Trained Emergency Physicians Research Articles

In reply

In reply

Building a trauma center and system in Tuscany, Italy

Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.

Emergency Medicine in México

In the past decade, México, with the third largest population of any country in the Americas, has experienced rapid growth in Emergency Medicine education. Emergency Medicine residency programs began in México City in 1986 and in 1991, spread throughout the country when the Medical Institute of Social Services (IMSS) instituted programs at their specialty hospitals. Although pre-hospital care is still rudimentary in many parts of the country and there are insufficient numbers of trained emergency physicians to staff the nation’s Emergency Departments, the growth of the specialty is helping to improve the quality of medical care in México. This article discusses the current condition of and prospects for Emergency Medicine in México within the context of its medical system, and outlines objectives and guidelines for future developments.

Prehospital airway management: A prospective evaluation of anaesthesia trained emergency physicians

To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.

Training Healthcare Professionals in Youth Violence Prevention: Closing the Gap

Training Healthcare Professionals in Youth Violence Prevention: Closing the Gap

Ultrasonography in Community Emergency Departments in the United States: Access to Ultrasonography Performed by Consultants and Status of Emergency Physician-Performed Ultrasonography

Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians. A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004. Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed. Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.

Critical care medicine training and certification for emergency physicians*

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.

Decisions, Decisions: Emergency Physician Evaluation of Low Probability–High Morbidity Conditions

Decisions, Decisions: Emergency Physician Evaluation of Low Probability–High Morbidity Conditions

Critical Care Medicine Training and Certification for Emergency Physicians

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Critical care is a continuum that includes out-of-hospital, emergency department (ED), and ICU care teams. Both emergency medicine and critical care medicine require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of critical care medicine fellowships do not accept emergency medicine residents, and those who do successfully complete a fellowship do not have access to a US certification examination in critical care medicine. Despite these barriers, interest in critical care medicine training among emergency physicians is increasing. Dual emergency medicine- and critical care medicine-trained physicians will not only help alleviate the intensivist shortage but also strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to critical care medicine certification for emergency physicians who complete a critical care fellowship.

Emergency airway management in the UK

Colin Graham, in his review article (March 2005 JRSM1), revisits the suggestion that all airway interventions in UK emergency departments could be managed by emergency physicians. If training of emergency physicians is standardized to six months in anaesthesia and six months in critical care, they would acquire only rudimentary skills in basic airway management and the conduct of anaesthesia. There is widespread use of the laryngeal mask airway, considerable decrease in working hours, and the need to concurrently teach anaesthesia trainees, paramedics, etc. In only six months trainees would participate in approximately 350 cases, on average performing less than 2 endotracheal intubations per week. Few of these will be in emergency circumstances.2-4 If anaesthesia experience mainly continues in emergency departments where 2 trauma patients will require rapid sequence intubation per month5 trainees cannot maintain their skills. How indeed are their consultants to revalidate as trainers? They must be able to predict and act immediately whenever there is difficulty. How will they recognize the difficult airway and call an anaesthetist early when even the most thorough examination is only 71% sensitive?6 It is one thing to intubate a patient following cardiac arrest and another to anaesthetize and intubate a patient on the brink of an arrest. Currently there is an inappropriate degree of self-confidence amongst emergency department trainees, despite their experience in emergency anaesthesia.7 So how can we best develop and maintain their skills despite infrequent exposure? I believe the answer is to regularly repeat anaesthesia training blocks, perhaps one training list per month. In addition, written, practical, and simulator testing for recertification ensures maintenance of skills.8,9 Anaesthesia emergencies are uncommon. Therefore knowledge or clinical experience, lacking in those not formally trained, could only become apparent in very large outcome studies.10,11

Emergency physicians can reliably assess emergency department patient cardiac output using the USCOM continuous wave Doppler cardiac output monitor

