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In 2017, more than one million children became identity theft victims. Many perpetrators of child identity theft are parents, but there are limited data on these perpetrators. The purpose of this study was to understand parental perpetrators of child identity theft through the experiences of victims. Using a phenomenological approach, six adult victims of child identity theft engaged in in-depth interviews. Findings revealed perpetrators were perceived to lack guilt, be manipulative of their victim, and concerned about their public image. Victims often utilized a credit report to understand the scope of the identity theft and begin recovery. Federal agencies and creditors were contacted by victims as part of the recovery process, but were perceived as unhelpful. Implications for financial counseling and education are discussed, including the ethical boundaries of financial counselors and educators when working with victims who experience significant mental and/or physical health challenges as a result of the victimization.

Abstract Background“Lock to Live” (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. ObjectiveThe goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. MethodsThe L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)—a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model—ReachAdoptionImplementation ResultsThe initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) “have an open conversation,” (2) “validate their situation,” (3) “share what to expect,” (4) “make it accessible and memorable,” and (5) “walk through the tool.” Clinicians’ interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from

Abstract Objective Nasal septum perforation (NSP) is a common condition affecting ~1.2% of the general population and is still considered challenging to treat. Therapeutic strategies range from conservative local treatments and septal button closures to over 40 different surgical approaches. This study aimed to present a novel secure approach. Methods We describe our novel and unique NSP closure approach using a “fascia taco,” in which conchal cartilage is enveloped by temporalis fascia like a taco and splints are left in place for 6–8 weeks. A review of patient charts was conducted and questionnaires including the German‐SNOT‐22 and D‐NOSE were sent by mail to all eligible patients who received a fascia taco between 2016 and 2021. Results Thirty‐three patients were identified. The questionnaire response rate was 54.5%. The mean operative time (cut to sew) for all patients who only underwent NSP closure was 90.4 min. The overall success rate in terms of postoperative NSP closure was 81.8%. We found an apparent but nonsignificant association between closure failure and smoking (failure rate 66.6% in smokers vs. 15.4% in nonsmokers; X2 = 3.4188, p = .064). Questionnaire analysis showed a significant postoperative reduction of mean values in D‐NOSE from 60.8 to 33.1 (p = .009) and in German‐SNOT‐22 from 38.6 to 21.2 (p = .005). Conclusion The fascia taco technique is an easy‐to‐apply, safe procedure for NSP closure that is short in duration and associated with a low morbidity, resulting in excellent patient satisfaction. Level of Evidence 4.

IntroductionArtificial Intelligence (AI) has proven effective in classifying skin cancers using dermoscopy images. In experimental settings, algorithms have outperformed expert dermatologists in classifying melanoma and keratinocyte cancers. However, clinical application is limited when algorithms are presented with ‘untrained’ or out-of-distribution lesion categories, often misclassifying benign lesions as malignant, or misclassifying malignant lesions as benign. Another limitation often raised is the lack of clinical context (e.g., medical history) used as input for the AI decision process. The increasing use of Total Body Photography (TBP) in clinical examinations presents new opportunities for AI to perform holistic analysis of the whole patient, rather than a single lesion. Currently there is a lack of existing literature or standards for image annotation of TBP, or on preserving patient privacy during the machine learning process.MethodsThis protocol describes the methods for the acquisition of patient data, including TBP, medical history, and genetic risk factors, to create a comprehensive dataset for machine learning. 500 patients of various risk profiles will be recruited from two clinical sites (Australia and Spain), to undergo temporal total body imaging, complete surveys on sun behaviors and medical history, and provide a DNA sample. This patient-level metadata is applied to image datasets using DICOM labels. Anonymization and masking methods are applied to preserve patient privacy. A two-step annotation process is followed to label skin images for lesion detection and classification using deep learning models. Skin phenotype characteristics are extracted from images, including innate and facultative skin color, nevi distribution, and UV damage. Several algorithms will be developed relating to skin lesion detection, segmentation and classification, 3D mapping, change detection, and risk profiling. Simultaneously, explainable AI (XAI) methods will be incorporated to foster clinician and patient trust. Additionally, a publicly released dataset of anonymized annotated TBP images will be released for an international challenge to advance the development of new algorithms using this type of data.ConclusionThe anticipated results from this protocol are validated AI-based tools to provide holistic risk assessment for individual lesions, and risk stratification of patients to assist clinicians in monitoring for skin cancer.

