Using Internet and Mobile Phone Technology to Deliver an Automated Physical Activity Program: Randomized Controlled Trial Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. The pilot study. Impact of telemonitoring home care patients with heart failure or chronic lung disease from primary care on healthcare resource use (the TELBIL study randomised controlled trial) A Digital Smoking Cessation Program Delivered Through Internet and Cell Phone Without Nicotine Replacement (Happy Ending): Randomized Controlled Trial Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial A telehealth program for self-management of COPD exacerbations and promotion of an active lifestyle: a pilot randomized controlled trial A feasibility study to investigate the acceptability and potential effectiveness of a telecare service for older people with chronic obstructive pulmonary disease Effects of COPD self-care management education at a nurse-led primary health care clinic. Digital health system for personalised COPD long-term management Efficacy of multiparametric telemonitoring on respiratory outcomes in elderly people with COPD: a randomized controlled trial A randomized trial of a telephone care-management strategy. Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease. A telerehabilitation intervention for patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot trial
Background The Internet has potential as a medium for health behavior change programs , but no controlled studies have yet evaluated the impact of a fully automated physical activity intervention over several months with real-time objective feedback from a monitor . Objective The aim was to evaluate the impact of a physical activity program based on the Internet and mobile phone technology provided to individuals for 9 weeks . Methods A single-center , r and omized , stratified controlled trial was conducted from September to December 2005 in Bedfordshire , United Kingdom , with 77 healthy adults whose mean age was 40.4 years ( SD = 7.6 ) and mean body mass index was 26.3 ( SD = 3.4 ) . Participants were r and omized to a test group that had access to an Internet and mobile phone – based physical activity program  ( n = 47 ) or to a control group ( n = 30 ) that  received no support . The test group received tailored solutions for perceived barriers , a schedule to plan weekly exercise sessions with mobile phone and email reminders , a message board to share their experiences with others , and feedback on their level of physical activity . Both groups were issued a wrist-worn accelerometer to monitor their level of physical activity ;  only the test group received real-time feedback via the Internet . The main outcome measures were accelerometer data and self-report of physical activity . Results At the end of the study period , the test group reported a significantly greater increase over baseline than did the control group for perceived control ( P < .001 ) and intention/expectation to exercise ( P < .001 ) . Intent-to-treat analyses of both the accelerometer data ( P = .02 ) and leisure time self-report data ( P = .03 ) found a higher level of moderate physical activity in the test group . The average increase ( over the control group ) in accelerometer-measured moderate physical activity was 2 h 18 min per week . The test group also lost more percent body fat than the control group ( test group : −2.18 , SD = 0.59 ; control group : −0.17 , SD = 0.81 ; P = .04 ) . Conclusions A fully automated Internet and mobile phone – based motivation and action support system can significantly increase and maintain the level of physical activity in healthy adults BACKGROUND Self-management interventions improve various outcomes for many chronic diseases . The definite place of self-management in the care of chronic obstructive pulmonary disease ( COPD ) has not been established . We evaluated the effect of a continuum of self-management , specific to COPD , on the use of hospital services and health status among patients with moderate to severe disease . METHODS A multicenter , r and omized clinical trial was carried out in 7 hospitals from February 1998 to July 1999 . All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year . Patients were assigned to a self-management program or to usual care . The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up . Over 12 months , data were collected regarding the primary outcome and number of hospitalizations ; secondary outcomes included emergency visits and patient health status . RESULTS Hospital admissions for exacerbation of COPD were reduced by 39.8 % in the intervention group compared with the usual care group ( P = .01 ) , and admissions for other health problems were reduced by 57.1 % ( P = .01 ) . Emergency department visits were reduced by 41.0 % ( P = .02 ) and unscheduled physician visits by 58.9 % ( P = .003 ) . Greater improvements in the impact subscale and total quality -of-life scores were observed in the intervention group at 4 months , although some of the benefits were maintained only for the impact score at 12 months . CONCLUSIONS