The number of patients “worse than death” while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic

2021 ◽  
pp. 1-9
Author(s):  
Nick D. Clement ◽  
Chloe E. H. Scott ◽  
James R. D. Murray ◽  
Colin R. Howie ◽  
David J. Deehan ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Knee Arthroplasty ◽  
Waiting List ◽  
Control Group ◽  
Health State ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Number Of Patients ◽  
The Uk

Aims The aim of this study was to assess the quality of life of patients on the waiting list for a total hip (THA) or knee arthroplasty (KA) during the COVID-19 pandemic. Secondary aims were to assess whether length of time on the waiting list influenced quality of life and rate of deferral of surgery. Methods During the study period (August and September 2020) 843 patients (THA n = 394, KA n = 449) from ten centres in the UK reported their EuroQol five dimension (EQ-5D) scores and completed a waiting list questionnaire (2020 group). Patient demographic details, procedure, and date when listed were recorded. Patients scoring less than zero for their EQ-5D score were defined to be in a health state “worse than death” (WTD). Data from a retrospective cohort (January 2014 to September 2017) were used as the control group. Results The 2020 group had a significantly worse EQ-5D score compared to the control group for both THA (p < 0.001) and KA (p < 0.001). Over one-third (35.0%, n = 138/394) of patients waiting for a THA and nearly a quarter (22.3%, n = 100/449) for KA were in a health state WTD, which was significantly greater than the control group (odds ratio 2.30 (95% confidence interval (CI) 1.83 to 2.93) and 2.08 (95% CI 1.61 to 2.70), respectively; p < 0.001). Over 80% (n = 680/843) of the 2020 group felt that their quality of life had deteriorated while waiting. Each additional month spent on the waiting list was independently associated with a decrease in quality of life (EQ-5D: -0.0135, p = 0.004). There were 117 (13.9%) patients who wished to defer their surgery and the main reason for this was health concerns for themselves and or their family (99.1%, n = 116/117). Conclusion Over one-third of patients waiting for THA and nearly one-quarter waiting for a KA were in a state WTD, which was approaching double that observed prior to the pandemic. Increasing length of time on the waiting list was associated with decreasing quality of life. Level of evidence: Level III retrospective case control study

The influence of obesity on functional outcome and quality of life after total knee arthroplasty

2018 ◽  
Vol 100-B (5) ◽  
pp. 579-583 ◽  
Author(s):  
S. Xu ◽  
J. Y. Chen ◽  
N. N. Lo ◽  
S. L. Chia ◽  
D. K. J. Tay ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Total Knee Arthroplasty ◽  
Functional Outcome ◽  
Knee Arthroplasty ◽  
Obese Group ◽  
Control Group ◽  
Obese Patients ◽  
Knee Score ◽  
Total Knee

AimsThis study investigated the influence of body mass index (BMI) on patients’ function and quality of life ten years after total knee arthroplasty (TKA).Patients and MethodsA total of 126 patients who underwent unilateral TKA in 2006 were prospectively included in this retrospective study. They were categorized into two groups based on BMI: < 30 kg/m2(control) and ≥ 30 kg/m2(obese). Functional outcome was assessed using the Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS), and Oxford Knee Score (OKS). Quality of life was assessed using the Physical (PCS) and Mental Component Scores (MCS) of the 36-Item Short-Form Health Survey.ResultsPatients in the obese group underwent TKA at a younger age (mean, 63.0 years, sd 8.0) compared with the control group (mean, 65.6 years, sd 7.6; p = 0.03). Preoperatively, both groups had comparable functional and quality-of-life scores. Ten years postoperatively, the control group had significantly higher OKS and MCS compared with the obese group (OKS, mean 18 (sd 5) vs mean 22 (sd 10), p = 0.03; MCS, mean 56 (sd 10) vs mean 50 (sd 11), p = 0.01). After applying multiple linear regression with the various outcomes scores as dependent variables and age, gender, and Charlson Comorbidity Index as independent variables, there was a clear association between obesity and poorer outcome in KSFS, OKS, and MCS at ten years postoperatively (p < 0.01 in both KSFS and OKS, and p = 0.03 in MCS). Both groups had a high satisfaction rate (97.8% in the control group vs 87.9% in the obese group, p = 0.11) and fulfillment of expectations at ten years (98.9% in the control group vs 100% in the obese group, p = 0.32).ConclusionAlthough both obese and non-obese patients have significant improvements in function and quality of life postoperatively, obese patients tend to have smaller improvements in the OKS and MCS ten years postoperatively. It is important to counsel patients on the importance of weight management to achieve a more sustained outcome after TKA. Cite this article: Bone Joint J 2018;100-B:579–83.

