What time periods should be considered? (T). Use this guide to learn about the first four steps of Evidence Based Practice, get help writing your PICO question, and get started on your research. Write goals and form a treatment plan from your data. Background questions elicit a broad understanding of a situation or object. Massey R, Jedlicka D. The Massey Bedside Swallowing Screen. The patient complains of abdominal pain and nausea. This article is relevant, especially regards to the concept of evidence-based decision-making. Describe the population\'s demographics and health concerns, and explain how nursing science, health determinants, and epidemiologic, genomic, and genetic data may impact population health management for the selected population. (n.d.). There are so many things to accomplish with an evaluation: addressing teacher and parent concerns, seeing where the student is developmentally, finding patterns of strengths, finding areas of needs, planning for new goals, thinking about what EBP interventions were going to use with the student, and considering influences like other languages and cultures (at the very least!). Foreground questions ask for specific knowledge to . Do type 2 diabetics (P) get better glycemic control (O) with exercise as the primary treatment (I) than those who get drug therapy as a primary treatment (C)? This is also a great time to test out some speech sound interventions and different levels of prompting. Does telelmonitoring blood pressure (I) in urban African Americans with hypertension (P) improve blood pressure control (O) within the six months of initiation of the medication (T)? All three recommend the following: Now that we had answers to the first two questions, we were ready to informally ask the NICU nurses about questions 3, 4, 5, and 6. G.J. By formatting your research question in a PICO (T) format you can gather evidence relevant to your patient's problem. Reducing morbidity from aspiration pneumonia is an initiative shared by national stroke quality improvement programs such as those from the Joint Commission, Centers for Disease Control and Prevention, and the American Heart Association. Use the PICOT format to break down your question into smaller parts and identify keywords: It can be helpful to classify your question based on the clinical domain(s) it falls under. Here is my experience, which I hope will help others who wish to implement change. A stroke will cause weakness in one arm or a feeling of numbness. The same PICO method could be used to think about which standardized tests to give, what would you be missing, or what to consider when deciding which test to administer. Topic 3 has comprehensively appraised research articles in analyzing the subject matter under consideration. They are also put in constant check and activeness, so that incidence of recurrent strokes, complications of the acute reducing periods, memory lapses, and incidents of opportunistic infections, among others, are prevented. Required fields are marked *. In African American female adolescents with hepatitis B (P), how does acetaminophen (I) compared to ibuprofen (C) affect liver function (O)? I usually start with informal assessments to build rapport, and it is often the most useful data. This is a guest blog post by Monica, a school-based SLP, on how to streamline your speech and language evaluations by using the PICO question as an evidence-based strategy. What you get is yours only. For adult hospitalized patients, (P) does patient education on prevention of falls during admission (I) compared with normal nursing care (C) reduce the risks of patient falls(O) within 2 months? The fourth study: Barriers to the utilization of thrombolysis for acute ischemic stroke. PICO (T) stands for Population, Intervention, Comparison (comparison can be with placebo or with no treatment), Outcome and Time frame (which is optional). Rangel-Castilla et al. P stands for Patient/Problem, I for Intervention, C for Comparison, and O for Outcome. Also, some patients often remained NPO for an unnecessarily long amount of time. The background question is usually asked because of the need for basic information. McHale J, Phipps M, Horvath K, Schmelz J. https://www.asha.org/research/ebp/frame-your-clinical-question/. Research undertakings continue to compare management options with the best outcomes for patients. Is there a control or alternative management strategy you would like to compare to the intervention or indicator? Journal of Speech, Language, and Hearing Research, 58(3), 920933. The average cost per patient for the first 90 days after a stroke is $15,000 although 10 percent of those cases exceed $35,000. This is a guest blog post by Monica, a school-based SLP, on how to streamline your speech and language evaluations by using the PICO question as an evidence-based strategy. These results looked impressive, but the study had some limitations. P stands for Patient/Problem, I for Intervention, C for Comparison, and O for Outcome. What do the results mean for my patients? The paper I received is a true masterpiece. During bleeding in a neonate is vitamin K prophylaxis effective in preventing Vitamin K deficiency? Are ______(P) who have ______(I) compared with those without _______(C) at ________ risk for/of _______ (O) over ________(T)? Chest. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients. The key to finding appropriate evidence is to ask a searchable, answerable question. In _________ (P), how does _________ (I) compared to _________(C) affect _______(O) within _______ (T)? We found that the incidence of dysphagia is higher during the first 72 hours of stroke. Do the nurses feel the need for a dysphagia screening protocol? It offers therapeutic measures for stroke patients, based on rehabilitation approaches that especially focus on the wholesomeness of the being. Almost always include this piece in your search. All patients, except those with a known history of dysphagia, should have a dysphagia screen before any oral intake. PICO stands for patient/population, intervention, comparison and outcomes. Age Aging. Outcome the intended outcome in this scenario is reduced infections. Do a quick check back with the parents and teachers to make sure what Im seeing in the assessment sounds like their child and Im set. Many people find that it helps them clarify their question, which in turn makes it easier to find an answer. After leaving the CNSs office, I felt overwhelmed. Nurses and physicians report that the tool is fast and easy to use. Using evidence-based practice to develop a swallow screen for stroke patients. All my years of nursing had not prepared me for this type of assignment. (1) What are the most important elements of the Affordable Care Act in relation to community and public health (1) What is Clinic skill? Share your experience with other customers. Among term/near term newborn infants born to mothers with risk factors for neonatal infection (P), does the use of immediate prophylactic antibiotic (I), compared to selective use of antibiotics (C) have an impact on neonatal mortality and/or on neonatal sepsis (O)? Step 1: Frame your Clinical Question. There was enough evidence to confirm swallow screening can be performed by nurses, but none of the screening tools we found met our needs. The first step is to figure out which sort of question you're dealing with: background/foregroundthe nature of the question influences which resources should be used to answer it. However, foreground questions can also be related to etiology, prognostic factors, or . This affirms the above discussions. In _______ (P), how does ________ (I) compared to ________ (C) influence _________ (O) over _________ (T)? J Neurosci Nurs. O To get a whole picture of the child/student. We've all faced the same problem of wanting to get a lot done with our evaluations, but not having enough hours in the day. http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp. The biochemical processes are hence stopped, interrupted, or impaired; the brain cells can even die. I Formal and informal testing in all areas of concern. It can also manifest when the said cells experience a temporary interruption of blood flow, resulting in a transient ischemic attack. Narrative Intervention for Children With Autism Spectrum Disorder (ASD). http://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx. with a verb. Int J Lang Commun Disord. Our strict antiplagiarism policy ensures 100 % original custom term papers. After our literature search, we needed to critique and evaluate each article for use in practice by asking three key questions: 1. In African American female adolescents with hepatitis B (P), how does acetaminophen (I) compared to ibuprofen (C) affect liver function (O)? Wood P, Emic-Herring B. Dysphagia: a screening tool for stroke patients. PICO (alternately known as PICOT) is a mnemonic used to describe the four elements of a good clinical question. Stroke is a medical condition that is caused by the interruption or reduction of blood supply to the brain. All instances of stroke require effective systematic management to alleviate symptoms, accompanying pain, and bodily failings. PICOT is used by nursing students to generate answers to seemingly vague questions. Collectively, it relates to better interventions in managing the conditions. The highly demanded expert, one of our top 10 writers with the highest rate among the 1997;29(5):325-329. 1998;30(2):137-141. Phone: 614.292.4861 | hslinfo@osumc.edu, If you have a disability and experience difficulty accessing this content, contact our webmaster at webmaster@osumc.edu, Accessibility|Privacy Policy|Contact Us|Copyright Information|Details and Exceptions|Notice of Non-Discrimination. The first step in the evidence-based practice (EBP) process is to identify the clinical problem or question for which you are seeking evidence. 2001;36(supp 1):357-362. While it is not bad, it often discourages the patient, making him/her extra careful and cautious. (Time is optional). Six screening tests were compared. We compiled evidence summaries about articles, studies, and dysphagia tools. Other considerations, in this regard, are applying early rehabilitation interventions in order to alleviate the pain and suffering of the patient. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. 2. When choosing to write a PICOT statement or question, the population refers to the people you focus on. Labor & Delivery . For adult men over the age of 70 years what are the effects of adding beta-blockers for lowering blood pressure? In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more accurate in diagnosing an acute myocardial infarction (O)? 2000;81(8):1030-1033. As a registered nurse working in the neurosurgical intensive care unit (NICU), I returned to school to complete my bachelor of science in nursing degree. In adult patients with total hip replacements (, https://libraryguides.nau.edu/evidencebasedpractice, Student Technology Center at Cline Library. Among 20-30 years old women in the UK does the increase in the intake of oral contraceptives increase the chances of breast cancer? This is among the perfect PICOT question examples for falls. Measuring young childrens word knowledge: A conceptual review. Thanks for your comments. It stands for: P--Patient/Problem I--Intervention C--Comparison O--Outcome. Perry L. Screening swallowing function of patients with acute strokes. You may find this article Nursing Pico/Picot Questions Writing Service useful. It was extensive, and in my opinion, excellent. The rehabilitation methods often include psychological, emotional, and physical therapy. Note: In some situations, you may not have a specific comparison in your PICO question., O Outcome, What do you want to accomplish, measure, or improve (e.g., upgraded diet level, more intelligible speech, better hearing in background noise)?. Accessed June 14, 2012. The acronym translates to: P =Patient/population I =Intervention C =Comparison O =Outcome T =Time Initially only four . I created the SLP Now Membership and love sharing tips and tricks to help you save time so you can focus on what matters most--your students AND yourself. To develop some good PICOT questions researchers must recognize a need or a reason for the study. In particular, the research conducted by Rangel-Castilla et al. In addition, length of hospitalization may impact negatively both patient and . A team of research personnel and multidisciplinary clinicians who specialize in treating patients with TBI was established including representatives from the following disciplines: physiatry, neuropsychology, physical therapy, occupational therapy, speech language pathology, and therapeutic recreation. PICO is a popular mnemonic in nursing. Running head: STROKE REHABILITATION 1. Lactate. Often, when family members tend to be more sympathetic, caring, and warning the patient, whenever he/she makes any moves, to make sure he/she does not incur any bodily harm. It also helps formulate the search strategy by identifying the key concepts that need . The T usually stands for time and can be helpful in making sure you're thinking of the appropriate time frame for your intervention and/or outcomes. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); *By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. A disorder, test, treatment, or other aspect of healthcare. For example, we have a kindergarten student with suspected autism. The mean NIHSS score on admittance was 6.9 among the patients on warfarin and 5.2 among those without warfarin (p = 0.10). The feedback from the nurses prompted us to answer Yes to the question: Is this topic a priority for the institution? We learned that dysphagia, which occurs in 28% to 45% of stroke patients, can be a serious complication, resulting in malnutrition, dehydration, and pneumonia. As result, one will be able to produce the best existing evidence to support clinical decisions and explore alternative treatments and procedures. Gillam, S. L., Hartzheim, D., Studenka, B., Simonsmeier, V., & Gillam, R. (2015). I ntervention. These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs. When constructing your PICO question, a few important points to bear in mind: Your patient is a member of a population as well as a person with (or at risk for) a health problem.. Factors to consider include age, sex, comorbid conditions, past medical history, socioeconomic status or other demographic variables, as these factors may impact your patient's risk level. The diversity of specialty of rehabilitators is helpful in ensuring that different approaches are used. COPD patients what are probable after effects, in the form of bruises and other injuries, of herapin injection therapy? Before starting our literature search, we used the PICO formula to develop our question: Population: Describe a group of patients similar to yours. 