COVID-19 Pandemic, Crisis Responses and the Changing World: Perspectives in Humanities and Social Sciences

This book comprehensively analyzes COVID-19 and its impact as well as the response from the perspectives of humanities and social sciences. This book covers topics ranging from geopolitical relations to regional integration, public health governance and even the evolution of professional practices in the time of COVID-19. It constitutes a precious and timely interdisciplinary reference for anyone aspiring not only to grasp the origins and dynamics of the present challenge, but also to identify future opportunities for further growth and holistic progress for humanity. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021.

Global Disorder for the Post-COVID-19 World

The COVID-19 Pandemic sweeping the globe has cost more than lives and livelihoods. It has rendered a heavy blow to the already shaking America's global leadership established after World War II. Instead of coordinating with its allies and international organizations to fight the common enemy, the Trump administration focused the bulk of its efforts on blaming China and the World Health Organization (WHO). Overwhelmed by the virus and doing a poor job of protecting its citizens, the US set a bad example for the world and offered no leadership to the rest of the world. The world has come to the post-American order. This Chapter argues that while US has failed to control the COVID-19 and created a vacuum on global leadership China was not yet ready to assume comprehensive leadership role by providing necessary public goods. China's good will was greatly undermined by politicians and public opinions in the West. Nevertheless China is a fast learner and it will play an increasingly important role in Global leadership. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021.

Government Emergency Responses During the COVID-19 Pandemic in the Context of Health Emergency and Disaster Risk Management: A Comparative Study

On January 23, 2020 China responded to the first wave of COVID-19 by locking down the city of Wuhan, a city of more than 10 million residents. The National Health Commission of China (CNHC 23 January 2020) reported 571 confirmed cases of COVID 19 patients, 19 seriously ill and 17 deaths in Wuhan on January 22. The number of confirmed cases exploded between January 20 and February 6 and reached 32, 583 with its peak on February 1. Centralized quarantine and treatment were found effective in leveling the curve of daily confirmed cases, although universal testing was not begun until February 17. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021.

Risk perception of the COVID-19 vaccines: revisiting the psychometric paradigm

Americans' concerns about the risks of vaccination are rising in recent years. In the original piece that explicated the psychometric paradigm, vaccinations were rated as less dreaded and less unknown. However, in 2016, vaccinations were more dreaded and more unknown in the public eye. A national survey (N = 1025) conducted in August 2021 reflects this trend in risk perception of the COVID-19 vaccines. Individuals who report different risk perceptions based on the unknown and dread characteristics associated with the COVID-19 vaccines also report different behavioral intent toward the vaccines. Overall, these findings show unknown risk to have a more salient impact on participants' risk perception that influence their vaccine-related decisions. © 2023 Informa UK Limited, trading as Taylor & Francis Group.

Explaining COVID-19-Related Concepts in Singapore: A Minimal Language Approach

After COVID-19 reportedly emerged in Wuhan, China, in late 2019 and spread across the world, governments everywhere were quick to impose mandatory preventive measures, such as safe distancing. However, many people ignored such measures, in some cases breaking the law. While some did it willfully, others probably did it out of ignorance;ignorant of what certain instructional keywords mean and/or of the gravity of the situation. This problem has to do with public communication and is especially acute in a country like Singapore, where many people (the locally-called ‘aunties' and ‘uncles') have not gone through much formal education and lack the intellectual means to understand technical ideas. In this paper, a method of making important, technical ideas accessible to the general public using a ‘minimal language' approach is showcased. However, it is argued that ‘minimal language' explanations need to be culture-specific to a certain extent, as they depend on the needs of the local community. This paper uses ‘Minimal English' (which can be fairly accurately translated to other ‘minimal languages' such as ‘Minimal Chinese') to explain a virus to the Singapore community. The ‘scripts' or explanations are functional in nature and include aspects of meaning and implications in the local context. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Zooming in or zoning out: examining undergraduate learning experiences with zoom and the role of mind-wandering