scholarly journals PHYSICAL EXERCISE ON THE RECOVERY OF OBESITY MYOCARDIAL INFARCTION

2021 ◽  
Vol 27 (8) ◽  
pp. 783-785
Author(s):  
Mian Wang ◽  
Fan Wu
Keyword(s):  
Quality Of Life ◽  
Myocardial Infarction ◽  
Physical Exercise ◽  
Nursing Intervention ◽  
Exercise Group ◽  
Control Group ◽  
Level Of Evidence ◽  
Early Exercise ◽  
Physical Functions

ABSTRACT Introduction: Myocardial infarction caused by human obesity can cause a decline in mobility and a decline in the quality of a healthy life. Sports training is beneficial to maintain early physical functions after myocardial infarction. Objective: This article deals with the effect of applying walking aerobic exercise in the rehabilitation treatment of patients with myocardial infarction. Methods: We enrolled 91 patients with myocardial infarction in the early exercise group and 90 patients in the control group. The control group received the routine nursing intervention, and the early exercise group received early physical exercise rehabilitation therapy. Results: The actual quality of life of the early exercise group was higher than that of the control group. The incidence of cardiovascular adverse events was lower than that of the control group. Conclusion: Physical exercise therapy used in acute myocardial infarction can reduce adverse cardiovascular events and improve the quality of life of patients. Level of evidence II; Therapeutic studies - investigation of treatment results.

scholarly journals THE EFFECT OF PHYSICAL EXERCISE ON THE REHABILITATION QUALITY OF HUMAN WAIST DYSFUNCTION

2021 ◽  
Vol 27 (3) ◽  
pp. 315-318
Author(s):  
Fanfan Li
Keyword(s):  
Quality Of Life ◽  
Effective Means ◽  
Training Group ◽  
Abdominal Muscle ◽  
Motor Dysfunction ◽  
Control Group ◽  
Treatment Results ◽  
Level Of Evidence ◽  
Human Motor

ABSTRACT Introduction Human motor dysfunction can affect the quality of life, especially waist dysfunction. And an effective means to improve muscle strength during exercise. Object This article compares and analyzes the effectiveness of human muscle exercise on the decline in quality of life caused by motor dysfunction. Method The article divides patients with motor dysfunction into trunk isokinetic training group (experimental group) and waist and abdominal muscle functional training group (control group), and comparative analysis of related indicators before and after treatment. Results Before treatment, the specific indicators of the two were different (P>0.05). After treatment, the patients’ quality of life indicators and motor function indicators were significantly different (P<0.05). Conclusion Exercise has an obvious curative effect for patients with human motor dysfunction, and it is worthy of clinical promotion. Level of evidence II; Therapeutic studies - investigation of treatment results.

scholarly journals Assessment of post-surgical pain after the application of ultrasound-guided percutaneous neuromodulation in total knee arthroplasty

2019 ◽  
Vol 02 (02) ◽  
pp. 092-092
Author(s):  
Martín-Macho Martínez M. ◽  
Ventero Gómez A. ◽  
Carrió Font M. ◽  
Martín Buigues A.
Keyword(s):  
Quality Of Life ◽  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Conventional Treatment ◽  
Control Group ◽  
Ultrasound Guided ◽  
Surgical Pain ◽  
Total Knee ◽  
Experimental Group