BackgroundAlzheimer’s disease (AD) is increasing in prevalence, but effective treatments for its cognitive impairment remain severely limited. This study investigates the impact of ketone body production through dietary manipulation on memory in persons with mild cognitive impairment due to early AD and explores potential mechanisms of action.MethodsWe conducted a 12-week, parallel-group, controlled feasibility trial of a ketogenic diet, the modified Atkins diet (MAD), compared to a control diet in patients with cognitive impairments attributed to AD. We administered neuropsychological assessments, including memory tests, and collected blood samples at baseline and after 12 weeks of intervention. We performed untargeted lipidomic and targeted metabolomic analyses on plasma samples to detect changes over time.ResultsA total of 839 individuals were screened to yield 38 randomized participants, with 20 assigned to receive MAD and 18 assigned to receive a control diet. Due to attrition, only 13 in the MAD arm and nine in the control arm were assessed for the primary endpoint, with two participants meeting ketosis levels used to define MAD adherence criteria. The average change from baseline in the Memory Composite Score was 1.37 (95% CI: −0.87, 4.90) points higher in the MAD group compared to the control group. The effect size of the intervention on baseline MAD change was moderate (Cohen’s D = 0.57, 95% CI: −0.67, 1.33). In the 15 participants (nine MAD, six control) assessed for lipidomic and metabolomic-lipidomics and metabolomics, 13 metabolites and 10 lipids showed significant changes from baseline to 12 weeks, including triacylglycerols (TAGs, 50:5, 52:5, and 52:6), sphingomyelins (SM, 44:3, 46:0, 46:3, and 48:1), acetoacetate, fatty acylcarnitines, glycerol-3-phosphate, and hydroxy fatty acids.ConclusionsAttrition was greatest between baseline and week 6. All participants retained at week 6 completed the study. Despite low rates of adherence by criteria defined a priori, lipidomic and metabolomic analyses indicate significant changes from baseline in circulating lipids and metabolites between MAD and control participants at 12-week postrandomization, and MAD participants showed greater, albeit nonsignificant, improvement in memory.

Aim: Social media (SoMe) are emerging as important tools for research dissemination. Twitter/X promotion has been shown to increase citation rates in well-established journals. We aimed to test the effect of a SoMe promotion strategy on the Mendeley reader counts, the Altmetric Attention Score and the number of citations in an upcoming open-access journal. Methods: The #TweetTheJournal study is a randomized, controlled study. Articles published in seven subsequent issues of the International Journal of Cardiology Heart & Vasculature (April 2021-April 2022) were randomized to a Twitter/X promotion arm (articles were posted four times) and to a control arm (without active posting). Articles with accompanied editorials were excluded. Primary endpoint of the study was Mendeley reader count, secondary endpoints were Altmetric Attention Score and number of citations. Follow-up was one year. Results: SoMe promotion of articles showed no statistically significant difference in Mendeley reader counts or number of citations at one year follow up. SoMe promotion resulted in a statistically significant higher Altmetric Attention Score in the intervention compared to the control group (RR 1.604, 95 % CI 1.024–2.511, p = 0.039). In the overall group, Altmetric Attention Score showed a correlation with Mendeley reader counts (Spearman’s ρ = 0.202, p = 0.010) and Mendeley reader counts correlated significantly with number of citations (Spearman’s ρ = 0.372, p

