Smart Watch to Avoid Face Touching During Pandemic Condition

The most dangerous Coronavirus, COVID-19, is the source of this pandemic illness. This illness was initially identified in Wuhan, China, in December 2019, and currently sweeping the globe. The virus spreads quickly because it is so simple to transmit from one person to another. Fever is one of the obvious signs of COVID-19 and is one of its prevalent symptoms. The mucosal areas, such as the nose, eyes, and mouth, are among the most significant ways to catch this virus. In order to prevent and track the corona virus infection, this research suggests a face-touching detection and self-health report monitoring system. Their hygiene will immediately improve thanks to this system. In this pandemic circumstance, people use their hands in dirty environments like buses, trains, and other surfaces, where the virus can remain active for a very long time. With an accelerometer and a pulse oximeter sensor, this system alerts the user when they are carrying their hands close to their faces. © 2023 IEEE.

Evaluating the Performance of Low-cost PM Sensors over Multiple COALESCE Network Sites

Air quality is a global concern, with particulate matter receiving considerable attention due to its impact on human health and climate change. Recent advances in low-cost sensors allow their deployment in large number to measure spatio-temporal and real-time air quality data. Low-cost sensors need careful evaluation with both regulatory approved methods and other data sets to understand their efficacy. In this work, PM concentrations measured by deploying low-cost sensors at four regional sites are evaluated through comparison with satellite-based model MERRA-2 and the SASS reference instrument. Daily PM2.5 mass concentration variation was analyzed at four regional sites of India from January 2020 to July 2020, including pre-lockdown and six different lockdown periods. Higher PM2.5 concentration was observed at Rohtak (119 mu g m-3) compared to Mahabaleshwar (33 mu g m-3), Bhopal (45 mu g m-3) and Kashmir sites during the pre-lock down period. During the lockdown period, the PM2.5 mass concentration was reduced significantly compared to the pre-lockdown period at every location, although the PM2.5 concentration was different at each location. The air quality trend was quite similar in both the measurements, however, MERRA-2 reconstructed PM2.5 was significantly lower in the pre-lockdown period compared to the lockdown periods. Significant differences were observed between low-cost sensor measurements and MERRA-2 reanalysis data. These are attributed to the MERRA-2 modelling analysis that measures less PM2.5 concentration as compared to ground-based measurements, whereas low-cost sensor are and biases.

A Single-Center Experience with More Than 200 Lung Transplant Recipients with COVID-19 Infection

There still have been limited data regarding COVID-19 in lung transplant recipients (LTR). We sought the outcomes after COVID-19 infection in LTR using our largest dataset. We analyzed our database of LTR who were diagnosed with COVID-19 between March 26, 2020 and September 6, 2022. First, we investigated the clinical outcomes of the all cohort, and then divided them into three groups depending on their time of diagnosis (Dx, 1st wave: 03/2020-10/2020, 2nd: 11/2020-11/2021, and 3rd: 12/2021-09/2022), and compared these results. 210 LTR (median age, 67;67% male) were enrolled. The median time from LT to their Dx was 2.1 years. Five patients had the Dx during their index admission for LT whereas all of them died during their admission. One hundred forty patients (67%) required readmission, including 46 (33%) receiving ICU management. Among those hospitalized, 35 patients (25%) were intubated and 7 patients (5%) were placed on VV ECMO. Overall survival was 67% at 1 year and 59% at 2 years post-Dx (Figure 1). While 89 patients (42%) were unvaccinated at the time of their Dx, 121 patients (58%) were vaccinated including 63 patients (30%) with boosters. Although survival was significantly better in the 3rd period (Figure 1), hospital mortality has not changed (1st: 28%, 2nd: 38%, 3rd: 28%). Vaccination was the only significant predictor for hospital admission (initial series vs none: odds ratio [OR] 0.22;boosters vs none: OR 0.27). Age ≥ 70 years (OR 2.87) and initial series of vaccines (vs None: OR 3.10;vs boosters: OR 3.71) contribute to hospital mortality as an independent predictor. Survival post-COVID-19 infection in LTR continues to improve, however, hospital mortality remains remarkably high with 30%. Whereas vaccination appears to have been impactful in preventing hospital admission, vaccination also has demonstrated inconsistent results for reducing hospital mortality. Further research is continued focused on how to better identify the high risk LTR who may lead to the mortality. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Interpretive Structural Modeling: Research Trends, Linkages to Sustainable Development Goals, and Impact of COVID-19

