The quality of life of men who have sex with men in China: reliability and validity testing of the SF-36 questionnaire

Comparing the efficacy of low-load resistance exercise combined with blood flow restriction versus conventional-load resistance exercise in Chinese community-dwelling older people with sarcopenic obesity: a study protocol for a randomised controlled trial

INTRODUCTION

Sarcopenic obesity (SO) is characterised by decreased muscle mass, diminished muscle strength and/or reduced physical performance and a high percentage of body fat (PBF). Conventional-load resistance exercise (CRE) may be difficult for older people with SO owing to their declining physical functions. Low-load resistance exercise (LRE) combined with blood flow restriction (BFR; LRE-BFR) is a viable alternative to CRE for improving muscle mass and strength and potential exercise mode for managing SO. This study has two objectives: (1) to comprehensively evaluate the efficacy of CRE and LRE-BFR in improving body composition, muscle strength, physical performance, haematological parameters, cardiovascular disease (CVD) risk factors and quality of life and (2) to compare the efficacy of CRE and LRE-BFR and explore their potential mechanisms.

METHODS AND ANALYSIS

This work is a 12-week assessor-blinded randomised clinical trial that will be conducted thrice a week. Sarcopenia will be defined using the Asian Working Group for Sarcopenia 2019, and obesity will be determined using the criteria developed by the World Health Organization. Community-dwelling older people aged ≥ 65 years will be screened as the participants using inclusion and exclusion criteria. A total of 33 participants will be randomised into a CRE group (n = 11), an LRE-BFR group (n = 11) and a control group that will be given only health education (n = 11). The primary outcomes will be knee extensor strength and PBF, and the secondary outcomes will be body composition, anthropometric measurements, muscle strength of upper limbs, physical performance, haematological parameters, CVD risk factors and quality of life. The outcomes will be measured at the baseline (week 0), end of the intervention (week 12) and follow up (week 24). All the collected data will be analysed following the intention-to-treat principle.

ETHICS AND DISSEMINATION

The Ethics Research Committee has approved this study (approval No. CMEC-2022-KT-51). Changes or developments in this study will be reported at www.chictr.org.cn .

TRIAL REGISTRATION

ChiCTR2300067296 (3 January 2023).

The Effectiveness of Electrical Vestibular Stimulation (VeNS) on Symptoms of Anxiety: Study Protocol of a Randomized, Double-Blinded, Sham-Controlled Trial

The prevalence of symptoms of anxiety is increasing, especially during the COVID-19 pandemic. A home use transdermal neurostimulation device might help to minimize the severity of anxiety disorder. To the best of our knowledge, there is no clinical trial using transdermal neurostimulation to treat individuals with symptoms of anxiety in Asia. This gives us the impetus to execute the first study which aims at evaluating the efficacy of Electrical Vestibular Stimulation (VeNS) on anxiety in Hong Kong. This study proposes a two-armed, double-blinded, randomized, sham-controlled trial including the active VeNS and sham VeNS group. Both groups will be measured at baseline (T1), immediately after the intervention (T2), and at the 1-month (T3) and 3-month follow-up (T4). A total of 66 community-dwelling adults aged 18 to 60 with anxiety symptoms will be recruited in this study. All subjects will be computer randomised into either the active VeNS group or the sham VeNS group in a 1:1 ratio. All subjects in each group will receive twenty 30 min VeNS sessions during weekdays, which will be completed in a 4-week period. Baseline measurements and post-VeNS evaluation of the psychological outcomes (i.e., anxiety, insomnia, and quality of life) will also be conducted on all participants. The 1-month and 3-month follow-up period will be used to assess the long-term sustainability of the VeNS intervention. For statistical analysis, ANOVA with repeated measures will be used to analyze data. Missing data were managed with multiple mutations. The level of significance will be set to p < 0.05. Results of this study will be used to determine whether this VeNS device can be considered as a self-help technological device to reduce perceived anxiety in the general population in the community setting. This clinical Trial was registered with the Clinical Trial government, identifier: NCT04999709.

