Seven-Day Continuous Abstinence Rate from Smoking at 1, 2, or 3 Years after the Use of Varenicline / 결핵및호흡기질환

BACKGROUND: Varenicline, a selective partial agonist/antagonist of the alpha4beta2 nicotinic receptor, has proven effectiveness for smoking cessation by several randomized, controlled trials. Because few studies have evaluated the long-term efficacy of varenicline, we tried to evaluate the smoking status of varenicline users up to 3 years after the initial prescription of the drug. METHODS: We interviewed varenicline users who were prescribed the drug from June 2007 to May 2010 by telephone, from June 2010 to May 2011. RESULTS: One-hundred and thirty-three of 250 varenicline users (53.2%) were available for the survey. Seven-day continuous abstinence from smoking was adhered to by 17 of 39 respondents (43.6%) at 1 year, and 11 of 36 (30.6%) and 19 of 58 (32.8%) at 2 and 3 years since the first use of varenicline, respectively. Compared to current smokers, successful quitters were older (55.0 years vs. 49.9 years, p=0.01), had better compliance to the 12-week course (27.7 vs. 9.3%, p=0.01), and had taken varenicline longer (10.1 vs. 5.9 weeks, p=0.01). Fifty-four of 71 current smokers (76.1%) were willing to stop smoking in the near future. The preferred ways to cease smoking were will-power (48.1%), varenicline (25.9%), nicotine replacement therapy (11.1%), and others (14.9%). CONCLUSION: Smokers should be encouraged to stick to the proven way for recommended period of time for successful cessation of smoking.

Two Cases of Newly Diagnosed Asthma with Spontaneous Pneumomediastinum During Asthma Exacerbation

Pneumomediastinum, a condition in which air is present in the mediastinum, is generally regarded as a benign, self-limited process. Rare life-threatening causes such as esophageal rupture must be excluded. A 26-year-old woman with allergic rhinitis presented with a 3-day history of increasing dyspnea, wheezing, and chest pain. Her high resolution CT (HRCT) showed extensive pneumomediastinum and subcutaneous emphysema without visible airway injury on the CT scan. With application of oxygen through a nasal cannula, bronchodilator inhalation, and systemic steroids, her pneumomediastinum and asthma symptoms were improved. A 30-year-old man with acute exacerbation of newly diagnosed asthma and spontaneous pneumomediastinum was treated with application of oxygen and asthma medication. Here, we reported two cases of newly diagnosed asthma with spontaneous pneumomediastinum during asthma exacerbation.

A Case of Giant, Benign Schwannoma Associated with Total Lung Collapse by Bloody Effusion / 결핵및호흡기질환

Benign schwannoma is the most common neurogenic tumor in the mediastinum. Mediastinal benign schwannomas are most often asymptomatic and rarely accompanied by bloody pleural effusion. In the clinical analysis of 7 cases of pulmonary schwannomas, pleural effusion, and blood invasion were evident in 3 patients with malignant schwannoma. Herein, we report a rare case of giant, benign schwannoma presented with total collapse of right lung by massive, bloody pleural effusion.

Self-care for Diabetic Patients in Primary Care

BACKGROUND: Diabetes mellitus is one of the most common chronic diseases which primary care family physician encounters. This study was performed to describe the medical care for patients with diabetes based on the Cheonan Practice-Based Research Network. METHODS: From May 2005 to July 2005, 193 patients with diabetes were assessed among the patients visiting seven family medicine clinics in Cheonan. The data were collected through a questionnaire about patient's socioeconomic characteristics, the details of medical care including screening practices of diabetic complications, self-monitoring of blood glucose and exercise. RESULTS: Among the patients with diabetes, 25.4% reported no exercise and another 29.6% reported regular exercise of more than 4 times a week. The less educated and the more elderly patients reported less exercise. Only 37.3% of patients monitored their blood glucose at home. The more educated, the more likely the patients monitored their blood glucose. Only 18.1% of patients reported having an annual 24-hour urine protein examination. The more educated and the more income they had, the more annual 24-hour urine protein examination was done. Only 32.6% of patients reported having an annual ophthalmologic examination, but there was no associated factors with having an annual ophthalmologic examination. CONCLUSION: These data indicate that the medical care for diabetic patients, including exercise, self-monitoring of blood glucose, screening of complications, may not be optimal for preventing diabetes complications, and was influenced by demographic characteristics such as age and education level. It is necessary for health care team to provide systematic education for diabetes and ongoing close monitoring of self care practices.

