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Introduction The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care. Aim The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward. Methods We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis. Setting A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU. Findings The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

Aims: The aim was to explore the experiences of relatives seeing and saying goodbye to brought in dead persons in a Danish emergency department. Design: This was a qualitative study based on interpretive description methodology. Methods: Data were collected through semi-structured individual interviews with relatives (n = 11) of brought in dead persons and 30 h of participatory observations of these relatives visiting the emergency department to see and say goodbye to the deceased. Data were collected between February 2019 and December 2020. Results: Our analyses revealed internal and external chaos as an overarching theme, covering 4 themes and 10 subthemes. The four themes were traumatic events, restricted access, briefly being together again, and final goodbyes and departures. Conclusion: Emergency departments were highly acute and busy settings that prioritized survival more than the care of deceased people and their relatives. The relatives were, in every way, affected by internal and external chaos; the external chaos in the emergency department reinforced the feeling of internal chaos. It is necessary for managers and nurses in emergency departments to organize and practice care for relatives, whilst bringing in deceased individuals in a less chaotic and more caring manner. Impact: This study contributes to the knowledge of relatives' experiences regarding brought in dead persons, underpinning the need to care for this subpopulation in emergency departments. Care for relatives of brought in dead individuals has the potential to relieve suffering and prevent diseases, which are core elements of nursing.

Background It is important to understand the total burden of COPD and thereby be able to identify patients who need more intensive palliative care to avoid deteriorated quality of life. The aim of this study was to describe the psychosocial and demographic characteristics of a population with advanced COPD in a stable phase of the disease. Methods This study was cross-sectional based on a prospective observational cohort. The following questionnaires were administered: Chronic Respiratory Disease Questionnaire (CRQ), The COPD Assessment Test (CAT), The Hospital and Anxiety and Depression Scale (HADS), The Medical Research Council dyspnoea scale (MRC), and self-rate general health. Results We included 242 patients with advanced COPD from a Danish pulmonary outpatient clinic. Their mean FEV1 was 38% (±12.7) and 19% were treated with long term oxygen. The mean CRQ domain score was CRQ-dyspnea 4.21 (±1.4), CRQ-Mastery 4.88 (±1.3), CRQ-Emotional 4.81 (±1.2), CRQ-Fatigue 3.93 (±1.3). The mean CAT-score was 18.4 (± 6.7), and 44% had a CAT score > 20. The mean score on the subscale for anxiety (HADS-A) and depression (HADS-D) was 5.07 (±3.9) and 5.77 (±3.9), respectively. Thirty percent self-rated their health as bad or very bad and 19.8% were current smokers. Conclusions This study describes the characteristics of a population with advanced COPD in a stable phase of their disease. Our results illustrate how the population although treated in an outpatient structure already focusing on palliative needs, still live with unmet palliative needs and impaired quality of life.

This project has two aims: (a) What do relatives to brought in dead (BID) describe as helpful and supportive care when they arrive at the emergency department to see and say goodbye to a deceased? (b) What do nurses describe as good nursing practice for BID persons and their relatives and what may hinder or facilitate this practice in an emergency setting?A qualitative study in the methodology interpretive description.Data will be collected through three data sources: Individual interviews with relatives to BID persons, participant observations of relatives to BID persons during their presence in the emergency department and focus group interviews with emergency nurses.Brought in dead persons and their relatives are received and cared for in emergency departments by emergency nurses. Knowledge of how to render care for the relatives to BID persons in an acute setting including what skills and competences this require of the nurses is warranted. We need to explore, describe, and comprehend the experiences of both the relatives and the nurses to point out potential areas of improvement.This study is a protocol of an Interpretive Description study offering insight into considerations and reflections in designing the study.目的: 该项目有两个目的:(a)当亲属到达急诊室与送来的死者告别时,如何描述对于死者的护理起到帮助性和支持性的作用?(b)护士如何描述送来的死者及其亲属的良好护理实践,以及在紧急情况下这一做法的可能助力和阻力因素? 设计: 对方法论解释性描述的定性研究 方法: 通过三种数据来源收集数据:对送来的死者亲属的个人访谈、送来的死者亲属在急诊间的参观察和对急诊护士的焦点小组访谈。 讨论: 急诊间由急诊护士接送送来的死者及其亲属。了解如何在紧急情况下向亲属提出为送来的死者进行护理的方法,包括护士需要具备的技能和能力。我们需要探索、描述和理解亲属和护士双方在这一方面的经历,指出潜在的改进领域。 影响: 本研究采取解释性描述研究方案,提供设计研究时的考虑和思考。.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess effects of cognitive training interventions initiated during ICU or hospital stay versus no cognitive training on global cognitive function in adult patients after cessation of intensive care therapy.