The mediating effect of mindfulness on demoralization syndrome and quality of life of thyroid cancer patients: A correlational study

Demoralization syndrome is prevalence among cancer patients in China. However, little research has examined how demoralization syndrome is associated with quality of life (QOL). The aims of this study were to investigate the relationship between mindfulness state, demoralization syndrome and QOL of thyroid cancer patients, and explore the mediating effect of mindfulness on demoralization syndrome and QOL. A correlational cross-sectional study was performed using an online questionnaire. The study was conducted from July to October 2022 among 310 thyroid cancer patients. General information questionnaire, the Demoralization Scale, Five Facet Mindfulness Questionnaire, short form health survey questionnaire were used for investigation. Calculations were performed using SPSS Statistics, version 25. Descriptive statistics, correlation, and process plug-in mediation effect analyses were used to analyze the data. A total of 310 valid questionnaires were finally recovered. The Five Facet Mindfulness Questionnaire score of 310 patients was (120.80 ± 16.57), Demoralization Scale score was (12.49 ± 4.73), short form health survey questionnaire score was (146.15 ± 28.46). Mindfulness played a partial mediating role between demoralization syndrome and QOL of thyroid cancer patients, and the mediating effect accounted for 68.57% of the total effect. Demoralization syndrome can influence QOL through mindfulness state. Measures are needed to increase the QOL of thyroid cancer patients by developing mindfulness programs to decrease their demoralization syndrome.

Evaluating the Efficacy of Electrical Vestibular Stimulation (VeNS) on Insomnia Adults: Study Protocol of a Double-Blinded, Randomized, Sham-Controlled Trial

Insomnia is a common health problem in the general population. There are different ways to improve sleeping habits and quality of sleep; however, there is no clinical trial using transdermal neurostimulation to treat individuals with symptoms of insomnia in Asia. This gives us the impetus to execute the first study in Asia which aims to evaluate the efficacy of Electrical Vestibular Stimulation (VeNS) on individuals with insomnia in Hong Kong. This study proposes a two-armed, double-blinded, randomized, sham-controlled trial including the active VeNS and sham VeNS group. Both groups will be measured at baseline (T1), immediately after the intervention (T2), and at the 1-month (T3) and 3-month follow-up (T4). A total of 60 community-dwelling adults aged 18 to 60 years, with insomnia symptoms will be recruited in this study. All subjects will be computer randomized into either the active VeNS group or the sham VeNS group on a 1:1 ratio. All subjects in each group will receive twenty 30-min VeNS sessions during weekdays, which will be completed in a 4-week period. Baseline measurements and post-VeNS evaluation of the psychological outcomes (i.e., insomnia severity, sleep quality and quality of life) will also be conducted on all participants. The 1-month and 3-month follow-up period will be used to assess the short-and long-term sustainability of the VeNS intervention. For statistical analysis, a mixed model will be used to analyze the repeated measures data. Missing data will be managed by multiple imputations. The level of significance will be set to p < 0.05. Significance of the study: The results of this study will be used to determine whether this VeNS device can be considered as a self-help technological device to reduce the severity of insomnia in the community setting. We registered this clinical trial with the Clinical trial government, identifier: NCT04452981.

HIV infection disclosure, treatment self-efficacy and quality of life in HIV-infected MSM receiving antiretroviral therapy

BACKGROUND

Research on the relationship between disclosure of HIV status to male sexual partners (HIV disclosure) and quality of life (QOL) revealed complex and even contradictory results. The impact of HIV disclosure on various domains of QOL and the mediation effect between them are unclear. The purposes of this study were to explore the impact of HIV disclosure on QOL among men who have sex with men (MSM), and whether HIV treatment self-efficacy mediated these relationships.

METHODS

The data came from a baseline survey on the design of a randomized control trial conducted in Shandong, China. A total of 579 MSM patients were included. SPSS 24.0 was used to conduct independent samples t test, one-way analysis of variance and nonparametric tests and the PROCESS macro was used to conduct mediation analysis.

RESULTS

Among 579 participants, 16.06% disclosed their HIV infection status to their male sexual partners. The effect of HIV disclosure on QOL was mediated by treatment self-efficacy. Self-efficacy played partial mediating role in social relationships, meaning that HIV disclosure had both direct and indirect effects on this factor. In the overall QOL and domains of physical, psychological, independence, and environment, HIV disclosure had an indirect effect only through self-efficacy and no significant effect on the spirituality domain.

