Tuesday, May 31, 2011
The Society for Academic Emergency Medicine (SAEM) has totally revamped its website into a really spiffy and professional looking site. I belong to the SAEM Web Editorial Board Committee and got to work with some really inspiring physicians and administrative staff who were able to launch this year-long project. Congrats team!
Monday, May 30, 2011
"To be or not to be?"
What could be more strange on a medical school curriculum than a theater training course? The authors of this study in Medical Humanities innovatively designed a 1-week elective course to help medical students at Mayo Medical School to improve their case presentation skills in partnership with the Guthrie Theater.
In this pilot course, seven medical students (six 1st year students, one 4th year student) participated. The learning objectives were:
- Hear stories: those told by patients, colleagues and in written narratives
- Identify the elements of a narrative, and examine stories for narrative structure
- Share stories: through case presentations, body movement, storytelling and acting
- Present a patient’s story with elements of traditional medical presentation and narrative
- The cognitive capacity and flexibility needed to evaluate and acquire reliable clinical information.
- The ability to actively and generously observe and listen to another.
- An understanding of the components of narrative leading to effective story construction.
- A performance sensibility that ensures the delivery of a good story, otherwise known as stage presence.
- The finesse to communicate empathically with a patient to create an environment in which she or he feels safe, satisfied and heard.
Eleven sessions, over 25 hours, comprised of the following topics:
- Improvisation activities
- Introduction to case presentations
- Body language - contact improvisation
- Performance of story
- Neutral dialogue and elements of a narrative
- Narrative in context - what’s lost, what’s gained?
- Listening with a neutral mask
- Writing and presenting case histories
- The art of personal monologue
- Final presentations with professional critique
Hammer RR, et al. Telling the Patient's Story: using theatre training to improve case presentation skills. Medical humanities. 2011, 37(1), 18-22. PMID: 21593246
Friday, May 27, 2011
The classic teaching for the treatment of diverticulitis includes:
- Hospital admission
- Bowel rest (NPO)
- IV fluids
- Broad spectrum IV antibiotics
This article from Annals of EM in the "Best Available Evidence" series summarizes the existing literature well. Plus, I was one of the journal reviewers for the article and am thrilled to see this coming out in print finally.
Word of caution: This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I'd still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.
Still it's nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.
Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011 - in early press. DOI: 10.1016/j.annemergmed.2010.11.008
Thursday, May 26, 2011
If you are a fan of the ingenious, creative TED videos, you'll want to see this 2 hour recording of TED's first ever auditions for TED2012: Full Spectrum. Applicants were to make a one-minute video that describes their idea worth sharing with the world. This video highlights the top 17 speakers (out of over 500 applicants). The live show was held online on Tues, May 24, 2011 and is currently available for viewing.
These talks are very short (< 5 minutes) and less polished than the mainstream TED talks, but they each are thought-provoking.
FYI, start at the 14:20 mark for the Introductions, and 20:50 mark to start listening to the first speaker.
The speakers are:
- Dr. Jane Rigby and Dr. Amber Straughn - The Hubble and space telescopes
- James McBennett - Brick in building future cities
- Onyx Ashanti - Beat Jazz, a new form of music
- Beth Urech - Author of "Speaking Globally"
- Virgil Wong - Artistic, graphic display of health information
- Joe Sabia - Evolution of storytelling
- Lior Zoref - The Crowd Generation
- Flux Foundation - A nonprofit group building art and community
- Erik Wahl - Creativity
- Eric Singer - New digital musical instruments
- Jared Ficklin - Sound visualization
- Joshua Walters
- LeeAnn Renninger
- Cesar Kuriyama - One Second EveryDay project
- Kevin Carroll - A ball can change the world
- Chris Plough - Driving an ambulance across Gobi desert
- Tania Luna - Being a "surpriseologist"
- Reggie Watts - Comedian, artist
Wednesday, May 25, 2011
A patient presents with a swollen finger after falling and fracturing it. The patient is more distraught by the fact that she can't get the ring off her finger. She implores you not to cut the ring off.
There are textbook chapters written about tightly wrapping the digit with string from distal-to-proximal and sliding the string under the ring. Theoretically, the provider can pull and unwind the proximal end of the string to gradually coax the ring over the coils of string.