Background and purpose of study Transition from the intensive care unit to the hospital ward can be considered as a vulnerable period for patients as nursing care changes hands. How the transition is experienced by the ICU patient and the family is influenced by how it is organised, communicated and executed. The transition may positively or negatively affect patient recovery. Aim To explore the experiences of intensive care unit patients and their relatives during the transition to hospital ward in order to find ways of supporting them during the transition process. Methods Eligible participants were asked for participation from April to September 2016 from a mixed medical and surgical intensive care unit (Level II) at a university hospital. We conducted six semi-structured interviews with former intensive care unit patients and four dyad interviews with patients and spouses. Data were analysed according to the methodology Interpretive Description with the aim to discover associations, relationships and patterns within the phenomenon. Results Our analysis revealed the following three themes: (1) Taking up the mantel (2) Adjusting to 'being one in the crowd' and (3) Integrated spouses became visitors. It was a change from an environment with high dependence to increasing independence and a shift from attention to loneliness. Focus moved from the bodily functions to basic activities of living. Spouses experienced that their position was reduced from integrated relatives in the intensive care unit to visitors of the hospital ward. Conclusions This article shows that it is important to mentally prepare patients and their family for transfer and a gradual withdrawal of intense nursing observation and monitoring. Discharge planning should begin early and involve spouses to a higher extent as they have a major role in the recovery process far beyond hospitalisation.

The World Health Organization (WHO)estimates that approximately 21,8 million people annually die due to cardio-pulmonary diseases[1]. Dyspnea is prevalent in cardio-pulmonary diseases [2], and ofte...

Aims: To explore Registered Nurses' experiences and perceptions with National Early Warning Score and Individual Early Warning Score to identify patient deterioration. Design: A qualitative exploratory design. Methods: Six focus groups were conducted at six Danish hospitals from February to June 2019. Registered Nurses from both medical, surgical and emergency departments participated. The focus groups were analysed using content analysis. Results: One theme and four categories were identified. Theme: Meaningful in identifying patient deterioration but causing frustration due to lack of flexibility. Categories: (a) Inter-professional collaboration strengthened through the use of Early Warning Score systems, (b) Enhanced professional development and communication among nurses when using Early Warning Score systems, (c) Detecting patient deterioration by integrating nurses' clinical gaze with Early Warning Score systems and (d) Modification and fear of making mistakes when using Early Warning Score systems.

ObjectiveWe aimed to investigate the experiences of Danish patients treated at home for an acute illness instead of being hospitalised.DesignThis study had a qualitative design inspired by the methodology of interpretive description. Data were collected through semistructured interviews.SettingHome treatment was conducted by a team of nurses (n=10–15) supported by physiotherapists and physicians, all affiliated with an emergency department, located in the capital region of Denmark. Interviews were conducted between August 2020 and April 2021.ParticipantsTwenty-one patients, aged 34–94 years, narrated their experiences of being treated at home for an acute illness.ResultsThe overarching theme in our analyses was that ‘being the centre of the nurses’ attention provided safety, patient involvement and quality of life during home treatment’. The following six themes emerged from analyses: (1) exclusive attention facilitates involvement and activity; (2) hospitals are for the sick; (3) maintaining a meaningful everyday life; (4) the hospital exudes productivity and busyness; (5) family relations and roles are maintained; (6) and concerns of deterioration.ConclusionsFrom a patient’s perspective, home treatment made sense and was perceived as a quality improvement. Being the centre of nurses’ attention induced a sense of safety, involvement and enhanced quality of life among patients during the treatment course for an acute illness.

