A social innovation to empower community-led monitoring and mobilization for HIV prevention in rural Kenya: experimenting to reduce the HIV prevention policy-implementation gap.

Introduction: Strong policy guidance has recently emerged identifying focal points at multiple levels and across sectors to end the persistent HIV pandemic and related inequities. Reducing the policy-implementation gap, as with the evidence-policy gap, requires strategic alignment between interventional research and policy realms. Global- and national-level HIV policy indicate a need for community-led efforts to reduce HIV stigma, and increase uptake of HIV prevention tools. Methods: This study assesses a process-driven approach to facilitating community-led efforts to reduce HIV stigma, and build a generative context for community-led HIV prevention. The study intervention combines an adapted group-based microfinance process, a novel psychological curriculum, and leadership development at a scale now involving over 10,000 rural Kenyans across 39 villages. Results: Consistent with interventional goals, and current relevant psychosocial theories, we find collective emotion, and HIV stigma (blame and discrimination) significantly improve with more time participating in the in the program and novel curriculum. Further, HIV stigma predicts subsequent reporting of ever being tested for HIV, and the intervention led to the development of "HIV prevention resource committees" - groups of participants committed to undergo training to reduce HIV stigma and prevent HIV within their communities. Discussion: Implications for further research to reduce the HIV policy-implementation gap are discussed, directly within this interventional context and more generally.

Disparities in the prevalence of ADHD diagnoses, suspicion, and medication use between Flanders and Québec from the lens of the medicalization process.

The prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) diagnoses and medication use has increased over time around the world, but significant regional differences remain. This paper aims to determine and explain disparities in ADHD prevalence and medication use among school-aged children in two distinct school systems, in Flanders (Belgium) and Québec (Canada). We present detailed descriptive and comparative analyses of data from 35 schools, 114 teachers, and 1046 parents (children) that were collected as part of a comparative international project. The data concern teacher and parent suspicions, teachers' ratings of ADHD-related behaviors in children, teachers' views of medication use, and teachers' beliefs about ADHD. The results show that, compared with Flanders, Québec had significantly more children diagnosed with ADHD and more frequent suspicions of ADHD in children by teachers and parents. We refer to the conceptual, institutional, and interactional levels of medicalization to interpret our findings and conclude that social and cultural readings of children's behaviors differ greatly between regions. Medicalization of children's behaviors is more common in Québec than in Flanders.

Assessing changes in adolescent girls' and young women's sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini.

The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls' and young women's (AGYW; aged 15-24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini's electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW's SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period.

Genetic control of tomato fruit quality: from QTL mapping to Genome Wide Association studies and breeding.

Consumers began to complain about the taste of tomato varieties in the late 1990's. Although tomato taste is influenced by environmental and post-harvest conditions, varieties show a large diversity for fruit quality traits. We herein review our past and present research work intended to improve tomato fruit quality. First, results from sensory analysis allowed identifying important traits for consumer preferences. Then, we dissected the genetic control of flavor related traits by mapping several QTL in the last 20 years, and identified the genes corresponding to a few major QTL. Since the availability of the tomato genome sequence, genome-wide association studies were performed on several panels of tomato accessions. We discovered a large number of associations for fruit composition and identified relevant allele combinations for breeding. We then performed a meta-analysis combining the results of several studies. We also checked the inheritance of quality traits at the hybrid level and assessed how genomic prediction could help selecting better tomato varieties.

Les consommateurs ont commencé à se plaindre du goût des variétés de tomates à la fin des années 1990. Bien que le goût de la tomate soit influencé par les conditions de culture et de post-récolte, les variétés présentent une grande diversité pour les caractéristiques de qualité des fruits. Nous passons ici en revue nos travaux de recherche passés et présents destinés à comprendre la diversité génétique et améliorer la qualité des fruits de tomate. Les résultats d'analyses sensorielles ont tout d'abord permis d'identifier les traits importants pour les préférences des consommateurs. Ensuite, nous avons disséqué le contrôle génétique des caractères liés à ces traits, cartographié de nombreux QTL depuis 20 ans et identifié les gènes correspondant à quelques QTL majeurs. Depuis la disponibilité de la séquence du génome de la tomate, des études d'association à l'échelle du génome ont été réalisées sur plusieurs panels d'accessions de tomate. Nous avons découvert un grand nombre d'associations pour la composition des fruits, et identifié les combinaisons d'allèles pertinentes pour la sélection. Nous avons ensuite réalisé une méta-analyse combinant les résultats de plusieurs études. Nous avons également vérifié l'hérédité des caractères de qualité au niveau hybride, et évalué comment la prédiction génomique pourrait aider à sélectionner de meilleures variétés de tomates.

