I can’t. I just can’t.
From the Journal of Clinical Oncology.
In April 2021, President Biden pledged to drastically reduce greenhouse gas (GHG) emissions by 50% relative to 2005 levels by 2030. This ambitious agenda will inevitably require significant changes across the breadth of the United States economy, including the health care sector. According to previous studies, the health care industry accounts for roughly 8.5% of total GHG emissions in the United States (the most in the world in per-capita and absolute terms),1,2 and in recent years, the provision of cancer care has increasingly been included in discussions about decarbonization.3,4 We believe that surgical oncologists are a crucial stakeholder community in the implementation of associated priorities for two reasons. First, owing to the prevalence of consumables, heating, ventilation, and air conditioning (HVAC) systems, volatile anesthetic gases, and sterilization processes, operating rooms (ORs) partially account for 70% of a hospital’s waste and are three to six times more carbon-intensive than the hospital as a whole, according to a 2017 life cycle analysis.5–7 In 2014, the release of hydrofluorocarbon and chlorofluorocarbon anesthetic gases stood at the equivalent of 3 million tons of carbon dioxide, with 80% of emissions from desflurane alone.8,9 Second, carbon-intensive minimally invasive surgical approaches, that is, laparoscopic and robotic-assisted, have become mainstays in the management of several cancers, for example, uterine, oropharyngeal, colorectal, and prostate.10–15 For example, the robotic hysterectomy has been associated with a carbon footprint of 814 KgCO2e, commensurate with a 2,273 mile journey in a gasoline car.16 This is salient because the adoption of robotic-assisted procedures increased eight-fold from 2012 to 201811 and overall minimally invasive surgical activity in the United States is associated with total CO2 emissions of 355,924 tons per year, synonymous with a country-level ranking of 198th among UN member states.17https://ascopubs.org/doi/full/10.1200/JCO.21.02581
Here is the press release for this “publication”.
Operating rooms are the climate change contributor no one’s talking about
Two surgeons-in-training suggest some sustainable solutions for their energy-intensive discipline.
MICHIGAN MEDICINE – UNIVERSITY OF MICHIGAN
In April 2021, during the Leaders Summit on Climate, President Biden announced his goal to drastically reduce the United States’ greenhouse gas emissions by 2030.
Victor Agbafe was watching the address on TV. The University of Michigan Medical School student, who is also studying law at Yale, immediately texted a few mentors, including Michigan Medicine integrated plastic surgery resident Nicholas Berlin, M.D., M.P.H., M.S.
The question that emerged from their messages was a crucial one: What role can the medical community, which accounts for about 8.5% of America’s greenhouse gas emissions, play in these climate change reduction efforts?
A year later, research that Agbafe and Berlin led outlines some answers. Their paper describes how surgery, particularly cancer surgery, contributes to climate change and suggests some solutions to combat the problem, from reducing waste to rethinking how surgical care is delivered.
“In general, these ideas are good for our planet,” Agbafe said. “But also, surgery unfortunately plays a disproportionate role in the carbon output and the waste we produce in medicine.”
Operating rooms are a massive source of greenhouse gas production for hospitals, representing 70% of their waste and generating three to six times as much carbon as the rest of health systems.
Cancer care is an obvious target for greener efforts within surgery, Berlin notes, because it often involves intense levels of care over a short period of time.
Plus, minimally invasive surgeries that require a lot of energy, including robotic-assisted operations, have become common treatments for cancers ranging from colorectal and uterine cancer to head and neck cancer. A robotic-assisted hysterectomy, for example, produces as much carbon as driving more than 2,200 miles in a car — the equivalent of a road trip from Ann Arbor, Mich., to Los Angeles.
“If we can lower our greenhouse gas output, we have a chance to extend the lifespan of our patients and expand access to timely care,” Agbafe said. “And we think it’s really important that the surgical community is proactive at being at that table.”
What to do differently
One of the most feasible changes to make in this space would be around waste reduction, Agbafe said.
This might be as simple as making sure that anything thrown away before or during surgery is properly categorized and labeled since it’s estimated that over 90% of OR waste does not meet the necessary standards for the type of trash it ends up in. (The red waste bags in ORs are intended only for items that have been exposed to bodily fluids and are much more expensive to dispose of than clear disposal bags.)