The COVID-19 pandemic necessitated a systematic change in course modalities due to the nationwide suspension of in-person instruction, resulting in the transition to emergency remote distance learning via Zoom. This transition certainly facilitated affordances of flexibility and continuity, but with it brought issues of unfamiliarity, lack of confidence, anxiety, distractions, and validity from both the instructors and the student perspectives. This in situ study aimed to better understand the students' learning experiences with Zoom by assessing the social, cognitive, and behavioral factors influencing learner's mind-wandering and its effect on online engagement. Undergraduate students from 14 classes across two research institutions in California (N = 633) were recruited to participate in an online survey while distance learning through a pandemic. Structural equation modeling was used to conduct a path analysis to explain the factors impacting students' online engagement mediated by students' frequency to mind-wander. Study findings revealed that (1) self-efficacy and trait anxiety had significant direct effects on students' mind-wandering;(2) self-efficacy, trait anxiety, task-value beliefs, and mind-wandering had significant direct effects on students' online engagement;and finally (3) the frequency of students' mind-wandering partially mediated the relationship between self-efficacy and engagement and between trait anxiety and engagement. Identifying these structural relationships further confirmed our hypotheses on sources contributing to students' mind-wandering while learning remotely, provided insights into potential mechanisms underpinning students' online engagement, and suggests practical pedagogical learning experience design recommendations for instructors to immediately implement while teaching and learning with Zoom..

Acute Massive Thrombus Following Fontan Procedure

Background Patients with hypoplastic left heart syndrome (HLHS) undergo a Fontan procedure as part of single ventricle surgical palliation. Post-Fontan, sluggish blood flow and an imbalance in coagulant factor proteins may predispose to thrombus formation. Other risk factors may include chylothorax as well as acute and chronic inflammation. Currently, there is no standardized surveillance strategy to detect thrombus in Fontan patients. Case A 34-month old male with HLHS underwent an extracardiac non-fenestrated Fontan complicated by chylothorax treated with 5 days of IV steroids and diuretics. He was on therapeutic aspirin. After progressive worsening of right pleural effusion, a chest tube was placed three weeks post-Fontan with continued chylous output. Stool alpha 1 antitrypsin was negative. Decision-making Given persistent chylothorax, a repeat echocardiogram was performed revealing a large mass in the Fontan circuit less than one month post-op. Cardiac CT showed occlusive thrombus filling the entirety of the Fontan conduit extending into hepatic veins and bilateral pulmonary arteries. He underwent extensive surgical thrombectomy and Fontan conduit revision. Hypercoagulable work-up revealed elevated factor 8 and von Willebrand factor activity which persisted more than one month post-op. Patient's history was also significant for COVID-19 infection 6 months prior. He was initially anticoagulated with bivalirudin with tirofiban initiated for antiplatelet therapy. He was ultimately transitioned to rivaroxaban, pentoxifylline and aspirin with chylothorax resolution over one month without thrombus recurrence. Conclusion Development of risk stratification tools to identify patients at higher risk for thrombi formation post-Fontan may facilitate patient selection for more aggressive anticoagulation. Consideration of elevated factor 8 as well as persistent or recurrent chylothorax may be beneficial, as increased thrombosis risk has been reported for both conditions in Fontan patients.Copyright © 2023 American College of Cardiology Foundation

TRENDS & EDUCATIONAL NEEDS IN POSTGRADUATES PROGRAMMES POST COVID-19

The trends and future needs of postgraduate programmes have recently been widely discussed across various disciplines of studies especially during and post pandemic. During this period, due to the life challenges posed by the pandemic such as unemployment and businesses closing, students have realised the importance of continuing their tertiary studies to a higher level. Hence, the purpose of this paper is to determine the relationship between demographic factors such as age, gender with variables such as willingness to study, study mode preferred, and study schedule preferred for the Postgraduate programmes. A total of 200 set of questionnaires were sent out and 139 questionnaires were returned and good for analysis. The data analysis method used was descriptive analysis and linear regression method was employed by using the Statistical Package for the Social Sciences (SPSS) software. The results demonstrated that age has a significant relationship with the willingness to study postgraduate programmes, study mode preferred, and study schedule. This means that adult students tend to make the decision to continue their tertiary study. Meanwhile, it was found that there was no relationship between gender and the variables. By applying these results in practice, the organisations can plan and roll out strategically their postgraduate programmes strategies in accordance with the respondents' needs. © School of Engineering, Taylor's University.

