Estimation of the Direct Cost of Management of Venous Thromboembolism in Three Reference Hospitals in the City of Yaoundé: A Retrospective Study over a Three-Year Period

Background: Venous thromboembolism (VTE) is a major public health problem due to its increasing frequency, mortality and management cost. This cost may require major financial efforts from patients, especially in developing countries like ours where less than 7% of the population has health insurance. This study aimed to estimate the direct cost of managing VTE in three reference hospitals in Yaoundé. Methods: This was a cross-sectional retrospective study over a three-year period (from January 1st 2018 to December 31 2020) carried out in the Cardiology departments of the Central and General Hospitals, and the Emergency Centre of the city of Yaoundé. All patients managed during the study period for deep vein thrombosis and pulmonary embolism confirmed by venous ultrasound coupled with Doppler and computed tomography pulmonary angiography respectively were included. For each patient, we collected sociodemographic and clinical data as well as data on the cost of consultation, hospital stay, workups and medications. These data were analysed using SPSS version 23.0. Results: A total of 92 patient’s records were analysed. The median age was 60 years [48 - 68] with a sex ratio of 0.53. The median direct cost of management of venous thromboembolism was 766,375 CFAF [536,455 - 1,029,745] or $1415 USD. Management of pulmonary embolism associated with deep vein thrombosis was more costly than isolated pulmonary embolism or deep vein thrombosis. Factors influencing the direct cost of management of venous thromboembolism were: hospital structure (p = 0.015), health insurance (p 0.001), type of pulmonary embolism (p = 0.021), and length of hospital stay (p = 0.001). Conclusion: Management of VTE is a major financial burden for our patients and this burden is influenced by the hospital structure, health insurance, type of pulmonary embolism and length of hospital stay.

A Hybrid Model for Improving Software Cost Estimation in Global Software Development

Accurate software cost estimation in Global Software Development(GSD)remains challenging due to reliance on historical data and expert judgments.Traditional models,such as the Constructive Cost Model(COCOMO II),rely heavily on historical and accurate data.In addition,expert judgment is required to set many input parameters,which can introduce subjectivity and variability in the estimation process.Consequently,there is a need to improve the current GSD models to mitigate reliance on historical data,subjectivity in expert judgment,inadequate consideration of GSD-based cost drivers and limited integration of modern technologies with cost overruns.This study introduces a novel hybrid model that synergizes the COCOMO II with Artificial Neural Networks(ANN)to address these challenges.The proposed hybrid model integrates additional GSD-based cost drivers identified through a systematic literature review and further vetted by industry experts.This article compares the effectiveness of the proposedmodelwith state-of-the-artmachine learning-basedmodels for software cost estimation.Evaluating the NASA 93 dataset by adopting twenty-six GSD-based cost drivers reveals that our hybrid model achieves superior accuracy,outperforming existing state-of-the-artmodels.The findings indicate the potential of combining COCOMO II,ANN,and additional GSD-based cost drivers to transform cost estimation in GSD.

Assessment of the Indirect Cost of Drug Resistant Tuberculosis Treatment to Patients in a High Burden, Low Income Setting in Mozambique

Introduction: Tuberculosis is closely linked to poverty, with patients facing significant indirect treatment costs. Treating drug-resistant tuberculosis further increases these expenses. Notably, there is a lack of published data on the indirect costs incurred by patients with drug-resistant tuberculosis in Mozambique. Objective: To assess the indirect costs, income reduction, and work productivity incurred by patients undergoing diagnosis and treatment for Drug-Resistant Tuberculosis (DRTB) in Mozambique during their TB treatment. Methods: As part of a comprehensive mixed-methods study conducted from January 2021 to April 2023, this research utilized a descriptive cross-sectional approach, incorporating both quantitative and qualitative methods. The primary goal was to evaluate the costs incurred by the national health system due to drug-resistant TB. Additionally, to explore the indirect costs experienced by patients and their families during treatment, semi-structured interviews were conducted with 27 individuals who had been undergoing treatment for over six months. Results: All survey participants unanimously reported a significant decline in labour productivity, with 70.3% experiencing a reduction in their monthly income. Before falling ill, the majority of respondents (33.3%) earned up to $76.92 monthly, representing the minimum earnings range, while 29.2% had a monthly income above $230.77, the maximum earnings range. Among those who experienced income loss, the majority (22.2%) reported a decrease of up to $76.92 per month, and 18.5% cited a loss exceeding $230.77 per month. Notably, patients with Drug-Resistant Tuberculosis (DRTB) have not incurred the direct costs of the disease, as these are covered by the government. Conclusion: The financial burden of treating Drug-Resistant Tuberculosis (DRTB), along with the income reduction it causes, is substantial. Implementing a patient-centred, multidisciplinary, and multisector approach, coupled with strong psychosocial support, can significantly reduce the catastrophic costs DRTB patients incur.