Friends as Informal Educators: The Role of Peer Relationships in Promotion of Sexual Health Services among College Students.

This ethnographic study of one United States university's sexual health resources explores the role of peer relationships in sexual health promotion to understand how these relationships shaped students' interactions with campus sexual health resources. Through analysis of seventeen semi-structured interviews with students, five policy interviews with providers and university personnel, and participant-observation of peer health educator training, the authors examine how trust in peer relationships can serve as a form of social capital to influence sexual health information sharing. The article introduces the term "peer administrator" to describe student actors who sit at the intersection of friend and official resource and explores the importance of these mentoring relationships for sexual health promotion. The analysis also considers how more individualistic models of public health promotion limit the impact of peer relationships and concludes with a discussion of how universities might imagine new forms of sexual health promotion among students.

Implementation of a Hardware-Assisted Bluetooth-Based COVID-19 Tracking Device in a High School: Mixed Methods Study.

BACKGROUND: Contact tracing is a vital public health tool used to prevent the spread of infectious diseases. However, traditional interview-format contact tracing (TCT) is labor-intensive and time-consuming and may be unsustainable for large-scale pandemics such as COVID-19. OBJECTIVE: In this study, we aimed to address the limitations of TCT. The Yale School of Engineering developed a Hardware-Assisted Bluetooth-based Infection Tracking (HABIT) device. Following the successful implementation of HABIT in a university setting, this study sought to evaluate the performance and implementation of HABIT in a high school setting using an embedded mixed methods design. METHODS: In this pilot implementation study, we first assessed the performance of HABIT using mock case simulations in which we compared contact tracing data collected from mock case interviews (TCT) versus Bluetooth devices (HABIT). For each method, we compared the number of close contacts identified and identification of unique contacts. We then conducted an embedded mixed methods evaluation of the implementation outcomes of HABIT devices using pre- and postimplementation quantitative surveys and qualitative focus group discussions with users and implementers according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: In total, 17 students and staff completed mock case simulations in which 161 close contact interactions were detected by interview or Bluetooth devices. We detected significant differences in the number of close contacts detected by interview versus Bluetooth devices (P<.001), with most (127/161, 78.9%) contacts being reported by interview only. However, a significant number (26/161, 16.1%; P<.001) of contacts were uniquely identified by Bluetooth devices. The interface, ease of use, coherence, and appropriateness were highly rated by both faculty and students. HABIT provided emotional security to users. However, the prototype design and technical difficulties presented barriers to the uptake and sustained use of HABIT. CONCLUSIONS: Implementation of HABIT in a high school was impeded by technical difficulties leading to decreased engagement and adherence. Nonetheless, HABIT identified a significant number of unique contacts not reported by interview, indicating that electronic technologies may augment traditional contact tracing once user preferences are accommodated and technical glitches are overcome. Participants indicated a high degree of acceptance, citing emotional reassurance and a sense of security with the device.

Relative Age Effect in Attention Deficit/Hyperactivity Disorder at Various Stages of the Medicalization Process.

Diagnosis and pharmacological treatment of ADHD are more common among the youngest children in a classroom, born in the months immediately preceding the school entry cutoff date. The mechanisms behind this phenomenon, called the relative age effect (RAE), are not yet well understood. Nearly all hypotheses involve the school system, various teachers' actions, and concern children's immaturity. However, most previous studies have been based on reports of health professionals' diagnoses and prescriptions found in official databases rather than on reports of teachers' behavior identification or suspicion of ADHD, despite their being at the first stages of the medicalization process. Our study overcomes this limitation by using reports of parents' and teachers' behavior identification or suspicion of ADHD within a three-level multilevel survey design, comprising 1294 children, 130 teachers, and 17 elementary public schools. The goal of our study was to investigate whether RAE stems (1) from adults' judgement of the child's expression of immaturity or (2) from the consequences associated with the child's double burden of being immature and exhibiting ADHD behaviors. Our multilevel analyses put forward the first hypothesis only, supporting the medicalization of immaturity. RAE in ADHD seems mostly initiated by teachers' pre-diagnostic actions toward younger children.