Practice Update – Social-psychological emergency response during Wuhan lockdown: Internet-based crisis intervention

Wuhan was completely locked down in 2020 because of the COVID-19 pandemic. Its residents were isolated, depressed. They were badly in need of information, advice, and psychological support. However, social and psychological services could only be provided by distance. The Social Workers Across Borders trained and supervised more than 120 volunteers to offer e-counselling services through WeChat platforms. The digital environment was very different from real life or even hotline settings. Wechat platforms, similar to that of WhatsApp, enabled multi-players, multi-media, and multidirectional exchanges for as many as 500 participants. They could raise questions, share information and offer opinions. Volunteers, composed of medical students, psychological counsellors, social workers, community workers, and lay community volunteers, were understandably not ready for the challenge. The teams found that traditional crisis intervention skills training, designed for face-to-face emotional support, was no longer sufficient to ensure satisfactory results in the digital environments. The current study, based on the analysis of the supervision records of the volunteers, discussed the hindering factors in providing Social Psychological e-services and proposed their respective solutions. A new mode of Social Psychological Emergency Response has emerged and our traditional training for respective responders needs to be revolutionized © The Author(s) 2022

Organizational values in support of leadership styles fostering organizational resilience: a process perspective

Purpose: The purpose of this paper is to describe how resilience unfolded in a project-based organization with the support of organizational values through changing leadership styles. The rapidly announced restrictions on businesses during the coronavirus disease 2019 (COVID-19) provided an opportunity to observe and study resilience unfold. Design/methodology/approach: The process-perspective case study approach of a structural and civil engineering design firm in San Francisco, California, USA, integrates interviews, observations, document analysis and information tracking via email and Microsoft Teams. The researchers adopted a leadership perspective, where the units of analysis are the internal management and the employees' behaviors. Findings: In the case examined, the capability represented in the organizational values influenced the choice of situation-appropriate leadership styles to support employees. The values of relationship, passion and trust influenced the dominant choice of a transformational style, where stability and excellence facilitate a transactional style – all equally important for the balance and resilience of the project-based organization. Originality/value: This study demonstrated that when organizational values support leaders in cultivating a learning environment, those values provide stability for leaders to promote resilience. To the best of the researchers' knowledge, no previous work described how situational-, transformational- and transactional-leadership styles evolve in response to a crisis and together facilitate organizational resilience. © 2023, Emerald Publishing Limited.

Utilisation and Management of an Emergency Department in a Tertiary Hospital in the Philippines During the COVID-19 Pandemic

The Emergency Department (ED) plays the role of providing efficient and quality healthcare services to patients. During the COVID-19 pandemic, there were observed changes in the ED's utilisation and management reflecting the underlying challenges faced by most tertiary hospitals in the Philippines. This study aims to describe the changes in the utilisation and management of ED in a major COVID-19 hospital in the Philippines, its implications for inpatient admissions, and effect on ED staff. Patient data from 2019 (pre-pandemic) and 2020 (pandemic) were compared. In addition, this study administered a COVID-19-specific psychometric tool to assess the pandemic's effect on ED staff. Comparing the pre-pandemic and pandemic census, this study found a 59.0% and 67.6% decrease in ED consultations and hospital admissions, respectively. ED consultations significantly shifted to older patients, with longer length of stay, increased out-of-pocket payment, and mostly presenting with respiratory-related chief complaints. There is a decrease in general hospital unit utilisation, and the addition of a COVID-19 ward and an ICU. Despite the changes, 63.6% of the ED staff exhibited good emotional adjustment to the stress brought by the pandemic. This study reported the situation of Philippine ED amid the pandemic and indicated the important management changes in ED. © 2023 Indian Institute of Health Management Research.

Fracture incidence and fracture-related mortality decreased with decreases in population mobility during the early days of the COVID-19 pandemic: an epidemiological study.

