Posted on Leave a comment

4 Ways Improved Hand Hygiene Can Change the World as We Know It

Months into the COVID-19 pandemic, many of us have become hyper-aware of the importance of proper hand hygiene. Yet, there still exist various misconceptions regarding the proper way to wash hands, while others still downplay the value of regular handwashing. In fact, the benefits of washing your hands with soap and water go beyond reducing the transmission of coronaviruses. As societies across the globe continue to promote the importance of regular handwashing in a way that leads to a sustained improvement in hand hygiene, there are many positive outcomes that this can lead to outside of the coronavirus pandemic.

Proper Handwashing: A Review

Before we delve into the possible outcomes for regular handwashing, let’s discuss what we (think) we already know: Proper handwashing. Since the beginning of the COVID-19 pandemic, there has been a flood of information educating people around the globe on proper hand hygiene in an effort to slow the virus’ spread. Government health agencies, including the WHO and the US-based CDC, provided excellent, detailed information to assist this movement. According to the CDC, the handwashing checklist is as follows:

  1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
  2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.
  3. Scrub your hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" song from beginning to end twice.
  4. Rinse your hands well under clean, running water.
  5. Dry your hands using a clean towel or air dry them.

Along with the various governmental promotions for hand hygiene, governments began encouraging celebrities and social media influencers to promote proper hand hygiene through the #handwashingchallenge. Before long, most of our social media feeds were overwhelmed with videos of athletes from Allison Becker of Brazil’s National soccer team, to movie stars to the likes of Hugh Jackman, encouraging hand hygiene to their millions of followers.

Before long, most of the world was stuck in a dizzying frenzy of hectic handwashing after touching any public surface, where many people began reporting severe dry hands due to excessive handwashing. Additionally, more specific questions began to arise, such as; How hard should I scrub my hands? – or – Is there such a thing as too much handwashing?

Mistakes and Misconceptions of Handwashing

As our handwashing becomes more frequent, many of us have inadvertently picked up bad habits in our hand hygiene. The most common being washing our hands too forcefully or too frequently. According to the Minnesota Department of Health, you should wash your hands at the following times:

  • After arriving at home
  • After coughing or blowing your nose
  • Before making or eating food
  • After playing with animals
  • After using the toilet
  • After being outdoors
  • Before and after changing contact lenses

Notice that it did not mention anything about vigorously washing your hands every 5 minutes from COVID-induced paranoia? All joking aside, the age-old truth regarding moderation in everything applies to handwashing as well. According to an article from Medscape Medical News, many of us are scrubbing our hands too hard, impacting an important top layer of our skin that helps keep germs away. It goes on to detail the fine line between rubbing versus scrubbing with Carrie Kovarik, MD from the Perelman School of Medicine remarking, “You don’t want to scrub because scrubbing will damage the skin barrier and possibly let in germs.” Instead of forcefully scrubbing our hands, doctors recommend gently washing hands in “a hand-over-hand motion, from palm to palm, back of the hands, around nails and up to the wrists.”

Possible Outcomes of Regular Handwashing

Now that we have established a clear picture of what proper hand hygiene looks like, we can imagine what outcomes might arise from regular handwashing. With the world’s attention focused on proper hand hygiene, many are wondering how this might impact population health outside of the COVID-19 pandemic. We can make many assumptions based on small scale benefits to populations and extrapolating those results across larger populations. Although these benefits are only potential outcomes, it is exciting to imagine the possibilities that can come about from this increased focus in hand hygiene.

Lower Incidences of Respiratory Diseases

In 2016, a study published in the Baltimore Medicine Journal observed a correlation between increased hand-washing and a reduction in influenza at a statistically significant level. Participants in the study were given a handwashing score based on the availability of washing stations and the availability of soap, among other factors. They were then evaluated for their protective effect towards confirmed influenza, and the researchers observed and analyzed which behaviors correlated with the groups with the highest protective effect. The highest behaviors associated with a high protective effect were frequent handwashing, the availability of soap for handwashing, and reduced levels of hand-to-face touching.

This study is one of many that organizations like the CDC and WHO refer to when making recommendations to national/international populations during a time of a pandemic. As we are all aware of the importance of handwashing in the reduction of COVID-19, this behavior is proven to reduce the spread of influenza and other respiratory diseases as well. With this being said, it is possible that given the rapid, worldwide development in hand hygiene, we could be seeing lower levels of seasonal respiratory sicknesses in the future.