Psychiatric Characteristics and Diagnosis of SHE in Patients with Liver Cirrhosis:Cognitive Functions and Evoked Potentials / 신경정신의학

OBJECTIVES: This study was designed to elucidate the psychiatric characteristics and nature of the neuropsychological deficits associated with subclinical hepatic encephalopathy(SHE) in patients with non-alcoholic liver cirrhosis. And also the authors prospectively studied the role of somatosensory evoked potentials(SEP) in the assessment of SHE. METHODS: Beck Depression Inventory(BDI) for measuring depression, State Trait Anxiety Inventory(STAI) for measuring anxiety, and Health-related Quality of Life Questionnaire(HQLQ) for measuring quality of life were administered the 41 non-encephalopathic liver cirrhosis patients(NELC) group and 31 carefully matched normal controls. And a prospective study to compare the performance of NELC group and normal controls on a short but comprehensive cognitive tests was conducted. After several cognitive tests, NELC group was divided into two groups, SHE group and non-SHE group by results of digit symbol substitution test(DSST) and/or trail making test(TMT) A and B. And then median nerve evoked cortical responses in 13 SHE patients group, 11 non-SHE patients group, and 8 normal controls were recorded for latencies of N13, P16, N20, P25, N30, P45, N65, and P95. And also responses for N13-N20 interpeak latency(IPL) and N20-N65 IPL were recorded. RESULTS: There were significant differences between the NELC group and normal controls on BDI, trait anxiety scales in STAI, and almost all HQLQ except for the cognitive function, social interaction and life satisfaction(p<0.05). The NELC group exhibited poor performance in DSST, TMT A and TMT B compared with normal controls(p<0.05). As 17 NELC patients had abnormal cognitive test results, 41.5% of cirrhotic patients had SHE. In SEP assessment, NELC group with SHE and without SHE had higher N20-N65 IPL and only NELC group with SHE had higher N65 latency compared with normal controls(p<0.05). CONCLUSION: This study suggests that the patients with liver cirrhosis exhibit relatively selective deficits in complex attentional and fine motor skills, with preservation of general intellectual ability, memory, language and visuospatial perception. DSST, TMT A and TMT B seem to be useful screening tests for the detection of SHE. And also it is expected that late components and N20-N65 IPLs of SEP are helpful in the assessment of SHE.

The Survey of the Concept about Using Herb-Medication & the Effect on Treatment-Seeking Behavior in Psychiatric and Non-Psychiatric Patients / 신경정신의학

OBJECTIVES: The anthors examined health-seeking behavior about using herbal medicine in psyciatric and other clinical patients. The effect, side effect and motives in selecting herbal medicine were examined also. This study aimed at presenting treatment guide for psychiatric patients hereafter. METHOD: Subjects were consisted of 277 patients who were 93 medical, 81 surgical, and 102 psyhiatric patients. We made a questionnaire checking circumstances on taking herbal medicine. The investigating psychiatrist conducted person to person semi-structured interview using this questionnaire. RESULTS: Psychiatric patients preferred herbal medicine to western medicine, as other clinical patients did. In their health seeking behavior, classical illness model of oriental herbal medicine occupied a central position. In addition, psychiatric patients not only regarded herbal medicine as a more symtom-specific therapeutic medication, but also accepted side effects of herbal medicine uncritically than other clinical patients. CONCLUSIONS: As it is known that many psychiatric patients take both oriental and western medical treatment, we should not have exclusive attitude to emphasize one side between oriental and western medicine. Rather, we should deepen our understandings about oriental herbal medicine.

A Case of Narcolepsy after Traumatic Brain Injury / 신경정신의학

The authors reported a case and its diagnostic process of post-traumatic narcolepsy which had developed after a head trauma. The 51-years-old patient showed frequent generalized paralytic attack, which was aggravated during stressful situation, diet time, and in front of hospital staffs. During the paralytic attack, consciousness was alert, and he never collapsed to hurt. All laboratory findings including serum potassium level were within normal limit, and also brain imaging studies and electroencephalography revealed no specific abnormal findings. Our clinical impression was a conversion disorder or a malingering at first, but after the detailed history taking and the careful observation, daytime sleep attack and some sleep problems were revealed. Thus nocturnal polysomnography and multiple sleep latency test(MSLT) were performed, and then the authors could diagnose as "narcolepsy". HLA-DR2 typing was negative. After imipramine trial, the frequency and the intensity of attack was dramatically reduced. The authors concluded that narcolepsy should be considered in the differential diagnosis of sleepiness or transient loss of muscle tone after traumatic brain injury.

