Sexual dysfunction and fertility-related distress in young adults with cancer over 5 years following diagnosis: study protocol of the Fex-Can Cohort study

Sexual life in adults treated for brain tumors: a retrospective study

Objective

Sexual functioning is a multifaceted aspect of human life that can be profoundly affected in patients with glioma. Most frequent symptoms include reduced sexual desire, difficulties in sexual arousal, or low satisfaction. Such symptoms may cause distress or interpersonal difficulties, inevitably resulting in negative outcomes on different domains of patients' quality of life. Despite this, sexuality is rarely addressed by medical staff and remains understudied. An important question still unanswered is whether sexual dysfunctions in glioma patients correlate with features of the tumor itself, with its treatment, or with the secondary effects of the tumor on the patient's psychological status. To answer this question, the present study aims to investigate the incidence of sexual life impairments in a very large population of patients with low- and high-grade gliomas, focusing on demographic, clinical, and treatment factors associated with their occurrence and developments.

Methods

A total of 148 patients treated for glioma were evaluated for sexual functioning, i.e., sexual dysfunction (SD), relationship status (RS), intercourse frequency (IF), and sexual satisfaction (SS), by using a specific anonymous questionnaire. Descriptive statistics were utilized to investigate participant characteristics and to evaluate the occurrence of sexual problems. Chi-squared tests were performed to detect the association between "SS" or "IF" and different clinical/demographic factors as well as between "SS" or "IF" and the "subjective-personal skills judgment".

Results

Results showed no difference between male and female patients, a very low frequency (1.4%) of SD, but a consistent percentage (25%) of subjective deterioration in sexual wellbeing. Notably, 24% of patients reported to have interrupted their relationship after the diagnosis. Chi-squared analyses reveal an association between adjuvant treatments (chemotherapy and radiotherapy) and reduction of IF. Interestingly, "SS" or "IF" was not associated with demographic, clinical, or histomolecular factors.

Conclusion

Our study showed that sexual problems in glioma patients are not uncommon, and they are especially linked to SS, RS, and IF. Specifically, intercourse frequency reduction is associated with the adjuvant treatments. Results highlight the need for improved assessment strategies and interventions tailored to the unique needs of brain tumor patients.

Health-related quality of life and supportive care needs in young adult cancer survivors-a longitudinal population-based study

PURPOSE

To examine health-related quality of life (HRQoL) and supportive care needs among young adult (YA) cancer survivors up to 3 years post-diagnosis.

METHODS

A national cohort of individuals diagnosed at 18-39 years with breast, cervical, ovarian, or testicular cancer, lymphoma or brain tumor was approached with surveys at 1.5 (n = 1010, response rate 67%) and 3 (n = 722) years post-diagnosis. HRQoL was measured using the EORTC QLQ-C30. Scores were dichotomized using cut-off scores to predict supportive care needs in the Supportive Care Needs Survey-Long Form 59 (SCNS-LF59). Swedish cancer quality registers provided clinical data. Factors predicting need of support at 1.5 and 3 years post-diagnosis were identified using logistic regression.

RESULTS

HRQoL improvements over time were trivial to small. At both time points, a majority of respondents rated HRQoL levels indicating supportive care needs. At 1.5 years post-diagnosis, the risk of having support needs was lower among survivors with testicular cancer (compared to lymphoma) or university-level education, and higher among those on treatment (predominantly endocrine therapy). At 3 years post-diagnosis, when controlling for previous HRQoL scores, most correlations persisted, and poor self-rated household economy and chronic health conditions were additionally associated with supportive care needs.

CONCLUSION

A majority of YAs diagnosed with cancer rate HRQoL at levels indicating support needs up to 3 years post-diagnosis. Testicular cancer survivors are at lower risk of having support needs. Concurrent health conditions and poor finances are linked to lower HRQoL. More efforts are needed to provide adequate, age-appropriate support to YA cancer survivors.

Translation and psychometric evaluation of the Korean version of the Reproductive Concerns After Cancer Scale (RCAC)

BACKGROUND

Improving cancer survival rates highlights post-treatment fertility implications for reproductive-aged women. To provide fertility care for cancer survivors, nurses need instruments to assess and communicate reproductive concerns with cancer survivors and healthcare providers. This study aimed to translate the Reproductive Concerns after Cancer Scale (RCAC) into Korean and examine its psychometric properties in young female cancer survivors in South Korea.