INTRODUCTION: We investigated the impact of coronavirus disease 2019 (COVID-19) social distancing measures on fracture incidence and fracture-related mortality, as well as associations with population mobility. METHODS: In total, 47 186 fractures were analysed across 43 public hospitals from 22 November 2016 to 26 March 2020. Considering the smartphone penetration of 91.5% in the study population, population mobility was quantified using Apple Inc's Mobility Trends Report, an index of internet location services usage volume. Fracture incidences were compared between the first 62 days of social distancing measures and corresponding preceding epochs. Primary outcomes were associations between fracture incidence and population mobility, quantified by incidence rate ratios (IRRs). Secondary outcomes included fracture-related mortality rate (death within 30 days of fracture) and associations between emergency orthopaedic healthcare demand and population mobility. RESULTS: Overall, 1748 fewer fractures than projected were observed during the first 62 days of COVID-19 social distancing (fracture incidence: 321.9 vs 459.1 per 100 000 person-years, P<0.001); the relative risk was 0.690, compared with mean incidences during the same period in the previous 3 years. Population mobility exhibited significant associations with fracture incidence (IRR=1.0055, P<0.001), fracture-related emergency department attendances (IRR=1.0076, P<0.001), hospital admissions (IRR=1.0054, P<0.001), and subsequent surgery (IRR=1.0041, P<0.001). Fracture-related mortality decreased from 4.70 (in prior years) to 3.22 deaths per 100 000 person-years during the COVID-19 social distancing period (P<0.001). CONCLUSION: Fracture incidence and fracture-related mortality decreased during the early days of the COVID-19 pandemic; they demonstrated significant temporal associations with daily population mobility, presumably as a collateral effect of social distancing measures.

Chest computed tomography analysis of lung sparing morphology: differentiation of COVID-19 pneumonia from influenza pneumonia and bacterial pneumonia using the arched bridge and vacuole signs.

INTRODUCTION: This study evaluated the arched bridge and vacuole signs, which constitute morphological patterns of lung sparing in coronavirus disease 2019 (COVID-19), then examined whether these signs could be used to differentiate COVID-19 pneumonia from influenza pneumonia or bacterial pneumonia. METHODS: In total, 187 patients were included: 66 patients with COVID-19 pneumonia, 50 patients with influenza pneumonia and positive computed tomography findings, and 71 patients with bacterial pneumonia and positive computed tomography findings. Images were independently reviewed by two radiologists. The incidences of the arched bridge sign and/or vacuole sign were compared among the COVID-19 pneumonia, influenza pneumonia, and bacterial pneumonia groups. RESULTS: The arched bridge sign was much more common among patients with COVID-19 pneumonia (42/66, 63.6%) than among patients with influenza pneumonia (4/50, 8.0%; P<0.001) or bacterial pneumonia (4/71, 5.6%; P<0.001). The vacuole sign was also much more common among patients with COVID-19 pneumonia (14/66, 21.2%) than among patients with influenza pneumonia (1/50, 2.0%; P=0.005) or bacterial pneumonia (1/71, 1.4%; P<0.001). The signs occurred together in 11 (16.7%) patients with COVID-19 pneumonia, but they did not occur together in patients with influenza pneumonia or bacterial pneumonia. The arched bridge and vacuole signs predicted COVID-19 pneumonia with respective specificities of 93.4% and 98.4%. CONCLUSION: The arched bridge and vacuole signs are much more common in patients with COVID-19 pneumonia and can help differentiate COVID-19 pneumonia from influenza and bacterial pneumonia.

Hospitalizations and mortality during the first year of the COVID-19 pandemic in Hong Kong, China: An observational study

Background: Hong Kong followed a strict COVID-19 elimination strategy in 2020. We estimated the impact of the COVID-19 pandemic responses on all-cause and cause-specific hospitalizations and deaths in 2020. Methods: Interrupted time-series analysis using negative binomial regression accounting for seasonality and long-term trend was used on weekly 2010–2020 data to estimate the change in hospitalization risk and excess mortality occurring both within and out of hospitals. Findings: In 2020, as compared to a 2010–2019 baseline, we observed an overall reduction in all-cause hospitalizations, and a concurrent increase in deaths. The overall hospitalization reduction (per 100,000 population) was 4809 (95% CI: 4692, 4926) in 2020, with respiratory diseases (632, 95% CI: 607, 658) and cardiovascular diseases (275, 95% CI: 264, 286) contributing most. The overall excess mortality (per 100,000 population) was 25 (95% CI: 23, 27) in 2020, mostly among individuals with pre-existing cardiovascular diseases (12, 95% CI: 11, 13). A reduction in excess in-hospital mortality (−10 per 100,000, 95% CI: −12, −8) was accompanied by an increase in excess out-of-hospital mortality (32, 95% CI: 29, 34). Interpretation: The COVID-19 pandemic might have caused indirect impact on population morbidity and mortality likely through changed healthcare seeking particularly in youngest and oldest individuals and those with cardiovascular diseases. Better healthcare planning is needed during public health emergencies with disruptions in healthcare services. Funding: Health and Medical Research Fund, Collaborative Research Fund, AIR@InnoHK and RGC Senior Research Fellow Scheme, Hong Kong. © 2022 The Authors

