Epidemiology Commons^™

Cognitive Complaints In Age-Related Chronic Conditions: A Systematic Review, Nikki L. Hill, Sakshi Bhargava, Monique J. Brown, Hyejin Kim, Iris Bhang, Kaitlyn Mullin, Kathleen Phillips, Jacqueline Mogle

Faculty Publications

Introduction

Cognitive complaints in older adults may be indicative of progressive cognitive decline including Alzheimer’s disease (AD), but also occur in other age-related chronic conditions, complicating identification of early AD symptoms. To better understand cognitive complaints in aging, we systematically reviewed the evidence to determine their prevalence and characterization among older adults with the most common age-related chronic conditions.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the review protocol was prospectively registered with PROSPERO (ID: CRD42020153147). Searches were conducted in PubMed, CINAHL, PsycINFO, Web of Science, and …

Association Of Chronic Pain With Participation In Motor Skill Activities In Children With Cerebral Palsy, Haresh Rochani, Christopher M. Modlesky, Barbara Weissman, Joshua Vova, Gavin T. Colquitt

Biostatistics, Epidemiology & Environmental Health Sciences: Faculty Publications

Many children with cerebral palsy (CP) experience the secondary condition of pain, which is problematic because children with CP face barriers to participation in motor skill activities.^1,2 Motor performance in activities of daily living among children with CP is markedly lower than that among their age-matched peers.³ Because of the potential effect of pain on children with CP, we sought to examine the association between pain and activities requiring motor skill performance (ie, difficulty dressing or bathing and participation in sport) among a nationally representative sample of US children with CP.

Mathematical Modeling, Analysis, And Simulation Of The Covid-19 Pandemic With Behavioral Patterns And Group Mixing, Comfort Ohajunwa, Padmanabhan Seshaiyer

Spora: A Journal of Biomathematics

Due to the rise of COVID-19 cases, many mathematical models have been developed to study the disease dynamics of the virus. However, despite its role in the spread of COVID-19, many SEIR models neglect to account for human behavior. In this project, we develop a novel mathematical modeling framework for studying the impact of mixing patterns and social behavior on the spread of COVID-19. Specifically, we consider two groups, one exhibiting normal behavior who do not reduce their contacts and another exhibiting altered behavior who reduce their contacts by practicing non-pharmaceutical interventions such as social distancing and self-isolation. The dynamics …

Identification Of Novel And Rare Variants Associated With Handgrip Strength Using Whole Genome Sequence Data From The Nhlbi Trans-Omics In Precision Medicine (Topmed) Program, Chloé Sarnowski, Han Chen, Mary L. Biggs, Sylvia Wassertheil-Smoller, Jan Bressler, Marguerite R. Irvin, Kathleen A. Ryan, David Karasik, Donna K. Arnett, L. Adrienne Cupples, David W. Fardo, Stephanie M. Gogarten, Benjamin D. Heavner, Deepti Jain, Hyun Min Kang, Charles Kooperberg, Arch G. Mainous, Braxton D. Mitchell, Alanna C. Morrison, Jeffrey R. O'Connell

Epidemiology and Environmental Health Faculty Publications

Handgrip strength is a widely used measure of muscle strength and a predictor of a range of morbidities including cardiovascular diseases and all-cause mortality. Previous genome-wide association studies of handgrip strength have focused on common variants primarily in persons of European descent. We aimed to identify rare and ancestry-specific genetic variants associated with handgrip strength by conducting whole-genome sequence association analyses using 13,552 participants from six studies representing diverse population groups from the Trans-Omics in Precision Medicine (TOPMed) Program. By leveraging multiple handgrip strength measures performed in study participants over time, we increased our effective sample size by 7-12%. Single-variant …

Mental Health Services Provision In Primary Care And Emergency Department Settings: Analysis Of Blended Fee-For-Service And Blended Capitation Models In Ontario, Canada., Thyna Vu, Kelly K Anderson, Nibene H Somé, Amardeep Thind, Sisira Sarma

Epidemiology and Biostatistics Publications

Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are in an ideal position to provide the bulk of mental health care, it is unclear how best to remunerate FPs for the adequate provision of mental health services. We examined the quantity of mental health services provided in Ontario's blended fee-for-service and blended capitation models. We evaluated the impact of FPs switching from blended fee-for-service to blended capitation on the provision of mental health services in primary care and emergency department using longitudinal health administrative data …