I have personally found little luck with this maneuver.
Trick of the Trade:
Tourniquet-wrap the entire finger
The basis of all techniques for ring removal involves reducing the edema distally in the finger. Tightly wrap the finger in a distal-to-proximal direction using a rubber tourniquet, typically used for phlebotomy. In fact, wrap over the ring itself as well. With a cooperative patient, have him/her hold the proximal end taut for 15 minutes. This may require a digital block for pain control. Keep the hand elevated.
After 15 minutes, unwrap the tourniquet, apply generous lubricant on the finger, and remove the ring in a twisting or rocking fashion. You can repeat the tourniquet wrapping if you are unsuccessful the first time.
Thanks to Dr. Patricio Chavez (emergency physician at Sutter Delta in Antioch, CA) for this trick, who tells me that he "can't remember the last time he had to cut a ring off" since using this typically successful technique.
Tuesday, May 24, 2011
Tuesday, May 31, 2011
- SAEM Bootcamp - Patient Care Services Reimbursement
- SAEM Bootcamp - Research Finances
Thursday, June 2, 2011
- Where is the Evidence: Current Progression and Future Directions for Common Pediatric Emergency Conditions
- Collaboration and Education: Defining the Future of Pediatric Care in Emergency Medicine
- Navigating Large Datasets for EM Research Questions: A How-To Primer
- Simulation in EM Clerkships: A How-To Workshop
- Emergency Medicine Measures Update 2011 "So You Think You Can Measure: How to Take Your Local QI Measures National"
- The Science of Peer Review
- Introduction to Hierarchical/Multilevel Modeling
- Beyond the Ivory Tower: Solutions for Faculty Development, Research and Education in Community-based Tertiary Care Centers
- Curricular Advances in Resident and Medical Student Education
- Work-life Balance in Academic Emergency Medicine: Not Necessarily a Quixotic Quest
- Opportunities for Basic and Translational Research in Aging and Emergency Care
- The Definition and Academic Emergency Medicine Practice of Wilderness Medicine
- Designing Great Education Research
- Emergency Neurological Life Support
- Single-Payer Health Insurance: What It Is, What It Isn’t, and Why We Need It
- The Next Match: What Academic EM Departments Want When They Hire
- Critical Career Decisions, Part 1: Should I Choose Academic EM?
- Guiding Junior Researchers through the Design and Completion of Time-Limited Research Projects
Monday, May 23, 2011
With the advent of new technologies, such as blogs (web-logs), how does blogging one's self-reflection pieces compare to the traditional method?
Some of the research questions included:
- How does the level of reflection evident in student writings compare between the two methods?
- How do reflective writing themes compare between the two methods?
- What are student perceptions of their respective assignments?
Internal medicine clerkships at two different US medical schools over two consecutive blocks were quasi-randomized into the control (written essay) or the experimental (blog) group. Convenience sampling made it possible that each study arm enrolled relatively equal numbers of students between the two sites.
Control group: Wrote a single reflective essay, which were shared in 2-hour, faculty-facilitated, face-to-face, small-group discussion.
Study group: Wrote 2 blog posts and provided at least 1 comment on a peer's blog post. A faculty member provided online commentary and feedback.
The reflection pieces were thematically coded by 2 coders with 91% agreement.
There were 95 total study participants (control group n=45; study group n=50).
Seven themes were found in the reflective writings for the 95 study participants.
- Being humanistic
- Professional behaviour
- Understanding caregiving relationships
- Being a student
- Clinical learning
- Dealing with death and dying
- The health care system, quality, safety and public health
Both study groups demonstrated similar distribution of themes and depths of reflection. Post-clerkship surveys showed that students who were in the control group favored written reflections with face-to-face discussions and the blogging group favored blogging. This means that both approaches are likely effective.
Blogging technology provides educators another option where reflections can be shared and discussed.
Fischer MA, Haley HL, Saarinen CL, Chretien KC. Comparison of blogged and written reflections in two medicine clerkships. Medical Education. 2011; 45 (2), 166-75 PMID: 21208262
Friday, May 20, 2011
What do these three people have in common?
