Vaccines Hesitancy and Public Health.

We are delighted to present this editorial to close the Special Issue, 'Vaccines Hesitancy and Public Health', which we have had the honour of coordinating [...].

Potential Impact of Omega 6/3 Ratio and CD68+ Macrophage Infiltration on Survival in NSCLC Patients Undergoing Pulmonary Resection.

Background: Lung cancer remains the leading cause of cancer-related mortality worldwide with non-small cell lung cancer (NSCLC) accounting for the majority of cases. The stage of detection significantly influences survival rates with early-stage diagnosis offering the best prognosis. This study investigates the prognostic impact of the omega-6/omega-3 ratio and tumor infiltration by CD8+ lymphocytes and CD68+ macrophages on overall survival (OS) and disease-free survival (DFS) in NSCLC patients undergoing pulmonary resection. Methods: We conducted a retrospective analysis of 53 patients with early-stage NSCLC who underwent pulmonary resection between September 2017 and January 2020. The omega-6/omega-3 ratio was quantified using gas chromatography and spectrometry. Tumor infiltration by CD8 and CD68 was assessed through immunohistochemistry. Survival outcomes were evaluated using Kaplan-Meier and Cox regression analyses. Results: An increased omega-6/omega-3 ratio and higher CD68+ macrophage infiltration were associated with a trend towards worse OS and DFS in NSCLC patients, though these results did not reach statistical significance. CD8+ T-cell infiltration was associated with improved survival outcomes, confirming its role as a favorable prognostic marker. Comparative analysis with existing datasets revealed similar demographic and clinical characteristics, reinforcing the generalizability of our findings. Conclusions: The omega-6/omega-3 ratio and CD68+ macrophage infiltration serve as important factors potentially influencing prognosis in NSCLC patients undergoing pulmonary resection. These findings highlight the need for further research to refine the prognostic utility of these biomarkers and to explore therapeutic strategies targeting inflammation and immune cell infiltration.

Excess secondary sludge reuse by H2O2 thermal dehydration.

The excess of activated sludge generated in municipal wastewater treatment plants constitutes one of the challenging problems facing modern society. The high-water content of this waste makes difficult the transport, disposal, and management of these solids. In this work, activated sludge excess from a secondary clarifier has been dehydrated by means of a combination of temperature and hydrogen peroxide treatment. Three main operating variables have been considered to affect sludge dewaterability and filterability. Temperature (120-180 °C), hydrogen peroxide dose (0.01-0.03 M), and treatment time (20-60 min) influence have been assessed by completing a 15-run Box Behnken experimental design. Different output variables (water content, resistance to filtration, sedimentation volumetric index, extracellular polymeric substances, etc.) have been monitored. Generally, temperature seems to be the most influencing parameter to obtain a dehydrated sludge with acceptable management/disposal characteristics (sludge volume reduction and filterability). In line with the concept of circular economy, an attempt has been conducted to obtain a sustainable biosorbent from the dehydrated sludge generated in the previous stage. Optimum conditions of carbonization and activation revealed that the solid obtained at 400 °C by using ammonium nitrate as activation agent was the most efficient absorbent to eliminate some model compounds from water (namely, phenol, ofloxacin, and diuron); however, a clear improvement margin in the synthesis is foreseen.

Evaluation of the use of a nursing diagnosis Risk for Falls in the Community of Madrid (Spain) Primary Care System.