Hospitals could also consider switching to some reusable or reprocessed devices and surgical gowns since there is no link between reused tools and hospital-acquired infections.
Some of the pair’s other suggestions involve optimizing ORs’ energy use. Agbafe and Berlin point to the American Society of Healthcare Engineering’s recommendations to install energy-efficient lighting, schedule preventive maintenance and minimize air flow into rooms that aren’t being used as easy ways to green the systems.
The surgical supply chain could be more efficient, too, they write. Estimates suggest that 87% of the surgical instruments laid out for an operation are rarely used, so coming up with standardized lists of the necessary tools for surgeries that occur regularly could cut down on cost, waste and the energy needed to sterilize and repackage those instruments.
Moving more manufacturing of surgical supplies closer to hospitals — or choosing to source from suppliers that are locally based — could also reduce the OR’s carbon footprint.
“Given some of the geopolitical events that have been going on right now in Ukraine and with China and the competition there along with the effects of pandemic is creating an increasing emphasis on resiliency within supply chains,” Agbafe said. “So this idea of localizing our operating room supply chains is something that there’s a lot of political energy and momentum within the public to move towards.”
Reimagining care delivery
But perhaps the broadest way the oncology space could cut down on its greenhouse gas emissions is to change how surgical care is delivered, starting with permanently offering telemedicine.
“We think telemedicine is a great opportunity for us to lower the climate impact and improve the quality of care by doing so,” Agbafe said. “During the pandemic, we’ve been using virtual care and if we could make that a routine aspect of cancer care for pre-op and post-op, that’s a way we can reduce the climate impact of delivering care and make it more convenient for patients.”
Reducing low-value care is another way to eliminate carbon-producing activities associated with unnecessary scans, testing and procedures.
This has been a priority for U-M, thanks to the Michigan Program on Value Enhancement — a collaboration of Michigan Medicine and the University of Michigan Institute for Healthcare Policy that aims to improve the quality of care at the institution — and a partnership with the similarly oriented Michigan Value Collaborative, also referred to as MVC, a collaborative quality initiative that serves the entire state.
Last year, the two organizations collaborated on a study that highlighted how much routine testing was still done before surgeries despite its low value. Berlin was the first author.
“U-M is considered one of the leading institutions studying low-value care and efforts to limit that type of care,” Berlin said. “But like a lot of other centers, we are really just at the precipice of these initiatives. I would anticipate big changes in the next 10 years.”
From gas to (more sustainable) gas
Some sustainability shifts may come even sooner at Michigan Medicine.
For instance, the Department of Anesthesiology recently launched the Green Anesthesia Initiative, or GAIA for short. Its mission: become more environmentally conscious about the types and rates of anesthesia its providers use, another area Agbafe and Berlin say is ripe for improvement.
“This is a topic of fairly intense discussion right now in the field, and I’ve been thinking about it for a while,” said George Mashour, M.D., Ph.D., the chair of the Department of Anesthesiology and the Robert B. Sweet Professor of Anesthesiology at the University of Michigan Medical School. “Unlike other industries, I don’t think that we require massive disruption in order to make progress because, fortunately, we have options.”
Several inhaled gases regularly used for anesthesia are A-list offenders when it comes to greenhouse gas production. Nitrous oxide, commonly known as laughing gas, is a greenhouse gas, a direct ozone depleter and does not dissipate from the atmosphere for more than a century after it’s produced.
However, the inhaled anesthetic sevoflurane has much less of an environmental impact than nitrous oxide and other common inhaled agents, so Mashour says it would be a good alternative.
“The overall goal is to shift away from some of these egregious culprits and start making better choices about which drug we use and then also how we use it,” Mashour said.
“The contributions in terms of greenhouse gas effect or ozone-depleting action partly relate to how much is getting pumped out into the atmosphere and that relates directly to how high we have our fresh gas flow,” he added. “If we have, for example, 10 liters going, we’re blowing a lot of anesthetic into the scavenging and waste and atmospheric systems that doesn’t need to be there.”
To that end, Mashour’s colleagues in the Department of Anesthesiology are already leading a national initiative to try to reduce anesthetic gas flow rates through the Multicenter Perioperative Outcomes Group, another quality initiative that includes health centers from across the country.
Mashour plans to roll out other elements of GAIA over a three- to- five-year period.