Evaluation Of Circulating Levels Of Interleukin-10 And Interleukin-16 And Dietary Inflammatory Index In Lebanese Knee Osteoarthritis Patients, Zeina El-Ali, Germine El-Kassas, Fouad M. Ziade, Nitin Shivappa Mbbs, Mph, Ph.D., James Hébert Scd, Nisrine Bissar

Faculty Publications

Objectives

To investigate plasma concentrations of Interleukin-16 (IL-16) and Interleukin-10 (IL-10) in Lebanese knee osteoarthritis (KOA) patients and to examine the association between the diet-associated inflammation and increased risk for KOA.

Methods

A total of 208 study participants were assigned to one of the 3 groups: Diagnosed Knee Osteoarthritis group (DKOA) (N = 78); Undiagnosed Knee Osteoarthritis group (UKOA) (N = 60) and controls matched on age, sex and sociodemographic characteristics (N = 70). UKOA represents KOA features before they are altered by therapeutic intervention and lifestyle modifications that follow the diagnosis. Energy-adjusted dietary inflammatory index (E-DII™) scores were calculated …

Comparing Dietary Score Associations With Lipoprotein Particle Subclass Profiles: A Cross-Sectional Analysis Of A Middle-To Older-Aged Population, Seán R. Millar, Pilar Navarro, Janas M. Harrington, Nitin Shivappa Mbbs, Mph, Ph.D., James Hébert Scd, Ivan J. Perry, Catherine M. Phillips

Faculty Publications

Background and objectives: Lipoprotein particle concentrations and size are associated with increased risk for atherosclerosis and premature cardiovascular disease. Studies also suggest that certain dietary behaviours may be cardioprotective. Limited comparative data regarding any dietary score/index-lipoprotein particle subclass associations exist. Thus, our objective was to assess relationships between the Dietary Approaches to Stop Hypertension (DASH), Health Eating Index-2015 (HEI-2015), Mediterranean Diet (MD) and Energy-adjusted Dietary Inflammatory Index (E-DII™) scores and plasma lipids and lipoprotein profiles to test the hypothesis that healthier diet (better quality and more anti-inflammatory) would be associated with a more favourable lipoprotein profile.

Materials and methods: This …

Adapting An Agent-Based Model Of Infectious Disease Spread In An Irish County To Covid-19, Elizabeth Hunter, John D. Kelleher

Articles

The dynamics that lead to the spread of an infectious disease through a population can be characterized as a complex system. One way to model such a system, in order to improve preparedness, and learn more about how an infectious disease, such as COVID-19, might spread through a population, is agent-based epidemiological modelling. When a pandemic is caused by an emerging disease, it takes time to develop a completely new model that captures the complexity of the system. In this paper, we discuss adapting an existing agent-based model for the spread of measles in Ireland to simulate the spread of …

Landscape-Based Mutational Sensitivity Cartography And Network Community Analysis Of The Sars-Cov-2 Spike Protein Structures: Quantifying Functional Effects Of The Circulating D614g Variant, Gennady M. Verkhivker, Steve Agajanian, Deniz Yasar Oztas, Grace Gupta

Mathematics, Physics, and Computer Science Faculty Articles and Research

We developed and applied a computational approach to simulate functional effects of the global circulating mutation D614G of the SARS-CoV-2 spike protein. All-atom molecular dynamics simulations are combined with deep mutational scanning and analysis of the residue interaction networks to investigate conformational landscapes and energetics of the SARS-CoV-2 spike proteins in different functional states of the D614G mutant. The results of conformational dynamics and analysis of collective motions demonstrated that the D614 site plays a key regulatory role in governing functional transitions between open and closed states. Using mutational scanning and sensitivity analysis of protein residues, we identified the stability …

Computational Analysis Of Protein Stability And Allosteric Interaction Networks In Distinct Conformational Forms Of The Sars Cov 2 Spike D614g Mutant: Reconciling Functional Mechanisms Through Allosteric Model Of Spike Regulation, Gennady M. Verkhivker, Steve Agajanian, Deniz Oztas, Grace Gupta