A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status . This approach of care can be implemented within normal practice This pilot aims to better underst and the market for childcare in Saudi Arabia – both the supply and dem and sides – and to design a r and omized controlled experiment to test whether access to affordable day care ( in the form of subsidies , for example ) would incentivize Saudi mothers to search actively for employment and to remain employed once they are hired . In addition , the study seeks to underst and the degree to which employment early on in one ’s life impacts employment in later stages . The pilot will provide information on the groups of women the experiment should target , appropriate levels for the childcare subsidy , and the quality and current geographic locations of daycare sites . Expected Impact Determine the effects of facilitating childcare access on Saudi women ’s employment . PRINCIPAL INVESTIGATORS  Boston University Patricia Cortes  Harvard University Claudia Goldin  Swarthmore College Jennifer Background There is growing evidence that home telemonitoring can be advantageous in societies with increasing prevalence of chronic diseases . The main objective of this study is to evaluate the effect of a primary care-based telemonitoring intervention on the number and length of hospital admissions . Methods A r and omised controlled trial was carried out across 20 health centres in Bilbao ( Basque Country , Spain ) to assess the impact of home telemonitoring on in-home chronic patients compared with st and ard care . The study lasted for one year . Fifty-eight in-home patients , diagnosed with heart failure ( HF ) and /or chronic lung disease ( CLD ) , aged 14 or above and with two or more hospital admissions in the previous year were recruited . The intervention consisted of daily patient self- measurements of respiratory-rate , heart-rate , blood pressure , oxygen saturation , weight , body temperature and the completion of a health status question naire using PDAs . Alerts were generated when pre-established thresholds were crossed . The control group ( CG ) received usual care . The primary outcome measure was the number of hospital admissions that occurred at 12 months post-r and omisation . The impact of telemonitoring on the length of hospital stay , use of other healthcare re sources and mortality was also explored . Results The intervention group ( IG ) included 28 patients and the CG 30 . Patient baseline characteristics were similar in both groups . Of the 21 intervention patients followed-up for a year , 12 had some admissions ( 57.1 % ) , compared to 19 of 22 controls ( 86.4 % ) , being the difference statistically significant ( p = 0.033 , RR 0.66 ; 95%CI 0.44 to 0.99 ) . The mean hospital stay was overall 9 days ( SD 4.3 ) in the IG versus 10.7 ( SD 11.2 ) among controls , and for cause-specific admissions 9 ( SD 4.5 ) vs. 11.2 ( SD 11.8 ) days , both without statistical significance ( p = 0.891 and 0.927 , respectively ) . Four patients need to be telemonitored for a year to prevent one admission ( NNT ) . There were more telephone contacts in the IG than in the CG ( 22.6 -SD 16.1- vs. 8.6 -SD 7.2- , p = 0.001 ) , but fewer home nursing visits ( 15.3 -SD 11.6- vs. 25.4 -SD 26.3- , respectively ) , though the difference was not statistically significant ( p = 0.3603 ) . Conclusions This study shows that telemonitoring of in-home patients with HF and /or CLD notably increases the percentage of patients with no hospital admissions and indicates a trend to reduce total and cause-specific hospitalisations and hospital stay .  Home telemonitoring can constitute a beneficial alternative mode of healthcare provision for medically unstable elderly patients .Trial registration Current Controlled Trials IS RCT Background Happy Ending ( HE ) is an intense 1-year smoking cessation program delivered via the Internet and cell phone . HE consists of more than 400 contacts by email , Web pages , interactive voice response , and short message service technology . HE includes a craving helpline and a relapse prevention system , providing just-in-time therapy . All the components of the program are fully automated . Objective The objectives were to describe the rationale for the design of HE , to assess the 12-month efficacy of HE in a sample of smokers willing to attempt to quit without the use of nicotine replacement therapy , and to explore the potential effect of HE on coping planning and self-efficacy ( prior to quitting ) and whether coping planning and self-efficacy mediate treatment effect . Methods A two-arm r and omized controlled trial was used . Subjects were recruited via Internet advertisements and r and omly assigned to condition . Inclusion criteria were willingness to quit on a prescribed day without using nicotine replacement and being aged 18 years or older . The intervention group received HE , and the control group received a 44-page self-help booklet .  