PURPOSE: The purpose of this study was to describe the use of the nursing diagnosis Risk for Falls in Primary Care System of the Community of Madrid. METHODS: A retrospective review of the clinical histories was carried out in 262 health centers from January 2005 to December 2015. The study population are the patients who have recorded in their electronic health record the nursing diagnosis Risk for Falls. FINDINGS: Frequency of use of the Risk for Falls ND in the Community of Madrid was 53,340 diagnoses, increasing from 650 nursing diagnosis in 2005 to 14,695 in 2015. NOC Nursing Outcomes total identified were 109,145, which represents an average of 2.05 NOC Nursing Outcomes per diagnosis. NOC Nursing Outcomes frequently appeared as follows: Fall Prevention Behavior (35.9%), Safe Home Environment (11.3%), and Risk Control (10.5%). NIC Nursing Interventions total identified were 104,293, representing an average of 1.96 NIC nursing interventions per diagnosis. NIC Nursing Interventions frequently appeared as follows: Fall Prevention (45.9%), Environmental Management: Safety (27%), and Risk Identification (5.8%). CONCLUSIONS: Nursing diagnosis of Risk for Falls and the care process related to this diagnosis is starting to be used by the primary care nurses of the Community of Madrid. IMPLICATION FOR NURSING PRACTICE: Risk factors related to the nursing diagnosis of risk for falls identified in our study can be addressed with activities that nurses must implement to prevent falls. Nursing methodology in general and specifically the diagnosis of risk for falls must be included in guides and protocols for the prevention of falls, and its use should be promoted by primary care nurses.

Correlation between Health and eHealth Literacy and a Healthy Lifestyle: A Cross-Sectional Study of Spanish Primary Healthcare Patients.

BACKGROUND: Health literacy and eHealth literacy play a crucial role in improving a community's ability to take care of themselves, ultimately leading to a reduction in disparities in health. Embracing a healthy way of living is vital in lessening the impact of illnesses and extending one's lifespan. This research delves into the link between the health and eHealth literacy levels of individuals accessing primary healthcare services and investigates how this relates to adopting a health-conscious lifestyle. METHODS: The approach involves a cross-sectional examination carried out at a healthcare facility in the Madrid region of Spain, focusing on adult patients who are in need of primary care nursing services. Health and eHealth literacy and a healthy lifestyle were measured using the Health Literacy Questionnaire (HLQ), the eHealth Literacy Questionnaire (eHLQ), and the "PA100" questionnaire, respectively. RESULTS: Only some of the dimensions of the HLQ and eHLQ were significantly related to a healthy lifestyle, predominantly with a very low or low relationship. Dimension three of the HLQ and dimension five of the eHLQ acquired more importance and were positioned as positive predictors of a healthy lifestyle. CONCLUSIONS: This study helps comprehend the relationship between health and eHealth literacy and a healthy lifestyle, which provides information that contributes to understanding the factors that might have a higher impact on lifestyles.

'Learning by doing', a model for improving the promotion of healthy lifestyles by student nurses.

BACKGROUND: 'Learning by doing' is a learning model based on performing actions and gaining experience. The 'nursing process' is a systematic, rational method for providing nursing care. During their university education, nursing students need to acquire the ability to promote healthy lifestyles. OBJECTIVE: To determine the effectiveness of a learning strategy based on learning by doing and grounded in the use of the nursing process, on the lifestyle of nursing students. METHODS: This quasi-experimental intervention (before-after), performed over 2011-2022, involved 2300 nursing students at a university nursing school in Spain. The risk factors for chronic diseases-being a smoker, being overweight, or having high blood pressure-to which each student was exposed were recorded. Those positive for at least one risk factor selected companion students as 'support nursing students' who became responsible for designing an individualised care plan to reduce the risk(s) faced. To ensure the correct use of the nursing process, teachers approved and monitored the implementation of the care plans. Whether risk-reduction objectives were met was determined three months later. RESULTS: The students with risk factors largely improved their lifestyles (targets for reducing smoking/body weight were met) with the help of their supporting peers. CONCLUSIONS: The learning by doing method demonstrated its effectiveness, improving the lifestyle of at-risk students via the use of the nursing process.

A Comparison of Total Thoracoscopic and Robotic Surgery for Lung Cancer Lymphadenectomy.