Depressive symptoms in higher education students during the COVID-19 pandemic: the role of containment measures.

BACKGROUND: Students are a vulnerable group for the indirect impact of the COVID-19 pandemic, particularly their mental health. This paper examined the cross-national variation in students' depressive symptoms and whether this can be related to the various protective measures implemented in response to the initial stage of the COVID-19 outbreak. METHODS: Student data stem from the COVID-19 International Student Well-being Study, covering 26 countries during the first wave of the COVID-19 pandemic. Country-level data on government responses to the COVID-19 pandemic were retrieved from the Oxford COVID-19 Tracker. Multilevel analyses were performed to estimate the impact of the containment and economic support measures on students' depressive symptoms (n = 78 312). RESULTS: School and workplace closures, and stay-at-home restrictions were positively related to students' depressive symptoms during the COVID-19 pandemic, while none of the economic support measures significantly related to depressive symptoms. Countries' scores on the index of these containment measures explained 1.5% of the cross-national variation in students' depressive symptoms (5.3%). This containment index's effect was stable, even when controlling for the economic support index, students' characteristics, and countries' epidemiological context and economic conditions. CONCLUSIONS: Our findings raise concerns about the potential adverse effects of existing containment measures (especially the closure of schools and workplaces and stay-at-home restrictions) on students' mental health.

Systematic Literature Review of Pediatric Male and Female Genital Hair Thread Tourniquet Syndrome.

OBJECTIVE: The aim of this study was to describe genital hair thread tourniquet syndrome (HTTS) and its treatment by pediatric and adolescent health care providers through a systematic literature review. METHODS: We performed a systematic literature review on pediatric male and female genital HTTS. Studies were included if they involved genital HTTS in males or females 21 years and younger and were published in English. The main outcomes were body parts involved, symptoms, treatment, anesthetic type, providers involved in diagnosis and management, and implications of delayed or missed diagnosis. RESULTS: There were 38 female cases from 33 publications (1973-2020) and 147 male cases from 47 publications (1951-2019). The average age among females and males was 9.1 and 5.1 years, respectively. Among cases involving female patients, 93% of them were premenarchal; patients were circumcised in 90% of reviewed cases of male HTTS. The most commonly involved body parts were clitoris and labia minora in females, and penis and urethra in males. Males most commonly presented with edema and urinary symptoms, whereas females most commonly presented with edema and pain. General anesthesia was used for tourniquet excision in most cases. Male and female genital HTTS were mostly managed by urologists and emergency medicine physicians, respectively. CONCLUSION: This systematic literature review of more than 150 cases of male and female genital HTTS describes evaluation and management of genital HTTS spanning 7 decades. The main treatment of genital HTTS remains prompt diagnosis and removal of the tourniquet, as well as education on prevention strategies. Delayed diagnosis due to lack of recognition of the HTTS can lead to serious sequelae. Development of national guidelines regarding best practices in management of genital HTTS disseminated to all providers taking care of pediatric and adolescent patients will lead to improved patient care.