Interpretive structural modeling (ISM) is widely used to understand the complex connections between different components. This study presents a bibliometric overview of ISM research, with a focus on its linkages to the Sustainable Development Goals (SDGs) and the impact of COVID-19. The study analyzed 1988 publications on ISM published between 2012 and 2021, of which 1202 were directly mapped to the SDGs and 59 were related to COVID-19. The study identified key authors, institutions, countries, and journals involved in the research and their linkages to the SDGs. The results showed that ISM research is strongly linked to SDG 12 (on responsible consumption and production) and SDG 9 (on industry, innovation, and infrastructure). We also identified influential SDGs on the basis of centrality measures such as betweenness and eigenvector. The top four countries contributing to ISM publications were India, China, the United Kingdom, and the United States. The most frequently cited journals were Benchmarking: An International Journal, Sustainability, the Journal of Modelling in Management, and the Journal of Cleaner Production. Four main clusters were identified in the ISM research, including (1) integration with AHP and fuzzy logic for promoting sustainability alignment, (2) ISM-based strategy development for various stakeholders, (3) ISM-based decision-making in various fields, and (4) ISM-based risk evaluation. For the first time, studies that used the ISM approach to understand the epidemiological characteristics of COVID-19 were identified, and their key findings were discussed. The study also identified several emerging topics for future ISM research, such as blockchain and IoT, environmental management systems, climate change adaptation, smart cities, and humanitarian logistics and their potential linkages to the SDGs.

Alzheimer's Disease Clinical Trial Research Adaptation Following COVID-19 Pandemic Onset: National Sample of Alzheimer's Clinical Trial Consortium Sites.

BACKGROUND: The COVID-19 pandemic created challenges in clinical research operations that required immediate and lasting changes. OJBECTIVES: The purpose of this study was to explore adaptations to clinical trial research due to COVID-19 and develop a theoretical framework of emergent strategies related to pandemic mitigation in a national network of Alzheimer's disease clinical trial sites. DESIGN: This qualitative study used a grounded theory approach including semi-structured interviews, constant comparative methods, and multi-level, iterative coding. PARTICIPANTS: Twenty-six member sites of the Alzheimer's Clinical Trial Consortium participated with a total of 49 participants. RESULTS: Findings demonstrate processes of adaptation following COVID-19 onset including establishing safety as priority, focus on scientific preservation, accommodations (creating policies, leadership mindset, maintaining operations, and determining research procedures), and evaluation of changes throughout the course of the pandemic. Communication and maintaining integrity were vital throughout these processes. CONCLUSION: Processes of accommodation among clinical research sites during the pandemic provide critical insights and direction for future clinical trials development and emergent methods in Alzheimer's disease and other therapeutic areas.

Role of High Flow Nasal Cannula for Respiratory Support During Oral Feeding for COVID-19 Patients on Non-invasive Ventilation: A Case Series