CONCLUSIONS

The results emphasize the importance of HIV disclosure and self-efficacy on the QOL of MSM patients and suggest that health care providers should assist MSM patients in deciding whether to disclose their HIV status during daily medical services.

The quality of life in papillary thyroid microcarcinoma patients undergoing lobectomy or total thyroidectomy: A cross-sectional study

OBJECTIVE

Papillary thyroid microcarcinoma (PTMC) has a good prognosis and a long survival time, surgery is the common treatment including total thyroidectomy (TT) and unilateral lobectomy (LT), but recent studies showed that TT does not show an advantage over LT for PTMC in preventing cancer recurrence and reducing mortality. Given this, the health-related quality of life (HRQoL) has become one of the important factors that physicians must consider when making treatment decisions. The aim of this study was to compare the HRQoL of patients between undergoing TT and LT.

METHODS

From October 2019 to December 2019, 69 PTMC patients were enrolled in our study, including 34 in the LT group and 35 in the TT group, respectively. We used three questionnaires which included the 36-item short-form health survey (SF-36), thyroid cancer-specific quality of life (THYCA-QOL), and Fear of Progression Questionnaire-Short Form (FoP-Q-SF) for each patient to evaluate their scores of HRQoL.

RESULTS

According to the SF-36, the scores of the domain for the role limitation due to physical problems, emotional problems, and social function (RP, RE, and SF) as well as Physical Component Summary (PCS) and Mental Component Summary (MCS) showed a significant negative linear association between the LT group and TT group: RP (coefficient [coef]: -33.953 [confidence interval (CI) -51.187 to -16.720], p < 0.001, RE (coef: -21.633 [CI -39.500 to -3.766], p = 0.018), SF (coef: -10.169 [CI -19.586 to -0.752], p = 0.035)and PCS (coef: -10.571 [CI -17.768 to -3.373], p = 0.005), MCS (coef: -10.694 [CI -19.465 to -1.923], p = 0.018). The THYCA-QOL showed that the scores of the TT group were higher than that of the LT group in the problem of scar (coef: 16.245 [CI 1.697 to 30.794], p = 0.029 according to the multivariate analysis), suggesting a higher level of complaint in the TT group. There was no statistically significant difference in the scores of FoP-Q-SF between the two groups.

CONCLUSIONS

In patients with PTMC, LT offers an advantage over TT in terms of HRQoL, which supports the role of LT as an alternative strategy to TT.

Validation of the Equine Behaviour Assessment and Research Questionnaire (E-BARQ): A New Survey Instrument for Exploring and Monitoring the Domestic Equine Triad

Simple Summary

The Equine Behaviour Assessment and Research Questionnaire (E-BARQ) is an online questionnaire collecting information from horse-owners and riders on their horses’ training, management and behaviour. In order to compare different populations of domestic equids—for example, according to their breed, discipline, training or management type—it is important that the questionnaire administered to participants has been validated and found to be reliable. The questionnaire must reflect a true assessment of the horse’s behaviour, and, when taken by different users or the same user over time, the results should remain consistent. This article describes the process of validating the E-BARQ questionnaire, using three separate procedures. The results confirmed that the E-BARQ represents a standardised and validated behavioural assessment tool for horses.

Abstract

The Equine Behaviour Assessment and Research Questionnaire (E-BARQ) was developed to obtain quantitative data on the domestic equine triad: training, management and behaviour. It can be taken repeatedly, thus collecting longitudinal data to enable evaluation of how changes in a horse’s training and management are reflected in that horse’s behaviour over time and how these changes can impact horse welfare in the longer term. Questionnaire validation and reliability were tested by determining (a) whether an owner’s subjective ratings of their horse’s problematic behaviours or undesirable temperament traits were reflected in the questionnaire scores obtained for that horse (construct validity), (b) whether two respondents, equally familiar with a particular horse, reported comparable scores for that horse through the questionnaire (inter-rater reliability), and (c) whether the same respondent, scoring the same horse after a known interval of time, recorded similar responses (intra-rater reliability). Construct validity testing of 1923 responses showed significant alignment between owners’ reported experience of focal horses’ behaviour and those horses’ E-BARQ scores, with scores varying from 1.13 to 1.34 for ridden horse behaviour (all p < 0.001) and from 1.06 to 1.43 for non-ridden horse behaviour (all p < 0.001). Inter-rater reliability testing of ten horse–rider pairs revealed that 203 of the 215 question items were significantly aligned (p < 0.001) when tested by two independent raters. Of the remaining 19 items, four had fair alignment (ĸ = 0.174–0.316; p = 0.281) and ten items, largely related to whether the horse shows behavioural signs related to anxiety when taken away from home, did not align (ĸ = 0; p = 1). Intra-rater reliability tests showed that the responses significantly aligned on all 215 question items tested (p < 0.001). The results of these tests confirmed the construct validity and reliability of E-BARQ as a standardised behavioural assessment tool for horses.

