Postgraduate Clinical Training Research Articles

Clinical Simulation Program for the Training of Health Profession Residents in Confidentiality and the Use of Social Networks.

In the transition to a professional learning environment, healthcare professionals in their first year of specialized postgraduate clinical training (known as residents in Spain) are suddenly required to handle confidential information with little or no prior training in the safe and appropriate use of digital media with respect to confidentiality issues. The aims of this study were: (1) to explore the usefulness of an advanced clinical simulation program for educating residents from different healthcare disciplines about confidentiality and the dissemination of clinical data or patient images; (2) to explore the use of social networks in healthcare settings; and (3) to explore participants' knowledge and attitudes on current regulations regarding confidentiality, image dissemination, and the use of social networks; Methods: This was a cross-sectional study. Data were collected from all 49 first-year residents of different health professions at a Spanish hospital between June and August 2022. High-fidelity clinical simulation sessions designed to address confidentiality and health information dissemination issues in hospital settings, including the use of social networks, were developed and implemented. Data were assessed using a 12-item ad hoc questionnaire on confidentiality and the use of social media in the healthcare setting. Descriptive of general data and chi-square test or Fisher's exact test were performed using the SPSS 25.0 software; Results: All the participants reported using the messaging application WhatsApp regularly during their working day. A total of 20.4% of the participants stated that they had taken photos of clinical data (radiographs, analyses, etc.) without permission, with 40.8% claiming that they were unaware of the legal consequences of improper access to clinical records. After the course, the participants reported intending to modify their behavior when sharing patient data without their consent and with respect to how patients are informed; Conclusions: The use of advanced simulation in the training of interprofessional teams of residents is as an effective tool for initiating attitudinal change and increasing knowledge related to patient privacy and confidentiality. Further follow-up studies are needed to see how these attitudes are incorporated into clinical practice.

Protocol for the SELECT study: a sequential mixed methods study of the selection of UK medical students into clinical academic training

BackgroundInternationally, there has been a move towards fostering diverse healthcare workforces that are representative of the patient populations they serve. Selection criteria for academic-clinicians often aim to capture skills and attributes that demonstrate both clinical and academic excellence. Currently, it is not known whether the selection criteria for early academic-clinical careers advantage or disadvantage certain ethnic or socioeconomic groups. The UK has a structured route of integrated clinical academic training with entry level training for newly qualified doctors administered through the ‘Specialised Foundation Programme’ which provides protected time for research within the first two years of postgraduate clinical training. In this study, we aim to identify what selection criteria are used within the UK Specialised Foundation Programme, and how these relate to demographic factors.MethodsWe will perform a mixed methods study consisting of a document analysis of person specifications and selection criteria used in the 2024 UK Specialised Foundation Programme, and a national cross-sectional survey of current medical students in the UK. We will obtain the person specifications, selection criteria, white space (open ended questions used during shortlisting) and interview questions and mark schemes from each Specialised Unit of Applications via information available on their websites or through Freedom of Information requests. Our survey will collect information relating to demographic data, selection criteria, and perceptions of specialised foundation programme selection.DiscussionInternational literature has demonstrated inequity in academic markers used in selection of post-graduate clinicians and that disadvantages caused by selection can compound over time. As such it is important to understand what inequity exists within the selection of early academic-clinicians, as this can help inform more equitable selection practices and help nurture a more diverse academic-clinical workforce.

Effects of (de)motivating supervision styles on junior doctors' intrinsic motivation through basic psychological need frustration and satisfaction: an experimental vignette study.

In clinical practice, junior doctors regularly receive supervision from consultants. Drawing on Basic Psychological Needs Theory, consultants' supervision styles are likely to affect junior doctors' intrinsic motivation differently in terms of psychological need frustration and psychological need satisfaction. To examine the effects of (de)motivating supervision styles, we conducted two experimental vignette studies among junior doctors. In Study 1 (N = 150, 73.3% female), we used a 2 (need support: high vs. low) x 2 (directiveness: high vs. low) between-subjects design and, in Study 2, a within-subjects design with the same factors (N = 46, 71.7% female). Both studies revealed a consistent positive effect of need-supportive supervision styles on psychological need satisfaction (+), need frustration (-), and intrinsic motivation (+). Particularly in Study 2, the main effect of need-supportive styles was strengthened by supervisor's directiveness. Moreover, in both studies, the effects of supervision styles on intrinsic motivation were explained through psychological need frustration and psychological need satisfaction. We discuss the implications of these findings for postgraduate clinical training.