Abstract Background and Aim The use of prosthetic knee replacements currently represent an alternative for patients who suffer from severe gonarthrosis. Treatment via the technique of ultrasound-guided percutaneous neuromodulation (US-guided PNM) is a therapeutic alternative worth considering as a new tool in physical therapy for the post-surgical recovery of total knee arthroplasty (TKA). The aim of this study was to evaluate the effectiveness of treatment with US-guided PNM in the post-surgical stage among patients intervened with TKA. Material and Methods Patients were selected between February and May 2017 at the Hospital of Denia and were randomly assigned into two groups. The initial sample was 13 patients. The experimental group (n = 7) received treatment with US-guided PNM plus conventional treatment. The control group (n = 6) only received conventional physiotherapy treatment. Patients in the experimental group received an application of PNM, which consisted of an alternate low frequency current at 10 Hz¸ pulse width 250 μs, with an intensity to the pain threshold. The intervention was performed during four consecutive weeks after hospital discharge. The control group received conventional treatment based on manual therapy, active mobilization and the use of the arthromotor until 115° of knee flexion and 0° knee extension was achieved. The main clinical variables evaluated were pain, measured using the Visual Analog Scale (VAS), quality of life, based on physical and mental components, using the SF12 scale and functional assessment using the Oxford Knee Score. Lastly, pain, stiffness and functional capacity was measured using the WOMAC scale. Results Both groups obtained statistically significant results in the four variables evaluated compared to the pre-surgery stage, however, the changes were more evident in the intervention group (p < 0.05). Furthermore, no significant differences were found in the variables evaluated regarding quality of life between the experimental and control group except for the emotional component of the SF-12 scale, where the result was only significant in the experimental group treated with US-guided PNM (P < 0.05). Regarding the improvement in the health status and decreased pain in the postoperative stage after TKA, no significant differences were observed between groups (p > 0.05). Conclusion The application of the US-guided PNM technique provides greater benefits than conventional therapy for decreasing the post-surgical pain in patients who have undergone knee arthroplasty and for emotional function, evaluated using the SF-12 questionnaire.

Evaluation of quality of life and walking ability among amputated patients and those who refused to undergo amputation following infection of total knee arthroplasty: Small case series

2014 ◽  
Vol 39 (6) ◽  
pp. 463-469 ◽  
Author(s):  
Camilo Partezani Helito ◽  
Andre Thiago Scandiuzzi de Brito ◽  
Riccardo Gomes Gobbi ◽  
Marco Kawamura Demange ◽  
Luis Eduardo P Tirico ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Short Form ◽  
Case Series ◽  
Medical Community ◽  
Walking Ability ◽  
Retrospective Case ◽  
Total Knee

Background:Patients who undergo transfemoral amputation after infection of a total knee arthroplasty do not have good functional outcomes and have major difficulty walking.Objectives:To evaluate the quality of life and walking ability among patients who underwent amputation and among those who refused to undergo amputation following infection of a total knee arthroplasty.Study design:Retrospective case series.Methods:Patients who received an indication for amputation following an infection of a total knee arthroplasty were evaluated retrospectively. The patients were divided between those who accepted the amputation procedure and those who refused amputation (four amputee vs four non-amputees). Walking ability and quality of life were evaluated using the Short Form–36 questionnaire.Results:The average physical health was 27.4 for the amputees and 31.3 for the non-amputees. The average mental health was 49.9 for the amputees and 47.1 for the non-amputees. In relation to walking ability, only one (25%) of the amputees was able to walk, as opposed to 100% in the non-amputee groups.Conclusion:Twenty-five percent of the amputee patients continued to be able to walk. The functional outcome of non-amputee patients was better, with 100% being able to walk, though with limitations.Clinical relevanceThis is the first study evaluating patients who refused the amputation procedure and remained with the spacer. Despite the fact that this option is not recommended by the medical community, we believe that these data are useful when discussing, with a patient, quality of life after amputation.

scholarly journals THE PECULIARITIES OF THE QUALITY OF LIFE OF PATIENTS, SUFFERED FROM ANEURYSMAL SUBARACHNOID HAEMORRHAGE

2019 ◽  
pp. 52-58
Author(s):  
K. V. Duve
Keyword(s):  
Quality Of Life ◽  
Mental Health ◽  
Emotional Disorders ◽  
Physical Functioning ◽  
Functional Dependence ◽  
Control Group ◽  
Aneurysmal Subarachnoid Haemorrhage ◽  
Number Of Patients ◽  
Sf 36