1 To develop a training package for ultrasonic cardiac output monitor (USCOM) cardiac output assessments and determine the number of proctored studies necessary for skill acquisition. 2 To develop criteria for acceptance of cardiac output results obtained with the USCOM. 3 To evaluate the reliability of USCOM cardiac output assessments in the ED. The authors developed an audiovisual training package. Four emergency physicians and one geriatrician subsequently underwent hands-on training, and skill acquisition was assessed at the fifth, 10th, 15th and 20th examinations. Six image-scoring criteria were developed to assess acoustic image quality. Upon completion of training a protocol was developed to optimize interassessor reliability. Two trained emergency physicians then performed blinded examinations on ED patients using the protocol and interassessor reliability was evaluated. During training average image score improved between the fifth and 20th assessed patient from 4.6 (95% CI 4.0-5.3) to 5.5 (95% CI 5.0-6.0, Pt-test=0.02) out of 6 and average intra-assessor cardiac output difference improved from 17% (95% CI 4-25) to 5% (95% CI 0-11, Pt-test=0.02). Analysis of 52 cardiac output assessments in 21 ED patients demonstrated excellent interassessor correlation (r=0.96, 95% CI 0.90-0.98, P<0.001). The average interassessor difference in cardiac output and index was 0.2 L/min (4%, 95% CI 3-6) and 0.1 L/min/m2 (4%, 95% CI 2-6), respectively. Emergency physicians with no prior ultrasonographic experience can be trained to obtain reliable cardiac output estimations upon conscious ED patients with the USCOM over the course of 20 patient assessments.

Prospective evaluation of an ultrasonography training model for emergency physicians: Can we teach old dogs new tricks?

Study objectives: Emergency bedside ultrasonography is gaining widespread use in emergency departments (EDs) throughout the country, and many guidelines exist for the training of emergency physicians in its use. One of the major challenges in training physicians in emergency bedside ultrasonography is the ability of new users to reliably recognize normal, abnormal, and nondiagnostic (technically limited) images. This study evaluated the retention of ultrasonographic knowledge and the accuracy of image interpretation 6 months after a standardized ultrasonographic course was completed. A novel approach to quality assurance in assessing interpretation skills, the recognition of technically limited studies, was tested. In addition, this study evaluated whether the training actually increases the use of bedside ultrasonography by attending-level emergency physicians. Methods: Emergency medicine attending faculty from 2 affiliated academic EDs completed an 8-hour introductory ultrasonographic course. The course consisted of 5 hours of lectures, with a printed syllabus covering the following topics: physics, focused abdominal sonography in trauma, cardiac, aorta, renal, gallbladder, pelvis. In addition, 3 hours of supervised hands-on sonography with live models was incorporated. Each participant completed the same pretest and posttest requiring the interpretation of 24 emergency bedside ultrasonography images. Four images from each of the 6 areas of emergency ultrasonography were included, with positive, negative, and nondiagnostic images represented in each area. The pretest was conducted the same day as the course, and the posttest was conducted 6 months later. A self-reporting survey of ultrasonography use in each of the primary indications was completed with each of the tests. Changes in test scores and the number of ultrasonographic examinations performed before and after the course were compared using the paired <i>t</i> test. Results: Nineteen emergency attending physicians (76% with no previous formal emergency bedside ultrasonography training) completed the introductory course and completed a pretest and posttest. The mean overall test score was improved from 57% before the course and 67% at 6 months (<i>P</i>=.003). Improvement in image interpretation accuracy was most pronounced in gallbladder (44% to 61%, <i>P</i>=.03) and cardiac (61% to 75%, <i>P</i>=.01) images. Recognition of true positive images improved (69% to 78%, <i>P</i>=.05); improvement in the recognition of true negative images approached significance (53% to 63%, <i>P</i>=.06). There was no significant improvement in the recognition of technically limited studies. There was a 68% increase in use of emergency bedside ultrasonography overall at 6 months that was not dependent on level of previous training. Conclusion: Consistent with previous studies, this evaluation demonstrates good retention of emergency bedside ultrasonography knowledge even 6 months after completion of a standardized 8-hour course. With minimal training of staff, the use of emergency bedside ultrasonography increased, and the accuracy of image interpretation improved, which may increase resident supervision and improve patient care. However, the recognition of technically limited studies did not improve. A common goal of quality assurance programs is to monitor the accuracy of emergency bedside ultrasonography within each of the 6 major indications; we recommend an ongoing educational and image review process to improve this outcome, and further research will test this prospectively.

