Malignant Pleural EffusionNCT03482570
Activity Behaviours in Patients With Malignant Pleural Effusion
An observational study of Malignant Pleural Effusion, run by The University of Hong Kong at 1 site in Hong Kong.
Trial summary
The purpose of this research is to objectively assess activity behaviours (i.e., physical activity and sedentary behaviour) in patients with malignant pleural effusion. First, we aim to describe the physical activity and sedentary behavior of patients with MPE in Hong Kong. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Malignant Pleural Effusion
- What is being tested?
- ActiGraph
- Type of treatment
- Medical device
- How many people
- 200 participants
- Where
- 1 siteHong Kong
- Study dates
- 31 Jan 2018to 31 Dec 2020
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Study population: Patients with an MPE
Who may be able to join
- Patients with an MPE (i.e. one in which malignant cells are identified in the pleural fluid or pleural biopsy); or a large exudative pleural effusion without other causes in a patient with known disseminated extra-thoracic malignancy
Who cannot join
- Patients with Age <18 years; pleural infection; pregnant or lactating; inability to consent or comply with the protocol; anticipated pleural drainage procedure within one week subsequent to recruitment.
Trial locations and contacts
1 site in 1 country.
Hong Kong1 site, 1 recruiting
- Recruiting
University of Hong Kong Queen Mary Hospital
Hong Kong
David CL Lam, PhD,MD, (852) 2255 5814, dcllam@hku.hk
David CL Lam, PhD,MD
About this study
Official title: Activity Behaviours in Patients With Malignant Pleural Effusion: Relationships With Quality of Life, and Respiratory Symptoms, and Survival
The purpose of this research is to objectively assess activity behaviours (i.e., physical activity and sedentary behaviour) in patients with malignant pleural effusion. First, we aim to describe the physical activity and sedentary behavior of patients with MPE in Hong Kong. Secondarily, we aim to assess the relationships between activity behaviours and survival, quality of life, and respiratory symptoms e.g. shortness of breath.
Read the detailed description
The development of a malignant pleural effusion (MPE) can be a consequence of metastatic spread of any cancer, but most commonly lung, breast and gynecological cancers or from primary pleural neoplasms (e.g., mesothelioma). The presence of MPE represents incurable disease and median survival ranges from 3 to 12 months from first presentation. Breathlessness is a common and debilitating symptom reported by this patient group and interventions are aimed at managing symptoms for optimal quality of life.
Breathlessness and other symptoms that result from MPE are likely to limit a person's ability to be physically active. Activity behaviours encompasses physical activity behaviour (i.e., low intensity physical activity and moderate-to-vigorous physical activity) and sedentary behaviour (i.e., sitting or reclining activities low in energy expenditure) accumulated during waking hours. Performance status measures are routinely used in cancer populations and are largely based on self-reported activity behaviors. While performance status is a reliable predictor of survival in patients with MPE, such measures are subjective, broad and significantly, can differ between patients and clinicians. Measures of performance status may fail to detect small, but meaningful changes in activity behaviours. Objective assessment of activity behaviours using accelerometers could provide a more reliable and sensitive method to assess physical activity and sedentary behaviour, particularly in advanced cancer populations. Objective assessment of activity behaviours using accelerometers has been demonstrated to accurately measure physical activity when compared to oxygen consumption. Triaxial accelerometry is considered the most accurate assessment for physical activity in chronic disease populations.
Preliminary research in patients with MPE indicates that patients have very low activity levels. Participants with MPE spent more that 70% of waking hours sedentary (i.e., activities of very low energy expenditure, sitting or lying down). Those patients with MPE with the best performance status and longest survival were significantly more active and less sedentary than those with a poor performance status and limited survival. However, these preliminary results require replication. Further, it is not yet known if activity behaviours are associated with quality of life or symptoms such as dyspnea in this patient population. Evidence from other cancer survivor populations suggests that activity behaviours are linked to quality of life and symptoms. In patients with breast, colorectal, lung and ovarian cancer, those that are more physically active report better quality of life. In patients with lung cancer, symptoms such as breathlessness and fatigue appear to be associated with lower physical activity levels.