BACKGROUND: Robotic-assisted thoracic surgery (RATS) is used increasingly frequently in major lung resection for early stage non-small-cell lung cancer (NSCLC) but has not yet been fully evaluated. The aim of this study was to compare the surgical outcomes of lymph node dissection (LND) performed via RATS with those from totally thoracoscopic (TT) four-port videothoracoscopy. METHODS: Clinical and pathological data were collected retrospectively from patients with clinical stage N0 NSCLC who underwent pulmonary resection in the form of lobectomy or segmental resection between June 2010 and November 2022. The assessment criteria were number of mediastinal lymph nodes and number of mediastinal stations dissected via the RATS approach compared with the four-port TT approach. RESULTS: A total of 246 pulmonary resections with LND for clinical stages I-II NSCLC were performed: 85 via TT and 161 via RATS. The clinical characteristics of the patients were similar in both groups. The number of mediastinal nodes dissected and mediastinal stations dissected was significantly higher in the RATS group (TT: mean ± SD, 10.72 ± 3.7; RATS, 14.74 ± 6.3 [p < 0.001]), except in the inferior mediastinal stations. There was no difference in terms of postoperative complications. CONCLUSIONS: In patients with early stage NSCLC undergoing major lung resection, the quality of hilomediastinal LND performed using RATS was superior to that performed using TT.

Design and Content Validation using Expert Opinions of an Instrument Assessing the Lifestyle of Adults: The 'PONTE A 100' Questionnaire.

Lifestyle, a major determinant of health status, comprises a number of habits and behaviours that form a part of daily life. People with healthy lifestyles have a better quality of life, suffer less disease, and have a longer life expectancy. This work reports the design and content validation of a questionnaire-the 'PONTE A 100' questionnaire-assessing the lifestyle of adults. This collects information across five dimensions-'Eating Habits', 'Physical Activity', 'Smoking and use of Alcohol and other Drugs', 'Emotional Wellbeing', and 'Safety and Non-intentional Injuries'-via the answering of a total 33 items. Psychometric validation of the instrument's content was obtained via expert opinions. This was performed by two rounds of assessment and involved 34 experts representing different health science disciplines (mean experience, 27.4 ± 9.4 years). At the end of each round, adjustments were made according to their recommendations. Agreement between the experts was examined using the Aiken V test. A final V value of 0.95 (95% CI, 0.90-1.00) was obtained for the questionnaire as a whole, highlighting the validity of its content. The questionnaire would therefore appear to be an appropriate instrument for assessing the lifestyle of adults.

Attitudes and Behaviors towards Vaccination in Portuguese Nursing Students.

Knowing the attitudes and behaviors of nursing students in relation to vaccination is important because they will soon be determinant for the health literacy of the population. Vaccination remains the most effective response in the fight against communicable diseases, including COVID-19 and influenza. The objective of this study is to analyze the attitudes and behaviors of Portuguese nursing students with regard to vaccination. A cross-sectional study was carried out, with data collection from nursing students at a university in Lisbon, Portugal. A sample of 216 nursing students was obtained, representing 67.1% of the students enrolled in this university. What stands out from the results of the questionnaire "Attitudes and Behaviors in Relation to Vaccination among Students of Health Sciences" is that for the majority of students the answers were positive; in addition, 84.7% had a completed vaccination schedule for COVID-19. Being a nursing student, being in the final years of the course and being a woman are the factors that most influence the positive attitude of the students. The results obtained are motivating, because these students will be the future health professionals most likely to integrate health promotion programs through vaccination.

The Influence of Preoperative Nutritional and Systemic Inflammatory Status on Perioperative Outcomes following Da Vinci Robot-Assisted Thoracic Lung Cancer Surgery.

Background: Nutrition is an important factor in the outcome of any disease process. We evaluated the relationship of nutritional status and inflammatory status of non-small cell lung cancer (NSCLC) patients undergoing robotic-assisted thoracic surgery (RATS) with postoperative complications. Methods: This prospective cohort study included 107 NSCLC patients undergoing surgical treatment, between 2019 and 2021. Nutritional status and inflammatory status were assessed before pulmonary resection using anthropometric assessment, blood tests, and body mass index (BMI). Results: The BMI was 27.5 ± 4.4. Based on BMI, 29% (n = 31) were classified as normal weight, 43% (n = 46) as overweight, and 28% (n = 30) as obese. The mean neutrophil/lymphocyte ratio (NLR) was 2.16 ± 0.85, the platelet/lymphocyte ratio (PLR) was 121.59 ± 44.21, and the lymphocyte/monocyte ratio (LMR) was 3.52 ± 1.17. There was no increase in the number of intraoperative complications or bleeding (p = 0.696), postoperative complications (p = 0.569), mean hospital stay (p = 0.258) or duration of chest drain (p = 0.369). Higher inflammatory status, with an NLR > 1.84, was associated with more overall postoperative complications (p = 0.028), only in univariate analysis, but this significance was not maintained on multivariate analysis. Conclusions: BMI was not a predictor of increased postoperative risk in this cohort; therefore, weight should not deter surgeons from using RATS for pulmonary resection.