Prevalence of abdominal aortic aneurysm in emergency department patients with high-risk symptoms

Study objectives: The prevalence of abdominal aortic aneurysm (AAA) has been measured in a number of populations, suggesting that the prevalence is anywhere from 3% to 11% of those populations studied. Men between the ages of 65 and 74 years have a prevalence rate of 5.4%, men and women between the ages of 65 and 80 years have a prevalence rate of 4.3%, and hypertensive patients with peripheral vascular disease have a prevalence rate of 9.6%. Although the classic triad of hypotension, pulsatile abdominal mass, and abdominal pain occurs infrequently, there is a lack of reliable information on the prevalence of this disease in an emergency department (ED) population with symptoms that could relate to aortic aneurysms. The purpose of this pilot study is to gather prevalence data on AAA dilatation in patients at risk for disease in an ED setting. Methods: This was a convenience sample of patients presenting during times when an emergency physician trained in ultrasonography was available. Any patient 50 years or older who had 1 of the 6 symptoms (abdominal pain, back pain, flank pain, groin pain, syncope, or hypotension) was considered for the study. Abdominal aortas were measured in the longitudinal plane and transverse plane using a Hitachi EUB 405 Ultrasound machine with a 3.5-MHz curvilinear probe. Informed consent was obtained from the patient. Images were obtained above the level of the bifurcation but below the level of the superior mesenteric artery. Because adequate previous studies have demonstrated the accuracy of trained emergency physicians in interpreting these studies, confirmatory examinations were not required as part of this study. Diameters greater than 3 cm were considered aneurysmal. Images were saved and reviewed by one of the investigators blinded to outcome. Data were analyzed using simple descriptive statistics. Results: Ninety-seven patients were entered in the study, of whom 57% were male patients, 66% had a history of hypertension, and 38% used tobacco. The mean age was 67.4±10.8 years. The most common symptom was abdominal pain (40.6%), followed by back pain and hypotension, each at 21.9%. The mean maximal aortic diameter was 2.0±0.7 cm. There were 5 patients with a maximal aortic diameter of 3 cm or more, resulting in a prevalence of 5.15% (95% confidence interval [CI] 0.8% to 9.6%). Two patients had a maximal diameter of greater than 5 cm (2.1%; 95% CI 0.4% to 8%). The outcome of the 2 patients with a maximal diameter greater than 5 cm was satisfactory. One patient had a known history of AAA status postrepair was admitted to vascular surgery and discharged 2 days later without intervention. The other patient had a newly diagnosed AAA, which vascular surgery evaluated and discharged from the ED for outpatient follow-up. No patient with aneurysmal dilation of the aorta was found to be ruptured. Conclusion: The prevalence of AAA in an ED population at risk with symptoms that could be referable to the aorta is in the range of that which has been described in other populations. Although the incidence of symptomatic aortic aneurysms is lower, the utility of screening of patients at risk warrants further study.

Digital photoplethysmography to detect deep venous thrombosis in the emergency department