Psychological Factors in Male Sexual Dysfunction: Anxiety, Depression and Gender Role / 대한남성과학회지

PURPOSE: It has been presumed that male sexual dysfunction correlates highly with psychological factors. We assessed psychological factors such as anxiety, depression, and gender role in patients of psychogenic impotence. We also evaluated the differences in serum lipid profile, norepinephrine and serotonin between the patients and age-matched control subjects. SUBJECTS AND METHODS: Twenty-five men with psychogenic impotence were enrolled in this study, and thirty patients were enrolled as the age-matched control subjects. Lipid profile and norepinephrine were measured with random blood samples. Twenty-four hour urinary 5-hydroxyindoleacetic acid (5-HIAA), a urinary metabolite of serotonin, was measured. Psychological assessment, including Minnesota Multiphasic Personality Inventory (MMPI), Beck's Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI) for anxiety, and the Bem Sexual Inventory (BSRI) for gender role, was conducted. RESULTS: There was no significant difference between the patients and control subjects I any laboratory test except low-density lipoprotein (LDL). The value of LDL wee within normal reference ranges but significantly higher in the patients (p<0.05). Scores for depression (p<0.001), psychasthenia (p<0.001), social introversion (p<0.001), schizophrenia (p<0.01), hypochondriasis (p<0.05), and hysteria (p<0.05) were significantly higher in men with sexual dysfunction than in the controls. Patients with sexual dysfunction had higher scores for state and trait anxiety, especially trait anxiety, than the control subjects (p<0.05). In BSRI, a female profile was more apparent in patients than in the control group (37% versus 14%). CONCLUSIONS: These results suggest that psychosocial factors such as stress, anxiety, and depression are highly correlates with male sexual dysfunction. These factors are poorly correlated with random norepinephrine, lipid profiles and serotonin in the patients with sexual dysfunction.

A Case of Meige's Syndrome: Differential Diagnosis from Conversion Disorder / 신경정신의학

A Meige's syndrome is a rare neurological syndrome characterized by blepharospam and oromandibular dystonia. Its pathophysiology is not clearly determined yet, but the hypothesis of dopaminergic and cholinergic hyperactivity is most widely accepted. Anticholinergic drugs, antidopaminergic drugs and botulism toxin injection are currently used for the treatment of Meige's syndrome. The Meige's syndrome could be misdiagnosed as a psychaitric disorder such as conversion disorder or anxiety disorder, because clinical features of the Meige's syndrome are very variable and affected by psychological factors. The authors experienced one case of a 49-year-old female patient who was initally misdiagnosed as conversion disorder but confirmed later as Meige's syndrome, and then successfully treated.

The Effect of Estrogen on Cognitive Functions in Female Schizophrenics: A Preliminary Study / 신경정신의학

OBJECTIVES: There have been many investigations into the evaluation and treatment of cognitive deficits in schizophrenia, because cognitive deficits do not respond well to antipsychotics and may be a very important prognostic factor for social and occupational outcomes. And it has been known that estrogen improves cognitive functions, as proved in animal studies and studies in postmenopausal women and dementia patients. And estrogen has been unvestigated as an etiologic factor of the neuroendocrine abnormalities of schizophrenia. This preliminary study was aimed to investigate the effect of estrogen on cognitive functions of female schizophrenics, as one of the estrogen projects on our institute. METHODS: The subjects consisted of 30 females with schizophrenia. During the study, all subjects maintained the same dosage of antipsychotics as before the study. Fifteen subjects were given estrogen (EG), and the other fifteen subjects were not(CG). Trail Making Test A and B, Digit Symbol Substitution Test, Finger Tapping Test, Visual continuous Performance Test, Spatial Memory Test, and Wisconsin Card Sorting Test were taken every four weeks from the baseline to the 12th week. RESULTS: At Baseline, there were no significant differences of ages, duration of illness, antipsychotic dose, ammenorrhea, PANSS, types of schizophrenia, MADRS and CGI, and cognitive function tests between EG and CG. There were no significant improvements of Trial Making Test A & B, Finger Tapping Test, and Visual continuous Performance Test in both groups. But there were significant improvements of Digit Symbol Substitution Test, Spatial Memory Test, and Wisconsin Card Sorting Test (total errors and completed categories) in EG, but not in CG. CONCLUSION: The authors found that estrogen improved some cognitive functions, such as memory and executive function in EG. But it could not be clearly defined whether those changes are due to the direct effect of estrogen on the cognitive functions, or the improvement of psychotic symptoms, or the generalized enhancing effect of cognitive functions.