Resistance development,cross-resistance,and fitness costs associated with Aphis gossypii resistance towards sulfoxaflor and acetamiprid in different geographical regions

Aphis gossypii has become increasingly difficult to manage due to its strong insecticide resistance.In the laboratory,we established sulfoxaflor-resistant and acetamiprid-resistant strains in two A.gossypii populations with different basal insecticide resistance levels,and evaluated the effects of basal insecticide resistance on the resistance development and cross-resistance,as well as differences in fitness.Under the same selection pressure,Yarkant A.gossypii(with low basal insecticide resistance)evolved resistance to sulfoxaflor and acetamiprid more quickly than Jinghe A.gossypii(with high basal insecticide resistance),and the evolution of A.gossypii resistance to sulfoxaflor developed faster than acetamiprid in both Yarkant and Jinghe,Xingjiang,China.The sulfoxaflor-resistant strains selected from Yarkant and Jinghe developed significant cross-resistance to acetamiprid,imidacloprid,thiamethoxam and pymetrozine;while the acetamiprid-resistant strains developed significant cross-resistance to sulfoxaflor,imidacloprid,thiamethoxam,pymetrozine,and chlorpyrifos.The relative fitness of A.gossypii decreased as the resistance to sulfoxaflor and acetamiprid developed.The relative fitness levels of the sulfoxaflor-resistant strains(Yarkant-SulR and Jinghe-SulR)were lower than those of the acetamipridresistant strains(Yarkant-AceR and Jinghe-AceR).In addition,the relative fitness levels of sulfoxaflor-and acetamiprid-resistant strains were lower in Jinghe than in Yarkant.In summary,basal insecticide resistance of A.gossypii and insecticide type affected the evolution of resistance to insecticides in A.gossypii,as well as cross-resistance to other insecticides.The sulfoxaflor-and acetamiprid-resistant A.gossypii strains had obvious fitness costs.The results of this work will contribute to the insecticide resistance management and integrated management of A.gossypii.

Analysis of a passive ankle exoskeleton for reduction of metabolic costs during walking

Modern conflicts demand substantial physical and psychological exertion,often resulting in fatigue and diminished combat or operational readiness.Several exoskeletons have been developed recently to address these challenges,presenting various limitations that affect their operational or everyday usability.This article evaluates the performance of a dual-purpose passive ankle exoskeleton developed for the reduction of metabolic costs during walking,seeking to identify a force element that could be applied to the target population.Based on the 6-min walk test,twenty-nine subjects participated in the study using three different force elements.The results indicate that it is possible to reduce metabolic expenditure while using the developed exoskeleton.Additionally,the comfort and range of motion results verify the exoskeleton's suitability for use in uneven terrain and during extended periods.Nevertheless,the choice of the force element should be tailored to each user,and the control system should be adjustable to optimise the exoskeleton's performance.

An Analysis of the Accounting Costs Associated with 20-Month DR TB Regimens in Maputo City, Mozambique

Introduction: Socioeconomic and demographic conditions in a country can influence tuberculosis incidence and mortality, with nearly 95% of tuberculosis-related deaths occurring in poorer countries. Mozambique is among the 30 countries with the highest TB burden. Objective: The study aimed to estimate the average direct medical cost of treating drug-resistant tuberculosis in 19 health centers in Maputo City, Mozambique. Methods: A retrospective analysis of direct medical costs was conducted on patients aged 18 and older who completed 20-month drug-resistant tuberculosis treatment regimens in Maputo City in 2019. Results: This analysis covered 140 patients who completed a 20-month treatment regimen, with 64.3% (78) being male and 35.7% (62) female. Approximately 50% of the participants were aged between 29 and 47. The average direct medical cost of DRTB treatment was $4789.43, reaching up to $6568.00, with a standard deviation of $753.26, including clinical interventions and treatment. Conclusion: The direct medical costs for a basic treatment package for a patient with drug-resistant TB in Mozambique equal 36 minimum wages. Developing alternative and innovative funding mechanisms and identifying ways to mitigate costs through the use of generic medicines would be beneficial.

