phase at a single hospital, 3.8% (123/3231) of cases triggered alarms for potentially unnecessary cesarean deliveries. Financial simulation results indicated potential benefits for 30% (15/48) of Portuguese public hospitals with the implementation of our tool. However, this study acknowledges biases in the model, such as combining different vaginal delivery types and focusing on potentially unwarranted cesarean deliveries. This study presents a promising system capable of identifying potentially incorrect cesarean delivery decisions, with potentially positive implications for medical practice and health care economics. However, it also highlights the challenges and considerations necessary for real-world application, including further evaluation of clinical decision-making impacts and understanding the diverse reasons behind delivery type choices. This study underscores the need for careful implementation and further robust analysis to realize the full potential and real-world applicability of such clinical support systems.

The impact of BMI on life expectancy in Portugal

The overweight represents a serious public health problem in Portugal, with a prevalence that exceeds 50%. Obesity-related diseases constitute the health system's main causes of death and economic issues. Despite this, there is no consensus on the relationship between the Body Mass Index (BMI) and the risk of early mortality. In this context, assessing the impact of the average BMI on life expectancy in Portugal is important. A retrospective cross-sectional observational study was carried out using an Autoregressive Distributed Lag model. The dependent variable is life expectancy at birth, expressed in the total years obtained from the World Development Indicators (WDI). The independent variables are: (i) the average BMI of the population (calculated based on the average male and female BMI obtained from Our World in Data); and (ii) the total population obtained from the WDI. The population's mean BMI variable limited the study's time horizon, comprising annual statistical data from 1975 to 2016. The increase in BMI negatively affects the life expectancy of the Portuguese population in the short term. A 1% variation in BMI reflects a 1.98% reduction in life expectancy. The result was statistically significant at 1%, and the p-value was 0.0001. In the long term, there was no statistically significant effect of the mean BMI on the population's life expectancy. Also, in the long term, population growth has a positive and statistically significant effect on life expectancy. Although there is no consensus in the literature that BMI is associated with increased mortality, the results obtained through this model captured this trend in Portugal in the short term. Therefore, promoting life expectancy by improving the Portuguese's health and quality of life is necessary. The adoption of measures that favor the recovery or maintenance of normal weight is essential.

Vertical Integration in Healthcare and Patient Satisfaction: An Exploratory Analysis of Portuguese Reforms

The performances of public corporate hospital units are being influenced by user behaviour, delayed service responses, and sustainability risks. Consequently, there is a need for these units to adopt a different approach to user care in order to attain overall success and mitigate discontent arising from delays and waiting lists. The faults within the public system are becoming increasingly apparent as a result of the growing emphasis on the transparency and authenticity of information. The reform of the Portuguese health system aims to enhance coordination among public, private, and social services. Additionally, it prioritises the integration of various levels of care within the Portuguese National Health Service, specifically by promoting the amalgamation of hospital business entities with primary care under single organisations known as Local Health Units. The objective of this study was to utilise the SWOT framework to examine the reform from the standpoint of citizens, as they are the focal point of the system and its long-term sustainability. The study revealed several benefits associated with the reform. However, it is crucial to address potential risks and opportunities in order to achieve the intended outcomes. If health managers and policy-makers effectively utilise the available opportunities, it can be inferred that there exists a favourable circumstance to implement a Local Health Unit model that seeks to integrate comprehensive care. This approach, by addressing the health issues of citizens, will create a larger scope for improvement and enhance citizen contentment. Moreover, it will ensure the long-term viability, ethical conduct, transparency, and genuineness of health outcomes.