“We could be doing better,” he said. “Right now, we’re starting the conversations, getting people on board and making structural choices in the department to help make it easy for people to do the right thing.”
Journal of Clinical Oncology
METHOD OF RESEARCH
Prescriptions for Mitigating Climate Change–Related Externalities in Cancer Care: A Surgeon’s Perspective
ARTICLE PUBLICATION DATE
LOL! Only the left could say such a thing and, worse, believe it.
Rank idiocracy on steroids – and two “surgeons” (assuming they make it thru training) that I would never want touching me or anyone I care about in a million years. What utter tripe!!!
actually much of it is just common sense which any cost conscious institution should look into implementing. Looks like a 6 sigma green belt project.
climate impact? LOL.
I was thinking the same but perhaps it only causes Brain Rot of those anxious about climate change.
Everything the left touches turns to cr@p.
The Covid-19 injections greatly reduce natural immunity and are leading to an increase in all forms of illness, including cancers. We advised our governments against the toxic and ineffective Covid-19 “vaccines” on 8Jan2021, before they were deployed here.
I would so much like to be wrong. The health tragedies are rolling in.
SYNTHETIC mRNA SUPPRESSES IMMUNE SYSTEM, POSSIBLY LEADS TO CANCER, BLOOD CLOTS, FERTILITY ISSUES, SPONTANEOUS ABORTIONS: DR. MALONE
Why are so many women experiencing delays in their menstrual cycle? And are the blood clots, cancers, spontaneous abortions, and other fertility issues that women are experiencing tied to the mRNA vaccines? In order to answer these questions, we sat down with Dr. Robert Malone—a vaccine expert who holds several patents to the original mRNA platform technology.
And during the discussion, he shed light on how, according to recent studies, the positively charged, synthetic lipids that are part of the mRNA vaccines accumulate in the ovaries—which might account for some of what pathologists are now seeing plague women.
dunno but yet another vaxxed 3x mates fallen over got the mild omicron was given the molnupiravir felt better but now? 2 weeks on and shes still seedy and in bed most days
Triple-vaxxed? Better to shoot yourself 3 times with a .22 LR.
Do NOT inject your children and young adults – all risk and NO reward.
Ivermectin is a quick cure for Covid-19 – as little as 12mg/day (for an adult) for five days and people are 95% better – losing the fatigue sometimes takes time, or more Ivermectin.
We’ve had some success apparently reversing mild “vaccine” injuries with Ivermectin plus etc (Multivitamin incl Zinc, Vitamins D & C, Melatonin at bedtime). Small sample, one specialist physician and one registered nurse, both with fatigue and chronic bleeding, both now say the bleeding has stopped and the fatigue is gone – after 5-10 more days of Ivermectin, total 10-15 days.
Try Quercetin if you can’t get Ivermectin, but it’s not as effective.
HOW THE COVID “VACCINES” CRIPPLE THE IMMUNE SYSTEM | PART 1 OF 5: UNDERSTANDING THE IMMUNE SYSTEM
Dr Mark Trozzi 2022-05-08
New video series collaboration with Strong and Free Canada
Here is the first of five short videos to explain how the forced covid injections damage their victims’ immune systems, rendering them more vulnerable to: coronaviruses and other infections, as well as cancer.
In this first video we introduce some basics of the immune system that are fundamental to understanding this subject.
They want you dead. Prove this statement wrong.
The longer you live, the more money they make. The vast majority of healthcare costs occur later in life. I know; I’m an old fart. These twit-wads will have alot of fun and make alot of money off this new medical scam.
No argument that they are making money off of healthcare, but there are inconsistencies. The left in general pushes for euthanasia and abortion at every possible step. It seems they make money on selling body parts too.
And don’t forget their push of ventilators (virtual death sentences) and $30K plus hospital bonuses for every patient placed on one.
They take their cut in your life for sure. But death is also a component of their “depopulation” agenda.
It is a fair observation that the healthcare industry has become an income-driving engine for industry and providers. That is not to say that most of the people working on the front lines of healthcare don’t truly care about the wellbeing of their patients, but on a higher level much of what we experience as health services was designed around profit rather than health. My approach and my advice to others is to aim for a healthy lifestyle where physician visits, prescription drugs, medical and surgical procedures and diagnostics are minimally necessary. Health comes from how we live, healthcare is for fixing our mistakes. Make as few of those as you can manage and the vagaries of healthcare will have minimal impact on your quality of life and finances barring the few catastrophes in health beyond our control.