Introduction: In addition to treating living patients, emergency nurses are also responsible for receiving and caring for persons who are dead on arrival and their relatives. There is limited knowledge about the dead on arrival patient and family population as well as care practice for the dead and their relatives. The first step in improving care for dead on arrival persons is to know the size and characteristics of the population. Therefore, the aim of this study was to describe the size and characteristics of the dead on arrival population in a Danish emergency department. Methods: A retrospective review of health records was undertaken forall consecutive dead on arrival persons received in 1 Danish emergency department between January2018 and December 2019. Results: A total of 719 dead on arrival persons were included, 350 in 2018 and 369 in 2019. Males accounted for 641 years with a range from 18 to 102 years. The place of death was 80 and more than half (54 were found either dead or dying by a spouse, cohabitant, or son/daughter. In most cases, the cause of death was described as unknown (92, whereas suicide and accidents accounted for 8 The population of dead on arrival persons in a Danish emergency department were mainly men, found dying or dead by relatives and brought in from home. Additional research and development are warranted regarding care practices for dead on arrival and their families in the emergency department. Introduction: In addition to treating living patients, emergency nurses are also responsible for receiving and caring for persons who are dead on arrival and their relatives. There is limited knowledge about the dead on arrival patient and family population as well as care practice for the dead and their relatives. The first step in improving care for dead on arrival persons is to know the size and characteristics of the population. Therefore, the aim of this study was to describe the size and characteristics of the dead on arrival population in a Danish emergency department. Methods: A retrospective review of health records was undertaken for all consecutive dead on arrival persons received in 1 Danish emergency department between January 2018 and December 2019. Results: A total of 719 dead on arrival persons were included, 350 in 2018 and 369 in 2019. Males accounted for 64%. The mean age was 71 years with a range from 18 to 102 years. The place of death was 80% at home, and more than half (54%) were found either dead or dying by a spouse, cohabitant, or son/daughter. In most cases, the cause of death was described as unknown (92%), whereas suicide and accidents accounted for 8%. Discussion: The population of dead on arrival persons in a Danish emergency department were mainly men, found dying or dead by relatives and brought in from home. Additional research and development are warranted regarding care practices for dead on arrival and their families in the emergency department.

Patients with chronic obstructive pulmonary disease (COPD) often live with unmet palliative needs and low quality of life, although several guidelines recommend that those with COPD should be offered early and integrated palliative care. However, none of the guidelines describe how these recommendations can be operationalised and the current literature offers little information about experiences with developing and implementing new palliative care services. This article offers insight into the experience of developing and implementing a new palliative outpatient structure for patients with severe COPD. All patients are assigned to a nurse who has overall responsibility for establishing and maintaining an individualised relationship with the patient and identifying their needs for care and treatment. Routine outpatient visits are replaced by ad hoc consultations, and patients are seen by pulmonary specialists only when there is a need for medical assessment and treatment or a planned advanced care planning dialogue. The new service was succesfully implemented; however, the changes required good multidisciplinary collaboration, dedicated health professionals and managerial support. This paper highlights the need for further studies to investigate the effectiveness of new palliative care interventions for patients with COPD.

Background Little is known of how to organize non-malign palliative care, and existing knowledge show that patients with COPD live with unmet palliative needs and low quality of life. With the intent to improve palliative care for patients with COPD, we changed the structure of our outpatient clinic from routine visits by a pulmonary specialist to a structure where each patient was assigned a nurse, offered annual advance care planning dialogues, and ad hoc pulmonary specialist visits. The aim of this study was to explore COPD patients’ experiences with a new and altered palliative organization. Methods The design was interpretive description as described by Thorne. We conducted ten semi-structured interviews with patients with severe COPD from January 2017 to December 2017. Results Patients described how the professional relationship and the availability of their nurse was considered as the most important and positive change. It made the patients feel safe, in control, and subsequently influenced their ability to self-manage their life and prevent being hospitalized. The patients did not emphasize the advanced care planning dialogues as something special or troublesome. Conclusion We showed that it is relevant and meaningful to establish a structure that supports professional relationships between patient, nurse and physician based on patients needs. The new way of structuring the outpatient care was highly appreciated by COPD patients and made them feel safe which brought confidence in self-management abilities. Electronic supplementary material The online version of this article (10.1186/s12904-019-0410-0) contains supplementary material, which is available to authorized users.