Decline in Healthcare-associated Infections

According to data from the CDC regarding healthcare-associated infections (HAIs), on a given day, about 3% of hospital patients has at minimum one HAI. Hospitals across the world are always looking for ways to reduce this statistic, as hospitalized individuals are often the most vulnerable to experience complications from infections. There are many common practices that hospitals enact to tackle this issue, with one of them being.. you guessed it, handwashing.

Healthcare workers follow strict protocols to ensure they are maintaining a clean environment for their patients and not tracking problematic pathogens throughout a facility. Handwashing is an important common practice that has been proven to reduce the risk of transmission of HAIs according to a 2002 CDC study. This is why most hospitals have sinks in patient rooms and also why we, at Lakeside, offer portable handwashing stations for areas that don’t have built-in sinks available.

If population health increases due to improved hand hygiene, hospitals could see a decrease in the number of potential illnesses entering a hospital environment. On a large scale, this could lead to an overall reduction in HAIs and improvements in patient health.

Improvement of Child Development in Developing Countries

In 2003 the CDC performed a study to monitor the effects of hygiene on child development and observed interesting results. When comparing groups who received an extensive 9 month hygiene promotion and soap against groups who did not receive the same hygiene education nor supplies, the children experienced nearly half as much diarrhea-related sicknesses than the control group in their first 2 ½ years of their lives, which is a critical time for child development. 6 years later, the children from the study were reevaluated for cognitive development. The children who received hygiene education and hygiene supplies scored higher than the control group. According to the study, the findings suggest that “handwashing promotion could be an important strategy for improving child welfare.”

Given the increased awareness around the world regarding proper hand hygiene and the increased availability of hygiene resources, it may be possible that the effects of the CDC study transfer to the real world. If this were to happen, we may see improvements in child development on a grand scale, as children in developed countries avoid illness and chronic inflammation related to diarrhea-linked diseases.

Reduction in Antibiotic Resistance

Antibiotic resistance is an issue of growing importance in the world. This takes place when bacteria evolves to overcome the intended effects of a given antibiotic. Various infections rely on antibiotics for treatment. If a bacteria develops antibiotic resistance, this has the potential to transform a curable sickness into a deadly illness.

The CDC states that the leading factor in antibiotic resistance is overuse of antibiotics. Many times, antibiotics are prescribed to individuals when they are not needed, leading to an increased risk of a bacteria developing antibiotic resistance. Research by the CDC indicates that handwashing leads to a reduction in diarrhea-related sicknesses and respiratory infections, diseases that are often unnecessarily prescribed antibiotics for treatment. Therefore, some speculate that a reduction in these diseases, due to handwashing or other factors, could impact global rates of antibiotic resistance.

The New Normal

Our world has quickly transformed into a hyper-aware, germaphobic one due to the brisk rise of the coronavirus pandemic, however, perhaps this acute awareness was long overdue. If international populations continue to emphasize hand hygiene in their COVID-19 responses and this leads to a sustained improvement in hand hygiene; we could see many beneficial outcomes that improve world populations beyond the pandemic. We have long been aware of the importance of hand hygiene in hospitals, schools and densely populated areas. Due to the sudden change in human behavior regarding hand hygiene, it is exciting to consider what possible outcomes might arise. As healthcare professionals, we will keep promoting proper hand hygiene and at Lakeside, we will continue to offer products that promote access to handwashing.

Posted on Leave a comment

Soap and Water or Hand Sanitizer? Which creates better Hand Hygiene?

Washing your hands has always been super important in healthcare facilities in order to prevent Hospital Acquired Illnesses (HAIs) or healthcare-associated infections which affect about 1 in every 31 patients. With the outbreak of COVID-19, it’s even more important for healthcare professionals, and all of us to practice good hand hygiene.

What is good hand hygiene?

Having good hand hygiene means keeping your hands clean as much as possible. The best way to practice proper hand hygiene is to wash your hands with soap and water, or to use hand sanitizer whenever your hands may have come into contact with a dirty surface. Dirty surface doesn’t just mean visibly dirty, as many surfaces that appear to be clean could actually be covered in germs and bacteria. If you’re not sure whether you need to clean your hands, it’s always best to err on the side of caution and wash up!