Abstinence was defined as “ not even a puff of smoke , for the last seven days ” and was assessed by means of Internet surveys or telephone interviews 1 , 3 , 6 , and 12 months postcessation . The main outcome was repeated point abstinence ( ie , abstinence at all four time points ) . Coping planning and self-efficacy were measured at baseline and at the end of the preparation phase ( ie , after 2 weeks of treatment , but prior to cessation day ) . Results A total of 290 participants received either the HE intervention ( n=144 ) or the control booklet ( n=146 ) . Using intent-to-treat analysis , participants in the intervention group reported clinical ly and statistically significantly higher repeated point abstinence rates than control participants ( 20 % versus 7 % , odds ratio [ OR ] = 3.43 , 95 % CI = 1.60 - 7.34 , P = .002 ) . Although no differences were observed at baseline , by the end of the preparation phase , significantly higher levels of coping planning ( t 261 = 3.07 , P = .002 ) and precessation self-efficacy ( t 261 = 2.63 , P = .01 ) were observed in the intervention group compared with the control group . However , neither coping planning nor self-efficacy mediated long-term treatment effect . For point abstinence 1 month after quitting , however , coping planning and self-efficacy showed a partial mediation of the treatment effect . Conclusions This 12-month trial documents a long-term treatment effect of a fully automated smoking cessation intervention without the use of nicotine replacement therapy . The study adds to the promise of using digital media in supporting behavior change Objective To test the effectiveness of telemonitoring integrated into existing clinical services such that intervention and control groups have access to the same clinical care . Design Research er blind , multicentre , r and omised controlled trial . Setting UK primary care ( Lothian , Scotl and ) . Participants Adults with at least one admission for chronic obstructive pulmonary disease ( COPD ) in the year before r and omisation . We excluded people who had other significant lung disease , who were unable to provide informed consent or complete the study , or who had other significant social or clinical problems . Interventions Participants were recruited between 21 May 2009 and 28 March 2011 , and central ly r and omised to receive telemonitoring or conventional self monitoring . Using a touch screen , telemonitoring participants recorded a daily question naire about symptoms and treatment use , and monitored oxygen saturation using linked instruments . Algorithms , based on the symptom score , generated alerts if readings were omitted or breached thresholds . Both groups received similar care from existing clinical services . Main outcome measures The primary outcome was time to hospital admission due to COPD exacerbation up to one year after r and omisation . Other outcomes included number and duration of admissions , and vali date d question naire assessment s of health related quality of life ( using St George ’s respiratory question naire ( SGRQ ) ) , anxiety or depression ( or both ) , self efficacy , knowledge , and adherence to treatment . Analysis was intention to treat . Results Of 256 patients completing the study , 128 patients were r and omised to telemonitoring and 128 to usual care ;  baseline characteristics of each group were similar . The number of days to admission did not differ significantly between groups ( adjusted hazard ratio 0.98 , 95 % confidence interval 0.66 to 1.44 ) . Over one year , the mean number of COPD admissions was similar in both groups ( telemonitoring 1.2 admissions per person ( st and ard deviation 1.9 ) v control 1.1 ( 1.6 ) ; P=0.59 ) . Mean duration of COPD admissions over one year was also similar between groups ( 9.5 days per person ( st and ard deviation 19.1 ) v 8.8 days ( 15.9 ) ; P=0.88 ) . The intervention had no significant effect on SGRQ scores between groups ( 68.2 ( st and ard deviation 16.3 ) v 67.3 ( 17.3 ) ; adjusted mean difference 1.39 ( 95 % confidence interval −1.57 to 4.35 ) ) , or on other question naire outcomes . Conclusions In participants with a history of admission for exacerbations of COPD , telemonitoring was not effective in postponing admissions and did not improve quality of life . The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication . Trial registration IS RCT N96634935 . Funding : The trial was funded by an NHS applied research programme grant from the Chief Scientist Office of the Scottish government ( ARPG/07/03 ) . The funder had no role in study design and the collection , analysis , and interpretation of data and the writing of the article and the decision to su bmi t it for publication . NHS Lothian supported the telemonitoring service and the clinical services The objective of this pilot study was to investigate the use of and satisfaction with a  chronic obstructive pulmonary disease ( COPD ) telehealth program applied in both primary and secondary care . The program consisted of four modules : 1 ) activity coach for ambulant activity monitoring and real-time coaching of daily activity behavior , 2 ) web-based exercise program for home exercising , 3 ) self-management of COPD exacerbations via a triage diary on the web portal , including self-treatment of exacerbations , and 4 ) teleconsultation .  