(Dis)connection between Multiculturalism, Higher Education and Health: Experiences of International Students in Portugal during the Covid-19 Pandemic

Multiculturalism may point to the idea of ‘cohesion in diversity’, but if differentiated institutional policies and practices do not accompany it, it may contribute to promoting or deepening inequalities between different groups/cultures. Given the increase in students’ international mobility, multicultural awareness in Higher Education Institutions (HEIs) must be considered. Based on this idea, this article aims to answer: (i) what were the main health problems (physical and mental) that international students (IS) in Portugal experienced during the COVID-19 pandemic; and (ii) how they perceived their health rights in Portugal. To this end, we used data from an online survey, which was made available to all IS enrolled in a Portuguese HEI between April and May 2020, and from 22 online interviews conducted between September 2020 and January 2021 with some of these students. The results showed that the pandemic impacted the mental health of IS; fear, anxiety and stress were some of the symptoms experienced. Portuguese public health services have been perceived as untrustworthy by IS, and some students’ experience reinforces the untrustworthiness. The research shows the (dis)connection between multiculturalism, health, and HEIs. While HEIs promote multiculturalism, they have failed to provide answers in the field of health that take into account the specificities of their different student groups.

Portuguese health and medicine during the first quarter of the twentieth century through the lenses of Jorge Marçal da Silva

This paper aims at illustrating the panorama of health and medicine in Portugal in the first quarter of the twentieth century using the photographic collection of Jorge Marçal da Silva, a doctor and amateur photographer, which has been preserved by his family. From his collection, we have chosen a selection of photographs that illustrate the modus vivendi of the Portuguese population, in the rural interior, on the fishing coast and in city life, as well as some that depict hospital environments and medical care in the capital, in order to reflect on their importance as a source for the historiographical reflection on the history of Portuguese medicine in the 1900s.

The evolution of the Portuguese health legislation and the new challenges for management from 2024 onwards

Resumo Nos últimos 40 anos, o Serviço Nacional de Saúde (SNS) gerou ganhos que colocaram Portugal num lugar cimeiro no que se refere à qualidade de vida de milhões de cidadãos e reduziu muitas das desigualdades na sociedade portuguesa. Revisitar a criação do Serviço Nacional de Saúde Português e todas as profundas alterações legislativas introduzidas após a publicação da nova Lei de Bases da Saúde, a definição dos eixos estratégicos da política de recursos humanos do SNS e a criação dos respetivos mecanismos de operacionalização, a aprovação do novo Estatuto do SNS e a aprovação da Orgânica e dos Estatutos da Direção Executiva do SNS e a criação, com natureza de entidades públicas empresariais, das Unidades Locais de Saúde. Estas alterações legislativas poderão ser um passo fundamental para o reforço da construção de um SNS mais justo e inclusivo, que responda melhor às necessidades da população mediante as necessárias reformas estruturais.

The evolution of the Portuguese health legislation and the new challenges for management from 2024 onwards

Resumen En los últimos 40 años, el Servicio Nacional de Salud (SNS) ha generado beneficios en salud que han posicionado a Portugal en un lugar destacado en cuanto a la calidad de vida de millones de ciudadanos y ha reducido muchas de las desigualdades en la sociedad portuguesa. Revisitar la creación del Servicio Nacional de Salud Portugués y todos los profundos cambios legislativos introducidos tras la publicación de la nueva Ley de Bases de la Salud, la definición de los ejes estratégicos de la política de recursos humanos del SNS y la creación de los respectivos mecanismos de operacionalización, la aprobación del nuevo Estatuto del SNS y la aprobación de la Orgánica y de los Estatutos de la Dirección Ejecutiva del SNS y la creación, con naturaleza de entidades públicas empresariales, de las Unidades Locales de Salud. Estos cambios legislativos podrán ser un paso fundamental para el fortalecimiento de la construcción de un SNS más justo e inclusivo, que responda mejor a las necesidades de la población mediante las necesarias reformas estructurales.