Developing mental health curricula and a service provision model for clinical associates in South Africa: a Delphi survey of family physicians and psychiatrists

BackgroundClinical associates are a health professional cadre that could be utilised in mental health task sharing in South Africa but this is training dependent. The objectives of the study were to identify the potential curricula content, training sites, and teaching modalities for undergraduate and potential postgraduate clinical associate mental health training and to identify the tasks that they should perform based on these curricula.MethodsWe utilised the Delphi method to reach consensus on items with the panel comprising psychiatrists and family physicians. The first round questionnaire of the Delphi survey was developed based on a literature review and the results from earlier phases of the overall study. The survey was administered electronically and consisted of three rounds. Following both the first and second rounds, an updated questionnaire was constructed omitting the items on which consensus was reached. The questionnaire consisted primarily of nine-point scales with consensus based on 70% of participants rating 1,2,3 or 7,8,9.ResultsThere were 26 participants in the first round with this number falling to 23 in later rounds. There was strong consensus on a training attachment to a mental health clinic at a community health centre (CHC) at undergraduate (96.2%) and postgraduate level (100%). Consensus was reached on the importance of training on the management of six categories of disorders at the undergraduate level and nine categories of disorders at the postgraduate level. Clerking patients as a teaching modality reached 100% consensus at both undergraduate and postgraduate levels. PHC clinics, CHCs and district hospitals reached consensus as appropriate settings for clinical associates to provide mental health services. In addition, GP practices and secondary hospitals reached consensus for those with postgraduate training. Consensus was reached on ten of the 21 listed tasks that could be performed based on undergraduate training and 20 of the 21 tasks based on a postgraduate qualification in mental health.ConclusionsThe Delphi panel’s recommendations provide a clear roadmap for enhancing mental health curricula for clinical associates, enabling their utilisation in mental health service provision. A future postgraduate mental health qualification for clinical associates would allow for expanded task sharing.

Training of clinical oncologists in Africa: Results of a regional survey.

9026 Background: Africa grapples with a significant human resource shortage in cancer care. The vast majority of practicing oncologists are clinical oncologists, performing the roles of both medical and radiation oncologists. Building a sustainable oncology workforce depends on robust training pipelines. However, the distribution and characteristics of oncology training programs across the continent have not been described. Methods: A cross-sectional study was conducted to outline the landscape of postgraduate clinical oncology training in Africa. A semi-structured electronic questionnaire designed to collect data on locations and capacity of training centers, components of training curriculum, and administration of training programs was distributed via e-mail between February and May 2023 to board-certified clinical oncology consultants practicing in Africa. Participants were identified through the personal contacts of the co-authors. Results: Responses were received from 31 oncologists practicing in 24 countries. We identified 74 centers in 16 countries (67%) with ongoing clinical oncology training, and Egypt, South Africa, and Tunisia accounted for two-thirds of all training centers identified. Duration of training ranged from 4 to 8 years. Each year, about 230 residents commence training, and 198 graduate from training and join the workforce. More than half of the countries with available data require an internship and passing an entrance examination before commencing training. Almost all countries require trainees to pass an exit examination and submit a thesis before completing training. We obtained data on training components in 19 (26%) centers, and all centers provide training in chemotherapy administration and radiotherapy techniques. However, marked variations were observed in the exposure to modern radiotherapy techniques, with 10 (53%) centers including IGRT and 5 (26%) including IMRT. More than three-quarters of respondents reported that most trainees find jobs in the government service after completing training. Conclusions: Clinical oncology training programs in Africa are relatively limited in number. Moreover, there is a wide variation in the existing programs in terms of training duration and components of curriculum. There is tremendous potential for expansion to countries without training, which can be facilitated by partnerships with existing training programs on the continent. Furthermore, regional coordination and accreditation is vital to ensure uniformity.