Depressive Symptoms of the Spousal Bereaved Elders

There are many studies of the spousal bereavement as an important etiologic factor of depression in elders. But there are some differernt natures of spousal bereavement between the Korean and the western elderly. The problems of spousal bereavement in Korean would be more persistent than that in western. And the depressive symptoms of Korean elders are different with that of western elders due to the differences of sociocultural background. The authors studied the effect of the spousal bereavement to the depressive symptoms of elders by using KGDS (Korean Form of Geriatric Depression Scale), which already has been standardized in Korea. The subjects were consist of one hundred seventy-five, 60 years and older. The authors compared KGDS and its 5 factors in the spousal bereaved subjects group (SBG) with those in the spousal non-bereaved subjects group (SNG), and also investigated the differences according to sex and children living with the subject in the SBG. And the authors analysed the correlations between ages at spousal death, durations after spousal death and KGDS in the SBG. The mean KGDS scores in the SBG were significantly higher than that of the SNG, and especially Factor 1, Factor 2 and Factor 4 were significant. In the SBG, the mean KGDS scores of the female were significantly higher than that of the male, and especially Factor 2, Factor 3, and Factor 5 were significant. And in the SBG, the mean KGDS scores of the subjects living with children were slightly higher than those of the subjects living without children. And also in the SBG, there were negative correlations between KGDS scores and ages at spousal death, and positive correlations between KGDS scores and durations after spousal death. The authors found that the spousal bearevement could be an important etiologic factor of geriatric depression, and the risk factors of depression were female, younger at spousal death and longer duration after spousal death in bereaved elders, as the earlier studies in the western. However, the authors found that, in Korea, there were some different results from the western, such as the longer duration after spousal death and higher ratio of the widower to the widow than that in the western, the spousal bereaved elders living with children were rather depressive than who living without children.

The Effects of Bethanechol on Anticholinergic Side Effects of Haloperidol / 대한정신약물학회지

OBJECTIVES: Haloperidol has been widely used for treating schizophrenia with somewhat limitation due to the side effects. Some of these side effects are anticholinergic side effects such as dry mouth, constipation, urinary difficulty, blurred vision, sexual dysfunction, etc. Some kinds strategies to minimize these side effects are tried, one of which is the use of bethanechol. The authors studied the effects of bethanechol on the anticholinergic side effects of typical antipsychotics. METHODS: The subjects of this study consisted of 60 chronic schizophrenics who had used haloperidol since 4 weeks before the study and whose score of 'Askers side effects rating scale' was above 7. They were assigned evenly to three groups (placebo group, bethanechol 40mg group, bethanechol 80mg group). Benztropin had been washed out for 2 weeks before the study. The authors measured ASRS for evaluating the anticholinergic side effect and BPRS for evaluating the effects of bethanechol on the psychopathology, at baseline, the 2nd week and the 4th week from baseline, respectively. RESULTS: At baseline, the mean age of patients was 38.00(+/- 10.55) years, the mean duration of illness was 11.12(+/- 8.09) years, and the mean dosage of the haloperidol was 15.07(+/- 6.03)mg. At baseline, mean score of BFRS was 50.25(+/- 5.24), and mean score of ASRS was 9.27 (+/- 3.04). There were no significant differences of ages, duration of illness, dosage of haloperidol, scores of BPRS and ASRS among 3 groups at baseline. There were no significant changes in BPRS at the 2nd week and the 4th week as compared with baseline, and also there were no changes among groups. The total sums of ASRS showed the statistically significant changes in the 80mg group at the 2nd week and the 4th week. The 80mg group showed statistically significant changes in dry mouth, constipation and urinary difficulty dom the 2nd week, and orthostatic symptoms from the 4th week. CONCLUSION: The authors found that the use of bethanechol for the chronic schizophrenics treating with haloperidol greatly improved the anticholinergic side effects with no change in psychopathology. The 80mg group showed more significant results than the placebo group and the 40mg group, especially in dry mouth, constipation, urinary diffculty and orthostatic symptoms. The authors suggest that high doses of bethanechol decrease the anticholinergic side effects and increase the drug compliance of chronic schizophrenics with anticholinergic side effects.