Background: The trans-membrane protease serine 2 (TMPRSS2) is essential for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cell entry and infection. Efficacy and safety of TMPRSS2 inhibitors in patients with coronavirus disease 2019 (Covid-19) have not been evaluated in randomized trials.Methods: We conducted an investigator-initiated, double-blind, randomized, placebo-controlled multicenter trial in patients hospitalized with confirmed SARS-CoV-2 infection from April 4, to December 31, 2020. Within 48 h of admission, participants were randomly assigned in a 2:1 ratio to receive the TMPRSS2 inhibitor camostat mesilate 200 mg three times daily for 5 days or placebo. The primary outcome was time to discharge or clinical improvement measured as ≥2 points improvement on a 7-point ordinal scale. Other outcomes included 30-day mortality, safety and change in oropharyngeal viral load.Findings: 137 patients were assigned to receive camostat mesilate and 68 to placebo. Median time to clinical improvement was 5 days (interquartile range [IQR], 3 to 7) in the camostat group and 5 days (IQR, 2 to 10) in the placebo group ( P = 0·31). The hazard ratio for 30-day mortality in the camostat compared with the placebo group was 0·82 (95% confidence interval [CI], 0·24 to 2·79; P = 0·75). The frequency of adverse events was similar in the two groups. Median change in viral load from baseline to day 5 in the camostat group was -0·22 log 10 copies/mL ( p Interpretation: Under this protocol, camostat mesilate treatment was not associated with increased adverse events during hospitalization for Covid-19 and did not affect time to clinical improvement, progression to ICU admission or mortality. ClinicalTrials.gov Identifier: NCT04321096. EudraCT Number: 2020-001200-42.

Background Anxiety is a common comorbidity in patients with advanced Chronic Obstructive Pulmonary Disease (COPD) with major impact on quality of life and associated with increased risk of death. The objective of this randomised controlled trial was to test the efficacy of a minimal home-based psychoeducative intervention versus usual care for reducing symptoms of anxiety in patients with advanced COPD. Methods The trial included 66 participants with advanced COPD and symptoms of anxiety. The primary outcome was anxiety assessed by the Hospital Anxiety and Depression scale (HADS) subscale for anxiety (HADS-A). The secondary outcome was mastery assessed by the Chronic Respiratory Questionnaire (CRQ) domain of mastery (CRQ-M). Assessments were performed at baseline and one and three months post-intervention. Results The intervention group had a lower post intervention HADS-A score on average, compared with the control group (p = 0.005), indicating a significant effect of the intervention. The average difference between the groups in HADS-A was 2.16 points (CI = [0.62; 3.71]) at one month and 2.32 points (CI = [0.74; 3.89]) at three months follow-up. The intervention group had a higher post intervention CRQ-M score on average compared with the control group (p = 0.016). The average differences between the groups were 0.58 points (CI = [0.09; 1.06]) after one month and 0.67 points (CI = [0.18; 1.17]) after three months. Conclusions The psychoeducative intervention provided sustainable symptom relief and improved the patients' self-management abilities.