Living a healthy lifestyle is great, and can certainly help. But health care isn’t for “fixing our mistakes.” Not unless you count things such as childbirth a “mistake.” Or cancer screenings, plus all the inevitable problems that come up as one ages no matter how healthy a lifestyle you live.
my first thought was because it allows one more person to live
More than want you dead! The eco-fraud left want you tortured to death! They want a return to Civil War era MASH units. Bone saws and whisky for anesthesia. Yes, they want you dead … but a painful, tortured death … as punishment for your sins against Gaia.
It’s easy to see how some conclude that there’s a satanic influence on the Left. Leaving aside any discussion of metaphysical ideas about personified evil, it isn’t necessary to posit a devil to show that there is evil intelligence at work.
My own assessment is that once they have been convinced of a wrong theory of reality and have decided on the necessity of depopulation, they push every approach that supports the end goal. They are well aware that a direct appeal to voluntary poverty and mass death is not going to win many adherents. So they cloak it in gibberish about the urgent need for decarbonization supposedly to save human civilization, which is ironic since the true end is to “reduce the surplus population”.
Of course most of them imagine that they will be in the elite cohort, not among the disposable useless eaters.
Look at it through this lens and there is very little happening today that is not compatible with a goal of a radical depopulation.
“We think telemedicine is a great opportunity for us to lower the climate impact and improve the quality of care by doing so,” Agbafe said.
My cancer could not be detected without a CT scan followed by a biopsy. How do you do that with telemedicine? Clearly, with their idea of lowering climate impact in healthcare, many cancers and other ailments will not be detected in a timely fashion, and people will die. That is not the way you “improve the quality of care.”
They want you dead, because the earth needs to shed 7 billion lives to get to the 1 billion population that the environmentalists claim is the proper one on earth.
How wondrously crackheaded green can one get?
The phrase “Jump the shark” has lost all meaning.
If they include the carbon footprint of transgender operations and plastic surgery I’m sure this will all get swept under the rug.
As long as the disfigurement results in sterility, all is well. The goal of depopulation is undeniably advanced by encouraging any form of sexuality that is sterile.
American medicine is doomed. Between med schools teaching men can get pregnant and climate change focused care the end is near for US medicine.
No problem, no more cancer treatment or any surgeries for all the greeniots.
Well, not exactly 2hotel9. No more cancer treatments, EXCEPT for the greeniots. No more cancer treatments for you or for me, that’s for sure. But if say, John Kerry, would require cancer treatments then he would be shuttling back and forth to the clinic in his private jet of course.
Trust us we’re doctors?
Good job they left x-rays, radiotherapy and MRI etc out of it
Reducing pre-surgery testing is reducing those items.
They eliminated the pre-op chest x-ray years ago. And everything is digital now. No more film, chemicals, automatic processors, etc. Progress!!
Have they eliminated MRI?
They are just too stupid to know how much energy is used in producing MV photons and/or MeV electrons by linear medical accelerators. Not to mention energy needed to keep 24/7 very strong magnetic field (1.5 to 3 Teslas) in MRI units. When they figure this out they will scream bloody murder.
Not even the Babylon Bee could have gone this far. Fiction has to at least seem plausible.
The climate death cult is itself a cancer of humanity, that curses everything that it touches.
They got it backwards.
“Uptown – downtown
No one’s fussy I’m a target
Old, white – day, night
No one’s fussy I’m a target”
As a retired surgeon who cured a lot of cancers by removing them before they spread, I will wait for the left/greenies to outlaw volcanoes and undersea thermal vents before I lose a minute of sleep over emissions from the OR.
Thank you for your hard work over the years. I myself had to have my left testicle removed nearly a year ago due to a cancerous growth. My urologist performed the surgery. Thankfully the growth was a pure seminoma, the least invasive type of testicular cancer. After consultation with my oncologist I was able to avoid chemo. A followup CT scan and blood work after surgery revealed no evidence for any metastatic disease. Two more CT scans and multiple blood tests since have been clear. I’m now on a 6 month CT scan schedule instead of 3 month.
I’d hate to be an OR patient in the future if hospitals/surgery centers start sacrificing care in the name of “Big Green”.