Norepinephrine and Serotonin in the Patients with Psychogenic Impotence

Various neurotransmitters have been proposed as possible mediators of penile erection. Especially, norepinephrine and serotonin might have a important role in sexual arousal and penile erection. And it could be hypothesized that the psychogenic impotence is associated with the depletion or imbalance of norepinephrine and serotonin from evidences such as the symptomatic manifestation of depression and the antidepressant-induced sexual dysfunction. The authors investigates the association of norepienphrine and serotonin with psychogenic impotence. The psychogenic impotent group(PIG) consisted of twenty-three patients with psychogenic impotence and the controlled group(CG) consisted of twenty-seven patients without psychogenic impotence. PIG had no organic cause accounting for their erectile dysfunction. The Beck Depression Inventory(BDI) and the State-Trait Anxiety Inventory(STAI) were applied to each subject to assess mood, state anxiety(SA) and trait anxiety(TA). Plasma norepinephrine level from systemic blood and 5-hydroxyindoleacetic acid(HIAA) levels from 24-hours urine were measured in each subject. The mean score of BDI of PIG was significantly higher than that of CG(p=0.015). PIG had a tendency of higher TA compared with CG(p=0.054). And also SA was higher in PIG, bud did not show significant difference(p=0.193). The level of norepinephrine was significantly lower in patient with psychogenic impotence(p=0.000). And the level of 24-hours urine 5-HIAA was lower in PIG but did not show significant difference(p=0.494). Although the authors did not exclude depressive disorders in PIG, the present findings suggest that psychogenic impotence might have higher depressive mood and trait anxiety, and be associated with the depletion of norepinephrine in systemic blood.

A Clinical Trial of Combined Treatment with Estrogen and Antipsychotics in Females with Chronic Schizophrenia

OBJECTIVE: This study was a open clinical trial aimed at exploring the effectiveness of combined treatment with estrogen and antipsychotics to the chronic female schizophrenics. METHOD: 40 female patients who met DSM-VI criteria for schizophrenia who were chronically ill were randomly assigned to estrogen group(EG) and control group(CG). EG patients were received estrogen 1.25mg for 8 weeks in addition to their routine antipsychotic regimens. CG patients were received their routine antipsychotic regimens only. Both groups were evaluated by PANSS(Positive and Negative Syndrome Scale), CGI(Clinical Global Impression) at 0, 4, 8 week during the trial period and compaired with each other. RESULTS: 40 female patients have completed the study during 8 weeks. EG was significantly improved in PANSS and CGI scores than CG during the 8 weeks. In EG patients, all symptom subtypes(positive symptoms, negative symptoms, general psychopathology symptoms) of PANSS were significantly improved and positive symptoms were most significantly improved at 8 weeks. CONCLUSIONS: This results support the clinical value of combined estrogen therapy among chronic female schizophrenics.

Postoperative Change in Mood and Cognition of the Elderly Patients

OBJECTIVES: Surgery is being offered to an increasing proportion of the over 60s and postpoerative cognitive dysfunction may occur in the elderly. We investigated that age could be a risk factor. The confounding effects, such as learning effect due to repeated testing and the effect of distress on the test performance, were controlled for by control group. METHOD: Twenty patients aged at least 60 years completed neuropsychological test 1 day before and 1 week after surgery. We measured Mini-Mental Status Examination (MMSE), digit span, 'A' test, similarity test, Digit Symbol Substitution Test (DSST), Beck Depression Inventory (BDI), Montgomery-Asberg Depression Rating Scale (MADRS) and State Anxiety Inventory (SAI). The authors compared postoperative cognitive dysfunction by neuropsychological test in the elderly patients with those in the control group. RESULTS: One week after operation, there was no cognitive impairment compared with before operation. Advanced age might not contribute to cognitive impairment except DSST. And there was an improvement in the scores for BDI and SAI in the control group only. We did not find a significant relation between early postoperative cognitive dysfunction and mood state before operation. Because the elderly patients had lower educational level and more depressive than control group before operation, we thought that the deterioration of DSST did not happened with operation, but by insufficiency of learning effect in the elderly patients. CONCLUSION: Cognition in the elderly patients was not impaired significantly after operation when attention was paid to the known perioperative influences on mental function.