Feasibility of Scaling up the Cost-Competitive and Clean Electrolytic Hydrogen Supply in China

Scaling up clean hydrogen supply in the near future is critical to achieving China’s hydrogen development target.This study established an electrolytic hydrogen development mechanism considering the generation mix and operation optimization of power systems with access to hydrogen.Based on the incremental cost principle,we quantified the provincial and national clean hydrogen production cost performance levels in 2030.The results indicated that this mechanism could effectively reduce the production cost of clean hydrogen in most provinces,with a national average value of less than 2 USD·kg^(-1) at the 40-megaton hydrogen supply scale.Provincial cooperation via power transmission lines could further reduce the production cost to 1.72 USD·kg^(-1).However,performance is affected by the potential distribution of hydrogen demand.From the supply side,competitiveness of the mechanism is limited to clean hydrogen production,while from the demand side,it could help electrolytic hydrogen fulfil a more significant role.This study could provide a solution for the ambitious development of renewables and the hydrogen economy in China.

Design and implementation of low-cost geomagnetic field monitoring equipment for high-density deployment

The observation of geomagnetic field variations is an important approach to studying earthquake precursors.Since 1987,the China Earthquake Administration has explored this seismomagnetic relationship.In particular,they studied local magnetic field anomalies over the Chinese mainland for earthquake prediction.Owing to the years of research on the seismomagnetic relationship,earthquake prediction experts have concluded that the compressive magnetic effect,tectonic magnetic effect,electric magnetic fluid effect,and other factors contribute to preearthquake magnetic anomalies.However,this involves a small magnitude of magnetic field changes.It is difficult to relate them to the abnormal changes of the extremely large magnetic field in regions with extreme earthquakes owing to the high cost of professional geomagnetic equipment,thereby limiting large-scale deployment.Moreover,it is difficult to obtain strong magnetic field changes before an earthquake.The Tianjin Earthquake Agency has developed low-cost geomagnetic field observation equipment through the Beijing–Tianjin–Hebei geomagnetic equipment test project.The new system was used to test the availability of equipment and determine the findings based on big data..

Costs of Schizophrenia at Psychiatric Hospital of Bingerville (Ivory Coast)

Schizophrenia is classified as a priority mental disorder by the World Health Organization (WHO) and accounts for around 35% of diagnoses at the Bingerville Psychiatric Hospital (HPB). The aims of the study were to identify the cost drivers for hospitalization and to calculate the costs of managing schizophrenia in hospital, with a view to planning household expenditure on care. This pilot cross-sectional study involved 31 patients with schizophrenia who had been hospitalized in the various third-category wards at the HPB between 1st January 2019 and 31st May 2020. Sampling was accidental. The methods used to estimate costs were based on the actual costs of drugs, hospitalization and additional examinations which prices were known, and on patients’ estimations for certain expenses such as food and transport. Results: The sex ratio was 3.42, the mean age was 29.52 years. The mean length of stay was 46.19 days, and the most frequent clinical forms were paranoid schizophrenia (41.9%) and schizoaffective disorder (29%). The combination of haloperidol and chlorpromazine was the most common medications for initial treatment (67.8%) and maintenance treatment (41.9%). The average cost of hospitalization at HPB for schizophrenia was XOF 164,412 (€249.90). The average direct medical cost was XOF 105,412 (€160.226) and the average direct non-medical cost was XOF 59,000 (€89.68). The average daily cost of antipsychotic treatment was XOF 795/day (€1.2084). The high cost of drugs as a proportion of hospitalization costs suggested the need of a reflection on the simplification of prescribing practices, assistance in psychiatric emergencies and the development of other alternatives to psychiatric hospitalization in Côte d’Ivoire.

