جستجوی مقالات مرتبط با کلیدواژه « علل » در نشریات گروه « پزشکی »

Induced demand is the provision of healthcare services to patients by the influence of healthcare providers. Induced demand causes excessive use of health services, increases the waiting time for receiving health services, increases the price of health services, increases the costs and reduces the efficiency of the health system. Policymakers and health managers should take measures to reduce induced demand. Hence, they should understand the reasons for induced demand in the health system. Therefore, this research aimed to identify the reasons for induced demand in the health system.

This research was carried out using the scoping review method. All published articles and documents about the reasons for induced demand in the health system until June 21, 2023 were searched in nine databases and Google Scholar search engine. Finally, 38 articles were selected and reviewed. The data were analyzed by thematic analysis method and using MAXQDA10 software.

Thirty-eight studies about the reasons of induced demand in the health system were published between 1974 and 2021. The number of researches in this area has been growing since 2011. Overall, 32 reasons for induced demand in the health system were identified and grouped into three categories: macro (health system), meso (health care organization) and micro (provider and receiver of health services). The most frequent reasons for healthcare induced demand in the literature include inappropriate policies, insufficient monitoring, inappropriate payment system, large number of physicians, lack of attention to clinical guidelines, financial motivation of healthcare providers, patient insurance coverage, unreasonable patients’ expectations, inappropriate price of health services, the complexity of the health service and patients’ inadequate medical knowledge.

Induced demand has negative effects on the health system and will lead to an increase in health costs, waste of health resources, a decrease in the efficiency of the health system, and finally, a decrease in people’s access to essential health services. Several factors at different levels of the health system lead to induced demand for health services. Therefore, interventions should be systematically applied at three levels of the health system, healthcare organizations, and providers and recipients of health services to prevent and reduce healthcare induced demand.

Background and

Despite so many advances in the treatment of heart failure, the rate of readmission is still relatively high which imposes additional costs on patients and hospitals. Therefore, this study was designed and implemented to determine the causes of rehospitalization of heart failure patients admitted to Fatemeh Zahra Heart Center in Sari during 2022.

In this descriptive study, 309 patients with heart failure, who were admitted at Fatemeh Zahra Heart center for the second time, were selected by available sampling method during 2022. The data collection tool was a questionnaire which included demographic information as well as factors associated with readmission of heart failure patients. The qualitative content validity of the questionnaire was checked and confirmed by five cardiologists. The samples were analyzed using SPSS V21 applying descriptive statistics of relative frequency, absolute frequency, mean, and standard deviation.

Dyspnea was reported in 88% of the patients, and according to the NYHA Class evaluation criteria, the highest level of severity was 2 (in 44% of cases). An increase in chest pain before rehospitalization was also reported in 30% of the patients, and according to the CCS Class evaluation criteria, the highest level of severity was 2 (in 54% of cases) Failure to comply with the rehabilitation program was observed among 74% of patients who had a rehabilitation program. The other main reasons for readmission of heart failure patients in order of priority were failure to comply with medication regimen (28% of patients), palpitation (28%), stressful event (22%), heavy activity (21%), non-adherence to food diet (21%), smoking (7%), infectious disease (4%), discontinuation of medication (4%), and alcohol use (3%).
Conclusion.: Considering that dyspnea was the main reason for rehospitalization of heart failure patients, and non-compliance with the rehabilitation program, non-observance of the drug, and food diet regimen accounted for a high percentage of readmission, it is recommended to emphasize compliance with the rehabilitation program due to its great impact on improving the respiratory condition. Furthermore, it is beneficial to educate patients on adhereing to their diet and medication, using consultations, and following the doctors' recommendations after discharge. This can be effective in preventing rehospitalization of patients and improving the quality of their life.

Considering the important issue of hospital deductions and the benefits of reducing them which increase the satisfaction of physicians, hospitals and patients, increase hospital income and efficiency, increase the quality of health care and prevent waste of hospital financial resources, this study was conducted to compare the insurance deductions of inpatient records of Shahid Rahnemoon Hospital in Yazd province in 2021 and 2022.

This descriptive study was performed on all records of hospitalized patients in Shahid Rahnemoon Hospital, affiliated to Shahid Sadoughi University of Medical Sciences, Yazd.