Exploring the reasons of unsuccessful attempts in examination during postgraduate clinical training.

To explore the reasons of unsuccessful attempt in examination during postgraduate clinical training in Pakistan. The qualitative, exploratory study was conducted at the Allied Hospital, Faisalabad, Pakistan, from December 1, 2022, to February 25, 2023, and comprised postgraduate trainees from different departments who had at least one unsuccessful attempt in examination during their residency programme. Data was collected through direct interviews that were recorded. The data was subjected to thematic narrative analysis. Of the 14 participants, 10(71.4%) were males and 4(28.5%) were females. The maximum number of unsuccessful attempts were 7(7%), followed by 6(14%), 4(7%), 3(14%), 2(42%) and 1(14%). There were 3 main themes; personal factors, training factors, and exam factors. All the themes had subthemes. At the start of the residency programme, postgraduate trainees must be provided with adequate guidance, and a support system must be present during the programme to help them cope with the stress during training.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study

BackgroundIn Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training’s quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach—whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience—and explored potential consequences for their clinical education.MethodsThis nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation.ResultsApproximately half of the participants chose IM rotation periods of 32–40 weeks. A significant proportion of participants rotated in 5–7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices.ConclusionsOur study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

Medical Professionalism as a Pivotal Goal in the Postgraduate Clinical Training

Postgraduate clinical training for physicians in Japan has been mandatory since 2004, with the provision that the system itself is to be revised every 5 years if necessary. Major revisions were implemented in 2020, involving the objectives, strategies, and evaluations of the clinical training program. Among the revisions was a section on professionalism in the first part of objectives. As one of the committee members involved in the process of this revision, I provide an explanation of the historical background, learning strategies, and assessment of professionalism in physician training.

Describing the landscape of integrated clinical educational programs for PAs and NPs.

Postgraduate clinical training (PCT) has been available to PAs since the 1970s and to NPs since at least 2007. Some programs now enroll PAs and NPs. Although this new training model appears to be expanding, little data about integrated PA/NP programs are available. This study examined the PA/NP PCT landscape in the United States. Programs were identified from membership rosters of the Association of Postgraduate Physician Assistant Programs and the Association of Post Graduate APRN Programs. Data (program name, sponsoring institution, location, specialty, accreditation status) were identified from programs' websites. We identified 106 programs at 42 sponsoring institutions. Various specialties, most commonly in emergency medicine, critical care, and surgery, were represented. Few were accredited. PA/NP PCT is now common, with about half of the programs accepting PAs and NPs. These programs represent a unique form of interprofessional education involving full integration of two professions in the same program and are worthy of further investigation.

Harnessing Capacity in Southern Africa to Support and Develop Human Resources for Nursing and Midwifery in Africa – Part 2: Case Studies from the DRC and Mozambique

Human resources for health has been the centre of attention for many decades as more African countries fail to meet health targets even though there is no shortage of country-specific policies and strategies to improve these resources. The WHO Africa region has a critical shortage of nurses and midwives, which will remain unresolved as long as funding and policy implementation challenges persist. In the interim, the profession itself must find innovative and collaborative ways to make inroads into the nursing shortages – specifically in areas where advanced clinical skills are needed. Harnessing capacity from within universities in southern Africa is posited as one of the ways to bolster the education of nurses and midwives. Presented in part 1, the New Partnership for Africa’s Development project aimed to increase the number and enhance the quality of postgraduate education and clinical training of nurses and midwives to improve the quality of healthcare services with particular reference to the reduction of maternal and neonatal mortality rates. In fulfilling this aim, clinical master’s programmes were developed and implemented in seven African countries. In this article, we chose illustrative case studies to describe the master’s programme design and roll-out, in line with the health profile of the Democratic Republic of the Congo and the Republic of Mozambique. We explain the programme electives, enrolments and throughput, including outputs and outcomes. From experiences gained and lessons learnt, we extrapolate implications for future cases that employ pan-African and south-to-south university partnerships.