Aims and objectives: To establish that non-invasive ventilation (NIV) can be substituted by high flow nasal cannula (HFNC) for respiratory support during oral feeding of a patient with COVID-19 patients. Materials and methods: This prospective case series was conducted after taking informed and written consent from the patients. Ten patients with severe COVID-19 disease requiring NIV with inspiratory pressure of <10 cm H2O, positive end-expiratory pressure of <6 cm H2O and FiO2 <0.6 were included in this study. Patients with altered consciousness, circulatory failure, or worsening acidosis were not included in the study. Patients underwent HFNC trial for 10 minutes and were screened for risk of dysphagia and aspiration using a 3-ounce water swallowing test. The patients were given a trial of HFNC for 10 minutes with a flow of 60 L/minute and FiO2 of 0.1 more than their requirement on NIV. The patients were observed for hypoxemia (SpO2 <88%) or signs of respiratory distress, e.g., increase in respiratory rate (>35/minute), laboured breathing pattern, use of accessory muscle of respiration, heart rate (>20% change), blood pressure (>20% change), perspiration, and anxiety. Then, HFNC was used for supporting respiration during oral feeding for up to 20 minutes. Feeding was started with a hypocaloric target on starting day and was increased progressively as per European Society for Clinical Nutrition and Metabolism guidelines to the target estimated caloric requirement. Results: The HFNC support for oral feeding was successful with adequate diet intake in eight patients without desaturation/respiratory distress during oral feeding. Other than COVID-19, co-morbidities in these eight patients included diabetes mellitus, obesity, chronic obstructive pulmonary disease, coronary artery disease, and dilated cardiomyopathy. Six patients, previously on enteral nutrition using the nasogastric tube, were successfully switched to oral feeding with help of HFNC. Four patients were directly started on the oral diet with help of HFNC support. HFNC could not support respiration adequately in two of these four patients. The initial trial was successful for one of the patients and HFNC support for oral feeding was used for 3 days, but a progressive increase in ventilatory requirements resulted in failure of HFNC trial subsequent days and the patient was switched to nasogastric feeding. In another patient, the initial trial of HFNC failed due to rapid desaturation within a few minutes of the trial. The eight patients in whom HFNC was used successfully for feeding were switched to HFNC completely and discharged from the hospital after weaning off from oxygen support. The patients who failed the HFNC support for feeding required higher ventilatory requirements and needed endotracheal intubation. Conclusion: Based on our case series, using daily screening trial of oral feeds with HFNC support in selected patients of severe COVID-19 pneumonia on NIV seems thought-provoking and should be explored for its potential in improving patient's nutrition with a positive impact on the outcome.

Clinico Hematological Profile of Anemia in Adolescent Age group: a Retrospective Study from Eastern India

Introduction: Globally anemia is one of the most important health problems. Adolescents are young people between the ages of 10 to 19 years. Anemia in adolescence may cause a wide range of functional consequences across the life course, including reduced resistance to infection, impaired physical performance and neurodevelopment, and suboptimal schooling outcomes. Aims and objectives: To estimate the prevalence of anemia, to determine the morphological types and patterns of anemia and to assess the etiological factors for different types of anemia among adolescent age group of Eastern India. Materials and methods: It is a retrospective observational study conducted in the department of Hematology at a tertiary care center in Bihar with a sample size of 200 cases. All patients belonging to adolescent age group (10-19 years) having sign and symptoms of anemia were chosen for study whereas children less than 10 years, patients on hematinic and Covid and viral positive cases were excluded. Clinical and demographic data along with hematological findings were retrieved from medical records and data were analysed by SPSS version 25. Results: 55% (n=110) patients were males while 45% (n=90) were females. Amongst males, 31.9% (n=23) were anemic in early adolescent age group and 39.4% (n=15) were anemic in age group 15-19years. While in females, 48.8% (n=21) were anemic in early adolescents and 78.7% (n=37) were anemic in late adolescent age group. Overall prevalence of anaemia among the study subjects was found to be 40.9 %. The prevalence of mild and moderate anaemia was almost similar, each comprising of 39.1% and 39 % respectively whereas 3.1% cases had severe anaemia. Conclusion: The prevalence of anemia amongst adolescents was a moderate public health problem. Factors associated with anemia were low socioeconomic status, rural background, larger family size, poor dietary habits and personal hygiene.

Impact Of COVID-19 On Employee Engagement In IT And Teaching Sector With Reference To Chennai City

The pandemic due to COVID-19 have changed the life of an employee in various sectors. A happy and satisfied employee opens the way of success to his/her organization. Employee engagement is the extent to which employees feel passionate about their jobs, are committed to the organization, and put discretionary effort into their work. Employee engagement is not the same as employee satisfaction. It can be said that the COVID-19 pandemic period is a period of trial related to relationships in both the dimensions - professional and personal (Meenakshi Kaushik & Neha Guleria, 2020). In this context, the present study is about the impact of COVID-19 on employee engagement in IT and teaching sector. A questionnaire survey was handled out to evaluate the impact of COVID-19 on employee engagement in these sectors.