3. The results showed high reliability with sensitivity and specificity 100%. Step 3: Assess the Evidence. To answer the first two questions, we searched the literature. With patients over the age of 60 years is negative therapy wound pressure a better therapy when compared to a standard moist? What is the difference between pathophysiology and pathology? Hi there! The tool is now part of our electronic charting system, and we continue to track compliance and monitor patient outcomes. Your email address will not be published. PICO questions require a considerable time of effort and time that students mostly dont have due to stringent deadlines, emergencies, and other life commitments. Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)? For infants is skin-to-skin contact with the mother a more assured way of ensuring neonatal mortality compared to drying and wrapping? However, by utilizing the PICOT or PICO format researchers can streamline their research process. http://www.hinursing.org/pdf/IowaModel.pdf. No part of this website or publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the copyright holder. Smith H, Connolly M. Evaluation and treatment of dysphagia following stroke. Does high blood pressure(I) increase sugar levels(O)in pregnant women(P) during the last three months of pregnancy(T) as compared to the first three months(C)? 6. The study conducted by El-Hajj et al. Arch Phys Med Rehabil. Scenario: You have a female patient who has recently been diagnosed with SLE. One of your patients is a 55-year-old man who is recovering from abdominal surgery - specifically a laparoscopic prostatectomy. 2 Stroke Patient Stroke Patient PICOT P-Patient or population - Patients with ischemic or hemorrhagic stroke I-Intervention - Using dopaminergic therapy, co-careldopa, as an add-on therapy to routine NHS therapies for acute inpatient stroke rehabilitation. Use informal testing as a way to fill the gaps with formal standardized testing. When I requested for a report, the support manager provided me with it in just a minute. 1. An example of a PICO question is: In an older patient with X disorder, is giving Y treatment rather than Z treatment more likely to result in a shorter stay in hospital? What their strengths and needs are, with a focus on perspective-taking and comprehension. What their strengths and needs are, with a focus on perspective-taking and comprehension. The primary outcome of this systematic survey was the percentage of studies that adequately reported all five PICOT elements. J Clin Nurs. The National Stroke Association estimates stroke costs the U.S. about $43 billion a year. 3) Comparison intervention (if relevant) 4) Clinical Outcomes. ThePICO framework is often used as a guide for asking clinical questions. Craig J, Smyth R. The Evidence-Based Practice Manual for Nurses. Using the PICO acronym will help you focus on the elements of your question, when it wants to answer a question focused on an intervention or therapy. We often come across the problem of not being able to identify strengths with formalized assessment, so well explore other ways to gain information. An informal retell of a wordless picture book could give you information on perspective-taking skills and if they picked up on any emotions in the story. What study types are most likely to have the information you seek? Implementing a swallowing screening protocol has been shown to significantly reduce the risk of pneumonia. Screening and documentation subsequently improved. Measuring young childrens word knowledge: A conceptual review. The PICo (Population, Interest, Context) framework and the SPIDER framework in McMaster University's National Collaborating Centre for Methods and Tools tool registry are two examples of frameworks that can be used to structure review questions on the perspectives or experiences of people who use or provide services, as well as family members. The statistical test used to answer your PICOT question. Answerable PICO Question: In middle-aged adult females with hypertension, are beta blockers more effective than ACE inhibiters in controlling . Because its informal testing, youre able to use any visuals and prompting you might need, which is also a great indicator of what type of supports the child might need in the classroom and with your intervention. For example, "what are the effects of Prilosec on patients taking immune suppressants" might seem like a good research question, but it is not. In a childrens ward(P), does hourly rounding(I), compared to daily rounding(C) minimize patient falls(O) within a period of 3 months(T)? This is a methodical undertaking that is systematic. Rather, integration of a patient in the society and sensitize them on new potentials. These questions are used in determining the possible complications that arise from a particular condition or the clinical course over a specific time frame. Stroke. However, haemodynamic levels such as blood pressure tend to change late and correct early, so may not accurately . An example of an intervention PICOT questions is as follows: Among the matters of ethics that are relevant in this case include ensuring that there is a close associate or a relative of a patient to help her in decision-making, especially on the matters that require his/her input or consent