Twenty-nine COPD patients were r and omly assigned to either the intervention group ( telehealth program for 9 months ) or the control group ( usual care ) . Page hits on the web portal showed the use of the program , and the Client Satisfaction Question naire showed satisfaction with received care . The telehealth program with decision support showed good satisfaction ( mean 26.4 , maximum score 32 ) . The program was accessed on 86 % of the treatment days , especially the diary . Patient adherence with the exercise scheme was low ( 21 % ) . Health care providers seem to play an important role in patients ’ adherence to telehealth in usual care . Future research should focus on full-scale implementation in daily care and investigating technological advances , like gaming , to increase adherence AIMS To investigate the feasibility , acceptance and potential effectiveness of delivering a telecare service on the health outcomes and hospital service utilization of community-dwelling patients with chronic obstructive pulmonary disease . METHODS Eligible participants were older people , with moderate or severe chronic obstructive pulmonary disease , and who had been admitted to hospital at least once for exacerbation during the previous year . The participants were r and omly assigned to the intervention or control group . Participants in the intervention group received a telecare device kit and they were asked to monitor their oxygen saturation , pulse rate and respiration rate using the device and to transmit the data to an online network platform . A medication and purse-lip breathing reminder with a feedback function is also provided in the device kit . A community nurse monitors changes in the physiological parameters and takes immediate action to address the patients ' needs . Participants in the control group received no other extra care . Study outcomes include user satisfaction , health-related quality of life , pulmonary function , hospital re-admission and use of emergency room services . RESULTS Twenty-two participants in the intervention group and 18 in the control group were included in the analysis . The mean age of all 40 participants was 72.93 years . Overall , the participants in the intervention group expressed satisfaction with the telecare service . Some patients reported difficulty in reading the screen of the mobile phone and manipulating the tiny key-in buttons . No significant differences were found between the two time points ( baseline and post-test period ) with regard to health-related quality of life . No significant differences in pulmonary function and in the number of emergency department visits and hospital re-admissions between the study groups were found . CONCLUSION The high level of user satisfaction indicated the feasibility of conducting a large-scale r and omized control trial to evaluate the effects of a telecare service on health outcomes of patients with chronic obstructive pulmonary disease Chronic obstructive pulmonary disease ( COPD ) is disabling , with symptoms such as chronic cough , phlegm , wheezing , shortness of breath and increased infections of the respiratory passage . The aim was to examine the effects of a structured educational intervention programme at a nurse-led primary health care clinic ( PHCC ) on quality of life ( QoL ) , knowledge about COPD and smoking cessation in patients with COPD . This study had an experimental design in which 52 patients with COPD from a Swedish primary care setting were r and omized into two groups ( intervention or control ) . Both groups received st and ard care but patients in the intervention group were also offered two visits to a nurse specialized in COPD care . The purpose of the visits was to increase the patients ' self-care ability and their knowledge about COPD . The study was approved by the local Research Ethics Committee . Data were collected using two question naires , one pertaining to knowledge about COPD and smoking habits and St. George 's Respiratory Question naire , addressing how QoL was affected by the patients ' respiratory symptoms . The intervention and control groups answered both question naires on their first and last visits to the PHCC . A statistically significant increase was noted in the intervention group on QoL , the number of patients who stopped smoking and patients ' knowledge about COPD at the follow-up , 3 - 5 months after intervention . However , a confounding factor may have been that one of the research ers ( Eva Osterlund Efr aims son ) , as a nurse in the PHCC , performed the intervention . This implies that patients were in a dependent relationship which may have affected the responses in a favourable direction . Our findings show that conventional care alone did not have an effect on patients ' QoL and smoking habits . Instead , the evidence suggests that a structured programme with self-care education is needed to motivate patients for life-style changes Background Recent telehealth studies have demonstrated minor impact on patients affected by