Mathematics, Physics, and Computer Science Faculty Articles and Research

In this study, we used an integrative computational approach to examine molecular mechanisms underlying functional effects of the D614G mutation by exploring atomistic modeling of the SARS-CoV-2 spike proteins as allosteric regulatory machines. We combined coarse-grained simulations, protein stability and dynamic fluctuation communication analysis with network-based community analysis to examine structures of the native and mutant SARS-CoV-2 spike proteins in different functional states. Through distance fluctuations communication analysis, we probed stability and allosteric communication propensities of protein residues in the native and mutant SARS-CoV-2 spike proteins, providing evidence that the D614G mutation can enhance long-range signaling of the allosteric spike …

The Essence Of Telemedicine For Bridging The Gap In Health Services, Budi Wiweko, Sarah Chairani Zakirah, Atha Luthfi

Kesmas

This study aimed to review the essence of telemedicine in this modern era of technology and innovation, especially in developing countries. It also investigated the regulation aspect as the main component for healthcare services. There were five main categories of telemedicine: revenue stream and technology literacy, health facilities, human resources, data authorization and security, and health protocol. Furthermore, when combined with wearable devices, it enhanced healthcare delivery opportunities. There were two major components of global electronic health, namely telehealth and health informatics, based one-commerce and e-learning systems. The World Health Organization (WHO) has been able to describe the roles of …

The Determinants Of Stunting For Children Aged 24-59 Months In Kulon Progo District 2019, Chatrine Aprilia Hendraswari, Yuliasti Eka Purnamaningrum, Tri Maryani, Yani Widyastuti, Sakinah Harith

Kesmas

This study pertains to stunting in children in Indonesian with z-scores of less than -2 Standard Deviation (SD) and less than -3 SD. The preliminary study results showed the highest prevalence of stunting to be 22.6%, at the Temon II Primary Health Care in Kulon Progo District. The study aimed to assess the determinants of stunting children aged 24–59 months. This study was conducted from September 2018–May 2019. The design of this study was analytical observational with study design case-control. The sample was 60 children aged 24–59 months. The method utilized proportional sampling, whereas the data analysis applied chi-square and …

A Path Analysis Model For Explaining The Factors Influencing Wearing A Mask Among Commuting Workers Using Commuter Line Bogor-Jakarta, David Kusmawan, Shofi Andari, Ira Gustina, Indri Hapsari Susilowati, Mufti Wirawan

Kesmas

Jakarta is one of the most air-polluted cities in the world, which can increase the health risk of commuting workers exposed to pollutants. This study aimed to determine the factors that directly and indirectly affect healthy behavior (wearing a mask) for commuters using the Bogor-Jakarta Commuter Line. Furthermore, a total of 155 respondents participated and the data collected were analyzed using descriptive and path analysis. The commuters aware of the hazard potential related to air pollution during commuting were 137 people (88.4%). While 104 people (67.1%) were aware of the good perception of pollution and 125 uses masks during commuting …

Empowering Health Cadres To Support Drug-Resistant Tuberculosis (Dr-Tb) Patient To Enroll In Treatment, Esty Febriani, Adik Wibowo, Neeraj Kak, Hala Jassim Al Mossawi

Kesmas

Tuberculosis (TB) remains a big challenge globally, while the involvement of health cadres’ constitutes one of the key strategies for the TB program in Indonesia. These roles were further expanded to providing support to DR-TB patients. This study was a qualitative study, conducted in 2015 to explore the various factors which influence the performance of health cadres’ in supporting DR-TB patients to enroll in treatment. A total of 39 informants consisting of 24 health cadres, three nurses, four DR-TB patients, and three family members, two peer support, a head of primary health care, and two TB staffs from the District …

National Health Insurance Scheme: Internal And External Barriers In The Use Of Reproductive Health Services Among Women, Evi Martha, Herna Lestari, Resvi Siti Zulfa, Yoslien Sopamena

Kesmas

Lack of familiarity among the community, medical workers, and administrative staff regarding reproductive health services covered by Badan Penyelenggara Jaminan Sosial (BPJS) or the National Health Insurance (NHI) in Indonesia remained a problem. Therefore, this resulted in sub-optimal use of the medical services, as shown by surveys from the Women's Health Foundation for three consecutive years (2015-2017). This qualitative study was conducted with a Rapid Assessment Procedure design in three cities within Indonesia: Padang Pariaman, Manado, and Kupang. Data were collected through IDIs (n = 47informants) and 6 FGDs (7 persons/group). Participants also consisted of NHI RHS users (mothers and …