Lucille Ball (comedienne)
Jonathan Larson (wrote the musical "Rent")
John Ritter (comedian)
I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren't actually very common. Here are some scary examples:
- A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
- A tearing or ripping quality of pain is present in only 50% of patients.
- Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).
Hagan P et al. The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease JAMA. 2000; 283(7), 897-903. DOI: 10.1001/jama.283.7.897
Free PDF article for download
Thursday, May 19, 2011
I am in the midst of generating posters for the Canadian Association of Emergency Physicians (CAEP) conference. My residents and I came across this resourceful site about making them.
This site is full of tips to make scientific posters cleaner and more informative. I particularly like when he offers suggestions to sample posters.
Tips we learned from the site:
- Colour scheme: choose colours so they are consistent, but not too much gray.
- Font matters: San serif fonts are easier to read, just like in slides. He happens to like Gill Sans, which is my favorite presentation font.
- Text should align.
- White spaces are essential. Try not to crowd the text.
- Some presenters now insert a QR code to embed more content, maybe a video or a website link when the code is scanned by a smartphone.
Wednesday, May 18, 2011
How can you improve your sensitivity of this exam?
Trick of the trade: Elbows up!
I used to do the exam with the patient's elbow down at his/her side. An abnormal finger-to-nose test can be masked because you are mainly testing only biceps and triceps strength. Also the arm motion momentum can easily compensate for a subtle deficit. Instead have the patient raise the elbows (a chicken-wing position) for the exam. It is a little more difficult to compensate now. I recently picked up a subtle cerebellar stroke with this maneuver.
Also, it is important to have the patient fully extend his/her arm so that it is stretching to reach your finger. A subtle deficit becomes more obvious.
Thanks to Dr. Farzan for demonstrating!
Tuesday, May 17, 2011
Often it helps to look beyond the field of Emergency Medicine to appreciate new perspectives on academics, education, and technology. This time I've looked completely outside of Medicine. This video is an interesting panel discussion by Harvard business, economics, government, and computer science professors on "Academic Uses of Social Media: Exploring 21st Century Communications".
Social media are a new means by which scholars communicate, collaborate, and teach. The panelists discuss how they are adapting to new communication and networking tools.
This is a bit of a long video (1 hr, 2 min) but it's worth listening to. Every once in a while a panelist busts out with a nugget of wisdom:
- "Technology is outstripping our learning models" in higher education.
- "We're going to need to do rapid-firing of smart experimentation."
- "There are good things and bad things about blogging."
- "See whether we can encourage [online] discussion"... from different societies and cultures
- "Why should [we] even publish in closed-access journals? We now have the ability to set the stage." Right on! Open-access dissemination of knowledge and information is the future. Listen to the 59:00 min mark when they hit on this controversial topic. In our outdated promotions system, you need to publish in a reputable journal with a high impact factor. However, for the more noble goal of open-access dissemination, we should be looking at completely redefining "success" in the academic promotions process.
James E. Robison Professor of Business Administration
Harvard Business School
So much of the information we receive and send on the overflowing river ways of social media is immediate and detached from a historical frame or often, from any kind of larger frame or context whatsoever. What does it mean for a society to increasingly default into reliance on immediacy and brevity and widespread access as the ne plus ultra in knowledge creation? Knowledge is more than access to information, and wisdom is more than knowledge accumulation. How can we use social networks to create strong foundations for right action and sound choices?
N. Gregory Mankiw
Professor of Economics
Over the past several years, Professor Mankiw has maintained a blog, originally aimed at students in his undergraduate course Ec 10, but eventually reaching a much larger audience. He will talk about the pros and cons of such academic blogging.
Anne T. and Robert M. Bass Professor of Government
Professor Sandel's course "Justice" is the first Harvard course to be made freely available online and on public television. A website including lecture videos, discussion guides, poll questions, and other resources has generated discussion among students and other viewers around the world. The website is currently being updated to make greater use of social media tools.
Harry R. Lewis
Gordon McKay Professor of Computer Science
School of Engineering and Applied Sciences
Faculty co-director of the Berkman Center for Internet and Society, moderator.