METHODS

The RCAC was translated into Korean, involving expert bilingual translators for initial translation and reverse translation for cultural and semantic accuracy. In detail, the RCAC was translated into Korean and evaluated in a preliminary study involving 10 cancer survivors. Subsequently, a revised version of the instrument was administered to 182 cancer survivors and a psychometric evaluation was conducted. The process included verifying content validity, and then assessing construct validity using exploratory factor analysis and criterion validity. The reliability of the instrument was quantified by measuring its internal consistency using Cronbach's alpha.

RESULTS

The translated RCAC demonstrated an item-level content validity index of 1.0 and a scale-level index of 1.0. The content was finalized based on preliminary survey findings, which revealed that all participants thought the instrument was clear. The Korean version of the RCAC demonstrated a satisfactory level of validity per exploratory factor analysis, which resulted in a 14-item instrument consisting of three subscales: "fertility potential" (six items), "health problem" (five items), and "acceptance" (three items). The items and subscales explained 57.6% of the variance. Criterion validity was confirmed through an analysis of the correlation between the Korean version of the RCAC and both the FACT-G (r = -0.36, p < .001) and PHQ-9 (r = 0.38, p < .001). Cronbach's alpha coefficient of the Korean version of the RCAC was 0.83.

CONCLUSIONS

The Korean version of the RCAC is a valid and reliable instrument for assessing reproductive concerns in female cancer survivors. Thus, this instrument can be used to provide tailored care to female cancer survivors of reproductive age by clarifying and assess their reproductive concerns. This may support the development of guidelines or policies to provide care for those with reproductive concerns who require nursing care.

Testicular Cancer Treatments and Sexuality: A Narrative Review

The incidence of testicular cancer (TC) has been rapidly increasing over the past years. Diagnosis and early treatment have shown good oncological control, guaranteeing the patient different treatment approaches according to histology and tumor stage. Currently, physicians usually prioritize oncological outcomes over sexual outcomes and quality of life, considering as a first aim the overall survival of the patients; however, differently from other neoplasms, quality of life is still strongly affected among TC patients, and sexual outcomes are frequently compromised after each TC treatment. Several studies have suggested that each treatment approach may be associated with sexual dysfunctions, including erectile dysfunction, ejaculatory disorders, fertility issues, and hormonal changes. Since testicular cancer patients are more frequently young men, the subject of this work is substantial and should be analyzed in detail to help specialists in the management of this disease. The aim of the current narrative review is to generally describe every treatment for TC, including surgery, chemotherapy, radiotherapy, and retroperitoneal lymph node dissection, and to establish which sexual dysfunction may be specifically associated with each therapy.

Efficacy of a web-based psychoeducational intervention targeting young adults with sexual problems 1.5 years after cancer diagnosis-Results from a randomized controlled trial

Objective

To test the efficacy of a web-based psychoeducational intervention, Fex-Can Sex, in reducing sexual dysfunction in young adults with cancer.

Methods

This randomized controlled trial evaluated a 12-week web-based self-help intervention. Young adults aged 19-40 who reported sexual dysfunction 1.5 years after cancer diagnosis were drawn from a population-based cohort. Participants were randomized to an intervention group (IG, n = 72) or a control group (CG, n = 66) that solely received standard care. Primary outcome was assessed by a domain of the Patient Reported Outcome Measures Information Systems® SexFS: "Satisfaction with sex life." Secondary outcomes included additional SexFS domains, body image (BIS), emotional distress (HADS), health-related quality of life (EORTC QLQ-C30), and self-efficacy related to sex. Surveys were completed at baseline, post-intervention, and three months later. Effects of the intervention were tested with t-tests, and linear mixed models (LMMs), including intention-to-treat and subgroup analyses. Additionally, the IG was asked about their experiences of the program with study-specific questions.

Results

There were no differences in primary or secondary outcomes between the IG and the CG at post-intervention. Subgroup analyses showed that individuals with greater sexual problems at baseline improved over time, regardless of group allocation. Participants spent a mean time of 20.7 min on the program. The study-specific items showed that the majority of participants in the IG appreciated the program and would recommend it to others.