Comparison of Automated and Manual Viral Nucleic Acid Extraction Kits for Covid-19 Detection Using qRT-PCR

Introduction: The emergence of a novel Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a pandemic. Rapid and accurate diagnosis method is crucial to reduce the disease burden and to improve early diagnosis approaches to control of the disease. Real time Reverse transcriptase PCR (qRT-PCR) has been identified by the World Health Organization as the most sensitive and specific method of detection. However, the success of this assay relies on the quantity and quality of the extracted viral RNA. Methods: Various methods have been developed for nucleic acid extraction however, the methods have not been assessed. RNA extraction was performed from 24 nasopharyngeal swab samples using a manual extraction kit (GF-1) and an automated extraction kit (Genolution). The concentration and purity of the extracted RNA samples were measured, and its performance were tested using qRT-PCR. Results: The average concentration and purity of the RNA samples extracted using GF-1 kit was higher compared to Genolution. Similarly, the qRT-PCR assay using the RNA samples extracted using manual extraction was better compared to automated kit. Conclusion: Both the manual and automated extraction kits have its advantages and disadvantages in terms of yield and purity. However, with proper optimization, both methods may be used for routine molecular diagnostic of COVID-19 in laboratories. © 2022 UPM Press. All rights reserved.

Vancomycin Induced Maturation Arrest with Reactive Promyelocyte Proliferation: A Diagnosticand Therapeutic Challenge

Introduction: Drug induced leucopenia complicates any clinicalsituation especially when it's associated with COVID-19 infection.Here we report a case of vancomycin induced myeloid maturationarrest in a patient with COVID-19 infection where his conditionreverted to normal after stopping the drug.Aims &Objectives: It highlights the adverse effects of Vancomycinleading to promyelocyte proliferation posing a diagnostic challenge todifferentiate it from neoplastic promyelocyte proliferation.Materials &Methods: Case report: A 47 year old male presentedwith fever, dry cough and difficulty in breathing for 12 days. He wasCOVID-19 positive with CT lung showing bilateral pneumonic consolidations for which Vancomycin was started. Hemogram showedhemoglobin-6.8 gm/dl, total leucocyte count-3200/cumm with a differential count revealing: Neutrophil-28% (with left shift and featuresof dyspoiesis), Lymphocyte-66%, Monocyte-4%, Eosinophil-2%(Fig. 1a), and platelets-90,000/cumm. Bone marrow aspiration(BMA) and biopsy was advised. BMA was hypercellular for age withmarked promyelocyte proliferation &maturation arrest with strongMPO positivity (1b, c d). Bone marrow biopsy also reflected similarfindings (Fig-1e). FISH for PML-RARA translocation turned out to benegative, differentiating it from Acute promyeloytic Leukemia(Fig. 1f). A diagnosis of drug induced leucopenia with reactivepromyelocyte proliferation was made. Considering worsening of thesehematological findings, Vancomycin was stopped and patient'shematological findings improved drastically with stabilization ofhematological parameters.Result: Discussion: Drug induced leukopenia occurs in a dosedependent or dose-independent (idiosyncratic) reaction. Vancomycindependent antibodies against neutrophils lead to an autoimmunereaction directly affecting progenitor cell growth especially of myeloid cell lineage leading to maturation arrest. Secondly cytotoxicT-cell mediated response also has damaging effects on hematopoieticcells. Infections like COVID-19 can also lead to suppression ofnormal myeloid maturation due to release of interleukins.Conclusions: Myeloid maturation arrest with marked promyelocyteproliferation poses a diagnostic dilemma especially in patients presenting with cytopenia as they are confused with Acute promyelocytic Leukemia. This case highlights the importance of detailed knowledgerelated to drug induced myeloid maturation arrest which is reversibleafter stoppage of the offending drug.