Synthesis, Optical Properties, and Antiproliferative Evaluation of NBD-Triterpene Fluorescent Probes.

A fluorescent labeling protocol for hydroxylated natural compounds with promising antitumor properties has been used to synthesize, in yields of 72-86%, 12 derivatives having fluorescent properties and biological activity. The reagent used for the synthesis of these fluorescent derivatives was 7-nitrobenzo-2-oxa-1,3-diazole chloride (NBD-Cl). The linkers employed to bind the NBD-Cl reagent to the natural compounds were ω-amino acids (Aa) of different chain lengths. The natural triterpene compounds chosen were oleanolic and maslinic acid, as their corresponding 28-benzylated derivatives. Thus, 12 NBD-Aa-triterpene conjugates have been studied for their optical fluorescence properties and their biological activities against cell proliferation in three cancer cell lines (B16-F10, HT-29, and HepG2), compared with three nontumor cell lines (HPF, IEC-18, and WRL68) from different tissues. The results of the fluorescence study have shown that the best fluorescent labels are those in which the ω-amino acid chain is shorter, and the carboxylic group is not benzylated. Analysis by confocal microscopy showed that these compounds were rapidly incorporated into cells in all three cancer cell lines, with these same derivatives showing the highest toxicity against the cancer cell lines tested. Then, the fluorescent labeling of these NBD-Aa-triterpene conjugates enabled their uptake and subcellular distribution to be followed in order to probe in detail their biological properties at the cellular and molecular level.

Efectos del apego y procesamiento sensorial en el desarrollo de niñas y niños. Una revisión sistemática / Efeitos do apego e do processamento sensorial no desenvolvimento da criança. Uma revisão sistemática / Effects of parental attachment and sensory processing on child development. Systematic review

Resumen Esta revisión se enfoca en la intersección de dos factores fundamentales en el desarrollo infantil: el procesamiento sensorial y el apego. Las transformaciones rápidas y profundas que ocurren en el cerebro durante la infancia influyen en la regulación emocional, la autoestima y la capacidad para establecer relaciones saludables. Siguiendo los lineamientos PRISMA, se llevó a cabo una revisión sistemática para explorar la relación entre el procesamiento sensorial y el apego en niños y niñas de 0 a 14 años. Se realizaron búsquedas en las bases de datos Web of Science, Scopus, Pubmed y PsycINFO, utilizando palabras clave relacionadas con la teoría del apego y el procesamiento sensorial. Los estudios se seleccionaron de los disponibles hasta mayo de 2022. De un total inicial de 87 artículos, 17 cumplieron los criterios de inclusión y proporcionaron una variedad de perspectivas sobre la relación entre el procesamiento sensorial y el apego en la infancia temprana. Se identificó una conexión significativa entre el trastorno del procesamiento sensorial y el apego, destacando la importancia de la visión en el desarrollo social y la comunicación, así como las estrategias parentales efectivas, los estilos de apego saludables y un procesamiento sensorial adecuado. Se respalda la idea de que un apego saludable durante la infancia favorece el desarrollo del procesamiento sensorial. Se evidencia la utilidad de la integración sensorial para mejorar las relaciones y orientar futuras investigaciones y prácticas en terapia ocupacional.