Conclusion

The Fex-Can Sex intervention did not show effect on primary and secondary outcomes. Adherence to the intervention was low, and future interventions are recommended to include more interactive components to enhance usage.

Clinical trial registration

The trial was registered on 25 January, 2016 (trial number: 36621459).

Prevalence and predictors for fertility-related distress among 1010 young adults 1.5 years following cancer diagnosis - results from the population-based Fex-Can Cohort study

BACKGROUND

Cancer treatment during reproductive ages may negatively impact fertility and there is a need of firm knowledge about the prevalence and predictors of fertility-related distress. The aim was to examine fertility-related distress in a population-based sample of young women and men recently treated for cancer and to identify predictors for this outcome.

MATERIAL AND METHODS

This nationwide cohort study included 1010 individuals (694 women and 316 men), mean age 34.5 ± 4.9 and 32.1 ± 5.5, respectively, diagnosed with breast, cervical, ovarian, testicular cancers, brain tumors or lymphoma at ages 18-39 in Sweden. Participants completed a survey 1.5-year post-diagnosis to assess fertility-related distress (RCAC), emotional distress (HADS) and self-efficacy, as well as sociodemographic and clinical factors and fertility preservation. Logistic regression was used to examine associations between explanatory factors and high fertility-related distress (RCAC subscale mean >4).

RESULTS

Many participants (69% of women and 47% of men) had previous children and about half reported a wish for future children. High fertility-related distress was more prevalent among women (54%) than men (27%), and women were more likely than men to report distress concerning all but one RCAC dimension after adjustment for sociodemographic factors. Use of fertility preservation was unevenly distributed (15% of women and 71% of men) and was not associated with decreased fertility-related distress. In multivariable logistic regression models, a wish for future children, being single, not having previous children, symptoms of anxiety and low self-efficacy regarding one's ability to handle threats of infertility were associated with high fertility-related distress.

CONCLUSION

This nationwide study found a high prevalence of fertility-related distress in young women and men recently treated for cancer and identified sociodemographic and psychological predictors. Fertility preservation was not found to act as a buffer against fertility-related distress, indicating the continuous need to identify strategies to alleviate fertility distress following cancer.

The role of a discussion forum within a web-based psychoeducational intervention focusing on sex and fertility-What do young adults communicate?

OBJECTIVE

This study sought to investigate interactive participation and content of a moderated discussion forum within a web-based psychoeducational intervention aimed at alleviating sexual dysfunction and fertility distress in young adults diagnosed with cancer.

METHODS

The study is part of the Fex-Can Young Adult randomized controlled trial (RCT), in which young adults with self-reported sexual dysfunction or fertility distress were invited to participate. This study focuses on RCT participants that were randomized into the intervention condition. Sociodemographics and clinical characteristics of intervention participants and level of activity in the intervention were analyzed with descriptive statistics and compared between subgroups ("high" and "low" activity participants). Inductive qualitative thematic analysis was used to analyze the posts in the discussion forum.

RESULTS

Of 135 intervention participants, 24% met the criteria for high activity participation. There were no statistically significant differences found in terms of clinical and sociodemographic characteristics between high and low activity participants. Ninety-one participants (67%) accessed the discussion forum, and 19 (14%) posted at least once. Posters shared intimate details of their experiences of sexuality and fertility following cancer. The thematic analysis of posts resulted in four themes: fertility fears, perceptions of the changed body, missing out on life, and importance of support and information.

CONCLUSIONS

While a smaller proportion of participants posted in the discussion forum, a majority spent time reading posts (lurkers). Participants posting in the forum shared experiences of intimate relationships, body image, parenthood concerns, and support needs. The discussion forum was used by a majority of intervention participants, and provided appreciated support for those who posted in the forum. We therefore recommend similar interventions to include this opportunity for interaction and communication.

Do young adults with cancer receive information about treatment-related impact on sex life? Results from a population-based study

BACKGROUND

Sexual dysfunction is common following a cancer diagnosis in young adulthood (18-39 years) and problems related to sex life are ranked among the core concerns in this age group. Yet, few studies have investigated to what extent adults younger than 40, receive information from healthcare providers about the potential impact of cancer and its treatment on their sex life.

