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Wan X, Yu H, Yang M, Hou W, Xie J, Xu K, Ma Y, Ma R, Wang F, Xu P. Study on the causal relationship between educational attainment and delirium: A two-sample Mendelian randomization study. Heliyon 2024; 10:e28697. [PMID: 38571646 PMCID: PMC10988048 DOI: 10.1016/j.heliyon.2024.e28697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024] Open
Abstract
This study aimed to investigate whether there is a causal relationship between educational attainment and delirium at the genetic level using the Mendelian randomization method, and provide new evidence for studies in this field. We found a causal relationship between educational attainment and delirium at the genetic level after excluding confounders using Mendelian randomization. The inverse variance weighting method of random effects was the main analysis method. The weighted median and Mendelian Randomization-Egger methods, as well as simple, and weighted modes were used as supplementary analysis methods. Additionally, horizontal pleiotropy tests were conducted, including the Mendelian Randomization-Egger intercept test and Mendelian Randomization Pleiotropy RESidual Sum and Outlier. Cochran's Q statistic was used to assess the size of heterogeneity. We retrieved all second single nucleotide polymorphism features and performed multivariate Mendelian randomization to adjust for the effect of potential confounders on our results. The inverse variance weighting suggested a negative correlation between genetically predicted educational attainment and delirium (0.67[0.49-0.92], p = 0.013); Mendelian Randomization Pleiotropy RESidual Sum and Outlier (0.67[0.49-0.92], p = 0.013) and multivariate Mendelian randomization (0.52[0.33-0.82], p = 0.005) results were generally consistent with the inverse variance weighting method. The Mendelian Randomization-Egger, simple, and weighted mode results were consistent with the inverse variance weighting results. Our results were not affected by pleiotropy or heterogeneity (p > 0.05, for both pleiotropy and heterogeneity). In addition, the "leave-one-out" analysis showed that the results of our Mendelian randomization analysis were not influenced by individual single nucleotide polymorphisms. Studies have found a causal relationship between educational attainment and delirium at the genetic level; higher educational attainment may be a protective factor against delirium. Clinically, more attention should be paid to patients at a high risk of delirium with low educational attainment.
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Affiliation(s)
| | | | - Mingyi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Weikun Hou
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Jiale Xie
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Ke Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Yujie Ma
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Rui Ma
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Fan Wang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Peng Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
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Zhang Y, Wei J, Zhao S, Zeng Q, Sun S, Cao W. Ambient fine particulate matter constituents and semen quality among adult men in China. JOURNAL OF HAZARDOUS MATERIALS 2024; 465:133313. [PMID: 38147745 DOI: 10.1016/j.jhazmat.2023.133313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/23/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
Exposure to ambient fine particulate matter (PM2.5) was associated with decreased semen quality, but the relationship between PM2.5 constituents and semen quality was unclear. We recruited 27,824 adult men attending an infertility clinic in Wuhan, China, between 2014 and 2020. We used a four-dimensional spatiotemporal deep forest model to estimate concentrations of PM2.5 mass and its chemical constituents, including organic matter (OM), black carbon (BC), sulfate (SO42-), nitrate (NO3-), ammonium (NH4+), and chloride (Cl-). We employed linear regression models to estimate the association between PM2.5 mass and its constituents with various sperm parameters. Exposure to PM2.5 was associated with a reduction in sperm quality, with a percent change of - 5.69% (95% confidence interval [CI]: -8.53%, -2.85%) for sperm density, - 15.09% (95% CI: -22.24%, -7.94%) for sperm total count, - 1.63% (95% CI: -2.36%, -0.91%) for sperm progressive motility, and - 2.30% (95% CI: -3.04%, -1.55%) for sperm total motility. Among specific constituents, exposure to OM, BC, Cl-, or NO3- was associated with a reduction in these four semen quality parameters. The association was more pronounced among older men or individuals with lower levels of education. Our findings suggest that PM2.5 mass and each constituent were associated with decreased semen quality in adult men.
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Affiliation(s)
- Yangchang Zhang
- School of Public Health, Capital Medical University, Beijing 100069, China
| | - Jing Wei
- Department of Atmospheric and Oceanic Science, Earth System Science Interdisciplinary Center, University of Maryland, College Park, MD 20740, USA
| | - Shi Zhao
- Centre for Health Systems and Policy Research, Chinese University of Hong Kong, 999077, the Hong Kong Special Administrative Region of China
| | - Qiang Zeng
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Shengzhi Sun
- School of Public Health, Capital Medical University, Beijing 100069, China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing 100069, China; Beijing Laboratory of Allergic Diseases and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing 100005, China; School of Public Health, The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, China.
| | - Wangnan Cao
- Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing 100191, China.