Resumo Esta revisão se concentra na intersecção de dois fatores fundamentais no desenvolvimento infantil: o processamento sensorial e o apego. Transformações rápidas e profundas que ocorrem no cérebro durante a infância influenciam a regulação emocional, a autoestima e a capacidade de estabelecer relações saudáveis. Seguindo as diretrizes PRISMA, foi realizada uma revisão sistemática para explorar a relação entre o processamento sensorial e o apego em crianças de 0 a 14 anos. Foram utilizadas as bases de dados Web of Science, Scopus, Pubmed e PsycINFO, usando palavras-chave relacionadas à teoria do apego e ao processamento sensorial. Os estudos foram selecionados entre os disponíveis até maio de 2022. De um total inicial de 87 artigos, 17 atenderam aos critérios de inclusão e forneceram uma variedade de perspectivas sobre a relação entre o processamento sensorial e o apego na primeira infância. Foi identificada uma conexão significativa entre o transtorno do processamento sensorial e o apego, destacando a importância da visão no desenvolvimento social e na comunicação, bem como estratégias parentais eficazes, estilos de apego saudáveis e um processamento sensorial adequado. É apoiada a ideia de que um apego saudável durante a infância favorece o desenvolvimento do processamento sensorial. Se evidencia a utilidade da integração sensorial para melhorar as relações e orientar futuras pesquisas e práticas em terapia ocupacional.

Abstract This review focuses on the intersection of two fundamental factors in child development: sensory processing and attachment. The rapid and profound transformations that occur in the brain during childhood influence emotional regulation, self-esteem, and the ability to establish healthy relationships. Following PRISMA guidelines, a systematic review was carried out to explore the relationship between sensory processing and attachment in boys and girls aged 0 to 14 years. The Web of Science, Scopus, Pubmed, and PsycINFO databases were searched using keywords related to attachment theory and sensory processing. Studies were selected from those available through May 2022. Of an initial 87 articles, 17 met the inclusion criteria and provided a variety of perspectives on the relationship between sensory processing and attachment in early childhood. A significant connection was identified between sensory processing disorder and attachment, highlighting the importance of vision in social development and communication, as well as effective parenting strategies, healthy attachment styles, and appropriate sensory processing. The idea that healthy attachment during childhood promotes the development of sensory processing is supported. The usefulness of sensory integration to improve relationships and guide future research and practices in occupational therapy is evident.

Factors Influencing eHealth Literacy among Spanish Primary Healthcare Users: Cross-Sectional Study.

BACKGROUND: Adequate eHealth literacy levels empower people to make informed decisions, enhancing their autonomy. The current study assessed a group using primary care services for their eHealth literacy and examined its relationship with sociodemographic characteristics. METHODS: Adult patients in need of primary care nursing services participated in this cross-sectional study, which was carried out in a healthcare center in the Madrid region of Spain. Through systematic random sampling, 166 participants were chosen for the study. The eHealth Literacy Questionnaire was used to assess eHealth literacy (eHLQ). RESULTS: The studied population showed higher eHealth literacy scores in dimensions 2 ("understanding of health concepts and language") and 4 ("feel safe and in control"); the lowest scores were recorded for dimensions 1 ("using technology to process health information"), 3 ("ability to actively engage with digital services"), and 7 ("digital services that suit individual needs"). People with completed secondary education and a better-perceived health status who were younger and employed showed a higher level of eHealth literacy. CONCLUSIONS: The findings advance our knowledge of the variables affecting eHealth literacy. We may be able to understand patients' needs and provide them with greater support if we can pinpoint the areas where they demonstrate the lowest eHealth literacy.

Preoperative Omega-6/Omega-3 Fatty Acid Ratio Could Predict Postoperative Outcomes in Patients with Surgically Resected Non-Small-Cell Lung Cancer.

Introduction: The aim of this study was to determine whether preoperative nutritional status and inflammatory status, specifically polyunsaturated acids and the omega 6/3 ratio, would affect postoperative outcomes and complications in patients with lung cancer undergoing lung resection. Methods: This prospective observational study included 68 patients with early-stage non-small-cell lung cancer who were candidates for radical surgery. A complete nutritional assessment was performed. The primary study variable was postoperative complications and mortality in the first 30 days. Descriptive, bivariate, and logistic regression analyses were carried out. Results: A total of 50 men (73.53%) and 18 women (26.47%) underwent surgery, with a median age of 64.2 (±9.74) years. The mean omega 6/3 ratio was 17.39 (±9.45). A complication occurred in 39.7% of the study sample (n = 27), the most common being persistent air leak in 23.53% (n = 16). After performing the bivariate analysis, the only variable that remained significant was the omega 6/3 ratio; we observed that it had a prognostic value for persistent air leak (p = 0.001) independent of age, sex, comorbidity, preoperative respiratory function, and approach or type of surgery. The remaining nutritional and inflammatory markers did not have a statistically significant association (p > 0.05) with postoperative complications. However, this significance was not maintained in the multivariate analysis by a small margin (p = 0.052; 95% CI: 0.77-1.41). Conclusions: Omega 6/3 ratio may be a prognostic factor for air leak, independent of the patient's clinical and pathological characteristics.