The analysis of data from a number of scientific sources shows that even those patients, with favorable outcomes after suffering from aneurysmal subarachnoid hemorrhage (aSAH), may often experience a decline in quality of life (QoL), both at the physical and psychosocial levels. The influence of functional dependence on the patient’s quality of life remains controversial, because among the number of patients, who save the ability of self-care, there exists a part of those, who are not able to return to their previous lifestyle, kind of activity, they have difficulties in their relationships and emotional disorders. The aim of study was to assess the quality of life of patients in recovery and residual periods of aSAH. Material and methods. We examined 114 patients (64.91 % - males, 35.09 % - females). The patients’ quality of life was studied by using the questionnaire SF-36. The control group consisted of 20 healthy participants, matched by age and gender. Results. The significant decrease in QoL of patients was observed in all scales, with the exception of physical functioning, vital activity and social functioning. It should be noted, that "mental health" scale rates correlated with the level of anxiety (r = -0,55) and depression (r = -0,61). In the different age groups, the QoL indicators were almost identical, with the exception of "physical functioning" component, because older patients received a lower score for this scale (p<0.01). Patients with a moderate level of disability were observed with a decline in all QoL categories of the scale SF-36. Patients, who were totally independent, had also a significant decline in all QoL scale components, with the exception of physical functioning. Conclusions. We found the decrease in QoL of patients in recovery and residual periods of aSAH, which does not depend on one’s level of functional dependence. The influence of anxiety (r = -0,55) and depression (r = -0,61) on the subscale "mental health" was established.

scholarly journals Efektivitas Pemberian Edukasi Berbasis Audiovisual dan Tutorial Tentang Antiretroviral (ARV) Terhadap Kepatuhan Pengobatan pada Pasien HIV/AIDS di Klinik Teratai Rumah Sakit Hasan Sadikin Bandung Tahun 2016

2017 ◽  
Vol 3 (2) ◽  
pp. 38
Author(s):  
Sinta Fresia
Keyword(s):  
Quality Of Life ◽  
Control Group ◽  
Research Use ◽  
Social And Emotional ◽  
Number Of Patients ◽  
Significant Difference ◽  
Quasi Experimental ◽  
The Difference ◽  
Hiv Aids

Abstrak Latar Belakang : Terjadinya peningkatan jumlah pasien HIV/AIDS dan rendahnya kualitas hidup pasien HIV/AIDS menimbulkan masalah yang cukup luas pada individu yang terinfeksi yakni masalah fisik, social dan emosional.Untuk meningkatkan kualitas dan harapan hidup pasien HIV/AIDS harus mendapatkan terapi Antiretrovirus (ARV) seumur hidup dan dibutuhkan pengawasan terhadap kepatuhan minum obat.Oleh karena itu pasien HIV/AIDS membutuhkan edukasi untuk meningkatkan kepatuhan minum obat dengan metode terbaru yaitu tutorial dan audiovisual.Tujuan penelitian ini untuk menganalisa perbedaan efektivitas pemberian edukasi berbasis audiovisual dan tutorial tentang ARV terhadap kepatuhan pengobatan pasien HIV/ AIDS. Metode : Penelitian ini menggunakan desain Quasi eksperimental dengan rancangan pretest-posttes design without control group.Jumlah sampel 27 responden dibagi 3 kelompok dengan 3 perlakuan berbeda.Masing-masing 9 responden diberikan edukasi dengan metode audiovisual, tutorial, audiovisual dan tutorial.Penelitian dilakukan di Klinik Teratai Rumah Sakit Hasan Sadikin Bandung pada bulan Mei-Juni 2016. Hasil : Ada perbedaan rata-rata mean kepatuhan edukasi dengan audiovisual 2,444, (Pvalue=0,003, 95% CI=1,107-3,782), edukasi dengan metode tutorial perbedaan mean 1,556 (Pvalue=0,023, 95% CI=1,274-2,837), edukasi dengan audiovisual dan tutorial didapatkan perbedaan mean 3,667 (Pvalue=0,003, 95% CI=1,670-5,664). Kesimpulan : Terdapat perbedaan yang significant rata-rata kepatuhan pada masing-masing kelompok intervensi edukasi.Kombinasi edukasi berbasis audiovisual dan tutorial memberikan hasil yang paling baik. Abstract Background : An increasing number of patients with HIV/AIDS and low quality of life of patients with HIV/AIDS cause considerable problems in individuals infected area.There are physical, social and emotional problems.To improve the quality of life of receive antiretroviral (ARV) therapy for life.This requires adherence and supervision taking medication. There fore urgently needed education to improve adherence with the latest audiovisual and tutorial methods. The purpose of this research is to analyze the difference effectiveness of education based audiovisual and tutorial method on ARV treatment adherence with HIV/AIDS patients.Methods : This research use quasi experimental design with pretest and posttest without control group. The numbers of sample in this research is 27 sample. Responden group divided into three different education methode. 9 responden in audiovisual methode,9 responden in tutorial methode and 9 responden in audiovisual and tutorial methode. The study was conducted at the Clinic Teratai Hasan Sadikin Hospital in May-June, 2016. Results : There is a diference in average adherence. In audiovisual methode mean 2,444 (Pvalue=0,003, 95% CI=1,107-3,782), tutorial methode 1,556(Pvalue=0,023, 95% CI=1,274-2,837), audiovisual and tutorial methode mean 3,667 (Pvalue =0,003, 95% CI=1,670-5,664).Conclusion : There is a significant difference in the average adherence in difference methode.Especially in audiovisual and tutorial methode. The combination of audiovisual and tutorial-based education gives the best results