Objective: Biomechanical Machine Learning (ML) models, particularly deep-learning models, demonstrate the best performance when trained using extensive datasets. However, biomechanical data are frequently limited due to diverse challenges. Effective methods for augmenting data in developing ML models, specifically in the human posture domain, are scarce. Therefore, this study explored the feasibility of leveraging generative artificial intelligence (AI) to produce realistic synthetic posture data by utilizing three-dimensional posture data.Methods: Data were collected from 338 subjects through surface topography. A Variational Autoencoder (VAE) architecture was employed to generate and evaluate synthetic posture data, examining its distinguishability from real data by domain experts, ML classifiers, and Statistical Parametric Mapping (SPM). The benefits of incorporating augmented posture data into the learning process were exemplified by a deep autoencoder (AE) for automated feature representation.Results: Our findings highlight the challenge of differentiating synthetic data from real data for both experts and ML classifiers, underscoring the quality of synthetic data. This observation was also confirmed by SPM. By integrating synthetic data into AE training, the reconstruction error can be reduced compared to using only real data samples. Moreover, this study demonstrates the potential for reduced latent dimensions, while maintaining a reconstruction accuracy comparable to AEs trained exclusively on real data samples.Conclusion: This study emphasizes the prospects of harnessing generative AI to enhance ML tasks in the biomechanics domain.

We derive a bound for entropy production in terms of the mean of normalizable path-antisymmetric observables. The optimal observable for this bound is shown to be the signum of entropy production, which is often easier determined or estimated than entropy production itself. It can be preserved under coarse graining by the use of a simple path grouping algorithm. We demonstrate this relation and its properties using a driven network on a ring, for which the bound saturates for short times for any driving strength. This work can open a way to systematic coarse graining of entropy production.

One aspirational goal of computational chemistry is to predict potent and drug-like binders for any protein, such that only those that bind are synthesized. In this Roadmap, we describe the launch of Critical Assessment of Computational Hit-finding Experiments (CACHE), a public benchmarking project to compare and improve small molecule hit-finding algorithms through cycles of prediction and experimental testing. Participants will predict small molecule binders for new and biologically relevant protein targets representing different prediction scenarios. Predicted compounds will be tested rigorously in an experimental hub, and all predicted binders as well as all experimental screening data, including the chemical structures of experimentally tested compounds, will be made publicly available, and not subject to any intellectual property restrictions. The ability of a range of computational approaches to find novel binders will be evaluated, compared, and openly published. CACHE will launch 3 new benchmarking exercises every year. The outcomes will be better prediction methods, new small molecule binders for target proteins of importance for fundamental biology or drug discovery, and a major technological step towards achieving the goal of Target 2035, a global initiative to identify pharmacological probes for all human proteins.

ObjectiveMultiple guidelines recommend continuing hydroxychloroquine (HCQ) for SLE during pregnancy based on observational data. The goal of this individual patient data meta-analysis was to identify the potential benefits and harms of HCQ use within lupus pregnancies.MethodsEligible studies included prospectively collected pregnancies in women with lupus. After a systematic literature search, seven datasets meeting inclusion criteria were obtained. Pregnancy outcomes and lupus activity were compared for pregnancies with a visit in the first trimester in women who did or did not take HCQ throughout pregnancy. Birth defects were not systematically collected. This analysis was conducted in each dataset, and results were aggregated to provide a pooled OR.ResultsSeven cohorts provided 938 pregnancies in 804 women. After selecting one pregnancy per patient with a first trimester visit, 668 pregnancies were included; 63% took HCQ throughout pregnancy. Compared with pregnancies without HCQ, those with HCQ had lower odds of highly active lupus, but did not have different odds of fetal loss, preterm delivery or pre-eclampsia. Among women with low lupus activity, HCQ reduced the odds of preterm delivery.ConclusionsThis large study of prospectively-collected lupus pregnancies demonstrates a decrease in lupus activity among woman who continue HCQ through pregnancy and no harm to pregnancy outcomes. Like all studies of HCQ in lupus pregnancy, this study is confounded by indication and non-adherence. As this study confirms the safety of HCQ and diminished SLE activity with use, it is consistent with current recommendations to continue HCQ throughout pregnancy.