Wellbeing matters: the Theatre Wellbeing Project improves employee wellbeing and belonging throughout 2020-2022

The Royal London Hospital commenced a Theatre Wellbeing Project in 2018. Between 2018-2020, there were sporadic half-day events, which became daily wellbeing sessions during the first wave of the COVID-19 pandemic. Since August 2020, this involves bi-weekly 30-min wellbeing exercises based on self-compassion with attention to some physical elements. The report by the Chartered Institute of Personnel and Development in 2016 [1] delineated the key indicators required to evaluate the effects of employee wellbeing on health and employee satisfaction measures. Methods Together with the Trust psychologists, we constructed an anonymised paper-based survey evaluating employee satisfaction with the Theatre Wellbeing Project. This tool included both qualitative and quantitative measures with questions about the perception of inclusivity, value of employees by the Trust, psychological safety and positive impact at work. These were delivered and analysed annually between 2020-2022. Results We had a positive response rate of 131, 94 and 124 in 2020, 2021 and 2022, respectively, yielding a 24-35% response rate. There was a striking change (16% to 53%) in staff perception of the Trust prioritising their mental wellbeing when the wellbeing sessions became regular. Ninety-three per cent of respondents valued the project as 'essential' or 'useful' in 2020, which reduced to 74% in 2022 when frequency reduced. The survey demonstrates that each year the wellbeing sessions have positively impacted upon the overall working environment (>73% of respondents), with staff reporting higher levels of inclusivity, feeling valued by the Trust, psychological safety and support to deal with increasingly stressful circumstances. Discussion The qualitative response in the white-space questions gives context to the results. There is an overwhelming demonstration of the positive impact on mental wellbeing, for example 'I look forward to going to work' and 'helped in a very difficult time' with < 5% respondents supporting cessation of the sessions. There was recognition that there is 'buy-in' from seniors and the Trust;however, there were some concerns about list delays and missed breaks. We are further assessing the organisational measures such as staff attrition rates and engagement over this time. (Figure Presented).

SHEAR saliva collection device augments sample properties for improved analytical performance

Despite being a convenient clinical substrate for biomonitoring, saliva's widespread utilization has not yet been realized. The non-Newtonian, heterogenous, and highly viscous nature of saliva complicate the development of automated fluid handling processes that are vital for accurate diagnoses. Furthermore, conventional saliva processing methods are resource and/or time intensive precluding certain testing capabilities, with these challenges aggravated during a pandemic. The conventional approaches may also alter analyte structure, reducing application opportunities in point-of-care diagnostics. To overcome these challenges, we introduce the SHEAR saliva collection device that mechanically processes saliva, in a rapid and resource-efficient way. We demonstrate the device's impact on reducing saliva's viscosity, improving sample's uniformity, and increasing diagnostic performance of a COVID-19 rapid antigen test. Additionally, a formal user experience study revealed generally positive comments. SHEAR saliva collection device may support realization of the saliva's potential, particularly in large-scale and/or resource-limited settings for global and community diagnostics. Copyright © 2023 The Authors. Bioengineering & Translational Medicine published by Wiley Periodicals LLC on behalf of American Institute of Chemical Engineers.