The highest deductions in 2020 were in June (13.8%) and the lowest was in February (0.09%) and February (0.06%). Also, the highest deductions in 1400 were in September (10.37%) and the lowest was in April (7.97%). The findings showed that there was no significant relationship between occupied beds, number of discharged and length of stay with deductions in 2020 and 1400 (p>0.05), however, there was a significant relationship between bed occupancy percentage and deductions in 2020 and 2020 (p<0.05).

According to the principle of parting and in order to effective intervention in order to reduce deductions, it is suggested that special attention be paid to the main causes of deductions identified and codified programs including solutions to reduce deductions of bills and hospital dissatisfaction with payment of receivables.

 Jealousy is one of the negative emotions that affect interpersonal relationships, physical and mental health and daily functioning in life and causes harm to the individual and society. Therefore, the purpose of this study is to provide a philosophical analysis of the causes, examples and strategies for dealing with "jealousy".

 In the present study, the methods of documentary-library research and the method of descriptive quantitative content analysis of the written text type were used. For this purpose, using available sampling, 150 male students of Farhangian University of Kurdistan province in the academic year 2022 were selected and data were collected and analyzed using a semi-structured researcher-made questionnaire.

Ethical Considerations: 

The adherence of researchers to the principles of the Helsinki Declaration has been considered throughout the research period.

 For the causes and examples of jealousy: in the psychological-physical field, 25 concepts, in the social field, 13 concepts, in the moral-religious field, 15 concepts and in the legal-economic field, 5 concepts were obtained. In terms of solutions: in the psychological-physical field, 29 concepts, in the social field, 21 concepts, in the moral-religious field, 19 concepts and in the legal-economic field, 3 concepts were obtained.

 Findings showed that in jealousy, both internal factors such as feelings, motivations and attitudes of the individual and external factors such as family, school and society are involved. As a result of each of the causes, motives and intentions and actions of the jealous person become negative and sometimes destructive. Therefore, choosing the right solution requires recognizing the causes and examples of jealousy. So, it is suggested that by holding training workshops for educational trainers to familiarize them with the causes and consequences of jealousy, it was effective in controlling and reducing jealousy.

A nursing error means failure and error in carrying out care standards, which occurs as a result of an organizational error or manpower error. The present study was conducted to investigate the causes of nursing errors and effective factors in non-reporting of errors from the perspective of nurses.

 This descriptive-analytical cross-sectional study was conducted among the nurses working in hospitals affiliated to Maragheh University of medical sciences in 2021. The sampling method of the present study was convenience sampling. The data collection tool was the Researcher-made questionnaire. Data were analyzed in SPSS software (version 25).

86.7% of participants were female and 13.3% were male. The important reasons for occurring and non-reporting of nursing errors were "Overcrowded work shift and lack of time and opportunity" with an average of 4.5±0.7 and "fear of informing department authorities and being reprimanded by them" with an average of 4±0.7.

The most important reason for the error incident among nurses was heavy workload and doing works beyond their power and it is possible to significantly reduce this workload by increasing and managing the manpower. The most important reason for non-reporting is fear of informing department authorities and being reprimanded by them; to solve this problem, the hospital managers and administrators can provide conditions for nurses so that they can trust in case of an error incident and report their errors to prevent further problems.

The present study aimed to determine the causes of patients' readmission in hospitals affiliated to Bam University of Medical Sciences in 2019.

The current study was a descriptive-analytic study and the study population included patients readmitted in Pasteur Hospital in Bam, Javad Al-Aimeh Hospital in Narmashir, and Ayatollah Hashemi Rafsanjani Hospital in Regan in 2019. The samples consisted of 312 patient records which were chosen randomly. Data were collected by a checklist and were analyzed using SPSS software version 23 and descriptive and analytical tests (Chi-square and one-way analysis of variance).

The results showed that the internal medicine department received 34% of readmissions. The average readmission cost was 17,265,353 Rials. The most common reasons for readmissions were having a new disease (46.2 percent) and recurrence of the former disease (39.8 percent). Findings of inferential statistics revealed no significant relationship between the causes of readmissions and gender (P = 0.566), age (P = 0.065), or costs (P = 0.625), but there was a significant relationship between the causes of readmissions and marital status (P = 0.049) and married people had more readmissions than single people.