Abstract Evidence-based indication for tonsil surgery in patients with recurrent acute tonsillitis (RAT) is an ongoing matter of debate. Since introduction of the German tonsillitis guideline in 2015, the indication criteria for tonsil surgery have become much stricter. It is unclear, if this has changed the indication policy. A retrospective population-based study was performed including all 1398 patients with RAT admitted for tonsil surgery in all Thuringian hospitals in 2011, 2015, and 2019. Changes over the years concerning patients’ characteristics, number of tonsillitis episodes in the last 12 months treated with antibiotics (T12), and decision for tonsillectomy or tonsillotomy were analyzed using univariable and multivariable statistics. The surgical rates decreased from 28.56/100,000 population in 2011 to 23.57 in 2015, and to 11.60 in 2019. The relative amount of patients with ≥ 6 T12 increased from 14.1% in 2011 over 13.3% in 2015 to 35.9% in 2019. Most patients received a tonsillectomy (98% of all surgeries). Decision for tonsillotomy was seldom (1.2%). Multinomial logistic regression analysis with the year 2011 as reference showed that compared to the year 2015, the age of the patients undergoing surgery increased in 2015 (Odds ratio [OR] = 1.024; 95% confidence interval [CI] = 1.014–1.034; p

Abstract Accelerating energy transitions that are both sustainable and just remains an important challenge, and social innovation can have a key role in this transition. Here, we examine the diversity and potential of social innovation in energy systems transformation, synthesizing original mixed methods data from expert interviews, document analysis, social innovation experiments, a representative survey, and an expert survey. Based on a thematic analysis of these data, we advance four key findings: (1) the diversity of social innovation in energy is best understood when recognizing core social practices (thinking, doing, and organizing) and accounting for changes in social relations (cooperation, exchange, competition, and conflict); (2) governance, policy networks, and national context strongly shape social innovation dynamics; (3) processes of social innovation are implicated by multidimensional power relations that can result in transformative changes; and (4) social innovation in energy generally has strong social acceptance among citizens, benefits local communities and is legitimized in key community and city organizations. We discuss an agenda for 9 future research directions on social innovation in energy, and conclude with insights related to national context, governance, and acceleration.

Abstract Gene fusions and MET exon skipping drive oncogenesis in 8–9% and 3% of non-small cell lung cancers (NSCLC) respectively. Their detection are essential for the management of patients since they confer sensitivity to specific targeted therapies with significant clinical benefit over conventional chemotherapy. Immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH) account for historical reference techniques however molecular-based technologies (RNA-based sequencing and RT-PCR) are emerging as alternative or complementary methods. Here, we evaluated the analytical performance of the fully-automated RT-PCR Idylla GeneFusion assay compared to reference methods using 35 fixed NSCLC samples. Idylla demonstrated overall agreement, sensitivity and specificity of 100% compared to RNASeq. Interestingly, it succeeded in retrieving 10 out of 11 samples with inconclusive results due to insufficient RNA quality for sequencing. Idylla showed an overall agreement, sensitivity and specificity of 90.32%, 91.67% and 89.47% compared to IHC/FISH respectively. Using commercial standards, the limit of detection of the Idylla system for the most frequent fusions and exon skipping ranges between 5 and 10 ng RNA input. These results support that the Idylla assay is a reliable and rapid option for the detection of these alterations, however a particular attention is needed for the interpretation of the expression imbalance.

Abstract Various chalcidoid wasps can actively steer their terebra (= ovipositor shaft) in diverse directions, despite the lack of terebral intrinsic musculature. To investigate the mechanisms of these bending and rotational movements, we combined microscopical and microtomographical techniques, together with videography, to analyse the musculoskeletal ovipositor system of the ectoparasitoid pteromalid wasp Lariophagus distinguendus (Förster, 1841) and the employment of its terebra during oviposition. The ovipositor consists of three pairs of valvulae, two pairs of valvifers and the female T9 (9th abdominal tergum). The paired 1st and the 2nd valvulae are interlocked via the olistheter system, which allows the three parts to slide longitudinally relative to each other, and form the terebra. The various ovipositor movements are actuated by a set of nine paired muscles, three of which (i.e. 1st valvifer-genital membrane muscle, ventral 2nd valvifer-venom gland reservoir muscle, T9-genital membrane muscle) are described here for the first time in chalcidoids. The anterior and posterior 2nd valvifer-2nd valvula muscles are adapted in function. (1) In the active probing position, they enable the wasps to pull the base of each of the longitudinally split and asymmetrically overlapping halves of the 2nd valvula that are fused at the apex dorsally, thus enabling lateral bending of the terebra. Concurrently, the 1st valvulae can be pro- and retracted regardless of this bending. (2) These muscles can also rotate the 2nd valvula and therefore the whole terebra at the basal articulation, allowing bending in various directions. The position of the terebra is anchored at the puncture site in hard substrates (in which drilling is extremely energy- and time-consuming). A freely steerable terebra increases the chance of contacting a potential host within a concealed cavity. The evolution of the ability actively to steer the terebra can be considered a key innovation that has putatively contributed to the acquisition of new hosts to a parasitoid’s host range. Such shifts in host exploitation, each followed by rapid radiations, have probably aided the evolutionary success of Chalcidoidea (with more than 500,000 species estimated).