Monday, May 16, 2011
In an interesting survey-based publication by Dr. Tabas (one of my colleagues) that just came out in Archives of Internal Medicine, we learn more about the ins and outs of CME activities. The authors set out to determine the audience members' opinions about:
- Commercial/ pharmaceutical support and its impact on bias
- Their willingness to pay extra conference registration fees to eliminate outside support
- Based on 5 live CME conferences, 770 of 1347 participants responded to the survey (57% response rate)
- 88% of responders believed that commercial/ pharmaceutical support introduces bias.
- 75% of responders overestimated the amount of funding provided by attendee registration fees (vs commercial support). Registration fees actually don't cover very much in the big-picture of conference costs. Did you know that a cup of coffee cost about $6.53 in a Los Angeles conference and $9.28 in a New York City conference? Ouch. No wonder registration fees are so high across the board!
- Only 42% of responders, however, were willing to pay increased registration fees to reduce/eliminate outside support.
- Some responders supported eliminating amenities by changing printed syllabi to online (56%), by holding the conference at a less desirable venue (50%), and by eliminating free food or snacks (50%).
As more and more academic institutions are imposing a blanket policy ban of commercial/ pharmaceutical support for CME activities, this study suggests that we should first look at the complexities behind hosting a CME conference before taking such sweeping actions. This study takes a fascinating first step in making the true operational costs and clinician perceptions transparent.
Tabas JA, Boscardin C, Jacobsen DM, Steinman MA, Volberding PA, Baron RB. Clinician attitudes about commercial support of continuing medical education: results of a detailed survey. Arch Intern Med. 2011; 171(9), 840-6. PMID: 21555662
Friday, May 13, 2011
You need a high sensitivity to be sure that your negative result indeed predicts a true negative. That means if your clinical decision tool suggests that you don't need to get a head CT, then your head CT would have been normal.
On the flip side, this realistically means there is a low-moderate specificity. That means a clinical decision tool with at least 1 positive criterion does not always mean that there will be an abnormal finding on head CT.
There are 3 major clinical decision rules that I've heard tossed around in the literature:
- Canadian CT Head Rules (CCHR)
- New Orleans Criteria (NOC)
- National Emergency X-Radiography Utilization Study (NEXUS)-II
Take a look at these decision rules and their inclusion criteria.
- The CCHR included patients with GCS 13-15. The NOC initially enrolled only patients with a GCS of 15.
- All factor in age (≥65 years for CCHR and NEXUS-II; ≥60 years for NOC).
- Interestingly only the CCHR, for better or worse, take into account mechanism of injury. I'm not sure I would obtain a head CT on a pedestrian with a graze wound on the foot from a slow-moving vehicle.
Thursday, May 12, 2011
Thanks to Dr. David Duong and Dr. Najm Haqu (UCSF) for letting me cross-post their amazing instructional video on the "EM Eye Exam". These videos were made for the purpose of teaching senior medical students on their UCSF-SFGH EM clerkship. I thought it'd be great to share these tutorials, since the eye exam is typically a daunting task for many medical students (and residents).
Is it just me, or does David have a great recording voice? I also cross-listed on the Videos page.
Is it just me, or does David have a great recording voice? I also cross-listed on the Videos page.
Wednesday, May 11, 2011
Have you ever been to an ultrasound workshop where each small group of attendees huddles around the small ultrasound display? Personally I think the 3 people closest to the display really see the images well. This tends to exclude the other participants.
Last week, I hosted (my first!) ultrasound workshop for the UCSF Alumni CME Conference where I showed peri-retired UCSF alumni from various specialties about the future of bedside ultrasonography. I equated it to the 21st century stethoscope. Thanks to my star team of ultrasonographers: Dr. Asaravala, Flores, Miss, Lenaghan, and Wilson.
In order to maximize engagement amongst the participants, I set up each of the 5 ultrasound stations with either a LCD projector or a large-screen TV screen so that everyone could see what was going on. While we encouraged them to do some hands-on scanning themselves, the participants were more interested in the novelty of bedside ultrasonography and how they might be able to incorporate into their practice.
What did I learn?
- Make sure each instructor has a laser pointer. I had to scramble for them last minute when I realized that the instructor couldn't actually touch the projector screen from where they were standing. It made it hard for them to point out key structures.