Soap and water or hand sanitizer?

The best ways to clean your hands is by washing with soap and water or using hand sanitizer. While hand sanitizer removes most germs, it does not remove all germs from your hands, and studies show that soap and water are more effective at removing certain types of germs. This is why the CDC recommends washing your hands with soap and water whenever possible, and using hand sanitizer if soap and water are not available.

When to Wash your Hands

Here are some of the times when the CDC recommends that you wash your hands with soap and water.

  • Before, after, or during any food preparation
  • Before eating food
  • Before and after caring for someone who is sick with vomiting or diarrhea
  • Before and after treating a cut or wound
  • After using the bathroom
  • After changing diapers or cleaning up for a child who has used the bathroom
  • After touching an animal or animal waste
  • After handling pet treats or food
  • After touching a garbage
  • Anytime that your hands are visibly dirty or greasy

When to Use Hand Sanitizer

Here are a couple of instances in which the CDC believes hand sanitizer will work to remove germs and bacteria.

  • Before and after visiting someone who is in a hospital or healthcare facility
  • If soap and water are not readily available

Proper Hand Washing

We’ve all been taught the importance of regular hand washing from a young age, but do you know how to correctly wash your hands? According to the CDC, there are a few steps for the proper hand washing technique.

  1. Wet your hands with warm water
  2. Apply the amount of soap that the manufacturer recommends
  3. Rub your hands together vigorously for at least 15 seconds, making sure cover all parts of your hands with soap
  4. Rinse your hands with more water
  5. Lastly, dry your hands with a paper towel or air dryer, and turn off the faucet with the towel to avoid any lingering germs.

Proper Hand Sanitizing

It seems like it’s obvious how to use hand sanitizer, but not everyone sanitizes their hands correctly.  Here are the steps for correctly sanitizing your hands.

  1. First, you should make sure that you are using a hand sanitizer that is at least 60% alcohol in order for it to be effective
  2. Put the amount of product that the manufacturer recommends on your hands and start to rub them together
  3. Continue rubbing your hands together for about 20 seconds until your hands are completely covered and dry
  4. Once your hands are dry, they will be sterile and you should be ready to move on to your next task

 

Hand Hygiene in Hospitals

Even among healthcare professionals, there is a need for better and more thorough hand hygiene training. In fact, a study was done which showed that even before COVID-19 took the world by storm, 40% of healthcare professionals wanted better hand hygiene training. According to the CDC, on average, healthcare providers clean their hands less than half of the times that they should which contributes to 1 of every 31 hospital patients contracting a HAI. So even though it may seem obvious that clean hands are super important for healthcare professionals, there is a need for more training and knowledge when it comes to hand hygiene.

When to Wash your Hands in the Hospital

Soap and water are very effective at cleaning your hands and removing pesky germs and bacteria that hand sanitizer will not. Here are a few circumstances when you should make sure to wash your hands when in a healthcare facility.

  • Anytime hands are visibly soiled.
    • Hand Sanitizer is not very effective at removing dirt and other germ-filled substances that may build up on your hands. Whenever you can physically see anything on your hands, wash them!
  • After caring for a person who may have infectious diarrhea
    • Diarrhea is caused by difficile, a common HAI that hand sanitizers are not able to get rid of.
  • After a potential exposure to spores
    • Spores are infections caused by bacteria that is resistant to hand sanitizers and require a thorough washing with soap and water to kill the bacteria.

When to use Hand Sanitizer in the Hospital

Although it is always best to wash your hands when possible, here are some instances in which hand sanitizer will do the trick.

  • Immediately before touching a patient
    • Using hand sanitizer before any contact with a patient is always the smart thing to do, even if you have recently washed!
  • Before performing any aseptic tasks
    • Hand hygiene is super important when it comes to any invasive medical devices, and you should make sure that everything, including yourself, is clean and sterile
  • Before moving to work on a clean part of a patient’s body from a soiled point of their body
    • You should frequently be sanitizing when working directly with patients, even if they are the only thing you’ve had contact with!
  • After touching a patient or their immediate environment
    • Always sanitize your hands when you’re done working with a patient, and before you move on to your next tasks
  • After contact with bodily fluids or contaminated surfaces
    • Sanitize after any contact with an un-sterile surface or object, and wash your hands if there is any remnants!
  • Immediately after glove removal
    • You may think that the inside of your gloves are sterile and clean, but sweat can build up inside and cause germs and bacteria to cover your hands.