Prevalence And Determinants Of Pre-Lacteal Feeding: Insights From The 2017 Indonesia Demographic And Health Survey, Siti Nurokhmah, Siti Masitoh, Kusuma Estu Werdani

Kesmas

Pre-lacteal feeding is widely known as a distraction to exclusive breastfeeding, and the malpractice continues to be prevalent in Indonesia. Therefore, this study aimed to explore the potential determinants of pre-lacteal feeding among mothers of infants below 24 months. A sample of 6,455 mother-infant pairs from the 2017 Indonesia Demographic and Health Survey (IDHS) was used. Also, multivariate logistic regression was employed to identify factors associated with pre-lacteal feeding practice. In Indonesia, 44% of infants were introduced to solid/liquid feeds in their first three days of life. Infant formula was the most common pre-lacteal feed given, followed by any other …

The Effect Of Smoking On Carbon Monoxide Respiration Among Active Smokers In Palembang City, Indonesia, Rico Januar Sitorus, Imelda Gernauli Purba, Merry Natalia, Kraichat Tantrakarnapa

Kesmas

Smoking leads to disease and disability as well as harm nearly every organ of the body. Furthermore, smoking of tobacco is known to cause pulmonary dysfunction and lead to complications, pain, or even death. This study aimed to measure the risk factors for the respiration of carbon monoxide among smokers. A cross-sectional design was implemented by involving 156 smokers in Karyajaya Subdistrict, Palembang City. The dependent variable was carbon monoxide levels (ppm), while the independent variables were smoking frequency, duration, and the last period of smoking. The carbon monoxide levels (ppm) measured with a PiCO + Smokerlyzer® device from Bedfont …

The Significance Of Super Depo Sutorejo: Waste Management Project In Surabaya Municipality, Indonesia, Yohanes Kambaru Windi, Dyah Wijayanti, Eko Rustamaji Wiyatno, Loetfia Dwi Rahariyani

Kesmas

The Super Depo Sutorejo Surabaya (SDSS) Project was created to separate household waste into fractions, but its separation effect is unknown. This study assessed the significance of the project in sorting general waste into biodegradable, non-biodegradable, and assorted. The t-test compared the means of general and biodegradable waste (normally distributed). The non-biodegradable and assorted waste were not significantly distributed; therefore, the Wilcoxon Signed Ranks Test was used to compare their medians against general waste. The multivariate analysis compared the significance level of each waste fraction. Each statistical analysis showed that the SDSS significantly sorts the general waste. The p-values were …

Inter-Related Factors Influencing Sexual Quality Of Life Among Women Living With Hiv In Banten Province, Indonesia: A Mixed Methods Study, Dyah Juliastuti, Judith Dean, Yati Afiyanti, Lisa Fitzgerald

Kesmas

Socio-cultural concerns often restrict women's sexual rights and well-being living with HIV (WLHIV) in developing countries. These convergent parallel mixed methods study combined quantitative and qualitative approaches to explore factors influencing WLHIV sexual quality of life in Banten Province, Indonesia. A 2017 cross-sectional survey of 207 reproductive-aged WLHIV was analyzed using univariate and multivariate logistic regression statistics. Furthermore, in-depth interviews with a sub-sample of survey participants (n = 30) were thematically analyzed. Most of the women (60%) involved reported loss of sexual pleasure and depressed sexual life. Meanwhile, 48% affirmed low sexual quality of life which was associated with unemployment …

Attitudes Concerning Sexual Behavior Towards Risky Sexual Behavior Of Sexual Transmitted Infections Among Male Adolescents In Indonesia, Helda Helda, Nurul Muchlisa

Kesmas

There has been an increase of sexually transmitted infections (STIs) such as HIV/AIDS worldwide, especially in Indonesia. Several studies on adolescent behavior, especially the male as the main predictor, reported increased in STIs’ cases due to risky sexual behavior. This study aimed to show the relationship between attitudes, sexual behavior, and the risks of STIs among male adolescents in Indonesia based on the Indonesia Demographic and Health Survey (IDHS) data in 2017. This cross-sectional study involved 10,547 male adolescents using the total sampling method according to the inclusion and exclusion criteria. Data were analyzed using a complex sample logistic regression …