long-term conditions . The use of technology does not guarantee the compliance required for sustained collection of high- quality symptom and physiological data . Remote monitoring alone is not sufficient for successful disease management . A patient-centred design approach is needed in order to allow the personalisation of interventions and encourage the completion of daily self-management tasks . Methods A digital health system was design ed to support patients suffering from chronic obstructive pulmonary disease in self-managing their condition . The system includes a mobile application running on a consumer tablet personal computer and a secure backend server accessible to the health professionals in charge of patient management . The patient daily routine included the completion of an adaptive , electronic symptom diary on the tablet , and the measurement of oxygen saturation via a wireless pulse oximeter . Results The design of the system was based on a patient-centred design approach , informed by patient workshops . One hundred and ten patients in the intervention arm of a r and omised controlled trial were subsequently given the tablet computer and pulse oximeter for a 12-month period . Patients were encouraged , but not m and ated , to use the digital health system daily . The average used was 6.0 times a week by all those who participated in the full trial . Three months after enrolment , patients were able to complete their symptom diary and oxygen saturation measurement in less than 1 m 40s ( 96 % of symptom diaries ) . Custom algorithms , based on the self-monitoring data collected during the first 50 days of use , were developed to personalise alert thresholds . Conclusions Strategies and tools aim ed at refining a digital health intervention require iterative use to enable convergence on an optimal , usable design . ‘ Continuous improvement ’ allowed feedback from users to have an immediate impact on the design of the system ( e.g. , collection of quality data ) , result ing in high compliance with self-monitoring over a prolonged period of time ( 12-month ) . Health professionals were prompted by prioritisation algorithms to review patient data , which led to their regular use of the remote monitoring website throughout the trial . Trial registration Trial registration : IS RCT N40367841 . Registered 17/10/2012 Background Chronic obstructive pulmonary disease ( COPD ) is a highly prevalent condition associated with a high health care re source consumption and health care expenditures , driven mainly by exacerbations-related hospitalizations . Telemedicine has been proposed as a mean for timely detection of exacerbation , but the available evidence is inadequate to provide conclusive information on its efficacy . The aim of this study is to evaluate the efficacy of a telemonitoring system in reducing COPD -related hospitalizations in an elderly population with COPD . Methods This is a parallel arms , r and omized trial including patients aged 65 or older with COPD in GOLD stages II and III enrolled in a Pulmonary Medicine outpatient facility . Patients were r and omly assigned to receive a non-invasive system able to telemonitor vital signs ( oxygen saturation , heart rate , near-body temperature , overall physical activity ) or st and ard care , and were followed up for 9 months . The outcome measures were the number of exacerbations and exacerbation-related hospitalization . Results Fifty patients were included in the telemonitoring group and 49 in the control group . The incidence rate of respiratory events was 28/100 person/years in the telemonitoring group vs. 42/100 person/years in the control group ( incidence rate ratio : 0.67 , 95 % CI : 0.32 – 1.36 ) . The corresponding figures for hospital admissions where 13/100 person/years and 20/100 person/years , respectively ( IRR : 0.66 , 95 % CI : 0.21 – 1.86 ) . Conclusions In our study , COPD patients followed up with the aid of a multiparametric remote monitoring system experienced a lower rate of exacerbations and COPD -related hospitalizations compared to patients followed up using the st and ard model of care . These results need to be replicated in larger studies before they can be applied to the general COPD population . Trial registration number : NCT01481506 ( clinical trials.gov ) . Funding : co-financed by Lazio Region and Intersistemi BACKGROUND Studies have shown that telephone interventions design ed to promote patients ' self-management skills and improve patient-physician communication can increase patients ' satisfaction and their use of preventive services . The effect of such a strategy on health care costs remains controversial . METHODS We conducted a stratified , r and omized study of 174,120 subjects to assess the effect of a telephone-based care-management strategy on medical costs and re source utilization . Health coaches contacted subjects with selected medical conditions and predicted high health care costs to instruct them about shared decision making , self-care , and behavioral change . The subjects were r and omly assigned to either a usual-support group or an