 

Myths about Hand Hygiene

Myth 1: Frequent Hand Washing dries out your skin

While washing your hands too much can cause the skin on your hands to dry out, it is likely that the reason for this is the water you are using is too hot. Using warm water drastically effects the amount of dryness that can come from hand washing, and will ensure that you are able to keep your hands clean whenever they need to be.

Myth 2: Hand Sanitizer causes antibiotic resistance

Some people claim that hand sanitizers can lead to antibiotic resistance, but this simply isn’t the case. The main cause of antibiotic resistance is repeated improper use of antibiotics according to the CDC.

Myth 3: All germs are the same

This is not accurate, as there are many different types of germs and bacteria that can build on your hands, some of which require soap and water rather than hand sanitizer to be taken care of.

Myth 4: Antibacterial soap reduces the amount of times you need to wash

Antibacterial soap is great for cleaning your hands, but studies show that it isn’t significantly better than normal hand soap. It also does not mean that you have to wash your hands less than you would with normal soap.

Is Hand Sanitizer really more convenient in Hospitals?

The main reason why healthcare facilities use hand sanitizer much more than soap and water is simply because it is much easier to quickly sanitize your hands with a busy schedule, something most healthcare professionals have every day. Sanitizer is easy to carry around with you or to put out for people to use on something like Lakeside’s high-traffic sanitizer dispenser, but that doesn’t mean that washing with soap and water is difficult!

To effectively wash your hands with soap and water, all you need is 30 seconds and a sink. Lakeside has helped to create a solution to one of those parts with the portable handwashing station, which allows you to put a sink with soap and water anywhere in your facility. This product also gives you the ability to move it around to areas that require more intense hand hygiene, and makes it easy to wash your hands with soap and water without a trip to the bathroom.

If time is a big concern in your healthcare facility, make sure to check out Lakeside’s product solutions designed to ensure efficient and proper hand hygiene for all healthcare professionals!

Posted on Leave a comment

The Top 3 Factors when it Comes to Hospital Cleanliness

Each year, an estimated 722,000 patients in the U.S. are infected by hospital-acquired pathogens.  This alarming statistic has motivated hospital organizations and healthcare professionals to consistently evaluate and reassess hospital cleaning methods.  Although there exist many studies relating to the effectiveness of various hospital cleaning methods, there is no consensus on a single method proven to be most effective.  As a manufacturer and supplier to the healthcare industry, Lakeside Manufacturing strives to stay up to date on hospital cleaning practices.  We see facilities with all types of cleaning practices and want to share our insights on the top 3 factors that can set your hospital apart when it comes to hospital cleanliness.

#1 Hand Hygiene

A systematic review of 80 studies relating to hospital cleaning strategies concluded that although there are many proven ways to reduce the amount of pathogens in a hospital setting, there are not enough comparative studies to identify superior monitoring or disinfecting strategies.  Health experts recommend a combination of proven methods to maintain a clean hospital environment and reduce Healthcare-Associated Infections (HAIs). However, a very consistent and principal factor in hospital cleanliness is hand washing practices.  A 270 page report published by the WHO details various guidelines, hand-washing methods and hand washing agents that have been proven to mitigate the level of HAIs in hospital settings.

#2 Extra Attention for High Touch Surfaces

Objects and surfaces in patient care areas that are handled frequently by several different users are more likely to be contaminated.  According to a review of multiple studies, items that were most likely to be contaminated were privacy curtains, sinks, bed linens and hospital personnel clothing. These high-touch surfaces require extra attention as they can enable pathogens to cultivate and spread throughout the patient environment. Additionally, high mobility items such as hospital carts, food carts and IV stands should be sanitized diligently to prevent pathogen spread from one patient location to another.  The CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend cleaning high touch surfaces more frequently.