Spatially Refined Time-Varying Reproduction Numbers Of Covid-19 By Health District In Georgia, Usa, March–December 2020, Chigozie A. Ogwara, Arshpreet Kaur Mallhi, Xinyi Hua, Kamalich Muniz-Rodriguez, Jessica S. Schwind, Xiaolu Zhou, Jeffery A. Jones, Joanne Chopak-Foss, Gerardo Chowell, Isaac Chun-Hai Fung

Biostatistics, Epidemiology & Environmental Health Sciences: Faculty Publications

This study quantifies the transmission potential of SARS-CoV-2 across public health districts in Georgia, USA, and tests if per capita cumulative case count varies across counties. To estimate the time-varying reproduction number, Rt of SARS-CoV-2 in Georgia and its 18 public health districts, we apply the R package ‘EpiEstim’ to the time series of historical daily incidence of confirmed cases, 2 March–15 December 2020. The epidemic curve is shifted backward by nine days to account for the incubation period and delay to testing. Linear regression is performed between log10-transformed per capita cumulative case count and log10-transformed population size. We observe …

Differences In ​The Proportion Of Children Meeting Behavior Guidelines ​Between Summer ​And School By Socioeconomic Status And Race, Ethan T. Hunt, Lauren Von Klinggraeff, Alexis Jones, Sarah Burkart, Roddrick Dugger, Bridget Armstrong Ph.D., Michael Beets Ph.D., Gabrielle Turner-Mcgrievy Ph.D., Rd, Marco Geraci, Robert Glenn Weaver Med, Phd

Faculty Publications

Objective

Children who fail to meet activity, sleep, and screen-time guidelines are at increased risk for obesity. Further, children who are Black are more likely to have obesity when compared to children who are White, and children from low-income households are at increased risk for obesity when compared to children from higher-income households. The objective of this study was to evaluate the proportion of days meeting obesogenic behavior guidelines during the school year compared to summer vacation by race and free/reduced priced lunch (FRPL) eligibility.

Methods

Mixed-effects linear and logistic regressions estimated the proportion of days participants met activity, sleep, …

Differences In Effectiveness And Use Of Laparoscopic Surgery In Locally Advanced Colon Cancer Patients, M. Schootman, Matthew Mutch, T. Loux, Jan M. Eberth Ph.D., N. O. Davidson

Faculty Publications

Patients with locally advanced colon cancer have worse outcomes. Guidelines of various organizations are conflicting about the use of laparoscopic colectomy (LC) in locally advanced colon cancer. We determined whether patient outcomes of LC and open colectomy (OC) for locally advanced (T4) colon cancer are comparable in all colon cancer patients, T4a versus T4b patients, obese versus non-obese patients, and tumors located in the ascending, descending, and transverse colon. We used data from the 2013–2015 American College of Surgeons’ National Surgical Quality Improvement Program. Patients were diagnosed with nonmetastatic pT4 colon cancer, with or without obstruction, and underwent LC (n …

Time Series Forecasting Of Covid-19 Deaths In Massachusetts, Andrew Disher

Honors Program Theses and Projects

The aim of this study was to use data provided by the Department of Public Health in the state of Massachusetts on its online dashboard to produce a time series model to accurately forecast the number of new confirmed deaths that have resulted from the spread of CoViD-19. Multiple different time series models were created, which can be classified as either an Auto-Regressive Integrated Moving Average (ARIMA) model or a Regression Model with ARIMA Errors. Two ARIMA models were created to provide a baseline forecasting performance for comparison with the Regression Model with ARIMA Errors, which used the number of …

Mathematical Models Of Covid-19, Kate Faria

Honors Program Theses and Projects

For more than a year, the COVID-19 pandemic has been a major public health issue, affecting the lives of most people around the world. With both people’s health and the economy at great risks, governments rushed to control the spread of the virus. Containment measures were heavily enforced worldwide until a vaccine was developed and distributed. Although researchers today know more about the characteristics of the virus, a lot of work still needs to be done in order to completely remove the disease from the population. However, this is true for most of the infectious diseases in existence, including Influenza, …