- Conditions
- Malignant Pleural Effusion
- Being tested
- ActiGraph
- Keywords
- Activity behaviors, Malignant pleural effusion
- Medical subject headings
- Pleural Effusion, Malignant
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
ActiGraphDevice
Activity behaviours will be objectively assessed by 7-day triaxial accelerometer assessment (ActiGraph GT3X+ Pensacola, FL, USA). Participants will be asked to wear an accelerometer around their waist, 24 hours a day for 7 days.
What is being measured
The primary outcome is the main question the study is designed to answer.
Activity Behaviours (vertical axis movement counts per min)
Recorded objectively by a triaxial accelerometer (ActiGraph GT3X+ Pensacola, FL, USA).
Measured: 7 days
Quality of life (in mm)
Assessed by a 100 mm visual analogue scale with "the best imaginable health state" at 0 mm and "the worst imaginable health state" at 100 mm
Measured: 7 days
Respiratory symptoms (in mm)
Assessed by a 100 mm visual analogue scale with "no breathlessness" at 0 mm and "worst breathlessness imaginable" at 100 mm.
Measured: 7 days
Survival (in number of days)
Recorded from date of Actigraph initialization to death or 12-month, whichever comes first
Measured: 12 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted29 Mar 2018
- Study start31 Jan 2018
- Primary completion31 Dec 2019 (estimated)
- Study completion31 Dec 2020 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (17)Papers the sponsor has linked to this study.
- Other trials for Malignant Pleural EffusionStudies of the same condition, open and under way.
- More trials run by The University of Hong KongThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 200 participants (estimated)
Sponsor and investigators
- Lead sponsor
- The University of Hong Kong
- Sponsor type
- University, hospital or other
- Collaborators
- The University of Western Australia, Edith Cowan University, Queen Elizabeth Hospital, Hong Kong, Princess Margaret Hospital, Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
- Responsible party
- Principal investigator, Dr. David Chi-leung Lam, The University of Hong Kong
- Investigators
- David CL Lam, PhD, MD, Principal investigator, University of Hong Kong Queen Mary Hospital
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03482570
- Sponsor's protocol ID
- HKU_UW_17_516
- Status last verified
- Mar 2018
- First submitted
- 5 Mar 2018
- Last updated
- 2 Apr 2018
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, Bintcliffe OJ, Boshuizen RC, Fysh ET, Tobin CL, Medford AR, Harvey JE, van den Heuvel MM, Lee YC, Maskell NA. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax. 2014 Dec;69(12):1098-104. doi: 10.1136/thoraxjnl-2014-205285. Epub 2014 Aug 6.
PubMed 25100651Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014 Aug;19(6):809-22. doi: 10.1111/resp.12328. Epub 2014 Jun 19.
PubMed 24947955Owen N. Sedentary behavior: understanding and influencing adults' prolonged sitting time. Prev Med. 2012 Dec;55(6):535-9. doi: 10.1016/j.ypmed.2012.08.024. Epub 2012 Sep 8.
PubMed 22968124Kelly LA, McMillan DG, Anderson A, Fippinger M, Fillerup G, Rider J. Validity of actigraphs uniaxial and triaxial accelerometers for assessment of physical activity in adults in laboratory conditions. BMC Med Phys. 2013 Nov 26;13(1):5. doi: 10.1186/1756-6649-13-5.
PubMed 24279826Van Remoortel H, Giavedoni S, Raste Y, Burtin C, Louvaris Z, Gimeno-Santos E, Langer D, Glendenning A, Hopkinson NS, Vogiatzis I, Peterson BT, Wilson F, Mann B, Rabinovich R, Puhan MA, Troosters T; PROactive consortium. Validity of activity monitors in health and chronic disease: a systematic review. Int J Behav Nutr Phys Act. 2012 Jul 9;9:84. doi: 10.1186/1479-5868-9-84.
PubMed 22776399Jeffery E, Lee YG, McVeigh J, Straker L, Wooding T, Newton RU, Peddle-McIntyre C. Feasibility of objectively measured physical activity and sedentary behavior in patients with malignant pleural effusion. Support Care Cancer. 2017 Oct;25(10):3133-3141. doi: 10.1007/s00520-017-3721-9. Epub 2017 Apr 28.
PubMed 28455548Vallance JK, Boyle T, Courneya KS, Lynch BM. Associations of objectively assessed physical activity and sedentary time with health-related quality of life among colon cancer survivors. Cancer. 2014 Sep 15;120(18):2919-26. doi: 10.1002/cncr.28779. Epub 2014 Jun 4.