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Rosenkilde S, Sørensen TIA, Algren MH, Thygesen LC. Changes in weight status during the COVID-19 pandemic: impact of educational level and mental health. Eur J Public Health 2024; 34:190-195. [PMID: 37968230 PMCID: PMC10843948 DOI: 10.1093/eurpub/ckad188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has resulted in a disruption of daily routines and changes in health behaviors leading to widespread concerns about unfavorable changes in weight status and a potential increase in the prevalence of obesity. This study examined the long-term impact of the COVID-19 pandemic on changes in weight status and its possible dependency on educational level and mental health. METHODS The study utilizes the Danish Health and Well-being Survey with repeated self-reported information on weight status collected before the COVID-19 pandemic (autumn of 2019) and twice during the pandemic (autumns of 2020 and 2021). Information on educational level was derived from registers, whereas mental health was measured using validated scales. Generalized estimating equations were performed to investigate changes in mean weight and body mass index (BMI) category (BMI < 30 to BMI ≥ 30) between 2019 and 2021 and to investigate potential differences in changes in weight status by pre-pandemic educational level and mental health. RESULTS Mean weight significantly increased by 0.34 kg [95% confidence interval (CI): 0.16-0.51] in 2020 and by 0.46 kg (95% CI: 0.26-0.66) in 2021 compared with pre-pandemic weight status. The increase was greater among individuals with lower educational levels and poorer mental health. There were no significant changes in BMI category during the pandemic. CONCLUSION The results showed a significant increase in mean weight among the Danish population, particularly among individuals with lower educational levels and poorer mental health, but without detectable differences in obesity, supporting a long-term but minor impact of the COVID-19 pandemic on weight status.
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Affiliation(s)
- Siri Rosenkilde
- National Institute of Public Health, University of Southern Denmark, Copenhagen K, Denmark
| | - Thorkild I A Sørensen
- National Institute of Public Health, University of Southern Denmark, Copenhagen K, Denmark
- Department of Public Health, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen K, Denmark
| | - Maria H Algren
- National Institute of Public Health, University of Southern Denmark, Copenhagen K, Denmark
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen K, Denmark
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Luzius A, Merriweather M, Busch S, James O, Dobbs PD. Social Risk of Pregnant Women at a Community Health Center: An Application of the PRAPARE Assessment Tool. J Immigr Minor Health 2023; 25:1254-1260. [PMID: 37284968 PMCID: PMC10246518 DOI: 10.1007/s10903-023-01498-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/08/2023]
Abstract
Community health centers (CHCs) screen patients for social determinants of health (SDoH). The study's purpose was to assess the relationship between demographic factors and unmet social needs (SDoH risk) among pregnant mothers. Patient data from 345 pregnant women between January 2019-December 2020 assessed SDoH risk, using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) tool. Chi-square analyses explored relationships between social needs and demographic factors, and a multivariate logistic regression examined associations between these variables controlling for covariates. Hispanic patients and those who preferred to speak Spanish had 2.35 and 5.39 times the odds, respectively as non-Hispanic Whites and English speakers of having moderate/high/urgent SDoH risks. Mothers who had not completed high school had increased odds (aOR = 7.38) of SDoH risk. By identifying indicators that increase social risk level, CHCs can connect patients to essential social services, improving the downstream health of mothers and children.
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Affiliation(s)
- Abbie Luzius
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, 72701, USA
- St. Francis House NWA Inc. dba. Community Clinic, Springdale, AR, USA
| | - Maya Merriweather
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Science, Little Rock, AR, 72205, USA
| | - Savannah Busch
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Olivia James
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Page D Dobbs
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, 72701, USA.
- Department of Health, Human Performance and Recreation, University of Arkansas, 308A HPER Building, Fayetteville, AR, 72730, USA.
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García-Mayor J, Moreno-Llamas A, De la Cruz-Sánchez E. How socioeconomic status affects weight status through health-related lifestyles: a latent class analysis. Eur J Cardiovasc Nurs 2023; 22:730-744. [PMID: 36316287 DOI: 10.1093/eurjcn/zvac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 10/12/2023]
Abstract
AIMS Obesity levels have increased worldwide with serious public health concerns. However, weight status is related to socioeconomic status (SES), which may also influence health-related lifestyles. Here, we study the association between SES and obesity mediated by diet and physical activity. METHODS AND RESULTS Using cross-sectional data from 2006, 2011, 2014, and 2017 Spanish health surveys (the final sample consisted of 61 768 adults aged between 18 and 64 years), we conducted a latent class analysis to estimate health-related lifestyle clusters (based on dietary patterns and physical activity) and mediation analyses to evaluate the association of SES and obesity through the clustering of health-related lifestyles. In both men and women, SES was inversely related to obesity (P < 0.001) and positively related to healthier lifestyle classes (P < 0.001). Obesity was inversely related to healthier lifestyle classes (P < 0.001). A small-although significant-proportion mediated by the clustering of lifestyles was found as follows: 4.9%, 95% CI (6.6%, 3.2%) in men and 2.3%, 95% CI (3.4%, 1.3%) in women for educational attainment, 5.3%, 95% CI (7.2%, 3.6%) in men and 2.0%, 95% CI (2.9%, 1.1%) in women for occupational social class, and 4.9%, 95% CI (6.5%, 3.1%) and 1.9%, 95% CI (2.9%, 1.1%) combining the above two SES indicators. CONCLUSIONS SES is related to obesity through clustering health-related lifestyles, with greater emphasis on men. However, the complex relationship between SES and weight status also suggests other indicators that contribute to the social gradient of obesity.