Draf 3-type frontal sinusotomy as a part of revision procedures in patients with recurrent nasal polyps

2021 ◽  
Vol 70 (1) ◽  
pp. 12-14
Author(s):  
Petr Schalek ◽  
Jakub Fuksa ◽  
Anasuya Guha ◽  
Martin Chovanec
Keyword(s):  
Quality Of Life ◽  
Revision Surgery ◽  
Nasal Polyps ◽  
Control Group ◽  
Retrospective Case ◽  
The Difference ◽  
Polyp Recurrence ◽  
Radical Revision ◽  
Snot 22

Introduction: The prevalence of chronic rhinosinusitis with nasal polyps (CRSwNP) in the population is estimated at 4%. If adequate conservative treatment fails to improve the quality of life, patients are indicated for surgical therapy, which is represented by a functional endonasal surgery. The recurrence of polyps after surgery is reported by up to 60% in some studies. At the moment, available data does not indicate the optimal extent of surgery, especially in the case of revision procedures. The aim of the presented study was to find out whether a more radical revision surgery, including Draf 3-type (D3) frontal sinotomy, could be beneficial for patients with recurrent disease. Material and methods: Forty-two patients with recurrent polyposis were included in a retrospective case-control study. Half of the patients had undergone a more radical procedure including D3, while the control group had a standard operation. In both groups, the quality of life was assessed using the Czech version of the SNOT-22 questionnaire, the incidence of polyp recurrence and the need for revision within 2 years after the operation. Results: The presented study recorded lower postoperative values of postoperative SNOT-22 questionnaire in patients with D3 frontal sinotomy, but the difference was not statistically significant compared to the group of patients after traditional FES. A significantly lower need for revision surgery was proved in patients with more radical surgery. Conclusion: These data suggest that more radical surgical procedure in a subgroup of patients with severe recurrent polyps may be beneficial for these patients.

scholarly journals Effectiveness of hybrid intraperitoneal mesh repair for paracolostomy hernia

2021 ◽  
Author(s):  
NV Malgina ◽  
TYu Dolgina ◽  
AD Epifanova ◽  
GV Rodoman
Keyword(s):  
Quality Of Life ◽  
Mesh Repair ◽  
Medical Science ◽  
Control Group ◽  
Intraperitoneal Mesh ◽  
Stoma Formation ◽  
Number Of Patients ◽  
Euroqol 5D ◽  
Experimental Group