Management of Chronic Obstructive Pulmonary Disease: Constraints in Patient Pathway and Mitigation Strategies

Introduction: Respiratory diseases, ranking the third in Portugal, contribute significantly to illness and mortality. Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally. Identifying high-risk individuals and implementing early treatment is crucial due to the variability of COPD symptoms and exacerbations. This study aimed to identify effective strategies for preventing exacerbations and complications. Methods: A Delphi involving 15 experts was performed. Experts included physicians, nurses, health managers, policymakers, public health experts, and patient organizations. Consensus was achieved at 73.3% for each strategy using a scale ranging from “agree” to “disagree.” Three rounds were conducted to address six questions related to early diagnosis and patient follow-up. Challenges faced by the Portuguese Health System in managing COPD, obstacles in COPD exacerbation diagnosis and management, and effective strategies to overcome barriers were identified in the first round. The second and third rounds involved analyzing the gathered information and voting on each indicator to achieve consensus, respectively. Indicators were categorized into constraints and barriers, and strategies for reducing COPD exacerbations and disease burden. Results: Out of a total of 134 valid indicators generated, 108 achieved consensus. Among the indicators agreed upon by experts, 18 pertained to barriers, challenges, and constraints, while 90 focused on action strategies for COPD. Among the strategies formulated, 25 consensus indicators target prevention strategies, 24 consensus indicators aim to enhance COPD referrals, and 41 consensus indicators focus on mitigating COPD exacerbations and reducing the overall disease burden. Discussion/Conclusion: This study emphasizes the need for integrated investment in respiratory healthcare and recognition of the impact of COPD on patients, healthcare systems, and economies. Prevention and appropriate treatment of exacerbations are crucial for effective COPD management and reducing associated morbidity and mortality. Experts highlight the importance of improving coordination between different levels of care, integrating information systems, and decentralizing hospital responsibilities. The COVID-19 pandemic has further emphasized the importance of individual and collective respiratory health, necessitating investment in health promotion and COPD awareness.

Strengthening the Relationship; A Digital and Educational Exchange Between Portuguese and Dutch Mental Health Care Associations

Strengthening the Relationship; A Digital and Educational Exchange Between Portuguese and Dutch Mental Health Care Associations

Comparing follow-up of patients with vitamin K antagonists in a health center: pre- and post- COVID-19 pandemic

Introduction and objectives: During the COVID-19 pandemic, the follow-up of patients treated with vitamin K antagonists (VKAs) may have been affected. This study aims to compare how these patients were monitored preand post-COVID-19 pandemic and understand the impact of non-face-to-face appointments on their follow-up. Methods: We conducted a retrospective cohort study in a Portuguese Health Center. The study included patients treated with VKAs and followed at the Health Center for international normalized ratio (INR) monitoring between March 2019 and March 2021. Data collected: sex, age, type of VKA; INR; date of INR assessment, type of appointment (face-to-face or phone/e-mail). Rosendaal’s method was used to calculate pre-COVID-19 and post-COVID-19 time in therapeutic range (TTR). Good TTR control was defined if values ≥ 70%. Results: 44 patients were included. The mean TTR in the pre-COVID-19 period was 64.55% (95% CI: 58.10 - 71.00%). The post-COVID-19 mean was slightly higher (+ 2.26%), 66.81% (95% CI: 59.66 - 73.97%), but the difference was not statistically significant (p = 0.576). The use of non-face-to-face appointments did not contribute to worsening post-pandemic TTR, showing no lower follow-up than during pre-pandemic period in which all contacts were face-to-face [CI (95%) -0.397 - 0.196 for a reference range -0.489 - 0.693]. Conclusions: The TTR value in both periods was similar and lower than the value defined for effective hypocoagulation. The use of non-face-to-face consultation in the post-COVID-19 period does not seem to have influenced the quality of hypocoagulation.