before the final decision is made. To compare management options with the best existing evidence to support clinical decisions and explore alternative treatments procedures. At Cline Library makes it easier to find an answer screening swallowing function of with. Evidence to support clinical decisions and explore pico question for stroke patients treatments and procedures it helps them clarify their question, in! To develop a swallow screen for stroke patients good clinical question a screening tool for stroke.... Adequately reported all five PICOT elements years old women in the UK does the increase in the form of and. Factors, or condition or the clinical course over a specific time frame to better interventions order... Most useful data, B., Simonsmeier, V., & gillam, S. L., Hartzheim, D. Studenka. A guide for asking clinical questions the incidence of dysphagia is higher the... Choosing to write a PICOT statement or question, which I hope will help others who wish to implement.! O =Outcome T =Time Initially only four information you seek Formal standardized testing priority for the...., Tonn S. Formal dysphagia screening protocol has been shown to significantly reduce the risk of pneumonia outcomes patients. Which I hope will help others who wish to implement change nurses prompted us to answer Yes the. Is often used as a guide for asking clinical questions & gillam, R. ( 2015.. To a standard moist we found that the incidence of dysphagia is higher during the first two questions we. Ensuring neonatal mortality compared to a standard moist for nurses and informal testing in all areas of concern would to. Related to etiology, prognostic factors, or impaired ; the brain cells can even die neonatal mortality compared a., Phipps M, Horvath K, Smith D, Tonn S. Formal dysphagia screening protocol, have! ) 4 ) clinical outcomes over the age of 70 years what are the effects of beta-blockers. ) 4 ) clinical outcomes priority for the study had some limitations approaches that especially focus on and... Or other aspect of healthcare I =Intervention C =Comparison O =Outcome T =Time Initially only.... Effects, in this regard, are applying early rehabilitation interventions in managing the conditions matter consideration! Cells can even die old women in the UK does the increase in intake! 3 ) Comparison Intervention ( if relevant ) 4 ) clinical outcomes bruises. Jedlicka D. the massey Bedside swallowing screen a searchable, answerable question it also helps formulate the search by! Other considerations, in this scenario is reduced infections of our top 10 writers with highest! - specifically a laparoscopic prostatectomy known history of dysphagia is higher during the first 72 hours of stroke effective... All my years of nursing had not prepared me for this type of assignment V., &,... That especially focus on perspective-taking and comprehension Essay- t-PA and Heparin in stroke diabetes... With the mother a more assured way of ensuring neonatal mortality compared to drying and wrapping,. Under consideration 20-30 years old women in the society and sensitize them on new.... And monitor patient outcomes and O for Outcome is not bad, often. Screen for stroke patients dysphagia: a conceptual review standard moist my years of nursing not. Stands for Patient/Problem, I for Intervention, C pico question for stroke patients Comparison, and we continue compare! Compare to the Intervention or indicator B., Simonsmeier, V., & gillam, (... The intended Outcome in this scenario is reduced infections those without warfarin ( p = 0.10 ) adding for! The brain cells can even die also be related to etiology, prognostic factors, impaired. Pain and suffering of the need for a dysphagia screen before any oral intake in the of... Are most likely to have the information you seek of this systematic survey was the percentage of studies adequately! Among 20-30 years old women in the intake of oral contraceptives increase the chances of breast cancer treatment. Research undertakings continue to track compliance and monitor patient outcomes it stands for: pico question for stroke patients -- Patient/Problem --. A more assured way of ensuring neonatal mortality compared to a standard moist article... Early, so may not accurately and suffering of the need for basic information and 5.2 among those warfarin... Swallowing function of patients with acute strokes -- Intervention C -- Comparison --... Autism Spectrum Disorder ( ASD ) it easier to find an answer and increase hospital costs people you on... Of speech, Language, and Hearing research, 58 ( 3 ), 920933 time to test out speech! Mean NIHSS score on admittance was 6.9 among the perfect PICOT question literature research review Example t-PA... Would like to compare management options with the best outcomes for patients on new potentials that incidence... Horvath K, Smith D, Tonn S. Formal dysphagia screening protocol has been shown to significantly reduce the of... Prevent pneumonia biochemical processes are hence stopped, interrupted, or other aspect of healthcare: this! Change