- Use thick masking tape to tape all the lose power cords (ultrasound machine, projectors, TV) to the ground. Bonus points if none of your participants trip and fall.
- I liked the fact that all the stations were in the same room. This allowed participants to freely wander amongst the different tables.
- I'm glad I made a last-minute handout which showed the basic anatomy of areas being ultrasounded and a potpourri of abnormal images as a reference for the participants as they were viewing the real-time normal scans.
Tuesday, May 10, 2011
What is Webicina?
It is an incredible one-stop shopping site for medical professionals and patients to join the Web 2.0 world. The site has and is constantly aggregating the most recent journal articles, blog posts, podcasts, and many more sources of media in 25 different specialties and in 17 languages.
They recently built an iPhone mobile app version which is pretty cool. It's so cool that it won the 2011 Medical Apps Award for Most Innovative App. Go to iTunes link to download this FREE iPhone app. Oh and I just read that the Android app will be available in June.
It's got a whole section on Emergency Medicine. In the app, you see that the EM section is broken down into:
- News and Information
- EM in the Blogosphere
- EM Podcasts and Interviews
- EM Community Sites, Facebook Groups
- Microblogging: Twitter and Friendfeed
- EM Wikis
- EM Videos, Animations, and Videocasts
- Mobile Applications
- Medical Search Engines
- Clinical Cases and Images in EM
- Slideshows about EM
Monday, May 9, 2011
Modeling after other "Expectations of a clerkship director" publications from other undergraduate medical education organizations in the fields of Internal Medicine, Surgery, Psychiatry and many others, this article sets forth a set of expectations and guidelines for the EM clerkship director.
Clerkship directors play a huge role in representing the department within the School of Medicine. They are often the "face" of the department. Oddly, however, clerkship directors in EM are usually the most junior faculty in the department, in contrast to Internal Medicine, Surgery, Pediatrics, and Ob/Gyn where the clerkship director is typically a senior faculty member. Furthermore, clerkship directors in EM get far less protected time than residency directors (their GME counterpart), who work an average of 17 clinical hours per week. Even comparing to clerkship directors in other specialties, EM clerkship directors receive less protected time.
Because EM clerkships come in many shapes and sizes (mandatory, selective, and/or elective EM rotations), negotiating protected time will vary from site to site. Each type of rotation has its unique challenges and requires different amounts of time commitment on the part of the clerkship director. We outline the roles, responsibilities, and essential skills of an EM clerkship director.
A table lists helpful resources for the EM clerkship director. This list is actually useful for anyone interested in EM medical education.
Full disclosure: I'm a proud co-author on this paper. Just another example of getting to be a part of great projects if you work with great people.
Rogers RL, Wald DA, Lin M, Zun LS, Christopher T, Manthey DE. Expectations of an Emergency Medicine Clerkship Director. Acad Emerg Med. 2011 - in press PMID: 21521403
Friday, May 6, 2011
Brugada, Brugada, Brugada
You always hear about it when working up syncope and sudden cardiac arrest in young patients, but it's so easy to forget what it looks like on EKG. We so rarely see it... or DO we?!
This Paucis Verbis card on Brugada Syndrome is to help emblazon these EKG tracings in our mind, so that we don't miss the subtle findings which place a patient at risk for sudden cardiac death. Pay special attention to Type 1, which is most specific for Brugada Syndrome.
ReferencesAntzelevitch C et al. Brugada Syndrome: Report of the Second Consensus Conference: Endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation, 2005; 111(5): 659-70. DOI: 10.1161/01.CIR.0000152479.54298.51
Free PDF article downloadable from Circulation.
Thursday, May 5, 2011
Thomas Goetz, the executive editor of WIRED magazine, gave a talk at the 2010 TedMed Conference on the importance of information presentation in health care. In this 19-minute talk, he covers many interesting points.
In the first half, he talks about how to motivate patients to take control of and change their behaviors. In the second half, he talks about how medical information should be presented not with the physician in mind but rather the patient.