Identifying Sources of Potential Bias When Using Online Survey Data to Explore Horse Training, Management, and Behaviour: A Systematic Literature Review

Owner-reported behavioural observations form an essential part of the veterinarians’ diagnosis and treatment plan. The way we train and manage horses affects their behaviour and, in turn, their health and welfare. Current horse training and management practices are largely driven by traditional techniques and longstanding methodologies. These approaches generally lack an evidence base for evaluation purposes. The absence of evidence and evaluation contributes to the persistent use of risky practices and this, in turn, increases risk of potential harms for both horse and rider, and fuels questioning of the equine industry’s current social license to operate. Objective evidence is required to make training and management decisions based on demonstrable best practice. Large-scale experimental or intervention studies using horses are generally not practical because of the associated costs and logistics of gaining ethical approval. Small studies generally lack statistical power and are subject to the effects of many forms of bias that demand caution in the interpretation of any observed effects. An alternative to collecting large amounts of empirical data is the use of owner-reported observations via online survey. Horse owners are ideally placed to report on the domestic equine triad of training, management, and behaviour. The current article highlights three sources of potential bias in a systematic review of literature on large-scale online studies of horse owners’ observational reports that met the following selection criteria: English-language, published, peer-reviewed articles reporting on studies with over 1000 respondents and open access to the survey instrument. The online surveys were evaluated for three common forms of bias: recall, confirmation, and sampling bias. This review reveals that online surveys are useful for gathering data on the triad of horse training, management, and behaviour. However, current use of online surveys to collect data on equitation science (including horse training, management, and behaviour) could be improved by using a standardised and validated tool. Such a tool would facilitate comparisons among equine and equitation science studies, thus advancing our understanding of the impacts of training and management on horse behaviour. The authors of the current review suggest the use of a standardised behavioural and management assessment tool for horses. Such a tool would help define what constitutes normal behaviour within geographically disparate populations of horses, leading to improvements in rider safety and horse welfare.

Quality of Life in Papillary Thyroid Microcarcinoma Patients Undergoing Radiofrequency Ablation or Surgery: A Comparative Study

Objective: Papillary thyroid microcarcinoma (PTMC) has a good prognosis and a long survival time. Health-related quality of life (HRQoL) is vital for PTMC patients during their survivorship. Ultrasound (US)-guided radiofrequency ablation (RFA), which has high efficacy and safety, is recommended as an alternative treatment to surgery for the patients with low-risk PTMC. However, the assessment of QoL of patients with PTMC has not been specially reported. The purpose of our study was to compare the HRQoL of patients with PTMC who underwent RFA and those who underwent surgery. Methods: From October 2019 to December 2019, 88 PTMC patients were enrolled in our study, including 54 in RFA group and 34 in surgery group. We used three questionnaires which included the 36-item short form health survey (SF-36), thyroid cancer-specific quality of life (THYCA-QOL), and Fear of Progression Questionnaire-Short Form (FoP-Q-SF) for each patient to evaluate their scores of HRQoL. The scores were compared after adjusting for age, sex, medical expense, and follow-up time. Results: According to the SF-36, the scores of the domain for the role limitation due to physical problems and emotional problems (RP, RE) as well as Physical Component Summary (PCS) showed a significant negative linear association between the RFA group and surgery group: RP coefficient [coef]-22.613 [confidence interval (CI) -33.504 to -11.723], p < 0.001, RE (coef: -21.901 [CI -36.737 to -7.064], p = 0.004), and PCS (coef: -8.312 [CI -13.694 to -2.930], p = 0.003). The THYCA-QOL showed that the scores of the surgery group were higher than that of the RFA group regarding scars (coef: 10.246 [CI 1.330 to 19.162], p = 0.025 according to the multivariate analysis), suggesting a higher level of complaint in the surgery group. There was no statistically significant difference in the scores of FoP-Q-SF between the two groups. Conclusions: In patients with PTMC, US-guided RFA offers advantage over surgery in terms of HRQoL, which supports the role of RFA as an alternative strategy to surgery.