Having had cancer surgery for a Stage 1 Tumor that saved my life, I can hardly begin to fathom stopping surgery because of Climate Change. The shear ignorance of what is going on in the world with developing countries vastly increasing GHG emissions while all efforts in the Western World have been futile is staggering. Not one responsible person is advocating a holistic approach to reducing GHG emissions which starts with the major sources. That being China. If they can’t control China, there is no point in controlling anything else. And. you cannot control China, so therefore there is no point in controlling anything else.
This does not even begin to address the physical need to control GHG emissions either, but I concede that there is no point in discussing this aspect of the problem with many people.
Ah yes … but this is really all about “equity”. You see the third world doesn’t have the shiny new technologically advanced OR’s like the capitalist West does … so we pampered Westerners MUST be forced to live like the most primitive of a third world existence. It’s only “fair”. Isn’t that what DIE actually means? Diversity, Inclusion, and … Equity?
We will own nothing, and be happy, or else!
Yep. The ultimate goal. Would be tyrants ALWAYS clearly state their goals…Too bad no one believes them until it is too late.
I guess we will have to go back to biting the bullet. Oh, but then there’s the lead; never mind. I can see the anesthesiologist personnel being replaced by motivational speakers encouraging patients to “Suck it up, cupcake” and take one for Team Green. A case of First World Anxiety if there ever was one.
Instead of biting the bullet, drink whisky.
Or even whiskey.
From the article [Mashour]: “We could be doing better,” he said. “Right now, we’re starting the conversations, getting people on board and making structural choices in the department to help make it easy for people to do the right thing.”
No. Don’t board the climate bus. Just do your best in your profession. The “right thing” is to snap out of this illusion that non-condensing greenhouse gases are capable of driving the climate in one direction or the other to a harmful outcome. Whatever is being discussed in this article will never, ever, have a detectable impact on the climate, but will make it more challenging to help people overcome their health issues.
Yes, of course we could. We can always do better. The question is about when the costs of doing better exceed the value of the results.
Every high school student should know about things like the law of diminishing returns. For someone with post-secondary education to not know such things is a serious indictment of the education system.
Defund the universities.
Anyone with an idea of the ultimate goals of Again 21 would glean that the goal her is to have zero CO2 emissions and zero GHG emissions. However, CO2 and GHGs cannot and do not warm the climate. It is impossible for any gas in the atmosphere to warm the climate.
That said, the goal would be to NOT do intensive surgery and reserve such services only for the ruling elite. It’s a win-win for the libtards, as they terminate people younger due to non services and they save the planet from a nonexistent threat.
My son asked me “dad what doesn’t cause climate change” I came up with 2 things.
1) people freezing to death
2) people starving to death
I guess I can add a third
3) letting people die of horrible diseases
This is ludicrous squared. 3 million tons of CO2 equivalent for anesthesia? Sounds like a lot, but it isn’t. One smaller 100 MW simple cycle gas turbine will emit that amount in less than 5 minutes when it is operating to power your A/C on a hot day.
They should have converted it to pounds to make it sound like more. 6 billion pounds, OMG!
2.7 TRILLION grams
Names noted as “Absolutely no way are these ‘doctors’ allowed to ‘care’ for myself or my loved ones.”
As Douglas Murray makes perfectly clear in his new book, the war on the West is relentless.
If we don’t fight this insanity we’re finished.
Perfectly nothing is off limits for these overly-cautious, utterly paranoid and chronically depressed muppets
If they really wanted to help while resolving the Cause/Effect misunderstanding they’re suffering, maybe they could address the causes of the cancer:
(The US healthcare figure of “approaching $6 Trillion annually” is gaining traction. Doncha wonder what’s being included that wasn’t in the previous $3.7 Trillion figure?)
We might not approve of some people’s choices, but they are their choices to make.
Yes, we are being taken.
Of course, a healthy lifestyle is beneficial to everyone. Still, at least in the U.S., there have been few calls for people to take steps to become more healthy on their own.
Naturally, death can only be cheated for so long. As a population ages, cancer increases as one of the diseases that finally takes ones life.
I’ve got an idea for a start. Get rid of a couple morons who think climate change is a bigger problem than cancer.
And divert the trillions wasted to cancer research.