School closures and reopenings during the COVID-19 pandemic: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to provide an overview of existing studies and evidence on the impact of school closures and reopenings during the pandemic. INTRODUCTION: The COVID-19 pandemic has necessitated widespread school closures, and reopening schools safely has a pivotal role in the well-being of children and teachers, SARS-CoV-2 transmission control and optimal societal functioning. Widespread school closures in response to the COVID-19 pandemic have caused adverse effects on the education, physical health and mental well-being of children. An understanding of the impact of school closures and reopenings as well as factors influencing school safety is critical to bringing schools' operational status back to normal. Despite the implication of individual concerns and knowledge on disease prevention practices, there is a paucity of research on individual knowledge, needs and behaviours in the context of school reopenings. In the proposed study, we will conduct a scoping review to identify and provide inventory of the current research and evidence on the impact of COVID-19 on K-12 schools (primary and secondary schools) and vice versa. METHODS AND ANALYSIS: Eligible studies/literature include members of K-12 (primary and secondary) schools (students, parents, staff, faculty, COVID-19 coordinator, school nurses) in countries affected by the COVID-19 pandemic. We will exclude university or college students. There will be no exclusion based on methods, timing or school operational status.All concepts regarding school closures and reopenings will be considered, and all types of research will be considered.This scoping review will follow the Joanna Briggs Institute methodology for scoping reviews. Sources of evidence published from 2020 to 31 October 2021 will be included. The search will include PubMed, preprints in EuropePMC, ERIC, Scopus, Web of Science Core Collection, PsycINFO, Embase, CINAHL and VHL. We will cover grey literature in Harvard Think Tank Database, COVID-19 Evidence Hub like COVID-END and Google Scholar. The abstract and title screening, full-text screening and data extraction will be done by two independent reviewers.Disagreements will be resolved by an independent third reviewer. Data extract will be done on Qualtrics form to ensure accurate extraction. Citation chaining will be performed on key articles identified. A critical appraisal will be performed.The scoping review will take place from 1 August 2021 to 15 November 2021. We will perform a final round of updated search and citation chaining. ETHICS AND DISSEMINATION: The review will be based on published works and grey literature, thus it is exempt from formal ethical approval. This protocol cannot be registered in the Prospective Register of Systematic Reviews because this registry is not for scoping reviews. We will register it in OSF Registration. The paper will appear in a peer-reviewed, open-access journal to ensure a broad dissemination.

Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women.

Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa.

In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President's Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.

Gender, work-family conflict and depressive symptoms during the COVID-19 pandemic among Quebec graduate students.

The increasing mental health inequalities between women and men following the COVID-19 crisis represent a major public health concern. Public health measures to mitigate the pandemic could severely impact populations with high prevalence of mental health problems such as graduate students. We aimed to document the gendered experience of the lockdown and its association with depressive symptoms among graduate students in Quebec. We contrast two hypotheses: whether inequalities in depressive symptoms between women and men could be linked to their differential exposure or vulnerability to work, family and study conditions, with the mediating role of work-to-family interference (WIF) and family-to-work interference (FIW). This observational study used path analysis to test our hypotheses using a cross-sectional data collected from 1,790 graduate students from three universities in Quebec. The exposure hypothesis received more support. Women reported more stress regarding new teaching methods, which was associated directly with more depressive symptoms, and indirectly through WIF. Women were more worried about COVID-19, which was associated with more depressive symptoms, and indirectly through WIF and FIW. However, women reported less FIW and more emotional support, both respectively associated with less depressive symptoms. The policy measures taken after the COVID-19 were not gender-neutral. This study demonstrates the importance of taking the potentially gendered effects of policies into consideration, and points to mitigating actions that can forestall the exacerbation of gendered inequalities in mental health.

Reopening Schools After a Novel Coronavirus Surge.

The coronavirus disease 2019 (COVID-19) pandemic shook the world in ways not seen since the pandemic influenza of 1918-1919. As of late August 2020, over 25 million persons had been infected, and we will see the global death toll exceed one million by the end of 2020. Both are minimum estimates. All segments of society have been drastically affected. Schools worldwide have been forced to close due to illness and absenteeism, transmission and risk to vulnerable members of the school community, and community concerns. The decision to reopen school during a pandemic will have a tremendous impact on children's safety, growth, and well-being. Not opening invites social isolation and suboptimal educational experiences, especially for youth whose computing assets and online access are limited and those with special needs. The opening has hazards as well, and the mitigation of these risks is the topic of this chapter. Opening schools requires careful considerations of benefits, risks, and precautions. Guiding principles for safety and strategic application of the principles in each educational niche are critical issues to consider during school reopening. The fundamental principles of disease control involve school-directed initiatives (physical distancing and mask use, hand/face and surface cleansing, administrative controls, engineering controls) and individual-level risk reduction approaches to maximize adherence to new guidelines. The school-initiated "top-down" approaches and the individual-level "bottom-up" approaches must be synergized, as no single method will ensure safety. We discuss how to effectively layer strategies in each educational space to increase safety. Since the vulnerability of children has been heightened during this pandemic crisis, we highlight the special considerations for mental health support that should be considered by schools. The safety principles, disease control strategies, and other critical issues discussed here will serve as a starting point for developing a safe, comprehensive, and feasible reopening plan.