Background: Patients with Chronic Obstructive Pulmonary Disease (COPD) experience long disease trajectories with heavy symptoms and reduced quality of life. There is an increasing attention on palliation for patients with COPD. Recognition of symptoms is a prerequisite for palliation. Aims and objectives: We put forward the hypothesis, that doctors or nurses do not recognize the symptomatology of patients with COPD. We aim to investigate the extent to which symptoms in patients with COPD are recognized in the documentation of the health professionals, indicated as “Doctors’ Symptom Recognition Rate” (DSR) or “Nurses’ Symptom Recognition Rate” (NSR), respectively. Method: Patients with COPD (N = 40) admitted in two respiratory units, responded within 48 hours on two symptom-screening-tools that access quality of life; CAT used for the treatment of COPD and EORTC-QLQ-C15-PAL used for palliation in patients with cancer. Patient-described symptomatology was compared to the symptoms as recognized in the documentation of doctors or nurses, respectively Results: The study shows a significant discrepancy between the symptomatology indicated by patients with COPD on CAT and EORTC-QLQ-C15-PAL, and the degree by which it is recognized in the medical records indicated in DSR or NSR. In 30 out of 44 items DSR or NSR were Conclusion: The low level of recognition reduces the ability to alleviate symptoms in patients with COPD and thus palliate

Context: Patients with chronic obstructive pulmonary disease (COPD) have a high symptom burden and reduced quality of life. There is an increasing attention on palliation for patients with COPD. Recognition of symptoms is a prerequisite for palliation. Objectives: We aim to investigate the extent to which symptoms in patients with COPD are recognized in the documentation of the health professionals, indicated in 'Doctors Symptom Recognition Rate' (DSR), 'Nurses Symptom Recognition Rate' (NSR) or 'Doctors and/or Nurses Symptom Recognition rates '(DNSR) as a team, respectively. Methods: Patients with COPD (n = 40) admitted in two respiratory units, responded within 48 h on two symptom-screening-tools that access quality of life; COPD assessment test (CAT) used for the treatment of COPD and EORTC-QLQ-C15-PAL used for palliation in patients with cancer. Patient-described symptomatology was compared to the symptoms as recognized in the documentation of doctors and/or nurses. Results: There was a significant discrepancy between the symptomatology indicated by patients with COPD on CAT and EORTC-QLQ-C15-PAL, and the degree by which it was recognized in the medical records indicated in DSR or NSR. In 30 out of 44 items DSR or NSR were < 70%. There was a significant difference between DNSR versus DSR or NSR, respectively, in 19 out of 22 items.Conclusion: A team-based symptom recognition DNSR is superior when compared to DSR or NSR. Team-based systematic screening is suggested as a pathway to increase symptom recognition in patients with COPD. Increased rates of symptom recognition may improve symptom alleviation and thus palliation.

OBJECTIVE: To explore the patients' experiences of a minimal home-based psychoeducative intervention aimed at reducing symptoms of anxiety.BACKGROUND: In a randomised controlled trial (RCT) we have shown that a minimal home-based and nurse-led psychoeducative intervention has a significant effect in reducing symptoms of anxiety and increasing mastery of dyspnoea in patients with advanced chronic obstructive pulmonary disease (COPD). However, we do not know if the intervention is perceived as meaningful and applicable in the everyday life of patients with advanced COPD.METHODS: We conducted a nested post-trial qualitative study. The study methodology was Interpretive Description as described by Thorne. The study was based on semi-structured interviews with twenty patients from the RCT intervention group i.g. home-living people with a diagnosis of advanced COPD and symptoms of anxiety.RESULTS: The patients described that making anxiety visible makes it manageable and provides relief. The patients described a feeling of being alone with managing anxiety and dyspnea, and the only way to gain in control of their cognitions was to mobilise internal resources. The intervention was appreciated by patients because it strengthened their internal resources. Further, it was perceived as a relief that the intervention insisted on talking about anxiety and thereby invited patients to verbalise worries related to end-of-life.CONCLUSION: This study offers knowledge to better understand the patients' experiences of a psychoeducative intervention. The intervention was perceived as comprehensible and applicable in the patients' everyday life and contributed to the patients' ability to self-manage their condition.