Does Social Support Moderate The Association Between Income And Food Security Status Among Seniors Living In Southern Nevada?, Adugna Teka Siweya

UNLV Theses, Dissertations, Professional Papers, and Capstones

Background: Income is the strongest predictor of food insecurity among seniors, and social support also an essential factor to help mitigate the effects of food insecurity. However, little is known about the potential role that social support may play as a moderator of the association between income and food insecurity. Thus, we aim to examine social support as a moderator for the relationship between income and food insecurity among seniors. Methods: Logistic regression models were used to analyze data collected in 2019 from seniors residing in Southern Nevada. Predictors of food insecurity, sociodemographic factors, social support variables, and income and …

Association Between Dietary Inflammatory Index, Dietary Patterns, Plant-Based Dietary Index And The Risk Of Obesity, Yoko B. Wang, Nitin Shivappa, James R. Hébert Scd, Amanda J. Page, Yohannes Adama Melaku

Faculty Publications

Evidence on the association between various dietary constructs and obesity risk is limited. This study aims to investigate the longitudinal relationship between different diet indices and dietary patterns with the risk of obesity. Non-obese participants (n = 787) in the North West Adelaide Health Study were followed from 2010 to 2015. The dietary inflammatory index (DII®), plant-based dietary index (PDI) and factor-derived dietary pattern scores were computed based on food frequency questionnaire data. We found the incidence of obesity was 7.62% at the 5-year follow up. In the adjusted model, results from multivariable log-binomial logistic regression showed that a prudent …

Diet Quality And Risk Of Lung Cancer In The Multiethnic Cohort Study, Song-Yi Park, Carol J. Boushey, Yurii B. Shvetsov, Michael David Wirth Msph,Ph.D., Nitin Shivappa Ph.D., James R. Hébert Sc.D., Christopher A. Haiman, Lynee R. Wilkens, Loic Le Marchand

Faculty Publications

Diet quality, assessed by the Healthy Eating Index-2015 (HEI-2015), the Alternative Healthy Eating Index-2010 (AHEI-2010), the alternate Mediterranean Diet (aMED) score, the Dietary Approaches to Stop Hypertension (DASH) score, and the Dietary Inflammatory Index (DII®), was examined in relation to risk of lung cancer in the Multiethnic Cohort Study. The analysis included 179,318 African Americans, Native Hawaiians, Japanese Americans, Latinos, and Whites aged 45–75 years, with 5350 incident lung cancer cases during an average follow-up of 17.5 ± 5.4 years. In multivariable Cox models comprehensively adjusted for cigarette smoking, the hazard ratios (95% confidence intervals) for the highest vs. lowest …

Association Between Appendicular Skeletal Muscle Index And Leukocyte Telomere Length In Adults: A Study From National Health And Nutrition Examination Survey (Nhanes) 1999-2002, Lingzhi Chen, Nitin Shivappa Mbbs, Mph, Ph.D., Xiuxun Dong, Jinjing Ming

Faculty Publications

Background

A higher body mass index (BMI) is associated with shorter telomeres. The loss of muscle mass with aging is associated with adverse outcomes. The appendicular skeletal muscle index (ASMI) is currently used to quantify muscle mass.

Objective

We investigated the association of the ASMI with leukocyte telomere length in adult Americans.

Methods

This cross-sectional study used the National Health and Nutrition Examination Survey (NHANES) 1999–2002 dataset. Body composition was measured by dual-energy X-ray absorptiometry. Low muscle mass was defined using sex-specific thresholds of the appendicular skeletal muscle mass index (ASMI). The telomere-to-single-copy gene ratio (T/S ratio) was converted to …

The Effects Of Differences In Vaccination Rates Across Socioeconomic Groups On The Size Of Measles Outbreaks, Elizabeth Hunter, John D. Kelleher

Conference papers

Vaccination rates are often presented at the level of a country or region. However, within those areas there might be geographic or demographic pockets that have higher or lower vaccination rates. We use an agent-based model designed to simulate the spread of measles in Irish towns to examine if the effectiveness of vaccination rates to reduce disease at a population level is sensitive to the uniformity of vaccinations across socioeconomic groups. We find that when vaccinations are not applied evenly across socioeconomic groups we see more outbreaks and outbreaks with larger magnitudes.