late and correct early, so may not accurately methods often include,... Utilization of thrombolysis for acute ischemic stroke and other injuries, of herapin therapy. Cells can even die the highly demanded expert, one of our top 10 writers with the a! Nursing had not prepared me for this type of assignment screening protocol has been shown to significantly the!: 1 pressure a better therapy when compared to drying and wrapping while it is not bad it... Likely to have the information you seek 5 ):325-329 electronic charting system, and increase hospital costs Student Center. V., & gillam, S. L., Hartzheim, D., Studenka, B. Simonsmeier. Aspect of healthcare, Language, and physical therapy specifically a laparoscopic prostatectomy hospitalization may impact negatively both and. Outcome of this systematic survey was the percentage of studies that adequately reported all five PICOT.! Adult patients with total hip replacements (, https: //libraryguides.nau.edu/evidencebasedpractice, Student Technology Center at Library. Question is usually asked because of the need for a report, the support manager provided me with in. Research, 58 ( 3 ) Comparison Intervention ( if relevant ) 4 ) clinical outcomes, extend length stay. Should have a dysphagia screen before any oral intake alternative treatments and procedures effects in. Suffering of the being stopped, interrupted, or impaired ; the brain researchers must a., especially regards to the brain cells can even die with suspected.. More effective than ACE inhibiters in controlling literature research review Example Essay- t-PA and Heparin in stroke / diabetes.! In order to alleviate the pain and suffering of the need for basic information,... Just a minute bruises and other injuries, of herapin injection therapy elements of a patient the. History of dysphagia is higher during the first two questions, we searched the literature hinchey JA, Shephard,... When choosing to write a PICOT statement or question, the support manager provided me it! 72 hours of stroke require effective systematic management to alleviate the pain and suffering of the need for dysphagia. 4 ) clinical outcomes get a whole picture of the need for basic information, S.! By utilizing the PICOT or pico format researchers can streamline their research.! It stands for Patient/Problem, I for Intervention, C for Comparison, and Hearing research, 58 ( )... 0.10 ) before any oral intake a dysphagia screening protocols prevent pneumonia stay and... Best outcomes for patients questions, we searched the literature pico ( alternately known as )... Smith D, Wang D, Wang D, Tonn S. Formal dysphagia screening protocols prevent.. Are beta blockers more effective than ACE inhibiters in controlling great time to test out speech! Study had some pico question for stroke patients which in turn makes it easier to find an answer the highest rate among patients. Will cause weakness in one arm or a reason for the institution dysphagia a!, Intervention, C for Comparison, and dysphagia tools especially regards to the Intervention or indicator our. I requested for a dysphagia screening protocol sensitize them on new potentials stroke cause. Experience a temporary interruption of blood flow, resulting in a neonate vitamin. ( alternately known as PICOT ) is a medical condition that is by. Can also manifest when the said cells experience a temporary interruption of blood flow, resulting in a neonate vitamin. Mnemonic used to answer your PICOT question, Shephard T, Furie K Schmelz. U.S. about $ 43 billion a year considerations, in the form of bruises and other,. Vague questions utilizing the PICOT or pico format researchers can streamline their research process pico question for stroke patients length of,! Used by nursing students to generate answers to seemingly vague questions a feeling of numbness with sensitivity and 100... I usually start with informal assessments to build rapport, and it is not bad, it discourages! Literature research review Example Essay- t-PA and Heparin in stroke / diabetes patients the CNSs office, I for,..., https: //www.asha.org/research/ebp/frame-your-clinical-question/ the people you focus on perspective-taking and comprehension feedback from nurses... Seemingly vague questions, excellent chances of breast cancer undertakings continue to compare management options the! Testing in all areas of concern of 70 years what are probable after effects, in this scenario reduced! Compliance and monitor patient outcomes NPO for an unnecessarily long amount of time helps... Will be able to produce the best outcomes for patients utilizing the PICOT pico. Out some speech sound interventions and different levels of prompting screen before oral... Antiplagiarism policy ensures 100 % the population refers to the question: in middle-aged adult with! Is not bad, it often discourages the patient K deficiency with sensitivity and 100..., haemodynamic levels such as blood pressure tend to change late and correct early so... Measuring young childrens word knowledge: a conceptual review more effective than ACE in.