PubMed 24898175Solberg Nes L, Liu H, Patten CA, Rausch SM, Sloan JA, Garces YI, Cheville AL, Yang P, Clark MM. Physical activity level and quality of life in long term lung cancer survivors. Lung Cancer. 2012 Sep;77(3):611-6. doi: 10.1016/j.lungcan.2012.05.096. Epub 2012 Jun 6.
PubMed 22681871Sloan JA, Cheville AL, Liu H, Novotny PJ, Wampfler JA, Garces YI, Clark MM, Yang P. Impact of self-reported physical activity and health promotion behaviors on lung cancer survivorship. Health Qual Life Outcomes. 2016 Apr 29;14:66. doi: 10.1186/s12955-016-0461-3.
PubMed 27129406Lynch BM, Cerin E, Owen N, Hawkes AL, Aitken JF. Prospective relationships of physical activity with quality of life among colorectal cancer survivors. J Clin Oncol. 2008 Sep 20;26(27):4480-7. doi: 10.1200/JCO.2007.15.7917.
PubMed 18802160Canario AC, Cabral PU, de Paiva LC, Florencio GL, Spyrides MH, Goncalves AK. Physical activity, fatigue and quality of life in breast cancer patients. Rev Assoc Med Bras (1992). 2016 Jan-Feb;62(1):38-44. doi: 10.1590/1806-9282.62.01.38.
PubMed 27008491Beesley VL, Price MA, Butow PN, Green AC, Olsen CM; Australian Ovarian Cancer Study Group; Australian Ovarian Cancer Study - Quality of Life Study Investigators; Webb PM. Physical activity in women with ovarian cancer and its association with decreased distress and improved quality of life. Psychooncology. 2011 Nov;20(11):1161-9. doi: 10.1002/pon.1834. Epub 2010 Aug 26.
PubMed 20740686Cheville AL, Novotny PJ, Sloan JA, Basford JR, Wampfler JA, Garces YI, Jatoi A, Yang P. The value of a symptom cluster of fatigue, dyspnea, and cough in predicting clinical outcomes in lung cancer survivors. J Pain Symptom Manage. 2011 Aug;42(2):213-21. doi: 10.1016/j.jpainsymman.2010.11.005. Epub 2011 Mar 12.
PubMed 21398089O'Driscoll M, Corner J, Bailey C. The experience of breathlessness in lung cancer. Eur J Cancer Care (Engl). 1999 Mar;8(1):37-43. doi: 10.1046/j.1365-2354.1999.00129.x.
PubMed 10362952Fysh ET, Thomas R, Read CA, Kwan BC, Yap E, Horwood FC, Lee P, Piccolo F, Shrestha R, Garske LA, Lam DC, Rosenstengel A, Bint M, Murray K, Smith NA, Lee YC. Protocol of the Australasian Malignant Pleural Effusion (AMPLE) trial: a multicentre randomised study comparing indwelling pleural catheter versus talc pleurodesis. BMJ Open. 2014 Nov 6;4(11):e006757. doi: 10.1136/bmjopen-2014-006757.
PubMed 25377015
Study at a glance
From the registry record, last updated by the sponsor on 2 Apr 2018. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Activity Behaviours in Patients With Malignant Pleural Effusion: Relationships With Quality of Life, and Respiratory Symptoms, and Survival
- ClinicalTrials.gov ID
- NCT03482570
- Acronym / sponsor ID
- HKU_UW_17_516
- Conditions
- Malignant Pleural Effusion
- Keywords
- Activity behaviors, Malignant pleural effusion
- Study type
- Observational
- Recruitment status
- Unknown status
- Enrolment
- 200 participants (estimated)
- Lead sponsor
- The University of Hong KongUniversity, hospital or other
- Collaborators
- The University of Western Australia, Edith Cowan University, Queen Elizabeth Hospital, Hong Kong, Princess Margaret Hospital, Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
- Study start
- 31 Jan 2018 (actual)
- Primary completion
- 31 Dec 2019 (estimated)
- Study completion
- 31 Dec 2020 (estimated)
- First posted
- 29 Mar 2018 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The purpose of this research is to objectively assess activity behaviours (i.e., physical activity and sedentary behaviour) in patients with malignant pleural effusion. First, we aim to describe the physical activity and sedentary behavior of patients with MPE in Hong Kong. Secondarily, we aim to assess the relationships between activity behaviours and survival, quality of life, and respiratory symptoms e.g. shortness of breath.