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Affiliation(s)
- Jesús García-Mayor
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, C/Santa Alicia s/n, Murcia 30720, Spain
| | - Antonio Moreno-Llamas
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, C/Santa Alicia s/n, Murcia 30720, Spain
| | - Ernesto De la Cruz-Sánchez
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, C/Santa Alicia s/n, Murcia 30720, Spain
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The Socioeconomic Paradox of Physical Activity and Sedentary Behavior in Europe. J Phys Act Health 2023; 20:193-203. [PMID: 36669502 DOI: 10.1123/jpah.2022-0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 09/21/2022] [Accepted: 11/29/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND A low socioeconomic status (SES) presents lower physical activity; however, the relationship between SES and sedentary behavior (SB) remains unclear. We aimed to assess this association of SES with physical activity (PA) and SB. METHODS We employed representative self-reported data of the European Union from the cross-sectional survey Eurobarometer 2017, comprising a final sample of 13,708 citizens (18-64 y old), to assess the association of SES (education, occupation, and economic issues) with PA and sitting time quartiles, and to describe inequalities in vigorous, moderate, and walking activity and sitting time. RESULTS Multinomial regressions revealed that people from higher SESs were more likely to report higher PA; nonetheless, higher educational attainment and occupations were also associated with higher sitting time but not with lower economic issues. The inequality, shown by Gini coefficients, describes a socioeconomic gradient in vigorous and moderate activity, from higher inequality in lower statuses to lower inequality in higher statuses. The Gini coefficients also indicated higher socioeconomic inequalities in PA than SB. CONCLUSIONS Higher SESs showed paradoxically more PA and SB; however, sitting time presented smaller differences and a more homogeneous distribution across the population.
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The mediating role of combined lifestyle factors on the relationship between education and gastric cancer in the Stomach cancer Pooling (StoP) Project. Br J Cancer 2022; 127:855-862. [PMID: 35624300 PMCID: PMC9427973 DOI: 10.1038/s41416-022-01857-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The causal pathway between high education and reduced risk of gastric cancer (GC) has not been explained. The study aimed at evaluating the mediating role of lifestyle factors on the relationship between education and GC METHODS: Ten studies with complete data on education and five lifestyle factors (smoking, alcohol drinking, fruit and vegetable intake, processed meat intake and salt consumption) were selected from a consortium of studies on GC including 4349 GC cases and 8441 controls. We created an a priori score based on the five lifestyle factors, and we carried out a counterfactual-based mediation analysis to decompose the total effect of education on GC into natural direct effect and natural indirect effect mediated by the combined lifestyle factors. Effects were expressed as odds ratios (ORs) with a low level of education as the reference category. RESULTS The natural direct and indirect effects of high versus low education were 0.69 (95% CI: 0.62-0.77) and 0.96 (95% CI: 0.95-0.97), respectively, corresponding to a mediated percentage of 10.1% (95% CI: 7.1-15.4%). The mediation effect was limited to men. CONCLUSIONS The mediation effect of the combined lifestyle factors on the relationship between education and GC is modest. Other potential pathways explaining that relationship warrants further investigation.
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Das D, Sarkar A, Debroy A. Impact of COVID-19 on changing consumer behaviour: Lessons from an emerging economy. INTERNATIONAL JOURNAL OF CONSUMER STUDIES 2022; 46:692-715. [PMID: 35602666 PMCID: PMC9111418 DOI: 10.1111/ijcs.12786] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/10/2021] [Accepted: 02/01/2022] [Indexed: 06/15/2023]
Abstract
The present study investigates the impact of COVID-19 on Consumers' changing way of life and buying behaviour based on their socio-economic backgrounds. A questionnaire survey was carried out to understand the impact of COVID-19 on consumers' affordability, lifestyle, and health awareness and how these effects influenced their buying behaviour. A total of 425 usable responses were analysed using the structural equation modelling considering Consumers' socio-economic background as exogenous variables and Consumers' changing way of life and Adaptation in consumers' buying behaviour as endogenous variables. The study reveals that COVID-19 has affected the consumers in the unorganised sectors more than others and induced an increase in the demand for affordable substitutes for daily necessities. The demand for wellness and entertainment products is found to depend upon the occupation and family earning status of consumers which is jointly mediated by affordability and lifestyle changes. Further, the findings show that the demand for health and hygiene products depends on the current employment status and family earning status of consumers which is jointly mediated by affordability and awareness towards health and hygiene. The model developed in the present study allows the decision-makers to identify which segments of the population with certain socio-economic backgrounds could be targeted for wellness products and which ones could be targeted for health and hygiene products. In addition, the model provides rich insights to the managers as to what kind of product substitution would be viable in the market during the pandemic.