OBJECTIVE: Hearing loss (HL) is highly prevalent among older adults and may lead to increased risk of depressive symptoms. In both cross-sectional and longitudinal analysis, we quantified the association between HL and depressive symptoms, incorporating the variable nature of depressive symptoms and characterizing by race and gender. METHODS: Data were from the Health, Aging, and Body Composition study. Depressive symptoms were measured using the Center for Epidemiologic Study Depression Scale short form (CES-D 10), defined as CES-D 10 score ≥10 or treatment for depression. Hearing was defined via four-frequency pure-tone average (PTA) decibel hearing level (dB HL), categorized as normal hearing (PTA ≤25 dB HL), mild HL (PTA26-40 dB HL), and ≥moderate HL (PTA > 40 dB HL). Associations at baseline were quantified using logistic regression, incident depressive symptoms using Cox proportional hazard models, and change in depressive symptoms over time using growth mixture models and multinomial logistic regression. RESULTS: Among 2,089 older adults (1,082 women, 793 Black; mean age 74.0 SD: 2.8), moderate or greater HL was associated with greater odds of concurrent [Odds Ratio (OR):2.45, 95% CI:1.33, 4.51] and incident depressive symptoms [Hazard Ratio (HR):1.26, 95% CI:1.00, 1.58]. Three depressive symptom trajectory patterns were identified from growth mixture models: low, moderate increasing, and borderline high depressive symptom levels. Those with moderate or greater HL were more likely to be in the borderline high depressive-symptom trajectory class than the low trajectory class [Relative Risk Ratio (RRR):1.16, 95% CI:1.01, 1.32]. CONCLUSIONS: HL was associated with greater depressive symptoms. Although findings were not statistically significantly different by gender and race, estimates were generally stronger for women and Black participants. Investigation of psychosocial factors and amelioration by hearing aid use could have significant benefit for older adults quality of life.

Case Presentation: A 53-year-old female presented to the emergency department with three days of nausea and dyspnea on exertion after using methamphetamine. Initial electrocardiogram revealed an ST-elevation myocardial infarction. While awaiting transfer to the cardiac catheterization lab the patient suffered a witnessed cardiac arrest. During resuscitative efforts an enlarging pericardial effusion on point-of-care ultrasound led to the detection of a left ventricular free-wall rupture (LVFWR). This case illustrates the progression of a left ventricular free-wall rupture using point-of-care ultrasound.Discussion: Left ventricular free-wall rupture has a low incidence rate in the setting of an acute myocardial infarction. Ultrasonography is the tool of choice for detecting a LVFWR.