METHODS

A population-based cross-sectional survey study was conducted with 1010 young adults 1.5 years after being diagnosed with cancer (response rate 67%). Patients with breast, cervical, ovarian and testicular cancer, lymphoma, and brain tumors were identified in national quality registries. Sociodemographic and clinical factors associated with receiving information were examined using multivariable binary logistic regression.

RESULTS

Men to a higher extent than women reported having received information about potential cancer-related impact on their sex life (68% vs. 54%, p < 0.001). Receipt of information varied across diagnoses; in separate regression models, using lymphoma as reference, both women and men with brain tumors were less likely to receive information (women: OR 0.10, CI = 0.03-0.30; men: OR 0.37, CI = 0.16-0.85). More intensive treatment was associated with higher odds of receiving information in both women (OR 1.89; CI = 1.28-2.79) and men (OR 2.08; CI = 1.09-3.94). None of the sociodemographic factors were associated with receipt of information.

CONCLUSIONS

To improve sexual health communication to young adults with cancer, we recommend diagnosis-specific routines that clarify when in the disease trajectory to discuss these issues with patients and what to address in these conversations.

Psychometric evaluation of the Swedish version of the PROMIS Sexual Function and Satisfaction Measures in clinical and nonclinical young adult populations

Background

The Patient-Reported Outcomes Measurement Information System (PROMIS®) Sexual Function and Satisfaction (SexFS) version 2.0 measurement tool was developed to assess sexual functioning and satisfaction in the general population regardless of health condition and sexual orientation.

Aim

The study aimed to evaluate the psychometric properties of the Swedish version of the PROMIS SexFS measure in clinical and nonclinical populations of young adults (aged &lt;40 years).

Methods

The SexFS was answered by a clinical population of young adult women (n = 180) and men (n = 110) with breast cancer and testicular cancer, respectively, and a nonclinical population of young adult women (n = 511) and men (n = 324) from the general population. Psychometric properties were evaluated by examining data quality (score distribution, floor and ceiling effects, proportion of missing data), construct validity (corrected item, total correlation, scaling success), and reliability (Cronbach α).

Outcomes

The following domains of the SexFS 2.0 were investigated: Vaginal Lubrication, Vaginal Discomfort, Vulvar Discomfort- Clitoral, Vulvar Discomfort- Labial, Erectile Function, Interest in Sexual Activity, Satisfaction With Sex Life, Orgasm– Ability, and Orgasm- Pleasure.

Results

The Swedish version of the SexFS 2.0 generated data of acceptable quality. Some noteworthy floor or ceiling effects were identified across domains and respondent groups. Corrected item totals were used to express the coherence between an item and the other items in the domain. The correlation coefficients were above 0.40 for all items, except for 1 of the items within the Vaginal Discomfort domain and for the items in the Erectile Function domain in the nonclinical group of men. High proportions of scaling success were noted across domains (96%-100%). Reliability was satisfactory (α = 0.74-0.92) for all domains, expect for Erectile Function of the nonclinical group (α = 0.53), due to low variability in item responses, which was improved somewhat (α = 0.65) when combined with the clinical group.

Clinical Implications

A flexible tool to measure self-reported sexual function and satisfaction in young men and women is available for researchers and clinicians in Sweden.

Strengths and Limitations

The nationwide population-based sample of patients with cancer, identified from national quality registers, minimized selection bias. However, men in the general population had a lower response rate (34%) compared to the other groups, which introduced a risk of bias in estimates. The psychometric evaluation was limited to young adults (aged 19-40 years).

Conclusion

The results provide evidence for the validity and reliability of the Swedish version of the SexFS measure for the assessment of sexual functioning and satisfaction in young adults from both clinical and nonclinical populations.

Translation and validation of Persian version of sexual function: vaginal changes questionnaire (SVQ) for women with gynecologic cancers

Background

Changing in the sexual function is an important condition in women with gynecological cancers. A valid and reliable questionnaire is required to assess this condition. The aim of this study was to translate and validate the Persian version of the Sexual-Vaginal Function Changes Questionnaire (SVQ) in women with gynecologic cancers.

Methods

This methodological study with a psychometric design was conducted on 250 women with gynecologic cancers, who visited public and private medical centers in Tehran to receive follow-up services. Convenience sampling was conducted from April 2019 to May 2020. First, the Persian version of the Sexual Function-Vaginal Changes Questionnaire was developed and then, psychometric properties such as content validity, face validity, construct validity and criterion validity were assessed. Reliability of the instrument was assessed by Cronbach's alpha coefficient.