It is necessary to pay more attention to readmissions caused by disease recurrence. It is also possible to prevent such readmissions and improve the quality of medical services by standardizing hospital processes and tools, standardizing staff training, and employing new diagnostic and treatment methods.

In recent years infant mortality rate has dropped in Iran, but this rate is still high in developing countries. This study investigates the causes of infant mortality in the neonatal intensive care unit during 2011-2016.
This descriptive study was conducted on 195 infants admitted to the Intensive Care Unit of Beesat Hospital in Hamadan. The sampling method was a full-scale study of all patients from birth to one month of age with a diagnosis of underlying diseases and various causes of death. SPSS software was used to analyse the data and the results were presented descriptively.
The results indicated that 53% of the cases were male and 47% were female and the highest mortality rate were in the age group of 1-10 days (63%) and 10 days to 1 month (31%). Highest mortality rate of infants in the NICU were due to pulmonary diseases (32.64%), coronary heart disease (23.72%), central nervous system diseases (9.62%), respectively.
Taking a special consideration into neonatal period and special care of infants born of at-risk mothers and the provision of health education and care to these mothers can have a significant role in reducing the mortality rate of neonates.

Being the first-line treatment of patients, emergency units have an especial importance. The mortality of patients in the emergency department is a problem that has been exacerbated in recent years. Further studies on the causes of death are required in the emergency for correct judgment. This study is conducted in order to better understand the causes of death, in patients referred to emergency unit of Tabriz Imam Reza hospital in 2014 – 2015.
This cross-sectional study was carried out on the profiles of all patients admitted to the emergency department of Tabriz Imam Reza hospital. Demographic data and causes of death were extracted.
Of the 604 patients who died in the emergency department, 60.6% were men, 54.6% married and 31.5% had over 75 years. The most common causes of death were internal illnesses (22.2%) and trauma (19%). In total, 39.1% patients were died before in the emergency department and 32.1% of patients were referred from anther hospitals.
It seems that internal illnesses and trauma are the most common causes of death in the emergency department. The high rate of mortality shows the importance of early aids and proper referral system.

Occupational accidents are important problems that can cause enormous problems for staff and employees of an organization. Therefore, controlling the rate of accidents for reducing of complications, providing security for staffs and the patients and the continuous efforts for preventing of its occurrence in clinical settings are essential. The target of this research was study of prevalence and factors of occupational accidents in nurses of educational and treatment centers of Urmia University of Medical Sciences, Urmia, 2016.
Material & This research was performed as a cross sectional study in 180 nurses. Data were collected by a demographic and researcher made questionnaires asking about their job accidents. The association between the sociodemographic variables and the variable of occurrence of the work accident was ascertained through using Pearson’s test, ANOVA and independent t tests adopting the level of significance of 0.05 and the confidence interval of 95%.
The following were ascertained as predominant: female nurses (76.7%), mean age range (33.75±6.9). All of them reported having had some type of work accident in the institution.
In biologic accidents, contact with blood or other body fluids (90.5%), chemical accidents, breathing vapors of disinfectants (46.7%), physical accidents, being exposed to X rays 46.9%), ergonomic accidents, low back pain due to patient’s repositioning (41.7%) were the main occupational hazards. The most prevalent reasons of it were: unendurable work load (61.1%) and work frustration (35.6%). There was a significant relationship between occupational accidents with long time of work, night shift, hesitation during the work, low time, and crowd of people in the wards (p ≤ 0.05).
Based on the results, it is really important to recognize the accidents’ causes, control the rate of them and provide sufficient and appropriate occupational health and safety services.

In recent years Infant Mortality Rate )IMR) has been decreased in the developed countries but this rate is still high in the developing countries. This study aimed to investigate the causes of neonatal mortality.
This descriptive-cross-sectional study was performed on 110 hospitalized neonatal in NICU of Amiralmomenin Educational Hospital of Zabol University of medical sciences. Neonatal Mortality’s Questionnaire was used to collect the data. For data analysis, descriptive statistics was used.
The most common causes of mortality were prematurity and low birth weight.
Special care for premature and low birth weight infant and strengthening health care programs and emphasizing the need to identify high risk groups should be the priorities in decreasing the rate of neonatal mortality.