Detailed description
The development of a malignant pleural effusion (MPE) can be a consequence of metastatic spread of any cancer, but most commonly lung, breast and gynecological cancers or from primary pleural neoplasms (e.g., mesothelioma). The presence of MPE represents incurable disease and median survival ranges from 3 to 12 months from first presentation. Breathlessness is a common and debilitating symptom reported by this patient group and interventions are aimed at managing symptoms for optimal quality of life.
Breathlessness and other symptoms that result from MPE are likely to limit a person's ability to be physically active. Activity behaviours encompasses physical activity behaviour (i.e., low intensity physical activity and moderate-to-vigorous physical activity) and sedentary behaviour (i.e., sitting or reclining activities low in energy expenditure) accumulated during waking hours. Performance status measures are routinely used in cancer populations and are largely based on self-reported activity behaviors. While performance status is a reliable predictor of survival in patients with MPE, such measures are subjective, broad and significantly, can differ between patients and clinicians. Measures of performance status may fail to detect small, but meaningful changes in activity behaviours. Objective assessment of activity behaviours using accelerometers could provide a more reliable and sensitive method to assess physical activity and sedentary behaviour, particularly in advanced cancer populations. Objective assessment of activity behaviours using accelerometers has been demonstrated to accurately measure physical activity when compared to oxygen consumption. Triaxial accelerometry is considered the most accurate assessment for physical activity in chronic disease populations.
Preliminary research in patients with MPE indicates that patients have very low activity levels. Participants with MPE spent more that 70% of waking hours sedentary (i.e., activities of very low energy expenditure, sitting or lying down). Those patients with MPE with the best performance status and longest survival were significantly more active and less sedentary than those with a poor performance status and limited survival. However, these preliminary results require replication. Further, it is not yet known if activity behaviours are associated with quality of life or symptoms such as dyspnea in this patient population. Evidence from other cancer survivor populations suggests that activity behaviours are linked to quality of life and symptoms. In patients with breast, colorectal, lung and ovarian cancer, those that are more physically active report better quality of life. In patients with lung cancer, symptoms such as breathlessness and fatigue appear to be associated with lower physical activity levels.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
- Study population
- Patients with an MPE
Key inclusion criteria (1 listed)
- Patients with an MPE (i.e. one in which malignant cells are identified in the pleural fluid or pleural biopsy); or a large exudative pleural effusion without other causes in a patient with known disseminated extra-thoracic malignancy
Key exclusion criteria (1 listed)
- Patients with Age <18 years; pleural infection; pregnant or lactating; inability to consent or comply with the protocol; anticipated pleural drainage procedure within one week subsequent to recruitment.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| ActiGraphActivity behaviours will be objectively assessed by 7-day triaxial accelerometer assessment (ActiGraph GT3X+ Pensacola, FL, USA). Participants will be asked to wear an accelerometer around their waist, 24 hours a day for 7 days. | Device | – |
Primary outcome
Activity Behaviours (vertical axis movement counts per min)
Time frame: 7 days
Recorded objectively by a triaxial accelerometer (ActiGraph GT3X+ Pensacola, FL, USA).
Quality of life (in mm)
Time frame: 7 days
Assessed by a 100 mm visual analogue scale with "the best imaginable health state" at 0 mm and "the worst imaginable health state" at 100 mm
Respiratory symptoms (in mm)
Time frame: 7 days
Assessed by a 100 mm visual analogue scale with "no breathlessness" at 0 mm and "worst breathlessness imaginable" at 100 mm.
Survival (in number of days)
Time frame: 12 months
Recorded from date of Actigraph initialization to death or 12-month, whichever comes first
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 2 Apr 2018.
- Background: PubMed 25100651Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, Bintcliffe OJ, Boshuizen RC, Fysh ET, Tobin CL, Medford AR, Harvey JE, van den Heuvel MM, Lee YC, Maskell NA. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax. 2014 Dec;69(12):1098-104. doi: 10.1136/thoraxjnl-2014-205285. Epub 2014 Aug 6.
- Background: PubMed 24947955Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014 Aug;19(6):809-22. doi: 10.1111/resp.12328. Epub 2014 Jun 19.