Establishing Entrustable Professional Activities for Entry-Level Dietitians in Teaching Hospitals in Taiwan

<p>可信賴專業活動(entrustable professional activities, EPAs)是將多種核心能力整合成專業任務，可應用於醫療職場教學訓練，以信賴等級作為能力進展依據，供臨床工作授權參考。此專案針對接受衛福部二年期營養師訓練課程之新進營養師，建置教學醫院新進營養師EPAs。來自全國教學醫院臨床營養及營養學專家，以名義團體法進行共識及投票，建置七項EPA任務及其對應核心能力架構。EPAs任務為「住院病人常見疾病營養照護」、「門診病人常見慢性疾病營養照護」、「重症單位營養照護」、「醫院膳食盤餐督餐作業」、「盤餐膳食設計與食材成本管理」、「疾病飲食營養團體衛教」及「住宿型長照機構個案營養照護」。EPAs建立可將能力進展轉化為臨床營養工作授權，促進營養醫療照護品質提升。</p> <p> </p><p>Entrustable professional activities (EPAs) involve the integration of a variety of core competencies into professional practice tasks, and they can be applied for learning and training in the medical workplace. Supervision levels can help guide the development of competencies and are referenced for clinical work authorization. This paper describes the development of EPAs for entry-level dietitians in a postgraduate clinical training program established by the Ministry of Health and Welfare at teaching hospitals in Taiwan. Clinical instructors in dietetics and nutrition experts from across Taiwan were invited to participate in a consensus development conference, and the nominal group technique was employed to develop profession-specific EPAs. This project established seven EPAs, namely, nutritional care for inpatients with common diseases, nutritional care for outpatients with common chronic diseases, nutritional care in critical care units, hospital plate-meal preparation and supervision, meal design and cost management, group education for disease-specific nutrition, and nutritional care in residential long-term-care institutions. The establishment of EPAs can help transform such competencies into criteria for the authorization of clinical nutrition work in teaching hospitals and may enhance the quality of nutritional medical services.</p> <p> </p>

Discussing Code Status—Balancing Obligations to Respect Patient Autonomy While Avoiding Harm

This essay describes a physician’s experience of completing medical education and postgraduate clinical training in Ireland vs adjusting to residency in the US.

Characteristics of University Hospitals Implementing the Postgraduate Clinical Training "Tasukigake Method" and Their Correlation with Program Popularity: A Cross-Sectional Study.

In 2004, the postgraduate clinical training system in Japan was radically revised by introducing a super-rotation matching system. Although postgraduate clinical training became a mandatory 2 years of training, the program and operation were left to each facility's discretion, leading to training-program popularity differences. The Japanese Tasukigake method provides clinical training in which "hospitals where junior residents work" and "external hospitals/clinics that provide clinical training" conduct clinical training alternately on a 1-year basis. The study aimed to identify the characteristics of university hospitals that implement the Tasukigake method to help educators and medical institutions create more attractive and effective programs. All 81 university main hospitals were included in this cross-sectional study. The information regarding Tasukigake method implementation was collected from the facilities' websites. The training program's matching rate (popularity) was calculated from the Japan Residency Matching Program's interim report data (academic 2020). We used multiple linear regression analysis to evaluate the association between Tasukigake method implementation, program popularity, and university hospital characteristics. The Tasukigake method was implemented by 55 (67.9%) university hospitals, significantly more by public university hospitals (44/55, 80%) than by private (11/55, 20%) (P < 0.01) and by hospitals without branches (38/55, 69.1%) than with branches (17/55, 30.9%) (P < 0.001). The maximum hiring capacity of junior residents (P = 0.015) and number of branches (P < 0.001) were negatively correlated, and the population of the hospital's city (P = 0.003) and salary/month (P = 0.011) were positively correlated with the Tasukigake method implementation. Multiple linear regression analysis results showed no significant association between the matching rate (popularity) and Tasukigake method implementation. The results show no association between Tasukigake method and program popularity; also, highly specialized university hospitals in cities with fewer branch hospitals were more likely to implement the Tasukigake method.