The end result of chronic kidney disease, irrespective of the type of kidney disease including progression to kidney failure and its complications as cardiopulmonary disease. The evidence show that recognition and treatment of this disease is often preventive and delay some complications of the disease and prevent the incidence of end stage renal failure. The purpose of this study was to determine the prevalence of complications of chronic kidney disease in children in Mofid hospital between 1392-1393.
A cross-sectional study was performed on 104 children between 2 months to 17 years old who were admitted in nephrology ward of Mofid hospital. They were evaluated by history taking, physical examination, blood and urine analysis, ultrasound, nuclear scan, and in some cases kidney biopsy according to the glomerular filtration and KDOQI instruction. Patients were divided into 5 groups: results were expressed using descriptive statistics with p Of the 104 cases, 56 patients (45%) were male and 48 (46%) were female. The age range was 4.9 ± 6.86. 37.5% of patients had high systolic or diastolic blood pressure, anemia was seen in 74%, 70% had bone disease and 63% had failure to thrive. The most common etiology of chronic kidney disease was neurogenic bladder and reflux nephropathy in 27.8% and 16.34%, respectively. 40% of patients were at stage 4 and 5, 17% at stage 3, 24% at stage 2, and 20% were in stage 1. 31.7% of patients had a glomerular filtration less than 15 at the time of diagnosis and 11.53% of patients treated with renal replacement therapy (RRT). During the study, 4.8% of patients were treated with a kidney transplant.
It seems that complications of urinary system is high in neurogenic bladder, and the most common complications are urinary tract infections, urinary reflux disease, and end stage renal disease. Troublesome complications, anemia, bone disease, growth failure and hypertension are significantly increased and endanger the lives of children. Therefore, it increases the mortality and morbidity.

Jaundice is the most common cause of neonatal admission within the first month after birth. Therefore, by identifying the causes of jaundice based on the infant’s age at disease onset and age at hospital admission and providing the required training, jaundice can be managed and its associated complications can be prevented. This study was performed to evaluate the causes of neonatal jaundice, based on the infant’s age at disease onset and age at hospital admission. In this cross-sectional study, out of 3,130 infants with jaundice, referring to Ghaem Hospital, Mashhad, Iran, from 2003 to 2015, 2,658 newborns were selected. Causes of jaundice are determined based on hematocrit, direct and indirect bilirubin, Coombs test, reticulocyte count, blood group and Rh of mother and neonate, thyroid tests, glucose-6-phosphate dehydrogenase (G6PD) enzyme testing, urinalysis, urine culture, and If necessary, Na, blood urea nitrogen, creatinine and other tests depending on the doctor's supervision. After confirming jaundice in infants, based on the physician’s diagnosis and laboratory results, a researcher-made questionnaire including the infant’s characteristics, was completed. Based on our study, 27.9% of infants had identified as causes of jaundice. Known causes of jaundice were blood group incompatibility (40%), infection (19%), G6PD enzyme deficiency (12%), endocrine disorders (8%), neonatal hypernatremic dehydration (7%), polycythemia (6%), congenital heart disease (CHD) (4%), occult bleeding (3%) and Crigler-Najjar syndrome (2%). The most common time of hospital admission of jaundice was 4-6 days after birth due to blood incompatibilities, occult bleeding, endocrine disorders, hypernatremic dehydration, CHD, polycythemia and G6PD enzyme deficiency. Moreover, the most common time of admission due to infection was after the first week of birth. The most common age of onset of jaundice was first three days of birth for blood incompatibility, although they were admitted two days later. Therefore, neonatal admission at appropriate time at onset of jaundice and receiving prompt treatments can reduce the probable complications (e.g., kernicterus).

the regret of vasectomy addition to costs for re-opening on vases also affect relations between couples. Regret of vasectomy may affect the willingness of other people regarding doing this operation. The aim of this study is to understand the causes of regret rate of vasectomy and to help the health planners to improve this situation. This cross sectional study conducted on 157 samples of vasectomized men who referred to this center from 1379 to 1389 in the city of Shahr-e Kord and was done vasectomy surgery with average duration of five years from their vasectomy.The total numbers of samples were 157 and multi-stage sampling (Cluster and simple random) was done. Referring to medical records, samples are randomly chosen. By visiting persons at home or asked them to refer to the clinic, a questionnaire was completed (Two sections of the questionnaire consist of demographic data and information about vasectomy). After collecting data using descriptive and analytical method, information was analyzed by spss16 software. Most people had done vasectomy before 40 years old and after family completion, because of sufficient children. Most of the men and their wives had counseling with each other and health professional before vasectomy. Most of persons vasectomized were employees and their wives were without job. The cause of regression in 15.9% of persons was complications. The job of most regretted people were self-employed. In cases who health staffs were the main incentives were the most satisfied with the vasectomy. The comparison of long-term complications in both happy and regretful group significant difference was found. This study revealed that vasectomy is an effective and successful in preventing pregnancy. Based on the results, complications is the main cause of regression because people are not consulted after the vasectomy. Most regretted people have low education and are self-employed. Satisfaction in men after vasectomy is associated with the medical team consultation. The consultation is needed with good quality and skilled health care personals to continue after vasectomy.