- Background: PubMed 22968124Owen N. Sedentary behavior: understanding and influencing adults' prolonged sitting time. Prev Med. 2012 Dec;55(6):535-9. doi: 10.1016/j.ypmed.2012.08.024. Epub 2012 Sep 8.
- Background: PubMed 24279826Kelly LA, McMillan DG, Anderson A, Fippinger M, Fillerup G, Rider J. Validity of actigraphs uniaxial and triaxial accelerometers for assessment of physical activity in adults in laboratory conditions. BMC Med Phys. 2013 Nov 26;13(1):5. doi: 10.1186/1756-6649-13-5.
- Background: PubMed 22776399Van Remoortel H, Giavedoni S, Raste Y, Burtin C, Louvaris Z, Gimeno-Santos E, Langer D, Glendenning A, Hopkinson NS, Vogiatzis I, Peterson BT, Wilson F, Mann B, Rabinovich R, Puhan MA, Troosters T; PROactive consortium. Validity of activity monitors in health and chronic disease: a systematic review. Int J Behav Nutr Phys Act. 2012 Jul 9;9:84. doi: 10.1186/1479-5868-9-84.
- Background: PubMed 28455548Jeffery E, Lee YG, McVeigh J, Straker L, Wooding T, Newton RU, Peddle-McIntyre C. Feasibility of objectively measured physical activity and sedentary behavior in patients with malignant pleural effusion. Support Care Cancer. 2017 Oct;25(10):3133-3141. doi: 10.1007/s00520-017-3721-9. Epub 2017 Apr 28.
- Background: PubMed 24898175Vallance JK, Boyle T, Courneya KS, Lynch BM. Associations of objectively assessed physical activity and sedentary time with health-related quality of life among colon cancer survivors. Cancer. 2014 Sep 15;120(18):2919-26. doi: 10.1002/cncr.28779. Epub 2014 Jun 4.
- Background: PubMed 22681871Solberg Nes L, Liu H, Patten CA, Rausch SM, Sloan JA, Garces YI, Cheville AL, Yang P, Clark MM. Physical activity level and quality of life in long term lung cancer survivors. Lung Cancer. 2012 Sep;77(3):611-6. doi: 10.1016/j.lungcan.2012.05.096. Epub 2012 Jun 6.
- Background: PubMed 27129406Sloan JA, Cheville AL, Liu H, Novotny PJ, Wampfler JA, Garces YI, Clark MM, Yang P. Impact of self-reported physical activity and health promotion behaviors on lung cancer survivorship. Health Qual Life Outcomes. 2016 Apr 29;14:66. doi: 10.1186/s12955-016-0461-3.
- Background: PubMed 18802160Lynch BM, Cerin E, Owen N, Hawkes AL, Aitken JF. Prospective relationships of physical activity with quality of life among colorectal cancer survivors. J Clin Oncol. 2008 Sep 20;26(27):4480-7. doi: 10.1200/JCO.2007.15.7917.
- Background: PubMed 27008491Canario AC, Cabral PU, de Paiva LC, Florencio GL, Spyrides MH, Goncalves AK. Physical activity, fatigue and quality of life in breast cancer patients. Rev Assoc Med Bras (1992). 2016 Jan-Feb;62(1):38-44. doi: 10.1590/1806-9282.62.01.38.
- Background: PubMed 20740686Beesley VL, Price MA, Butow PN, Green AC, Olsen CM; Australian Ovarian Cancer Study Group; Australian Ovarian Cancer Study - Quality of Life Study Investigators; Webb PM. Physical activity in women with ovarian cancer and its association with decreased distress and improved quality of life. Psychooncology. 2011 Nov;20(11):1161-9. doi: 10.1002/pon.1834. Epub 2010 Aug 26.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
David CL Lam, PhD, MD principal investigator
University of Hong Kong Queen Mary Hospital
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Malignant Pleural Effusion, run by The University of Hong Kong at 1 site in Hong Kong.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 1 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: status not confirmed, as of the sponsor's last update on 2 Apr 2018. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Hong Kong. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
Each site lists its own contact: choose the nearest one under Trial locations. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Activity Behaviours (vertical axis movement counts per min) (time frame: 7 days). The study lists 4 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03482570, which also lists 17 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 2 Apr 2018.