#3 Cleaning According to Manufacturer Instructions

Another key factor in hospital cleanliness was the ability for hospital staff to follow recommended sanitization instructions for items located in the hospital. Specific manufactured items such as IV stands, hospital machinery and hospital carts should be sanitized following the manufacturer’s instructions. Different types of pathogens exist for varying durations depending on the material and are best cleaned with methods specific to the item. Therefore, hospitals should pay close attention to these recommendations rather than using a single uniform method.

The Importance of Patient Safety

With patient safety at the forefront, reducing the abundance of hazardous pathogens in the hospital environment is a clear way to improve patient outcomes.  A lack of comparative studies makes it difficult to discern a clear best-practice for hospital cleaning, but practicing proper hand-hygiene, identifying and cleaning high-touch items, and following manufacturer’s cleaning instructions are proven methods to improving hospital cleanliness when performed simultaneously. At Lakeside Manufacturing, we feel it is important for all of us within the medical community to stay up to date on this topic.  We aim to work with hospitals and manufacturers towards the shared goal of eliminating healthcare-associated infections.  For more information on how to disinfect Lakeside products, review our page on cleaning stainless steel.  We also welcome any feedback or additional information related to patient safety, cleaning practices or Lakeside products.

Posted on 1 Comment

The Importance of Stainless Steel

Amidst the global spread of COVID-19, sanitization is more important than ever, especially for healthcare facilities, who are on the front lines of the battle against this pandemic. Sanitary equipment is imperative to slowing the spread of COVID-19, and our healthcare facilities need access to increased amounts of supplies such as masks, ventilators, hospital beds, emergency carts, and other ancillary equipment. While hospitals are investing in additional supplies, we must consider what materials are best suited to combat this situation. Medical equipment is manufactured with various types of metals, plastics, and more. But which is the best for safety and sanitization? The consensus of the medical community is widely agreed upon: stainless steel.

What is stainless steel?

Stainless steels are iron-based alloys that contain at least 10.5% chromium and 1.2% or less carbon. There are many different types or grades of stainless steel which are created by altering the percentages of its contents, and adding in different metals and elements such as:

• Nickel
• Molybdenum
• Titanium
• Copper
• Carbon
• Nitrogen

In fact, there are over 50 different grades of stainless steel. Grades such as 200 and 400 series are widely used but they all share properties that cause this metal to have its unique sterilization capabilities. Stainless Steel gets its “claim to fame” due to its ability to resist rust and corrosion. This property is due to the addition of chromium which creates a chromium-oxide film on the surface when exposed to oxygen. This film acts as a barrier between the steel and the environment. If the film is broken, it has the ability to self-heal, as long as oxygen is present. With this ability, stainless steel makes an excellent choice for medical equipment that is constantly wiped down, washed and cleaned. All this cleaning would likely damage other materials but this where stainless really shines! It’s chromium-oxide film allows it to heal itself after getting beat up by the variety of cleaning methods necessary in a healthcare environment.

Why is stainless steel the hygienic standard in healthcare facilities?

The unique capability to self-heal helps create a surface that is very easy to sanitize in comparison to other materials used widely in medical equipment. Other materials such as ceramics, plastics and polymers are susceptible to micro cracks, dents, and scratches which harbor bacteria and other germs. Oftentimes these micro cracks are invisible to the naked eye, making these materials especially challenging to thoroughly clean. Stainless steel, on the other hand, is highly durable and resistant to cracks, dents and scratches. Its natural film protects the metal and reduces the amount of maintenance necessary. With all this in mind, it becomes clear why other materials cannot steel the crown from stainless steel as the king of durability and cleanability.

We can also see why stainless steel is widely used in medical applications. Not only is it extremely durable, but it is also an easy material to work with as it can be cut, welded, and shaped very easily, while providing extra strength. Stainless steel also lasts much longer than other materials and won’t scratch and dent over time. This makes stainless steel an excellent investment that ensures easy cleaning and low maintenance for years to come. Stainless steel also has high temperature resistance, meaning that even in high temperature environments it won’t deform or break under mechanical stress unlike many other materials.