Lost in Transition: Recommendations for transition in mental health and description of two innovative Portuguese initiatives

The process of transition from Child and Adolescent Mental Health Services to Adult Mental Health Services cannot be defined only as a process of transfer from one service to another, but as an intentional and planned process, meeting the medical, psychosocial and educational needs of patients. According to descriptions from various countries, the transition process currently lacks careful planning and execution, being experienced as an abrupt process by patients and multiple people involved in their care. This paper reflects upon transition practices in mental health services, summarising the current literature and presenting two Portuguese mental health transition projects, as examples of how the process of transition might be improved. Poorly planned transitions may contribute to an increased risk of non-adherence to treatment, loss to follow-up, and poorer health outcomes, as well as significant economic costs. Despite some general guidelines on this topic, transition protocols, if available, vary significantly across countries and regions, and no current existing model appears to fully meet the identified needs of patients in transition. In Portugal, the Semente Program in Hospital Prof. Doutor Fernando Fonseca intends to identify and intervene in the care of children of adult patients with mental health issues. The Shared Service for Teens and Young Adults, a collaboration between Centro Hospitalar Psiquiátrico de Lisboa and Hospital Dona Estefânia, incorporates some of the recommendations summarised in this paper. Better understanding and development of communication pathways, continuity, coordination of care, referral protocols, and service delivery might contribute to a more robust design of transitional mental health care, thus making it more accessible, acceptable and efficient.

Assessing Portuguese health risks: Anisakiks parasite in Atlantic chub mackerel (Scomber colias) sold in Portuguese markets.

Anisakiosis is a significant zoonotic disease caused by parasitic nematodes of the Anisakis genus. It can be contracted by humans through the consumption of raw or undercooked fish contaminated with the parasite, leading to gastrointestinal and allergic symptoms. While anisakiosis is not frequently documented in Portugal, the presence of allergic reactions to Anisakis in Spain suggests ongoing exposure in the Iberian Peninsula. To address this concern, the Interdisciplinary Centre of Marine and Environmental Research in Porto, Portugal, in collaboration with the Biology Centre of Czech Academy of Sciences in Ceske Budejovice, Czech Republic, has proposed a project entitled 'Assessing Portuguese Health Risks: Anisakis Parasite in Atlantic Chub Mackerel (Scomber colias) Sold in Portuguese Markets' under the European Food Risk Assessment Fellowship Programme. The primary objective of the project is to gather valuable epidemiological data on the host, Atlantic chub mackerel (S. colias) and the parasitic nematode (Anisakis spp.) with the focus on assessing contamination levels and evaluating potential health risks associated with anisakiosis in the Portuguese population. By conducting this research, the project aims to contribute to the understanding of anisakiosis and its impact on public health in Portugal. Investigation of the presence of the Anisakis parasite in Atlantic chub mackerel sold in Portuguese markets will provide crucial insights into the risks associated with consuming raw or undercooked fish. Ultimately, our findings will aid in the development of preventive measures and guidelines to ensure the well-being of the Portuguese population.

Consultation analysis of dementia triads in Portuguese general prac-tice: exploratory study

Introduction: Despite policy recommendations worldwide, too often dementia remains outside the scope of primary health care. In the context of Portuguese primary health care services, our group previously explored the experiences of people with dementia, carers, general practitioners (GPs), and other professionals, together with their perspectives on barriers to dementia care. However, we know little about triadic consultations that involve a patient, their carer, and their GP. Objective: To explore dementia care in triadic consultations in general practice. Methods: Analysis of ten consultations with dementia triads across six Portuguese practices from different social contexts. Purposive sampling was used to recruit nine GPs, ten patients, and ten carers. Triadic consultations were digitally recorded, transcribed, and analysed. The analytical framework combined codes derived from the transcripts with codes from the available literature. Themes focused on the corollaries of dementia (e.g. need for information), and coordination of services. Results: Dementia-related content took up only 30% of consultations, despite their length (median 27 min). The GPs did not seem engaged in dementia management, their assessments lacked breadth and person-centredness, and interventions were limited. Carers facilitated GPs’ assessment of dementia consequences, but their needs were poorly assessed. Patients’ self-expression was limited by communication patterns within the triad. Conclusion: It is challenging for GPs to assess dementia among other conditions in a context of fragmented care. Strategies for improving family carers’ assessments are needed. The analysis of triadic consultations may provide potential process measures for assessing the quality of clinical practice and consultation training in general practice, but this requires further study.