Aims and objectives To explore how spouses of patients with severe chronic obstructive pulmonary disease experience their role as informal caregiver. Background Informal caregiver spouses are of pivotal importance in the way that patients with chronic obstructive pulmonary disease cope with their daily life, including their opportunity to stay at home and avoid hospitalisations in the last stages of the disease. However, caregiving is associated with increased morbidity and mortality among caregivers. Further understanding of the role as an informal caregiver spouse of patients with severe chronic obstructive pulmonary disease is needed to develop supportive interventions aimed at reducing the caregiver burden. Design The study had a qualitative exploratory design. The data collection and analysis were based on framework method. Framework method is a thematic methodology and consists of five key stages: familiarisation, identifying a thematic framework, indexing, charting and mapping & interpretation. Methods Three focus groups were conducted in November 2013 with 22 spouses of patients with severe chronic obstructive pulmonary disease. Results Undefined and unpredictable responsibility was found to be the overarching theme describing the informal caregiver role. Underlying themes were: being constantly in a state of alertness, social life modified, maintaining normality, ambivalence in the relationship and a willingness to be involved. Conclusions The informal caregiver spouses experienced ambiguity about expectations from their private and the health professionals’ surroundings. The informal caregiver spouses wanted to provide meaningful care for their partners, but sought knowledge and support from the health professionals. Relevance to clinical practice We recommend that nurses take on the responsibility for including the informal caregiver spouses in those aspects of decision-making that involve the common life of the patients and their spouses.

Aim: To explore how spouses of patients with severe chronic obstructive pulmonary disease (COPD) experience their role as informal caregiver. Background: Informal caregiver spouses are of pivotal importance in the way that patients with severe COPD cope with their life including their opportunity to stay at home and avoid hospitalizations. However, caregiving is associated with increased morbidity and mortality among caregivers. There is a need of knowledge of the role as informal caregiver spouse to patients with severe COPD, in order to develop interventions aimed at reducing the caregiver burden and retaining the informal caregiver spouses9 health. Design: The study had a qualitative exploratory design. The data collection and analysis was based on framework method. Methods: Three focus group interviews were conducted in November 2013 with twenty-two spouses of patients with severe COPD. Findings: The key theme was that the role and the responsibility of the informal caregiver spouses were undefined, constantly changing and multifaceted . The fives underlying themes were: constantly in a state of alertness, social life modified, maintaining normality, ambivalence in the relationship and a willingness to be involved. Conclusion: The informal caregiver spouses are challenged by undefined and constantly changing roles and tasks with ambiguity about expectations from both their surroundings and the health system. To ease the caregiver burden nurses should take responsibility for matching expectations and involving the informal caregiver spouses in decision making.

Introduction In its final stages, chronic obstructive pulmonary disease is a severely disabling condition that is characterised by dyspnoea, which causes substantial anxiety. Anxiety is associated with an impaired quality of life and increased hospital admissions. Untreated comorbid anxiety can have devastating consequences for both patients and their relatives. Non-pharmacological interventions, including cognitive–behavioural therapy, have been effective in managing anxiety and dyspnoea in patients with chronic obstructive pulmonary disease. However, the majority of existing interventions have tested the efficacy of relatively intensive comprehensive programmes and primarily targeted patients who have moderate pulmonary disease. We present the rationale and design for a trial that focused on addressing the challenges experienced by severe pulmonary disease populations. The trial investigates the efficacy of a minimal home-based psychoeducative intervention versus usual care for patients with severe chronic obstructive pulmonary disease. Methods and analysis The trial is a randomised controlled trial with a 4-week and 3-month follow-up. 66 patients with severe chronic obstructive pulmonary disease and associated anxiety will be randomised 1:1 to either an intervention or control group. The intervention consists of a single psychoeducative session in the patient9s home in combination with a telephone booster session. The intervention is based on a manual, with a theoretical foundation in cognitive–behavioural therapy and psychoeducation. The primary outcome is patient-reported anxiety as assessed by the Hospital and Anxiety and Depression Scale (HADS). Ethics and dissemination This trial complies with the latest Declaration of Helsinki, and The Ethics Committee of the Capital Region of Denmark (number H-1-2013-092) was queried for ethical approval. Trial results will be disseminated in peer-reviewed publications and presented at scientific conferences. Trial registration number NCT02366390.