Motivating patients to change behavior:
This part of the talk in many ways could just as easily have been pulled from a talk on Medical Education. How do we motivate students to learn? How do we get patients to stop smoking, brush their teeth, or change their diet? It's not just about instilling fear but rather giving them a sense of "high efficacy," or belief that they can indeed accomplish the task at hand.
- Patient action plans and education curricula should be personalized. In education, this means creating a Personal Learning Environment for each learner so that s/he sets their own learning goals and manages both the content and process of learning.
- Changing and motivating behavior requires active engagement by the patient/learner and can be characterized by this cycle:
Information presentation should target the patient:
Lab results and medical information should be geared not just to physicians but also to patients. The speaker gives some compelling evidence showing that medical information presentation can draw patients into the medical decision making process of their own health and incentivizing them to change.
Wednesday, May 4, 2011
Mandible, or TMJ, dislocations occur when the patient excessively opens the mouth, such as in a yawn. They are typically bilateral and are difficult to relocate because of masseter and medial pterygoid muscle spasm. You can relocate the condyles back into the TMJ space with gentle but firm intraoral pressure inferiorly and posteriorly. Often it requires some sedation to help relax the muscles of mastication.
Trick of the Trade:
Tire out the muscles of mastication
Thanks to Dr. Sa'ad Lahri (Cape Town, South Africa), I viewed this innovative trick in relocating a TMJ dislocation, posted by the BBC on YouTube. The basic principle is that you slightly over-exaggerate the dislocation to stretch the muscles even more. This was done using a stack of tongue blades. This constant stretch of the muscles for a few minutes will cause them to be relaxed when you remove the tongue blades. This provides a small window of time when you can relocate the mandible.
Has anyone else tried this before? I haven't and can't personally vouch for it, but I'll be trying it on the next opportunity that I have. It'd be nice not to have to sedate the patient unnecessarily.
Poor patient -- this video has gotten over 1.3 million views...
Tuesday, May 3, 2011
For those of you in an EM residency program, the American Board of Emergency Medicine oral board exam looms in the not-too-distance future. I came across the University of Maryland's EM Oral Boards Training Video Series, produced by Dr. Mak Moayedi and Dr. Dan Lemkin. These videos can be found on their departmental website: http://www.umem.org/res_video.php
The videos are included here below for your viewing convenience. The videos illustrate the "gamesmanship" in doing well in the cases. In the following 5 videos, there is a video providing general instructions, 3 videos of sample cases, and a video giving you tips on doing well.
These professional-quality videos are worth checking out.
Monday, May 2, 2011
This article provides a framework for teachers to allow learners to appreciate these encounters in the Family Medicine. Their points are highly relevant to Emergency Medicine. Strategies include:
1. Label encounters as being difficult rather than patients.
- The difference in language is important. Many factors - perceived physician attitude, life history of the patient - will affect the encounter.
- In the ED, factors such as wait times, patient discomfort and physician interruption will also color the encounter. Learners need to understand that not all factors can be controlled.
- Teachers should challenge the learners to explore their emotional reaction.
- Learners should understand that their own emotions can affect the encounters significantly.
- While reflection is an excellent learning tool, there may be insufficient time to do it in real time in the ED. (Is there time to do anything in the ED?)
- It would, however, be useful at the end of the shift.
- At times, saying no is the correct medical decision.
- However, patients need to feel understood and their concerns taken seriously.
- Deliver the 'no' tactfully. Involve patients in the decision making process.
- This is probably the *most* useful skill in the ED.
- While to a clinician some demands are 'unreasonable', often a true concern hides underneath. So the 'whole body MRI' might come after a relative gets diagnosed with a rare cancer, or a 'plastic surgeon referral' might be due to worry about a keloid scar.
- Learners need to understand the particular concerns and offer medically appropriate alternatives while involving the patient in the decision.
- This Jedi-skill will take years to hone!
- Learners need to understand the context of the patient, who they are, and why they might be difficult in their encounters with physicians.
- This approach is more feasible in primary or longitudinal care than the ED.
- In the ED, the 'why today?' question for chronic problem can often yield the real agenda that clinicians can focus on.
Oliver D. Teaching medical learners to appreciate “difficult” patients Canadian Family Physician. 2011, 57(4), 506-508.
Free link to the full article.