Psychosocial Factors Associated with Quality of Life in Young Men Who Have Sex with Men Living with HIV/AIDS in Zhejiang, China

OBJECTIVES

To explore the quality of life (QOL) status and related factors in young human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) aged 16 to 24 years in Zhejiang province.

METHODS

A cross-sectional study was conducted in 22 counties of Zhejiang province, and 395 subjects took part in our research. A t-test, one-way Analysis of variance (ANOVA), and multivariate stepwise linear regression analysis were used to investigate the factors associated with QOL in young HIV-infected MSM.

RESULTS

The total score on the QOL was 86.86 ± 14.01. The multivariate stepwise linear regression analysis revealed that self-efficacy and discrimination were associated with all domains on the QOL assessment, monthly income was associated with QOL for all domains except spirituality and consistent condom use during oral sex with men in the past three months was associated with QOL for all domains except the relationship domain. Those individuals within the group of young HIV-infected MSM who have higher self-efficacy, a higher monthly income, greater social support, safer sexual behaviors, a higher level of education, and a higher cluster of differentiation 4 (CD4) count have a better QOL.

CONCLUSIONS

These findings suggest that to improve the QOL of this population, greater emphasis should be placed on improving social support, self-efficacy, and antiviral therapy adherence and on reducing discrimination, disease progression, and high-risk behaviors.

Evaluating the Longitudinal Item and Category Stability of the SF-36 Full and Summary Scales Using Rasch Analysis

INTRODUCTION

The Medical Outcome Study Short Form 36 (SF-36) is widely used for measuring Health-Related Quality of Life (HRQoL) and has undergone rigorous psychometric evaluation using Classic Test Theory (CTT). However, Item Response Theory-based evaluation of the SF-36 has been limited with an overwhelming focus on individual scales and cross-sectional data.

PURPOSE

This study aimed to examine the longitudinal item and category stability of the SF-36 using Rasch analysis.

METHOD

Using data from the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health, responses of the SF-36 from six waves of data collection were analysed. Rasch analysis using Winsteps version 3.92.0 was performed on all 36 items of the SF-36 and items that constitute the physical health and mental health scales.

RESULTS

Rasch analysis revealed issues with the SF-36 not detected using classical methods. Redundancy was seen for items on the total measure and both scales across all waves of data. Person separation indexes indicate that the measure lacks sensitivity to discriminate between high and low performances in this sample. The presence of Differential Item Functioning suggests that responses to items were influenced by locality and marital status.

CONCLUSION

Previous evaluations of the SF-36 have relied on cross-sectional data; however, the findings of the current study demonstrate the longitudinal efficacy of the measure. Application of the Rasch Measurement Model indicated issues with internal consistency, generalisability, and sensitivity when the measure was evaluated as a whole and as both physical and mental health summary scales. Implications for future research are discussed.

Health-related quality-of-life assessment in surgical patients with papillary thyroid carcinoma: A single-center analysis from Mainland China

Even with a favorable prognosis, the health-related quality of life (HRQoL) of papillary thyroid carcinoma (PTC) patients remains unclear and conflicting. Thus, in the present study, we compared the HRQoL of PTC patients with that of the general population (GP).The study was performed in our thyroid and parathyroid surgery department, and 186 PTC patients who had undergone thyroidectomy were included. The exclusion criteria were an age < 18 years, no follow-up, and the presence of other malignant neoplasms. The control group included 186 volunteers who were matched by age, gender, and socioeconomic status. The survivor and control groups were asked to complete the Chinese version of the SF-36 questionnaire.The 186 volunteers from the GP were well matched to PTC patients with respect to the baseline demographic characteristics. PTC patients showed significantly lower scores than those of the control group in 7 domains of the HRQoL: role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). PTC was a risk factor for a low Physical Component Summary (PCS) score and a low Mental Component Summary (MCS) score (all P values were less than .05). Significant reductions in the scores of all 8 domains were observed at 1 month after the operation, and obvious recovery was noted at 6 months according to the PCS and MCS scores (all P values were less than .05). However, even 2 years after surgery, few domain scores had recovered to levels found in the GP, including the PCS and MCS scores (all P values were less than .05).Due to the decreased preoperative and postoperative HRQoL scores, much attention should be given to and more long-term observation should be performed for PTC patients, even those who have undergone surgery.