Results

Mean age of participants was 53.3 ± 11.8 and mean score of SVQ was 63.0 ± 9.1 in the possible range of 26–104. Content validity was tested through qualitative method and six items were revised as suggested by the expert panel. Cronbach's alpha coefficient was 0.71 for the whole questionnaire and it was 0.93, 0.92, 0.89, 0.78, 0.88 and 0.78 for the 6 subscales, respectively, which shows the optimal internal consistency. Results of exploratory factor analysis revealed six factors as (1) intemacy and sexual interst, (2) arousal, (3) changes in intemacy and sexual interst after cancer, (4) vaginal changes after cancer, (5) vaginal bleeding during coitus, (6) and sexual worry and dissatisfaction after cancer. explained 70.09% of the variance observed. Criterion validity test of the questionnaire showed a significant correlation between the total SVQ scores and the total Female Sexual Function Index (FSFI) scores as well as between SVQ dimensions and dimensions of FSFI (P < 0.001).

Conclusions

The findings from this study indicated that the Persian version of the SVQ is a valid and reliable instrument to assess sexual function-vaginal changes in women with gynecologic cancers.

Prevalence and risk factors for sexual dysfunction in young women following a cancer diagnosis - a population-based study

BACKGROUND

Self-reported sex problems among women diagnosed with reproductive and nonreproductive cancers before the age of 40 are not fully understood. This study aimed to determine sexual dysfunction in young women following a cancer diagnosis in relation to women of the general population. Furthermore, to identify factors associated with sexual dysfunction in women diagnosed with cancer.

MATERIALS AND METHODS

A population-based cross-sectional study with 694 young women was conducted 1.5 years after being diagnosed with cancer (response rate 72%). Potential participants were identified in national quality registries covering breast and gynecological cancer, lymphoma and brain tumors. The women with cancer were compared to a group of women drawn from the general population (N = 493). Sexual activity and function were assessed with the PROMIS® SexFS. Logistic regression was used to assess differences between women with cancer and the comparison group, and to identify factors associated with sexual dysfunction.

RESULTS

The majority of the women with cancer (83%) as well as the women from the comparison group (87%) reported having had sex the last month (partner sex and/or masturbation). More than 60% of the women with cancer (all diagnoses) reported sexual dysfunction in at least one of the measured domains. The women with cancer reported statistically significantly more problems than women of the comparison group across domains such as decreased interest in having sex, and vaginal and vulvar discomfort. Women with gynecological or breast cancer and those receiving more intense treatment were at particular high risk of sexual dysfunction (≥2 domains). Concurrent emotional distress and body image disturbance were associated with more dysfunction.

CONCLUSION

The results underscore the need to routinely assess sexual health in clinical care and follow-up. Based on the results, development of interventions to support women to cope with cancer-related sexual dysfunction is recommended.

Reproductive concerns and contributing factors in women of childbearing age with systemic lupus erythematosus

OBJECTIVES

Reproductive concerns are common in women of childbearing age with systemic lupus erythematosus (SLE) with inadequate disclosure. This study aimed to investigate the contributing factors of reproductive concerns and to evaluate their impact on health-related quality of life.

METHODS

One hundred eighty women of childbearing age with SLE were enrolled in this cross-sectional study in Affiliated Hospital of Nantong University from March 2021 to December 2021. A series of questionnaires were conducted: Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Fatigue Inventory (MFI-20), Female Sexual Distress Scale-Revised (FSDS-R), Family Assessment Device (APGAR), the Medical Coping Modes Questionnaire (MCMQ), the Short-Form 36 (SF-36), and the Chinese version of Reproductive Concerns After Cancer (RCAC). Independent t test, one-way ANOVA, Mann-Whitney U test, Pearson/Spearman, and multiple linear stepwise regression were used to analyze the data.

RESULTS

The results indicated that female SLE patients were more concerned about the child's health and personal health than becoming pregnant, fertility potential, partner disclose and acceptance; SLE patients with the characteristics of living in rural residence, having no reproductive history, fearing unexpected pregnancy, sexual distress, and depression showed more serious fertility concerns. Meanwhile, most female SLE patients adopted active confrontation when facing reproductive concerns, and these patients were significantly lower in the dimension score of mental related quality of life.