Role of jejunoplasty in complex esophageal reconstruction.

INTRODUCTION: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. METHODS: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. RESULTS: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. CONCLUSIONS: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus.

Health Literacy and Its Sociodemographic Predictors: A Cross-Sectional Study of a Population in Madrid (Spain).

BACKGROUND: Health literacy enhances a population's self-care capacity and helps to reduce health inequalities. This work examines the health literacy of a population attending primary care services and explores its relationship with sociodemographic factors. METHODS: This cross-sectional study, conducted at a healthcare center in the Madrid region (Spain), involved adult patients requiring primary care nursing services. One hundred and sixty-six participants were recruited via systematic random sampling. Health literacy was measured using the Health Literacy Questionnaire (HLQ). RESULTS: The studied population showed higher health literacy scores for literacy dimensions 1 (feeling understood and supported by healthcare providers) and 4 (social support for health); the lowest scores were recorded for dimensions 5 (appraisal of health information) and 8 (ability to find good health information). People with a better perceived health status showed a higher level of health literacy. People over 65 years of age, those with an incomplete secondary education, and those who were unemployed returned lower scores for several literacy dimensions. CONCLUSIONS: The results contribute to our understanding of the factors that influence health literacy. Identifying the areas in which patients show the poorest health literacy may help us comprehend their needs and better support them.

A Generic Deep Learning Based Cough Analysis System From Clinically Validated Samples for Point-of-Need Covid-19 Test and Severity Levels.

In an attempt to reduce the infection rate of the COrona VIrus Disease-19 (Covid-19) countries around the world have echoed the exigency for an economical, accessible, point-of-need diagnostic test to identify Covid-19 carriers so that they (individuals who test positive) can be advised to self isolate rather than the entire community. Availability of a quick turn-around time diagnostic test would essentially mean that life, in general, can return to normality-at-large. In this regards, studies concurrent in time with ours have investigated different respiratory sounds, including cough, to recognise potential Covid-19 carriers. However, these studies lack clinical control and rely on Internet users confirming their test results in a web questionnaire (crowdsourcing) thus rendering their analysis inadequate. We seek to evaluate the detection performance of a primary screening tool of Covid-19 solely based on the cough sound from 8,380 clinically validated samples with laboratory molecular-test (2,339 Covid-19 positive and 6,041 Covid-19 negative) under quantitative RT-PCR (qRT-PCR) from certified laboratories. All collected samples were clinically labelled, i.e., Covid-19 positive or negative, according to the results in addition to the disease severity based on the qRT-PCR threshold cycle (Ct) and lymphocytes count from the patients. Our proposed generic method is an algorithm based on Empirical Mode Decomposition (EMD) for cough sound detection with subsequent classification based on a tensor of audio sonographs and deep artificial neural network classifier with convolutional layers called 'DeepCough'. Two different versions of DeepCough based on the number of tensor dimensions, i.e., DeepCough2D and DeepCough3D, have been investigated. These methods have been deployed in a multi-platform prototype web-app 'CoughDetect'. Covid-19 recognition results rates achieved a promising AUC (Area Under Curve) of [Formula: see text] 98 . 80 % ± 0 . 83 % , sensitivity of [Formula: see text] 96 . 43 % ± 1 . 85 % , and specificity of [Formula: see text] 96 . 20 % ± 1 . 74 % and average AUC of [Formula: see text] 81 . 08 % ± 5 . 05 % for the recognition of three severity levels. Our proposed web tool as a point-of-need primary diagnostic test for Covid-19 facilitates the rapid detection of the infection. We believe it has the potential to significantly hamper the Covid-19 pandemic across the world.