Editorial introductions.

Editorial introductions.

Starving for knowledge. Addressing the place of clinical nutrition within undergraduate and postgraduate clinical training: A national survey of practicing clinicians

Clinical Nutrition is finding its place within medical training. In response to IrSPEN's objectives and ESPEN's manifesto, IrSPEN distributed an electronic survey investigating attitudes to Clinical Nutrition and unmet educational needs. A 35-part questionnaire was designed and distributed to clinicians in Ireland. Questions elicited clinician demographics, education history and experience assessing and managing malnutrition. Descriptive statistics were reported, comparisons analysed using Chi-squared test and correlation between experience and confidence analysed with Spearman correlation coefficient. Of 168 respondents, 41% (n=58) were male and most practice medicine in an academic centre (87.5%). Fifty-eight (34.7%) were regularly involved in nutrition support. Despite 20% (n=33) of respondents regularly managing patients on parenteral nutrition (PN) and a fifth (n=34) regularly managing complications of obesity, few had confidence in assessment for artificial nutrition (15.7% (n=26), enteral nutrition; 8% (n=13), PN). Trainees were less confident than attending staff in assessing and managing artificial enteral feeding (p=0.022) and complications of PN (p=0.01). Over 70% respondents reported they received <2h clinical nutrition education. Only 32% (n=52) received any formal training within postgraduate training (PGT), more often GI trainees (p=0.01). A striking 98% felt additional focus on nutrition education in PGT is required. This survey elicits physician attitudes on nutrition education in undergraduate and postgraduate curricula in Ireland. Practicing physicians identify the need to increase clinical nutrition education. IrSPEN are actively engaging with Irish medical schools and training bodies to address these deficits with multidisciplinary engagement from expert physicians and allied dietetic colleagues.

A national study of the psychological theories and therapies covered within clinical psychology training programs in Australia

ABSTRACT Objective Recent advancements in the field of psychotherapy have included a diversification in Cognitive Behaviour Therapies (CBTs), often referred to as the “third wave”, yet relatively little is known about their coverage in Australian postgraduate clinical psychology training. Data were gathered to study the relationships between training program theoretical orientation, therapies covered, and factors determining the coverage of therapies. Method Responses to a semi-structured interview of 28 Directors of Clinical Training (DCT) or equivalent of Australian Psychology Accreditation Council (APAC) approved clinical psychology training programs (representing 72% of all accredited programs) were examined. Results Behaviour and cognitive theories were identified as dominant in programs. Coverage of Beck’s CBT was not correlated with other CBTs, and the number of therapies covered did not distinguish integrative (64.3%) from non-integrative programs. In an examination of the factors guiding the adoption of insight orientated therapies (i.e., Cognitive Analytic Therapy, Interpersonal Psychotherapy, Humanistic Therapy, Psychoanalytic Therapy, Process Experiential/Emotion-Focused Therapy, Gestalt Therapy, and Existential Therapy), the focus of clinical research, and student interest emerged as significant predictors (β = −.16, SE =.06, p < .05, 95% Boot CI [−.27, −.03]). Conclusions Beck’s CBT, and its undergirding theories emerged as dominant and was not associated with coverage of more recent CBTs, suggesting that there is opportunity to diversify therapies covered considering their evidence base.