CONCLUSIONS

Our study demonstrated that female SLE patients should be paid more attention to their fertility concerns and effective intervention measures should be carried out to relieve their reproductive concerns, so as to improve their long-term quality of life if their disease condition permits.

Cross-sectional study on the impact of age, menopause and quality of life on female sexual function

We sought to determine the prevalence of female sexual dysfunction (FSD) and to examine the influence of age, menopausal state and quality of life (QoL) on the female sexual function (FSF) of healthy women and those with benign gynaecological disease. With this purpose, we conducted a cross-sectional study, based on self-report questionnaires (sociodemographic, WHOQOL-BREF and FSFI), enrolling 107 women. Some 51.6% (n = 55) were diagnosed with FSD. We found no statistical significant differences between grouped reason for consultation and FSFI total score (p = .72) and its domains (p > .05). The results showed a negative strong correlation between age and FSFI total score (S= -0.71) and a positive moderate correlation between WHOQOL-BREF and FSFI total scores (S = 0.39). We observed statistically significant differences between menopausal state and FSFI total score (p = .001). In conclusion, the prevalence of FSD in our population was 51.6%. Our study results reveal that a reduction in FSFI scores has a negative impact on QoL and vice versa, regardless of the reason for consultation. Elderly age and postmenopausal state have deleterious effects on FSF.Impact statementWhat is already known on this subject? Poor QoL can adversely affect FSF and vice versa. The study of FSF is relatively recent and there is controversy regarding the deleterious effects of elderly age and menopause on FSF. The prevalence of FSD is difficult to precisely determine, given the studies' use of different definitions for FSD and the highly heterogeneous study populations, as well as the types of tests and questionnaires employed. Sexual difficulties are problems seldom discussed between patients and their physicians. Lack of time, misconceptions, shame and frustration, considering sexuality as too intimate to discuss in the doctor's office, uncertainty regarding therapeutic options and insufficient training of health professionals are just some of the reasons mentioned for not addressing sexual dysfunction in a general consultation.What do the results of this study add? Our study is the first research in Spain on the impact of age, menopause and QoL on gynaecological patients´ FSF. Our results indicate that an impaired FSF could be related to poorer well-being and QoL; however, benign gynaecological disease does not appear to affect FSF. Elderly age and postmenopausal state can have deleterious effects on FSF.What are the implications of these findings for clinical practice and/or further research? Sexuality is an important aspect of QoL. Therefore, gynaecologists should discuss issues of sexuality with their patients in routine visits, especially in case of elderly and postmenopausal women. In addition, gynaecologists should train in the diagnosis and treatment of the female sexual dysfunction.

Fertility-related information received by young women and men with cancer - a population-based survey

BACKGROUND

Infertility is a well-known sequela of cancer treatment. Despite guidelines recommending early discussions about risk of fertility impairment and fertility preservation options, not all patients of reproductive age receive such information.

AIMS

This study aimed to investigate young adult cancer patients' receipt of fertility-related information and use of fertility preservation, and to identify sociodemographic and clinical factors associated with receipt of information.

MATERIALS AND METHODS

A population-based cross-sectional survey study was conducted with 1010 young adults with cancer in Sweden (response rate 67%). The inclusion criteria were: a previous diagnosis of breast cancer, cervical cancer, ovarian cancer, brain tumor, lymphoma or testicular cancer between 2016 and 2017, at an age between 18 and 39 years. Data were analyzed using logistic regression models.

RESULTS

A majority of men (81%) and women (78%) reported having received information about the potential impact of cancer/treatment on their fertility. A higher percentage of men than women reported being informed about fertility preservation (84% men vs. 40% women, p < .001) and using gamete or gonadal cryopreservation (71% men vs. 15% women, p < .001). Patients with brain tumors and patients without a pretreatment desire for children were less likely to report being informed about potential impact on their fertility and about fertility preservation. In addition, being born outside Sweden was negatively associated with reported receipt of information about impact of cancer treatment on fertility. Among women, older age (>35 years), non-heterosexuality and being a parent were additional factors negatively associated with reported receipt of information about fertility preservation.

CONCLUSION

There is room for improvement in the equal provision of information about fertility issues to young adult cancer patients.