So that should reassure everyone who may depend on the healthcare system for their own healthcare or that of loved ones. Even oncology surgeons are willing to put imaginary environmental and climate concerns ahead of best practices for their patients. As a physician I know there are many ways we can and should improve the functioning of the the very expensive healthcare system, improving clinical decision-making being among the most important. But when clinicians prioritize the emissions of mischaracterized greenhouse gasses or multi-category useless recycling practices over best patient care we are going in the wrong direction.
Just when you think you’ve heard and seen it all…
So then … Obamakkare is actually driving the carbonization of America? Obama forgot to tell the truth about THAT too? You can keep your Doctor and your Medical Plan … but you will be killing the planet?
Do US hospitals not have incinerators?
Just why did these idiots concentrate on ORs and anaesthetics?
What about all that [sterile] plastic packaging, the drips, the syringes ad nauseam….
“Several inhaled gases regularly used for anesthesia are A-list offenders when it comes to greenhouse gas production. Nitrous oxide, commonly known as laughing gas, is a greenhouse gas, a direct ozone depleter and does not dissipate from the atmosphere for more than a century after it’s produced.”
Have they considered the amount of Nitrous oxide released to the atmosphere as a result of recreational use? The number of small, silver canisters that litter the streets of most UK towns & cities suggest that it is not a small amount.
Not good for life saving surgery but OK for a weekend high? Idiots.
The solution to this crisis is simple. Get a list of all those who believe it and never allow them to have surgery. What a bunch of dummies.
They should try doing something useful. And stop blaming anything and everything as the cause of a non problem.
Distorted or criminal minds.
Can’t believe medicine has fallen that low.
Put these emissions in the context that the total atmosphere weighs 5.5 quadrillion (5,500,000,000,000,000) tonnes.
There was quite a bit of hyperventilating, but the suggested solutions mostly come down to dropping some routine pre-surgery tests which don’t provide much information, changing anaesthetic (it’s amazing that anybody still uses Nitrous), modularising the initial surgical kit and a rather dubious approach to handling theatre waste.
Reading between the lines, it seems there is a “standard” surgical kit used for everything rather than starting with a specialised kit for the type of operation with other, more specialised, kits quickly available if required. Where this becomes a problem is if the instruments which are very rarely used are the ones which are needed right now if something goes wrong
the volume of thrown out inc stainless steel scissors in hospital wound dressing kits is insane! Ive snaffled 2 sets off my doc blue dot =single use
autoclave so much saner and so is OLD fashioned scrubs and op covers etc
This article on “Operating rooms are the climate change contributor no one’s talking about” takes the cake as the most lunatic ever shown on WUWT. Congratulations!
I’ll second that! The lunacy seems to be accelerating.
There was a lot of funding available back in 1998-9 for Y2K remediation, with a lot of hardware and software upgrades. This appears to be analogous.
In case anybody is interested, the preparation work did reveal potential problems and largely headed them off.
And, yes, the most dire predictions were rather exaggerated.
spitting angry@these two fools
theres a reason certain anaesthetics are used, safety!
guess they didnt factor in the travel for the far away docs doing remote surgery?
and as for telelhealth, thats bullsh*t doc cant SEE you properly or touch/listen etc
ok for a repeat script is about all
Just the fact that these “doctors” believe in the climate religion tells me that they are not too very intelligent. Perhaps, in their fields they are brilliant, however, outside anything within their areas of study they show complete ignorance.
Typical of so many of the intelligent folks within the “professional” communities. They are “woke” and don’t even realize it. Or, if they do, they don’t care because the current ideological idiots allow them to proceed within their fields allowing them to become what they wanted all along…rich and elite.
I suspect most medical folks don’t really believe in the climate ideology, they just go along to keep paying the bills.
The medical community accounts for 8.5% of America’s greenhouse gases, per the article. Yet healthcare is about 20% of GDP.
For the “1 billion earth population is ideal” crowd, cancer is a good thing. It helps get the earth’s population down to that level. Cancer surgery is a bad thing, as it delays the earth reaching that goal quicker.
No need to worry; when the Watermelons have eliminated industrial society, we’ll all be dying of cholera, typhus and TB; no one will live long enough to die of cancer.
My beautiful wife of 44 years is fighting cancer. It is the worst trial we’ve ever faced. That these ghouls would diminish her care to push their stupid global warming agenda is beyond belief. I loath them.