Study objectives: We determine the sensitivity and specificity of digital photoplethysmography (DPPG) performed by emergency physicians in patients suggestive of a deep venous thrombosis. Methods: This was a prospective longitudinal cohort study conducted in the 2 emergency departments (EDs) of Summa Health System. The EDs treat a combined 97,000 patients per year. On average, 88 patients per month are evaluated for deep venous thrombosis with duplex scans; approximately 23% are positive for deep venous thrombosis. We enrolled consecutive ED patients aged 18 years or older and with lower extremity symptoms of deep venous thrombosis requiring venous duplex scanning, who gave consent to participate. Patients were excluded if they were unable to comply with DPPG testing, had fragile or broken skin in the area on which the DPPG probe was placed, had inadequate arterial flow to the lower extremities, did not complete the required testing (duplex ultrasonography and DPPG), had a deep venous thrombosis in the previous 6 months, were at least 13 weeks pregnant, or were previously enrolled. A trained emergency physician performed and interpreted the DPPG. All patients underwent noninvasive duplex scanning; the vascular surgeons' interpretation was the criterion standard. Emergency physicians were blinded to the duplex result, and the vascular technologists and vascular surgeons were blinded to the results of the DPPG. The primary study outcome was the sensitivity and specificity of the DPPG. Results: Results are presented as proportions with 95% confidence intervals (CIs). The study was discontinued early because of technical problems with the software and scans, resulting in poor quality control and low sensitivity. We evaluated the data on 116 total legs in 101 total patients (15 patients had bilateral legs evaluated). Twenty-eight legs in 23 patients were excluded because of technically inadequate scans (24% of legs; 95% CI 17% to 33%), which left 88 eligible legs in 78 patients. The prevalence of deep venous thrombosis was 12.5% (95% CI 6% to 22%). Using the old software, the sensitivity of DPPG was 40% (4/10; 95% CI 12% to 47%), and the specificity was 63% (49/78; 95% CI 51% to 74%). The manufacturer used the data obtained to reprogram the DPPG software; the sensitivity of DPPG with the new software was 90% (9/10; 95% CI 55% to 100%), and the specificity was 51% (40/78; 95% CI 40% to 63%). The sensitivity for above-knee deep venous thrombosis was 100% (95% CI 66% to 100%). Conclusion: The sensitivity for above-knee deep venous thrombosis using the new software is promising but requires further study before it can be recommended for ED use.

Access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians in community emergency departments

Study objectives: Nearly all emergency medicine residency programs provide some training in emergency physician–performed ultrasonography, but the extent of emergency physician–performed ultrasonography in community emergency departments (EDs) is unknown. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians.Methods: A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician–performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. One thousand two hundred out of 5,264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from fall 2003 to spring 2004.Results: The response rate was 61%. Respondents were predominantly community EDs (88%). EDs reported being requested or required to limit ultrasonographic orders in 40% of EDs, whereas 40% of EDs described access to radiology-performed ultrasonography as “always easily available.” Ultrasonography was available in the ED for use by emergency physicians at all times in 23% of EDs, with 10% reporting a machine available from radiology for use by emergency physicians. Of EDs with emergency physician–performed ultrasonography, the most common applications were focused abdominal sonography for trauma examination (82%), code situation (77%), and check for pericardial effusion (75%). Of those performing ultrasonography, 21% stated they were currently requesting reimbursement (billing). Of those performing ultrasonography but not billing, 47% reported plans to begin billing. Ultrasonography was unavailable for use by emergency physicians in 63% of EDs. Of those who did not have ultrasonography, 40% reported plans to obtain ultrasonography for use by emergency physicians. The top 2 reasons cited for not implementing emergency physician–performed ultrasonography were lack of emergency physician training (57%) and resistance from radiology (42%). In regard to the statement “emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasound,” 85% of ED directors agreed, 14% were neutral, and less than 2% disagreed.Conclusion: A minority of community EDs have easily available access to ultrasonography performed by other specialists. Approximately one third of community EDs report ultrasonography available for use by emergency physicians; of those who do not, nearly half intend to obtain ultrasonography for use by emergency physicians. A majority of community ED directors support residency training in emergency physician–performed ultrasonography.

Acute airway management in the emergency department by non-anesthesiologists

The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed. A narrative review of the literature on the practice of airway management by non-anesthesiologists. A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.

Critical care training for emergency physicians

Critical care training for emergency physicians

Critical care training for emergency physicians

Critical care training for emergency physicians

Focused training of emergency physicians in goal-directed echocardiography

Objective: The aim of this study was to determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency physicians.

Critical care and emergency medicine.

The changing landscape of health care has resulted in an increase in the delivery of critical care in the emergency department. Although the emergency department duration is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. The care provided during the emergency department stay for critically ill patients has been shown to significantly impact the progression of organ failure and mortality. Despite these trends, formal critical care training for emergency physicians is limited. The need to maximize patient throughput in frequently overcrowded emergency departments hinders the provision of optimal care to the critically ill patient. Methodologies should be developed to examine the quality of patient care and objectively measure the impact of clinical interventions. The potential to improve outcome through educational initiatives and resource allocation should not be viewed as a burden of delivering a higher level of care in this setting but as a significant opportunity to effectively mitigate the socioeconomic consequences.