Common Medical Applications of Stainless Steel

Stainless steel is used for a variety of different medical applications including:

  • Surgical Instruments
  • Cabinets
  • Sinks
  • Tables
  • Stands
  • Case Carts
  • Utility Carts

Stainless steel is specifically useful for utility carts as they must be able to carry heavy loads, while not being too heavy by themselves. Additionally, the sanitary element is very important for utility carts in healthcare facilities, and stainless steel provides the best surface to ensure safe and sanitary equipment. A great example of the strength of stainless steel comes from the Lakeside 444 Utility Cart which has a capacity of 500 lbs. while only weighing 68 lbs. itself. Utility carts like this have the best durability and value, because they will last much longer than a similar cart made from aluminum or a different alloy.

Importance of Stainless Steel During COVID-19

The ongoing pandemic is pushing the healthcare industry to the limit, and the need for safe and sanitary equipment is at an all-time high. Because COVID-19 is a respiratory virus, it spreads very easily, and healthcare facilities and equipment must be sanitized effectively. It is recommended that healthcare facilities assign the daily cleaning and disinfection of high touch surfaces to the nurses and personnel who will already be in close contact with the patient. The use of stainless steel instead of plastic or aluminum equipment makes the sterilization process simpler and takes a load off the healthcare professionals who are tasked with the job of cleaning these hazardous surfaces.

Lakeside Manufacturing is committed to supporting medical facilities with rapid manufacturing and shipping times. Our facility remains open and operational under the essential business provisions granted by local and federal guidelines. Please reach out if your facility is in need of case carts or utility carts during this challenging time. Lakeside is prepared to support increased demand of stainless steel products and remains dedicated to providing quality healthcare solutions.

Lakeside Has You Covered

 

Check out our COVID-19 resources page and product solutions pages for helpful, informative, and up to date information relevant to the pandemic in real time.

Posted on 3 Comments

A Guide to Disinfecting Stainless Steel

Medical communities around the globe are more preoccupied than ever with disinfecting equipment.  COVID-19 is changing the conversation about how we clean, not only in medical facilities but also at home and throughout our communities.  With stainless steel being the preferred material by the medical community, it is imperative that we understand how to properly sanitize stainless steel equipment.  Lakeside manufactures a wide variety of stainless steel medical carts, shelves and accessories and we’ve put together a guide on how to accomplish this.

Selecting a Disinfectant

According to a study from the National Institute of Health, the virus that causes COVID-19 was detectable on up to three days on stainless steel products. Therefore, verifying that the correct product is being used to disinfect surfaces is paramount.  The Environment Protection Agency created a list of disinfectants that are effective against COVID-19.

While bleach should generally be avoided for cleaning stainless steel products, common products such as Lysol Spray or Lysol Wipes can be used on stainless steel.  If you decide to use a product of this type, it is extremely important that you rinse the surface thoroughly with fresh water.  Lysol and similar products can be abrasive to stainless steel if the substance is on the surface of the stainless steel for an extended period.

Using the Right Tools

Prior to cleaning and disinfecting any surface, it is imperative to use Personal Protective Equipment (PPE).  There are four major types of PPE including face shields, gloves, goggles, and gowns. At minimum gloves and eye protection should be used before cleaning any potentially contaminated surface.

Certain cleaning utensils like steel wool or other steel brushes are too abrasive for stainless steel.  These types of tools can contain iron particles.  When used to clean stainless steel, they can leave metal particles on the surface and lead to rust formation.  A soft cloth, gentle brushes, or sponges are much better alternatives.

The Cleaning Process

To effectively sanitize a stainless steel surface, it is recommended to begin by using hot soap and water. Using your towel, you can then begin to use any additional cleaning solutions.  Always rub in the direction of the steel grain for maximum effectiveness and to avoid scratching the surface.

After all disinfectants are applied, rinse the surface thoroughly with fresh, warm water.  Always remember to completely wipe the surface dry. This process should be repeated after every disinfecting operation.  As always – and especially during the COVID-19 pandemic – frequent cleaning is strongly recommended.

Lakeside Manufacturing is committed to supporting medical facilities with rapid manufacturing and lead times.  Our facility remains open and operational under the essential business provisions granted by local and federal guidelines. Lakeside is prepared to support increased demand of stainless steel products and remains dedicated to providing quality healthcare solutions.  For more information about the stainless steel carts we have available, please review our Healthcare Catalog.

Lakeside Has You Covered

 

Check out our COVID-19 resources page and product solutions pages for helpful, informative, and up to date information relevant to the pandemic in real time.