enhanced-support group . Although the same telephone intervention was delivered to the two groups , a greater number of subjects in the enhanced-support group were made eligible for coaching through the lowering of cutoff points for predicted future costs and expansion of the number of qualifying health conditions . Primary outcome measures at 1 year were total medical costs and number of hospital admissions . RESULTS At baseline , medical costs and re source utilization were similar in the two groups . After 12 months , 10.4 % of the enhanced-support group and 3.7 % of the usual-support group received the telephone intervention . The average monthly medical and pharmacy costs per person in the enhanced-support group were 3.6 % ( $ 7.96 ) lower than those in the usual-support group ( $ 213.82 vs. $ 221.78 , P=0.05 ) ; a 10.1 % reduction in annual hospital admissions ( P<0.001 ) accounted for the majority of savings . The cost of this intervention program was less than $ 2.00 per person per month . CONCLUSIONS A targeted telephone care-management program was successful in reducing medical costs and hospitalizations in this population -based study . ( Funded by Health Dialog Services ; Clinical Trials.gov number , NCT00793260 . AIMS To describe self-management , symptom monitoring  and the associated influences among older adults with chronic obstructive pulmonary disease . BACKGROUND Optimal self-management and monitoring of key symptoms in patients with chronic obstructive pulmonary disease reduces dyspnoea and preventable hospitalizations . METHOD A prospect i ve , descriptive survey design was used and data collected from patients with moderate severity chronic obstructive pulmonary disease during home interviews between April 2005 and June 2006 . Predictors of self-management and symptom monitoring were determined by linear regression analyses . RESULTS Patients ' ( n = 78 ) mean age was 73.37 years ( SD 7.52 ) ; 55.1 % were male and 66.7 % were married . Most ( 92.3 % ) had concurrent illnesses , and 48.7 % had been admitted to hospital for chronic obstructive pulmonary disease in the past 6 months . Self-management was good to very good , with poorer self-management predicted by lower self-efficacy ( beta = -0.21 ) , a weaker sense of coherence ( beta = -0.03 ) , and no hospitalization in the past 6 months ( beta = -05 ) . Symptom monitoring was not ideal , with more than 20 % of patients not monitoring any of the key symptoms . More frequent symptom monitoring occurred among participants who were married ( beta = 5.14 ) and had more severe disease ( beta = 0.79 ) . CONCLUSION As self-management and symptom monitoring ensure better outcomes among patients with chronic obstructive pulmonary disease , health professionals should encourage these behaviours . Involving partners , promoting self-efficacy and underst and ing of sense of coherence are helpful in this process Objective : First , to investigate the effects of a telerehabilitation intervention on health status and activity level of patients with Chronic Obstructive Pulmonary Disease ( COPD ) , compared to usual care . Second , to investigate how patients comply with the intervention and whether compliance is related to treatment outcomes . Design : a r and omized controlled pilot trial Subjects : Thirty-four patients diagnosed with COPD . Intervention : The telerehabilitation application consists of an activity coach ( 3D-accelerometer with smartphone ) for ambulant activity registration and real-time feedback , complemented by a web portal with a symptom diary for self-treatment of exacerbations . The intervention group used the application for 4 weeks . The control group received usual care . Main measures : Activity level measured by a pedometer ( in steps/day ) , health status by the Clinical COPD Question naire at baseline and after intervention . Compliance was expressed as the time the activity coach was worn . Results : Fourteen intervention and 16 control patients completed the study .  Activity level ( steps/day ) was not significantly affected by the intervention over time . There was a non-significant difference in improvement in health status between the intervention ( −0.34±0.55 ) and control group ( 0.02±0.57 , p=0.10 ) . Health status significantly improved within the intervention group ( p=0.05 ) . The activity coach was used more than prescribed ( 108 % ) and compliance was related to the increase in activity level for the first two feedback weeks ( r=0.62 , p=0.03 ) . Conclusions : This pilot study shows the potential of the telerehabilitation intervention : compliance with the activity coach was high , which directly related to an improvement in activity levels
Background Mobile health applications are increasingly used in patients with Chronic Obstructive Pulmonary Disease ( COPD ) to improve their self-management , nonetheless , without firm evidence of their efficacy .
This meta- analysis was aim ed to assess the efficacy of mobile health applications in supporting self-management as an intervention to reduce hospital admission rates and average days of hospitalization , etc .