Cost-Efficient Edge Caching for NOMA-Enabled IoT Services

Mobile edge computing(MEC)is a promising paradigm by deploying edge servers(nodes)with computation and storage capacity close to IoT devices.Content Providers can cache data in edge servers and provide services for IoT devices,which effectively reduces the delay for acquiring data.With the increasing number of IoT devices requesting for services,the spectrum resources are generally limited.In order to effectively meet the challenge of limited spectrum resources,the Non-Orthogonal Multiple Access(NOMA)is proposed to improve the transmission efficiency.In this paper,we consider the caching scenario in a NOMA-enabled MEC system.All the devices compete for the limited resources and tend to minimize their own cost.We formulate the caching problem,and the goal is to minimize the delay cost for each individual device subject to resource constraints.We reformulate the optimization as a non-cooperative game model.We prove the existence of Nash equilibrium(NE)solution in the game model.Then,we design the Game-based Cost-Efficient Edge Caching Algorithm(GCECA)to solve the problem.The effectiveness of our GCECA algorithm is validated by both parameter analysis and comparison experiments.

Cost of Medical Treatment for Primary Open-Angle Glaucoma in Relation to Patients’ Income and Its Impact on the Prognosis of the Disease, in Bouaké University Hospital

Introduction: Medical treatment for POAG is continuous and lifelong treatment. The aim of this study was to evaluate the relationship between the cost of this treatment and patients’ income and the impact of this relationship on treatment compliance. Materials and Methods: Prospective cross-sectional study with a descriptive aim covering sociodemographic data, average incomes, and direct and indirect costs of treatment of 57 patients followed for POAG during the period from January 1, 2012, to December 31, 2016 (5 years). Results: The patients were aged 25 to 77 years (mean = 54.4 years) with a male predominance (sex ratio = 1.5). Retirees were the most represented (26.32%), followed by workers in the informal sector (14.04%) and housewives (12.28%). Patients who had an annual income less than or equal to 900,000 CFA francs (€1370.83) per year represented 56.14% and those who did not have health coverage represented 57.89%. The treatment was monotherapy (64.91%), dual therapy (31.58%) or triple therapy (3.05%) and the average ratio of “annual cost of treatment to annual income” was 0.56 with for maximum 2.23 and 0.02 as minimum. Patients who considered the cost of treatment unbearable for their income represented 78.95%. Conclusion: Prevention of blindness due to glaucoma requires early detection but also the establishment of health coverage mechanisms to improve compliance with medical treatment. In addition, consideration should be given to the development of glaucoma surgery in our country, the indication of which could be the first intention in certain patients, considering for those patients, the geographical and financial accessibility of medical treatment. .

Cost analysis of radical resection of malignant breast tumors under the China Healthcare Security Diagnosis Related Groups payment system

BACKGROUND Breast cancer is one of the most common malignant tumors in women worldwide and poses a severe threat to their health.Therefore,this study examined patients who underwent breast cancer surgery,analyzed hospitalization costs and structure,and explored the impact of China Healthcare Security Diagnosis Related Groups(CHS-DRG)management on patient costs.It aimed to provide medical institutions with ways to reduce costs,optimize cost structures,reduce patient burden,and improve service efficiency.AIM To study the CHS-DRG payment system’s impact on breast cancer surgery costs.METHODS Using the CHS-DRG(version 1.1)grouping criteria,4073 patients,who underwent the radical resection of breast malignant tumors from January to December 2023,were included in the JA29 group;1028 patients were part of the CHS-DRG payment system,unlike the rest.Through an independent sample t-test,the length of hospital stay as well as total hospitalization,medicine and consumables,medical,nursing,medical technology,and management expenses were compared.Pearson’s correlation coefficient was used to test the cost correlation.RESULTS In terms of hospitalization expenses,patients in the CHS-DRG payment group had lower medical,nursing,and management expenses than those in the diagnosis-related group(DRG)non-payment group.For patients in the DRG payment group,the factors affecting the total hospitalization cost,in descending order of relevance,were medicine and consumable costs,consumable costs,medicine costs,medical costs,medical technology costs,management costs,nursing costs,and length of hospital stay.For patients in the DRG nonpayment group,the factors affecting the total hospitalization expenses in descending order of relevance were medicines and consumable expenses,consumable expenses,medical technology expenses,the cost of medicines,medical expenses,nursing expenses,length of hospital stay,and management expenses.CONCLUSION The CHS-DRG system can help control and reduce unnecessary medical expenses by controlling medicine costs,medical consumable costs,and the length of hospital stay while ensuring medical safety.