Patient safety is key to the trust in any health care system nowadays. Medication errors, as a key safety threatening factors, could increase patients’ length of stay and healthcare costs in hospitals and might lead into injury and finally death. Therefore, this study seeks to compare the incidence and proposed solutions of Iran and selected countries in order for preventing medication errors. This is a review article searching in such databases as SID, IranMedex, Pubmed, Scopous to identify and select its related papers. At last, 24 studies were considered for this study. According to the results of studies, shortage of nurses, nurses’ inexperience, job stress, physicians’ handwriting and lack of information on medications were the highly frequent incidence causes. Training courses on medicine dispensing and hands-on training were the most important solution. Given the existing gap between the medication errors incidence rate of Iran and selected countries, the latter’s experiences such as transparency and responsibility and active role of hospital pharmacies could be utilized by the former.

Death of pregnant mother is an important public health indicator that reflects both the quality of health care system and the role of women in the society. This study was performed with aim to determine the rate and causes of maternal mortality using Geographic Information System in Kermanshah. In this cross-sectional study، the recorded cases of maternal mortality and cause of death from 2001 to 2012 was extracted via census from family health unit of the province health center. To determine mortality rates، the cases of maternal death per year were divided to the number of live births. Information about the maternity facilities and literacy ratio was obtained from Kermanshah Heath Deputy and Governor. The data were analyzed using Stata 12 and Arc GIS 10. 1 software and χ2 test and linear regression. P<0. 05 was considered significant. The mean age of subjects was 31. 3±7. 3 years. 65 cases (65. 3%) were placed in high-risk pregnancy group. The rate of maternal mortality during 12-years was reported 25. 9 deaths per 100،000 live births، and mortality rate had 1. 3 unit decrease per each year of change (P=0. 04). In this study، the highest maternal mortality rate was in Northwest and Southwest cities of the province. The common cause of maternal death was bleeding (28. 3%) and abruption (28. 3%). The literacy rate in any city had an impact on the cause and rate of mortality، so that in the cities where literacy ratio was higher، the death rate was lower، and also more causes of death were indirect causes (P=0. 02). maternal mortality rate in some cities of this province is very high and higher than the mean of province and country.

Caesarean section، exiting the fetus، placenta and membranes through an incision of the abdomen and uterine wall shed. According to WHO، cesarean rates in in each region should not to go beyond 15 percent cesarean rates in recent decades has increased in most countries. The rate in the Country Iran is increasing، so that، according to the Ministry of Health in the country is 44%، which is a high figure. This study aimed to Prevalence and Causes of Cesarean Section in the hospital of Amir Al Momenin in Zabol city. This study is a descriptive study in the hospital of Amir Al Momenin in Zabol city during 1390 and 1391 was performed. The records related to the total deliveries during these years that records relating to a cesarean delivery is chosen، based on the research objectives، the information in this document was collected. Results showed that during these years، 2/25 percent by cesarean section was performed in 90، 93/30% of elective and 07/69% on an emergency basis، and in 91، 75/22% to elective and 24/77% to the emergency. The most common reason for cesarean section in 90 years، previous cesarean (4/45%) and the second leading cause of fetal distress (16%)، and in 91 years، the previous cesarean (6/51%) and the second leading cause of fetal distress (9/11%) had been. The most common reason for cesarean section in 90 years، previous cesarean (4/45%) and the second cause fetal distress (16%)، and in 91 years، the previous cesarean (6/51%) and the second cause fetal distress (9/11%) had been. In the present study، a high rate of cesarean section compared to international statistics. It is needed to provide the necessary education and increase awareness towards complications of cesarean to reduce it.