Epidemiology of Severe Pediatric Pneumonia in Asia: A Prospective Multinational Observational Study

INTRODUCTION: Severe pneumonia is a common indication for admission to the pediatric intensive care unit (PICU) and a leading cause of morbidity and mortality. The lack of epidemiology and outcome data from Asia is a barrier to improving outcomes of severe pneumonia in the region. METHOD(S): This is a prospective multicenter cohort study carried out from April 2019 to April 2022. Fifteen PICUs participated in this study under the Pediatric Acute & Critical Care Medicine Asian Network. Epidemiological, microbiological and outcome data were collected up to hospital discharge. Univariate logistic regression analysis were conducted to explore the association between potential risk factors and severe outcomes [acute respiratory distress syndrome (ARDS) and PICU mortality]. Multivariable analysis was performed withforward stepwise logistic regression adjusted for sites and COVID-19 pandemic including variables with p< 0.05 in univariate model. RESULT(S): There were 786 children with severe pneumonia in PICU with mean (standard deviation) age 2.8 (3.9) years. 384/786 (48.9%) had comorbidities;126/786 (16.0%) had a history of prematurity (gestational age < 37 weeks). Admission Pediatric Index of Mortality 3 (PIM3) and Pediatric Logistic Organ Dysfunction 2 (PELOD2) score were 16.2 (22.9) and 4.1(4.6). A sole viral or bacterial pathogen was identified in 179/786 (22.4%) and 165/786 (21.0%). Co-infections occurred in 114/786 (14.5%) patients. ARDS and mortality occurred in 156/786 (20.1%) and 70/786(8.9%) patients. In the multivariable model, risk factors for ARDS included PIM3 [adjusted odds ratio (aOR) [95% confidence interval (CI)] of 1.02 (1.01, 1.03)], PELOD2 [aOR 1.08 (95%CI 1.02, 1.13)] and involvement of 4 quadrants on chest-x-ray, [aOR 2.69 (95%CI 1.39, 5.18)]. Risk factors for mortality included PIM 3 [aOR 1.03 (95%CI 1.01, 1.04)], involvement of 4 quadrants on chest-x-ray [aOR 2.72 (95%CI 1.10, 6.73)], bacterial [aOR 2.61 (95%CI 1.00, 6.82)], fungus or mycobacterium [aOR 12.30 (95%CI 1.45, 104.57)] and co-infections [aOR 2.72 (95%CI 1.10, 10.35)]. CONCLUSION(S): The rate of ARDS and mortality in severe pneumonia admitted to PICU in Asia was high. Risk factors for poor outcomes were admission severity scores, generalized X-ray involvement and identification of bacteria, fungus/mycobacteria or co-infections.

Perceptions of staff and leadership teams on implementation of telepresence robots in long-term care: a qualitative descriptive study

Background: COVID-19's physical distancing mandates have increased the likelihood of experiencing social isolation and loneliness for residents in long-term care (LTC), especially those living with dementia. Social isolation correlates with health risks, including depression and cognitive decline. Telepresence robots can be remotely driven and facilitate social interactions through videoconferencing. Researchers have begun to explore opportunities of using these robots in the healthcare field;however, there is a research gap on examining factors influencing their implementation in LTC from the perspectives of key stakeholders. This qualitative descriptive study focuses on exploring LTC staff and leadership teams' perspectives on facilitators and barriers to implementing telepresence robots. Method(s): We employed purposive and snowballing methods to recruit 22 participants from two LTC homes in British Columbia, Canada: operational and unit leaders, and interdisciplinary staff including nursing staff, care aides and allied health practitioners. Consolidated Framework for Implementation Research (CFIR) guided our data collection and analysis. Semi-structured interviews were conducted by virtual meetings. Thematic analysis was performed to identify themes. Result(s): Analysis of the data produced three themes: (a) perceived needs and values for family-resident connections, (b) engagement through conversation and partnership, and (c) confidence with training and timely support. Based on the findings and CFIR guidance, we offer a preliminary conceptual tool "START": Share benefits and successes;Tailor policies and plans with staff partners;Acknowledge and address staff concerns;Repeated training and demonstrations;and Timely technical support. Conclusion(s): This study offers pragmatic insights into staff and leadership teams' perceptions of facilitators and barriers of implementing telepresence robots in LTC. The complexity of technology implementation will require executive and leadership teams to consider additional factors beyond the Plan-Do-Study-Act (PDSA) cycle. Copyright © 2022 the Alzheimer's Association.

Using telepresence robots to support family virtual visits during the COVID-19 Pandemic

BACKGROUND: The COVID-19 pandemic has disproportionately impacted older adults living with dementia in Long-Term Care (LTC). Social isolation and loss of connections with families among residents have been detrimental and severely impacted quality of life.