Background and objectivesThe Covid-19 pandemic reduced access to social activities and routine health care that are central to dementia prevention. We developed a group-based, video-call, cognitive well-being intervention; and investigated its acceptability and feasibility; exploring through participants' accounts how the intervention was experienced and used in the pandemic context.Research design and methodWe recruited adults aged 60+ years with memory concerns (without dementia). Participants completed baseline assessments and qualitative interviews/focus groups before and after the 10-week intervention. Qualitative interview data and facilitator notes were integrated in a thematic analysis.Results12/17 participants approached completed baseline assessments, attended 100/120 (83.3%) intervention sessions and met 140/170 (82.4%) of goals set. Most had not used video calling before. In the thematic analysis, our overarching theme was social connectedness. Three sub-themes were as follows: Retaining independence and social connectedness: social connectedness could not be at the expense of independence; Adapting social connectedness in the pandemic: participants strived to compensate for previous social connectedness as the pandemic reduced support networks; Managing social connections within and through the intervention: although there were tensions, for example, between sharing of achievements feeling supportive and competitive, participants engaged with various lifestyle changes; social connections supported group attendance and implementation of lifestyle changes.Discussion and implicationsOur intervention was acceptable and feasible to deliver by group video-call. We argue that dementia prevention is both an individual and societal concern. For more vulnerable populations, messages that lifestyle change can help memory should be communicated alongside supportive, relational approaches to enabling lifestyle changes.

Under the influences of climate change and human activities, habitat quality (HQ) in inland river basins continues to decline. Studying the spatiotemporal distributions of land use and HQ can provide support for sustainable development strategies of the ecological environment in arid regions. Therefore, this study utilized the SD-PLUS model, InVEST-HQ model, and Geodetector to assess and simulate the land-use changes and HQ in the Tarim River Basin (TRB) at multiple scales (county and grid scales) and scenarios (SSP126, SSP245, and SSP585). The results indicated that (1) the Figure of Merit (FoM) values for Globeland 30, China’s 30 m annual land-cover product, and the Chinese Academy of Sciences (30 m) product were 0.22, 0.12, and 0.15, respectively. A comparison of land-use datasets with different resolutions revealed that the kappa value tended to decline as the resolution decreased. (2) In 2000, 2010, and 2020, the HQ values were 0.4656, 0.4646, and 0.5143, respectively. Under the SSP126 and SSP245 scenarios, the HQ values showed an increasing trend: for the years 2030, 2040, and 2050, they were 0.4797, 0.4834, and 0.4855 and 0.4805, 0.4861, and 0.4924, respectively. Under SSP585, the HQ values first increased and then decreased, with values of 0.4791, 0.4800, and 0.4766 for 2030, 2040, and 2050, respectively. (3) Under three scenarios, areas with improved HQ were mainly located in the southern and northern high mountain regions and around urban areas, while areas with diminished HQ were primarily in the western part of the basin and central urban areas. (4) At the county scale, the spatial correlation was not significant, with Moran’s I ranging between 0.07 and 0.12, except in 2000 and 2020. At the grid scale, the spatial correlation was significant, with clear high- and low-value clustering (Moran’s I between 0.80 and 0.83). This study will assist land-use planners and policymakers in formulating sustainable development policies to promote ecological civilization in the basin.

Background: Cardiogenic shock (CS) following an out-of-hospital cardiac arrest (OHCA) poses significant management challenges, exacerbated by inflammatory responses and infectious complications. This study investigates the microbiological profiles and impacts of mechanical circulatory support (MCS) on inflammation and infection in OHCA patients. Methods: We retrospectively analyzed microbiological data from various specimens of 372 OHCA patients, who were treated at the Cardiac Arrest Center of the University Hospital of Marburg from January 2018 to December 2022. Clinical outcomes were evaluated to investigate the potential impact of MCS on infection and inflammation. Results: Of the study cohort, 115 patients received MCS. The microbiological analysis revealed a higher incidence of positive blood cultures in the MCS group vs. the non-MCS group (39% vs. 27.7%, p = 0.037), with predominantly Gram-positive bacteria. Patients with positive microbiological findings had longer in-hospital stays and prolonged periods of mechanical ventilation. The levels of inflammatory markers such as C-reactive protein (CRP) and procalcitonin (PCT) differed, suggesting a more pronounced inflammatory response in MCS patients, especially in the later ICU stages. Notably, despite the higher infection rate in the MCS group, the survival rates did not significantly differ in the two groups. Conclusions: MCS appears to influence the microbiological and inflammatory landscape in OHCA patients, increasing the susceptibility to certain infections but not affecting the overall mortality. This study underscores the complexity of managing post-resuscitation care and highlights the need for tailored therapeutic strategies to effectively mitigate infectious and inflammatory complications.