According to the statement of World Health Organization، about 70–80% of people use of herbal medicine in their primary care. This study was performed with aim to determine the frequency and type of herbal medicine used pregnant women referred to health centers of Tabriz. This cross-sectional and descriptive studywas performed on 318 pregnant women referred to health centers of Tabriz for performing pregnancy care at the second half of 2013. A researcher-made questionnaire was used for data collection. Data was analyzed with statistical software (version 21) and descriptive statistics and Chi-square test. The results indicated that 100 pregnant women (31. 4%) had used herbal plants during pregnancy. The most common reason (36%) for using herbal medicines during pregnancy was cold. The majority of studied pregnant women used of herbal plants and the most common reason for using herbal medicines during pregnancy was cold.

dropping out of treatment is a common problem to providing psychotherapeutic services that can negatively affect the process. Exploration of the reasons for dropping out of psychotherapy is necessary to design specific intervention in this area. This study was aimed to explore the reasons for dropping out of psychotherapy from psychotherapists’ points of views. This qualitative content analysis study was conducted on 12 psychotherapists who were working in Kermanshah city. They were selected by purposeful sampling. Data were collected through semi-structured interviews. The taped interviews were transcribed and analyzed. 5 main categories and 12 subcategories were extracted from the data. The main categories were financial problems in psychotherapy، incorrect beliefs and expectations toward psychotherapy، dual nature of psychotherapy، unprepared structure of education and supervision in psychotherapy، and inappropriate referral system in psychotherapy. Economic difficulties of clients، negative attitudes، poor supervision over psychotherapy، and inappropriate referral time were among the extracted subcategories. The results showed that there are economic، cultural and social aspects for dropping out of psychotherapy. These aspects are suggested to be taken into consideration in providing psychotherapeutic services.

Pregnancy-related mortality is one of the most important indicators of the overall health of a population and the functioning of the healthcare system. Mainly, pregnant women are admitted to intensive care units (ICUs) for reducing maternal and neonatal complications and mortality. The present study aimed to determine the causes and outcomes of maternal hospitalization during pregnancy and puerperium in the ICUs of Babol and Sari teaching hospitals during April 2001-March 2012. In this descriptive analytical study, all pregnant women, admitted to the ICUs of Babol and Sari hospitals during 2001-2012, were enrolled. Demographic data, as well as complications and procedures, documented in hospital records, were collected. For data analysis, Chi-square test was performed, using SPSS version 18. In 64 pregnant women, who were admitted to the ICUs, hypertension was the most common cause of hospitalization (39.1%). The most commonly performed procedure was blood transfusion (32.8%), followed by intubation (21.9%). Overall, maternal death was reported in 6 cases (9.4%), and embolism was observed in 4 patients (6.3%). Cesarean section (c-section) was performed in 93.75% of subjects, hospitalized after childbirth. In this study, the most common cause of ICU admission was hypertension, and the most commonly performed procedure was blood transfusion. Since c-section was the most common mode of delivery, unnecessary cases of c-section should be avoided. In addition, identifying factors, which lead to ICU admission or death in pregnant women, and increasing the quality of prenatal care for reducing maternal and mortality rates are essential.

Occupational exposures are one of greatest risk of transmission blood borne diseases through blood and blood products, among health professionals. Given the importance of the issue, this study was carried by aimed to determine the frequency, causes and functions of nurses, about occupational exposures in Hamadan. This study was cross-sectional conducted. 120 names of nurses working in hospitals in Hamadan extracted based on random and stratified sampling. At continue the designed occupational exposures questionnaire that confirmed its validity and reliability had delivered them for complete. After data collection, data were analyzed by descriptive statistics, chi-square test and logistic regression models. 71.7% of nurses reported occupational exposures during their service. Occupational exposure history in women and the staff by lower than 5 year work, was higher. About Type of exposure, most cases are related to injection or blood sampling (44%). Majority of exposures were splashing blood and secretions of patients in 39.4%. Washing and disinfection actions after exposure, at the 56.3% of them had been done. Incidence of occupational exposures as common risk factors for diseases transmitted through blood and blood products is common among nursing staff in Hamadan. Some bad habits such as not recapping needles and not using of special disposal boxes are common among nurses. Therefore, standard precautions training of personnel are essential.