Supporting Patient-centered Communication on Adolescent Sexual and Reproductive Health-Perspectives to Build an Appointment Planning Tool.

STUDY OBJECTIVE: Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings. DESIGN: In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8. SETTING: An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic. PARTICIPANTS: Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10). MAIN OUTCOME MEASURES: Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool. RESULTS: Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress. CONCLUSIONS: Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.

The children's eating attitudes test: French validation of a short version.

PURPOSE: Disordered eating attitudes and behaviors (DEAB) in childhood have been prospectively associated with eating disorders and obesity in adolescence. Therefore, evaluating DEAB in children with a reliable, sensitive and well-adapted scale is very important. The Children's Eating Attitudes Test (ChEAT) is one of the most popular measuring tools for DEAB in children, but no French version is available. Moreover, while completion time is an important factor to be considered when working with children, only one recent study proposed a shorter version of the ChEAT. Taking the previous works of Murphy and colleagues (2019) as a starting point, the current study aimed to provide the first French-speaking validated 14-item short version of the ChEAT. METHODS: A sample of 1092 boys and girls aged between 8 and 12 years old were recruited in two urban areas in the province of Quebec, Canada. They completed the ChEAT, and their height and weight were measured at school. Factorial structure and internal consistency were assessed. RESULTS: After the initial factorial analysis, two "vomiting (or purging)" items were yielded as problematic and were thus removed from the analysis. The remaining 12 items provided a good fit to the data and a good internal consistency. Moreover, the factorial structure was proved to be invariant across sexes. CONCLUSION: This study is the first to provide a French assessment of DEAB in elementary school children. The French short version of the ChEAT provided a quick and reliable assessment for DEAB with non-clinical children population and could be used as a screening tool, even though no cut-off was established yet. LEVEL OF EVIDENCE: Cross-sectional, descriptive study, Level V.

Project Last Mile and the development of the Girl Champ brand in eSwatini: engaging the private sector to promote uptake of health services among adolescent girls and young women.

In eSwatini and across sub-Saharan Africa, adolescent girls and young women (AGYW) are at significantly higher risk of HIV infection and poorer sexual and reproductive health (SRH) than their male counterparts. AGYW demonstrate low demand for SRH services, further contributing to poor outcomes. Strategic marketing approaches, including those used by multinational corporations, have potential to support demand creation for SRH services among AGYW, but there is limited empirical evidence on the direct application of private-sector strategic marketing approaches in this context. Therefore, we examined how Project Last Mile worked with eSwatini's Ministry of Heath to translate strategic marketing approaches from the Coca-Cola system to attract AGYW to SRH services. We present qualitative market research using the ZMET® methodology with 12 young Swazi women (ages 15-24), which informed development of a highly branded communication strategy consistent with other successful gain-framing approaches. Qualitative in-depth interviews with 19 stakeholders revealed receptivity to the market research findings, and highlighted local ownership over the strategic marketing process and brand. These results can inform similar efforts to translate strategic marketing to support demand generation in pursuit of public health goals to reduce HIV risk and improve SRH.

Appearance Esteem Trajectory According to Three Different Sources of Support Among Adolescents Over a School Year.

Although social support has been linked to body satisfaction, there has been little research on the effect of differential sources of support on the trajectory of appearance esteem over time. To address this gap, this study explored changes in adolescents' appearance esteem to perceived social support over one year. Data were collected from 339 Canadian adolescents (54.57% females) in Grade 7 (Mage = 12.05) and Grade 10 (Mage = 15.14). Multilevel growth modeling revealed that perceived social support from fathers was not associated with appearance esteem, whereas mothers' support had the strongest effect on appearance esteem, consistently over time. Friends' support was also related to an increase in the appearance esteem trajectory, but only for older students. Overall, this prospective study provides a better understanding of the unique contribution of three different sources of social support during adolescence for preventing negative appearance esteem, beyond the effects of other related variables.

Correction to: Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials.

The original version of this review article unfortunately contained a mistake in the category section. The Section Editor was inadvertently captured as "E Geng" instead of "SH Vermund".