Due to advances in medical science, the frequency of surgical interventions that once ended in end-stoma formation has decreased significantly. An ostomy is a life-saving surgery performed when there are no other options. Unfortunately, the number of patients with life-threatening conditions requiring colostomy or ileostomy is growing. A stoma in itself is a cause of social alienation; stoma-associated complications reduce the quality of life and debilitate the patient. The aim of this study was to assess the effectiveness of hybrid intraperitoneal mesh repair of paracolostomy hernia using a modified EUROQOL 5D-5L questionnaire. Sixty patients with paracolostomy hernias included in the study were divided in 2 groups (30 persons per group). The experimental group (10 (33%) men and 20 (67%) women) and the control group (11 (37%) men and 19 (63%) women) were comparable in terms of sex (р = 0.787) and age (66.5 (62.2; 72.0) years vs. 65.0 (61.25; 71.75) years, respectively; р = 0.246). Patients included in the control group underwent a classic Sugarbaker procedure; the experimental group underwent hybrid intraperitoneal mesh repair. The quality of life of the patients was evaluated before surgery and then 1 and 2 years after surgery using a modified EUROQOL 5D-5L questionnaire. Hybrid intraperitoneal mesh repair proved to be effective in the early and late postoperative periods. Based on the significant improvement of the patients’ quality of life after hybrid intraperitoneal mesh repair, we conclude that this technique is an effective surgical treatment for paracolostomy hernias.

scholarly journals The influence of myocardoprotection on the course of postinfarction chronic heart failure

2020 ◽  
pp. 64-65
Author(s):  
A.A. Ruzieva
Keyword(s):  
Quality Of Life ◽  
Myocardial Infarction ◽  
Heart Failure ◽  
Chronic Heart Failure ◽  
Control Group ◽  
Positive Trend ◽  
Quality Of Life Indicators ◽  
Number Of Patients ◽  
Group 1

Objective. To study the effect of Thiotriazoline in patients with post-infarction chronic heart failure (CHF). Materials and methods. We examined 46 patients with ischemic heart disease (IHD) who had undergone myocardial infarction. The average age was 50.8±3.2 years; men – 32 (70 %), women – 14 (30 %). All patients were examined in the form of anamnesis and examination, general clinical and biochemical studies, electrocardiography. The assessment of CHF manifestations in patients of both groups was carried out according to the New York classification based on the results of the 6-minute walk test. The distribution into two groups was carried out according to the following parameters: the 1st group included 26 (56.5 %) patients (men – 19 [73.1 %], women – 7 [26.9 %]), who, along with basic therapy, received Thiotriazoline at a dose of 8.0 intravenously jet for 10 days; the 2nd (control) group included 22 (43.5 %) patients (men – 14 [63.6 %], women – 8 [36.4 %]) who received standard therapy (β-blockers, angiotensin-converting enzyme inhibitors, calcium antagonists, nitrates). Distribution by class of CHF at the time of inclusion in the study was observed in 1st group in 21 (80.7 %) patients: I functional class (FC) – 2 (9.5 %), II FC – 11 (52.4 %), III FC – 6 (28.6 %) and IV FC – 2 (9.5 %). In 2nd group – (77.3 %) patients: I FC – 3 (17.6 %), II FC – 6 (35.3 %), III FC – 7 (41.2 %) and IV FC – 1 (5.9 %) patients. According to the Minnesota questionnaire in group 1, the quality of life indicators (average value in points) were 71.1±1.8 points (p<0.05). The 2nd group had 67.9±1.9 points (p<0.05). Results and discussion. Positive hemodynamics and assessment of CHF manifestations by FC served as a clear statement of improvement in the quality of life. In the group receiving Thiotriazoline, the number of patients with II FC increased from 11 (42.3 %) to 14 (54 %), I FC – from 2 (9.5 %) to 6 (23 %) compared to the initial data due to patients from III FC and IV FC. The number of patients with III FC decreased to 2 (7.8 %) and IV FC – to 1 (3.8 %), and in the control group there was a slight negative dynamic (III FC – to 2 (9.5 %) and IV FC – without changes). The quality of life according to the Minnesota questionnaire indicated a positive trend. In group 1, the quality of life indicators improved from 71.1±1.8 to 53.3±0.6 points (p<0.01); in group 2 – from 67.9±1.9 to 63.3±1.9 points (p<0.05). Conclusions. Thiotriazoline is a cytoprotector of the highest class, in particular, a myocardoprotector, which, when used (from 10 days in a hospital and then up to 1 month), improves the metabolism of the heart muscle, stabilizing intracellular mechanisms. Thiotriazoline is indicated for all patients with IHD who have suffered a myocardial infarction in the early stages of CHF.

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