Depressive Factors in the Korean Elderly

Depression is one of most frequent psychiatric disorders in the elderly. Major depression has higher prevalence in the elderly compared with younger subjects. Depression in the elderly is a major health concern that can be life threatening, if not recognized and not treated. An untreated depression may result in needless suffering, institutionalization, and suicide. Inadequated treatment may occur because the signs and symptoms of depression in the elderly are different from those in the young, and because the depressive symptoms may be viewed by the physician as a normal part of aging. The purpose of this study is to evaluate depressive factors in the Korean elderly. Four hundred and sixty eight Koreans were evaluated for depressive factors in 60 years old or more. The author performed a clinical evaluation guide, an intensive questionnaire, and Mini-Mental Status Examination-Korean version (MMSE-K). Stastically ANOVA, Scheffe, Duncan and Chi-square methods were used to find out depressive factors in the Korean elderly. Depression, dissatisfaction, suicidal idea and distress factors were evaluated in the Korean elderly depressed persons. Depressive factors were associated with physical health problems, family problems, psychiatric health problems, loneliness, economic problems, interpersonal conflicts, and occupational problems. Among these depressive factors, physical health problems were most frequently dominant in the elderly. Physical health problems are closely related to depression in the elderly. Depressive syndromes in the elderly are frequently combined with somatic complaints. And depression may be masked by multiple somatic complaints or by pain, for which no organic cause can be found. However, the etiology and mechanism of the association between physical illness and depression are unkown. Such factors as described above may be important in reducing the high prevalence of depression in elderly people.

Depressive Factors in the Korean Elderly

Depression is one of most frequent psychiatric disorders in the elderly. Major depression has higher prevalence in the elderly compared with younger subjects. Depression in the elderly is a major health concern that can be life threatening, if not recognized and not treated. An untreated depression may result in needless suffering, institutionalization, and suicide. Inadequated treatment may occur because the signs and symptoms of depression in the elderly are different from those in the young, and because the depressive symptoms may be viewed by the physician as a normal part of aging. The purpose of this study is to evaluate depressive factors in the Korean elderly. Four hundred and sixty eight Koreans were evaluated for depressive factors in 60 years old or more. The author performed a clinical evaluation guide, an intensive questionnaire, and Mini-Mental Status Examination-Korean version (MMSE-K). Stastically ANOVA, Scheffe, Duncan and Chi-square methods were used to find out depressive factors in the Korean elderly. Depression, dissatisfaction, suicidal idea and distress factors were evaluated in the Korean elderly depressed persons. Depressive factors were associated with physical health problems, family problems, psychiatric health problems, loneliness, economic problems, interpersonal conflicts, and occupational problems. Among these depressive factors, physical health problems were most frequently dominant in the elderly. Physical health problems are closely related to depression in the elderly. Depressive syndromes in the elderly are frequently combined with somatic complaints. And depression may be masked by multiple somatic complaints or by pain, for which no organic cause can be found. However, the etiology and mechanism of the association between physical illness and depression are unkown. Such factors as described above may be important in reducing the high prevalence of depression in elderly people.

The Role of Serotonin in pathology and Treatment of the Mood Disorders

The serotonin has been known to play important roles in pathology of the mood disorders. We summerize the evidences of serotonin in pathology of the mood disorders in a view of neuroanatomical and neurochemical aspects. Nowaday, the selective serotonin reuptake inhibitors(SSRIs)may be practically the first line of antidepressants with traditional tricyclic antidepressants(TCAs. Authors review the role of serotonin in the treatment of the mood disorders, in a view of the general considerations in selecting antidepressants, pharmacology, therapeutic, indications, side effects, doses of medication, drug-discontinuation syndrome, drug-to-drug interactions, and special therapeutic situations.