Influence of Sparshanam, a Medical Humanities Module on Personal and Professional Development among the First Batch of Medical Graduates in Lalitpur, Nepal: A Cross-Sectional Study

Background: Medical humanities (MH) uses subjects like literature, music, drama, and painting for specific purposes in medical education. We aimed to assess its medium-term impact on medical alumni whose curriculum incorporated a module on MH which was named as Sparshanam. Methods: After approval from the Institutional Review Committee of KIST Medical College, this cross-sectional online survey was performed from December 2020 to January 2021on the 2008 batch medical alumni who had experienced Sparshanam in their medical education curriculum 10 years before. A mixed modal design (both qualitative and quantitative) was applied. The participants’ perception of the module, like its strengths, weaknesses, and its contribution to personal and professional development were assessed. Results: Out of the 75 first batch alumni, 39 (52%) participated. Most of them were working in the Kathmandu valley. The perceived strengths were teamwork, interactive group sessions, and imparting a holistic perspective of patients. The Sparshanam was perceived to enhance their teamwork, communication, leadership and clinical observation skills, and ability to empathize with patients. Participants perceived it to have an important influence on their development and recommended its introduction in the undergraduate and postgraduate clinical training. Conclusion: The Sparshanam was perceived to have a significant impact on their personal and professional development.

Identifying the current status and future needs of clinical, educational, and laboratory genetics services in Pakistan: a web-based panel discussion.

While the prevalence of genetic disorders has been well documented in the Muslim-majority, low-socioeconomic country of Pakistan, the provision of medical genetic services remains limited and cost-prohibitive to the masses in the country. With the objective of identifying gaps in the provision of medical genetics services as perceived by the healthcare providers and the general public, the Pakistani Society of Medical Genetics and Genomics (PSMG) organized a needs assessment webinar on December 6, 2020, titled, “A Vibrant Discussion on the Current Status and Future Needs of Medical Genetic Services in Pakistan.” The objectives of the webinar were (1) to explore the current availability of medical genetics services, (2) to identify areas in clinical genetics delivery models needed to improve the state of medical genetics in the country, and (3) to garner the interest in such provisions from the expert and lay audience. The webinar consisted of a moderator-led, structured interview of an expert panel including the following topics: (1) postgraduate clinical genetics and genetic counseling training programs, (2) medical genetics clinics and formal genetic counseling services), (3) clinical genetic testing and (4) patient support and advocacy groups. The webinar was followed by a short, web-based survey completed by 35 of the 60 attendees. The results of this survey indicated overwhelming support for establishing formal genetic counseling educational opportunities (91.6%) and increasing the availability of genetic testing (100%). This report further summarizes the opinions and recommendations of the panelists and the audience survey results.

COVID-19 and Research Projects for Postgraduate Clinical Training

COVID-19 and Research Projects for Postgraduate Clinical Training

Association between patient care ownership and personal or environmental factors among medical trainees: a multicenter cross-sectional study

BackgroundPatient care ownership (PCO) is crucial to enhancing accountability, clinical skills, and medical care quality among medical trainees. Despite its relevance, there is limited information on the association of personal or environmental factors with PCO, and thus, authors aimed to explore this association.MethodsIn 2021, the authors conducted a multicentered cross-sectional study in 25 hospitals across Japan. PCO was assessed by using the Japanese version of the PCO Scale (J-PCOS). To examine the association between personal (level of training, gender, and department) or environmental factors (hospital size, hospital type, medical care system, number of team members, number of patients receiving care, mean working hours per week, number of off-hour calls per month, and perceived level of the workplace as a learning environment) and PCO after adjusting for clustering within hospitals, the authors employed a linear mixed-effects model.ResultsThe analysis included 401 trainees. After adjusting for clustering within hospitals, it was confirmed that the senior residents had significantly better J-PCOS total scores (adjusted mean difference: 8.64, 95% confidence interval [CI]: 6.18–11.09) than the junior residents and the perceived level of the workplace as a learning environment had a positive association with J-PCOS total scores (adjusted mean difference per point on a global rating of 0–10 points: 1.39, 95% CI: 0.88–1.90). Trainees who received calls after duty hours had significantly higher J-PCOS total scores than those who did not (adjusted mean difference: 2.51, 95% CI: 0.17–4.85). There was no clear trend in the association between working hours and PCO.ConclusionsSeniority and the perceived level of the workplace as a learning environment are associated with PCO. An approach that establishes a supportive learning environment and offers trainees a reasonable amount of autonomy may be beneficial in fostering PCO among trainees. The study findings will serve as a useful reference for designing an effective postgraduate clinical training program for PCO development.