A digital twin model-based approach to cost optimization of residential community microgrids

This paper presents a peer-to-peer community cost optimization approach based on a single-prosumer energy management system.Its objective is to optimize energy costs for prosumers in the community by enhancing the consumption efficiency.This study was conducted along two main axes.The first axis focuses on designing a digital twin for a residential community microgrid platform.This phase involves data collection,cleaning,exploration,and interpretation.Moreover,it includes replicating the functionality of the real platform and validating the results.The second axis involves the development of a novel approach that incorporates two distinct prosumer behaviors within the same community microgrid,while maintaining the concept of peer-to-peer energy trading.Prosumers without storage utilize their individual PV systems to fulfill their energy requirements and inject excess energy into a local microgrid.Meanwhile,a single prosumer with a storage system actively engages in energy exchange to maximize the community’s profit.This is achieved by optimizing battery usage using a cost optimization solution.The proposed solution is validated using the developed digital twin.

The potential impact of increased whole grain consumption among Chinese adults on reducing healthcare costs and carbon footprint

Excessive consumption of refined grains harms human health and ecosystem viability.Whole grains,as a healthy and sustainable alternative to refined grains,can benefit individual health by providing dietary fiber,B vitamins,and bioactive substances.Additionally,they aid in improving the environment due to their higher extraction rate and lower carbon emission during the processing stage.However,few studies have attempted to evaluate the economic and social benefits of increasing the amount of whole grain in grain intake.This paper estimates the potential savings in healthcare costs and reduced food carbon footprints(CFs)that could result from a shift toward whole grain consumption following the Chinese Dietary Guidelines(CDG).We investigate hypothetical scenarios where a certain proportion(5–100%)of Chinese adults could increase their whole grain intakes as proposed by CDG to meet the average shortfall of 30.2 g.In that case,the healthcare costs for associated diseases(e.g.,type2 diabetes mellitus(T2DM),cardiovascular disease(CVD),and colorectal cancer(CRC))are expected to reduce by a substantial amount,from USD 2.82 to 56.37 billion;the carbon emission levels are also projected to decrease by0.24–5.72 million tons.This study provides compelling evidence that advocating for the transition towards greater consumption of whole grain products could benefit individual health,the environment,and society,by reducing both healthcare costs and carbon emissions.

Impact of carbon disclosure on debt financing costs

Creditors,such as banks,often use disclosed environmental information to assess a company’s environmental risk and ensure the safety of debt funds.Consequently,carbon disclosures have become an important consideration for creditors when making investments.This study explores the relationship between carbon disclosure and debt financing costs using data on listed companies from 2008 to 2019.The results show that carbon disclosure can reduce the debt financing costs of enterprises,and that this influence is more significant for private companies than for state-owned enterprises.Instrumental variables and Propensity Score Matching(PSM)were used to evaluate the robustness of negative relationships.Furthermore,carbon disclosure has a more significant impact on debt costs with less environmental supervision pressure,weak residents’environmental awareness,and weak product market competition.These findings provide guidance for companies’carbon information disclosure and support the establishment of official carbon disclosure standards.

The Impact of the Digital Economy on Financial Regulatory Costs: An Empirical Analysis Based on the Solow Growth Model

As a novel economic form,the digital economy is reshaping the financial regulatory landscape and significantly impacting regulatory costs.This paper incorporates the digital economy and financial regulatory costs into the classic Solow growth model,uncovering an inverted U-shaped relationship between them.A subsequent mechanism analysis explains the rationale behind this relationship.To empirically examine this relationship in China,the paper utilizes inter-provincial panel data from 2013 to 2021 and employs methodologies such as the two-way fixed effects and moderating effects models.These analyses have important implications for the sound and sustainable development of China’s financial industry.The findings indicate:(a)As China’s digital economy develops,its impact on financial regulatory costs follows an inverted U-shaped pattern,initially increasing and then declining.This conclusion remains valid after robustness tests.(b)The influence of the digital economy on regulatory costs depends on favorable external conditions.Specifically,the impact is more pronounced in regions and periods with better digital infrastructure and more abundant human capital.(c)Additionally,redundant resources moderate this impact,which can weaken the inverted U-shaped relationship.Our findings not only provide a theoretical foundation for understanding the impact of the digital economy on financial regulatory costs but also offer valuable policy insights for optimizing financial regulation in China.