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Affiliation(s)
- Debadyuti Das
- Faculty of Management StudiesDelhi UniversityDelhiIndia
| | | | - Arindam Debroy
- Symbiosis Institute of Business Management NagpurNagpurMaharashtraIndia
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Arena R, Myers J, Ozemek C, Hall G, Severin R, Laddu D, Kaminsky LA, Stoner L, Conners RT, Faghy MA. An Evolving Approach to Assessing Cardiorespiratory Fitness, Muscle Function and Bone and Joint Health in the COVID-19 Era. Curr Probl Cardiol 2022; 47:100879. [PMID: 34103194 PMCID: PMC8093163 DOI: 10.1016/j.cpcardiol.2021.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 01/12/2023]
Abstract
Cardiorespiratory fitness (CRF) is now an established vital sign. CRF, along with muscle function and bone and joint health is related to functional independence and a higher quality of life. Wasserman and colleagues proposed a gear model illustrating the integrated role of the respiratory, cardiovascular, and skeletal muscle systems during aerobic exercise; in 2015, a revision to the original model was proposed. Our understanding of the effects and challenges associated with the coronavirus disease 2019 (COVID-19) are rapidly evolving. Initial evidence indicates higher levels of CRF, and muscle function protect individuals infected with COVID-19 from a complicated medical course. Moreover, for those individuals infected with COVID-19, there are initial signs of a reduction in CRF following the initial phase of recovery. We are also gaining an understanding of long COVID syndrome, where individuals who have recovered from the acute phase of viral infection present with lasting symptoms, which include but are not limited to reduced CRF, shortness of breath, and fatigue. Clearly, these individuals will require rehabilitation to restore and/or improve CRF, muscle function, bone and joint health, functional capacity (ie, the ability to perform activities of daily living), and quality of life. The importance of assessing the synergistic function of systems essential to performing activities that require physical exertion is a health care imperative. This graphical narrative provides an update to the gear model initially proposed by Wasserman and updated to a gear and circuit in 2015. External CRF, muscle function, and bone and joint health influencers and an approach to clinical assessment are also introduced.
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Affiliation(s)
- Ross Arena
- Corresponding author. Ross Arena, PhD, PT, FAHA, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, 1919 W. Taylor St (MC 898), Chicago, IL 60612
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Moreno-Llamas A, García-Mayor J, De la Cruz-Sánchez E. How Europeans move: a moderate-to-vigorous physical activity and sitting time paradox in the European Union. Public Health 2021; 203:1-8. [PMID: 34968833 DOI: 10.1016/j.puhe.2021.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/29/2021] [Accepted: 11/24/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to assess the interactions between physical activity (PA) and sedentary behaviour in a large population taking account of major sociodemographic characteristics. STUDY DESIGN Cross-sectional population-based study. METHODS Data from 28,031 individuals living in the European Union who were aged ≥15 years were retrieved from a cross-sectional survey, the Eurobarometer 2017. Interactions among the four mobility components (vigorous, moderate, walking activity and sitting time) were assessed at the individual level across age, gender and place of residence, and at the country level by compositional data analysis, hierarchical linear regressions and principal component analysis. RESULTS The most frequently reported PA was walking; however, sitting time represented >95% of the reported weekly times, whereas moderate-to-vigorous PA (MVPA) represented <1%. Women reported less PA and sitting time, age decreased total PA and increased sitting time, and individuals living in large urban areas reported lower PA and higher sitting times. MVPA decreased with age (β = -0.047, P < 0.001) and was lower in women (β = -0.760, P < 0.001) and those living in large urban areas (β = -0.581, P < 0.001), while walking and sitting times increased with age, being higher in women and lower in those living in rural areas. At the country level, sitting time was positively associated with moderate activity (β = 0.389, P = 0.041) and marginally non-significant with MVPA (β = 0.330, P = 0.087). CONCLUSIONS Walking was the highest contributor to weekly PA, whereas sitting time was paradoxically associated with higher MVPA. Specific measures to reduce sitting time are required to achieve an active lifestyle.
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Affiliation(s)
- A Moreno-Llamas
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, Murcia, Spain
| | - J García-Mayor
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, Murcia, Spain
| | - E De la Cruz-Sánchez
- Public Health and Epidemiology Research Group, San Javier Campus, University of Murcia, Murcia, Spain.
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