Relationship between quality of life and unprotected anal intercourse among Chinese men who have sex with men: a cross-sectional study

Background

The prevalence of unprotected anal intercourse (UAI) is high among Chinese men who have sex with men (MSM). As important aspects of quality of life (QOL), psychological health and social relationships have been found to be associated with UAI among MSM, which was of great concern for intervening on UAI.

Methods

We conducted a cross-sectional study in Zhengzhou, Henan province, and in Huludao, Liaoning province, China, to measure quality of life (QOL) using the brief version of the World Health Organization Quality of Life (WHOQOL-BREF). Cronbach's α coefficient was used to test the internal consistency of the questionnaire items, and construction validity was assessed by exploratory factor analysis. T-test, chi-square test and multivariate logistic analysis were carried out to test the relationship between quality of life and unprotected anal intercourse.

Results

The questionnaires of 320 of the 373 men who have sex with men that were surveyed met our validity criteria (response rate: 85.8 %). A total of 161 subjects (50.3 %) reported having unprotected anal sex in the last 6 months. The results of univariate analysis indicated that having unprotected anal sex was significantly associated with psychological health (PSYCH), social relationships (SOCIL), age, and marital status (P-value <0.05). The 3 items (“Negative feelings”, “Hopeness on your life”, and “Be able to concentrate”) in the PSYCH subscale were associated with UAI significantly (P-value <0.05). Multivariate analysis showed that psychological health (adjusted odd ratio (AOR) 0.979, 95 % confidence interval (CI) 0.961-0.998) was independent factor affecting the likelihood of having UAI in the population of Chinese MSM, and participants who aged 45 or more had higher odds of UAI (AOR 3.986, 95 % CI 1.199-13.255).

Conclusions

WHOQOL-BREF was acceptable for evaluating the quality of life of MSM. Psychological health, as one important aspect of quality of life, was negatively associated with unprotected anal intercourse. The finding underscored the needs to incorporate the strategies on improving psychological health into the UAI intervention to reduce the HIV transmission among MSM.

Reliability and validity of 12-item Short-Form health survey (SF-12) for the health status of Chinese community elderly population in Xujiahui district of Shanghai

BACKGROUND

The 12-item Short-Form Health Survey (SF-12) is the abridged practical version of SF-36.

AIMS

This cross-sectional study was aimed to assess the reliability and validity of SF-12 for the health status of Chinese community elderly population.

METHODS

The Chinese community elderly people in Xujiahui district of Shanghai were investigated. The internal consistency reliability was assessed using Cronbach's alpha and split-half reliability coefficients. Construct validity was analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Spearman's correlation coefficient (ρ) was used for the evaluation of criterion, convergent, and discriminant validity with Spearman's ρ ≥ 0.4 as satisfactory. Comparisons of the SF-12 summary scores among populations that differed in demographics were performed for discriminant validity.

RESULTS

Total 1343 individuals aged ≥60 and <85 years old (response rate: 91.3 %) were analyzed. The Cronbach's α value (0.910) and the split-half reliability coefficient (0.812) reflected satisfactory internal consistency reliability of SF-12. EFA extracted a two-factor model (physical and mental health). About 60.7 % of the total variance was explained by the two factors. CFA showed that the two-factor solution provided a good fit to the data. Good convergent validity and discriminant validity of SF-12 were proved by the correction analyses (Spearman's ρ > 0.4) and the comparisons of the SF-12 summary scores among populations (P < 0.05). SF-12 summary scores were significantly correlated with the SF-36 summary scores (Spearman's ρ > 0.4, P < 0.05).

CONCLUSIONS

In conclusion, SF-12 had satisfactory reliability and validity in measuring health status of Chinese community elderly population in Xujiahui district of Shanghai.