TRADE DEPENDENCIES AND TRANSACTION COSTS: THE OC-CUPATION OF DECELEA HIGHLIGHTS BOTH THE BENEFITS AND THE DRAWBACKS OF A MARITIME ECONOMY

Thucydides asserts that the occupation of Decelea by the Spartans in 413 BC made the grain supply for Athens costly by forcing the transport from land onto the sea.This calls into question the well-established consensus that sea transport was far cheaper than land transport.This paper contends that the cost of protecting supply lines-specifically the expenses associated with the warships which escorted the supply ships-rendered the grain transported on the new route exceptionally costly.In this paper,the benefits and drawbacks of a maritime economy,including transaction costs,trade dependencies,and the capabilities of warships and supply ships are discussed.

Social Cost Analysis of Biological Control Technology for Crop Diseases and Insect Pests

With the rapid development of modern agriculture,the prevention and control of crop diseases and insect pests has become an important part to ensure the safety of agricultural production,the quality of agricultural products and the safety of agricultural ecological environment.Although the effect of traditional chemical prevention and control technology is remarkable,the health risks and environmental problems brought by it should not be ignored.As a green and environmentally friendly means of prevention and control,biological prevention and control technology has gradually become a hot research topic and a trend of agricultural production.This paper is intended to comprehensively evaluate the social costs of biological control technologies for crop diseases and pests,including the health risks reduced,environmental improvements,economic benefits,and barriers to promotion,and put forward corresponding policy recommendations.

Assessing the effectiveness of PM2.5 pollution control from the perspective of interprovincial transport and PM2.5 mitigation costs across China

Due to the transboundary nature of air pollutants,a province's efforts to improve air quality can reduce PM2.5 concentration in the surrounding area.The inter-provincial PM2.5 pollution transport could bring great challenges to related environmental management work,such as financial fund allocation and subsidy policy formulation.Herein,we examined the transport characteristics of PM2.5 pollution across provinces in 2013 and 2020 via chemical transport modeling and then monetized inter-provincial contributions of PM2.5 improvement based on pollutant emission control costs.We found that approximately 60%of the PM2.5 pollution was from local sources,while the remaining 40%originated from outside provinces.Furthermore,about 1011 billion RMB of provincial air pollutant abatement costs contributed to the PM2.5 concentration decline in other provinces during 2013-2020,accounting for 41.2%of the total abatement costs.Provinces with lower unit improvement costs for PM2.5,such as Jiangsu,Hebei,and Shandong,were major contributors,while Guangdong,Guangxi,and Fujian,bearing higher unit costs,were among the main beneficiaries.Our study identifies provinces that contribute to air quality improvement in other provinces,have high economic efficiency,and provide a quantitative framework for determining inter-provincial compensations.This study also reveals the uneven distribution of pollution abatement costs(PM2.5 improvement/abatement costs)due to transboundary PM2.5 transport,calling for adopting inter-provincial economic compensation policies.Such mechanisms ensure equitable cost-sharing and effective regional air quality management.

Reliability-based life-cycle cost seismic design optimization of coastal bridge piers with nonuniform corrosion using different materials

Reinforcement corrosion is the main cause of performance deterioration of reinforced concrete(RC)structures.Limited research has been performed to investigate the life-cycle cost(LCC)of coastal bridge piers with nonuniform corrosion using different materials.In this study,a reliability-based design optimization(RBDO)procedure is improved for the design of coastal bridge piers using six groups of commonly used materials,i.e.,normal performance concrete(NPC)with black steel(BS)rebar,high strength steel(HSS)rebar,epoxy coated(EC)rebar,and stainless steel(SS)rebar(named NPC-BS,NPC-HSS,NPC-EC,and NPC-SS,respectively),NPC with BS with silane soakage on the pier surface(named NPC-Silane),and high-performance concrete(HPC)with BS rebar(named HPC-BS).First,the RBDO procedure is improved for the design optimization of coastal bridge piers,and a bridge is selected to illustrate the procedure.Then,reliability analysis of the pier designed with each group of materials is carried out to obtain the time-dependent reliability in terms of the ultimate and serviceability performances.Next,the repair time of the pier is predicted based on the time-dependent reliability indices.Finally,the time-dependent LCCs for the pier are obtained for the selection of the optimal design.