Impact of the COVID-19 pandemic on the design, operations, and analysis plans of dementiatrials

Multi-center randomized clinical trials in dementia research, especially in the stages aimed at primary and secondary prevention, have design characteristics that are particularly susceptible to the disruption caused by the COVID-19 pandemic, as well as the impact of COVID-19 illness on older adults. In this session, we will present the impact of the pandemic on design and analytical issues related to the choice of study population, trial design, clinical endpoints, and methods of outcome ascertainment. We will also discuss operational complexities and approaches to address or evaluate the impact of this global pandemic. This session will consist of three invited talks and a discussant. Each talk, representing clinical trials with different study designs, will be given by a member of the trial's statistical leadership team. The studies to be discussed are as follows: • Pharmacological Trials-The Anti-Amyloid Treatment in Asymptomatic Alzheimer's (A4) study: This is ongoing double-blind, placebocontrolled 240-week Phase 3 trial of an anti- Amyloid monoclonal antibody in older individuals (ages = 65-85 years) who have normal cognition and memory function but who may be at risk for memory loss due to Alzheimer's disease. This study completed enrollment in December 2017 and is anticipated to be completed in 2022. The primary outcome in the study is the Preclinical Alzheimer Cognitive Composite, with the Cognitive Function Index as a key secondary outcome. It is conducted as a public-private partnership between the National Institute on Aging and Eli Lilly. • Non-Pharmacological Trials-The US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (US POINTER): This is an ongoing 2-year clinical trial, that began recruiting in May 2019, to evaluate whether lifestyle interventions that simultaneously target many risk factors protect cognitive function in older adults (ages 60-79 years) who are at increased risk for cognitive decline. The primary outcome of this study is a global cognitive composite score. It is funded by the Alzheimer's Association. • Pragmatic Trials-The Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults (PREVENTABLE): This is a pragmatic trial that began recruitment in September 2020, studying the effectiveness of statins in adults 75 years or older without known cardiovascular disease on a primary outcome of survival free of dementia and disability. It is funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute. While the talks in the session will describe the experiences and decisions of the individual study team, the discussant will compare and contrast these experiences across the types of designs and stage of study. Speakers: Michael Donohue, PhD, Mark Espeland, PhD, and Nicholas Pajewski, PhD. Discussant: Rema Raman, PhD, University of Southern California.

Lost in Transmission: Investigating Filtering of COVID-19 Websites

After the unprecedented arrival of the COVID-19 pandemic, the Internet has become a crucial source of essential information on the virus. To prevent the spread of misinformation and panic, many authorities have resorted to exercising higher control over Internet resources. Although there is anecdotal evidence that websites containing information about the pandemic are blocked in specific countries, the global extent of these censorship efforts is unknown. In this work, we perform the first global censorship measurement study of websites obtained from search engine queries on COVID-19 information in more than 180 countries. Using two remote censorship measurement techniques, Satellite and Quack, we collect more than 67 million measurements on the DNS and Application layer blocking of 1,291 domains containing COVID-19 information from 49,245 vantage points in 5,081 ASes. Analyzing global patterns, we find that blocking of these COVID-19 websites is relatively low on average, 0.20%-0.34% of websites containing information about the pandemic experience interference. As expected, we see higher blocking in countries known for censorship such as Iran, China, and Kazakhstan. Surprisingly, however, we also find significant blocking of websites containing information about the pandemic in countries generally considered as "free" in the Internet space, such as Switzerland (DNS), Croatia (DNS), and Canada (Application layer). We discover that network filters in these countries flag many websites related to COVID-19 as phishing or malicious and hence restrict access to them. However, our investigation suggests that this categorization may be incorrect most websites do not contain serious security threats causing unnecessary blocking. We advocate for stricter auditing of filtering policies worldwide to help prevent the loss of access to relevant information.

When Worlds Collide: Framing Students' Challenges with Stay-at-home Learning During COVID-19 through the Lens of Conflicting Role Identities

Based on a survey of undergraduate business students at a private Midwestern university in the United States, we found that the abrupt mid-semester transition from campus learning to at-home online learning due to the coronavirus disease of 2019 (COVID-19) pandemic led to an unexpected challenge for students. Students reported that stay-at-home learning eroded support for their student role while also creating conflicts between the student role and other competing roles, such as child, sibling, or supplemental wage earner. As a result, they significantly lacked motivation to complete schoolwork during stay-at-home orders. Using a framework rooted in role identity theory, we analyze this role erosion and role conflict. Based on that analysis, we suggest potential actions for faculty to mitigate the adverse impact that this role erosion/conflict has on learning and, thus, bolster the student role while simultaneously reducing conflict between the student role and other competing roles. As we brace for multiple semesters of teaching during the COVID-19 pandemic, such efforts to facilitate positive stay-at-home learning experiences for our students will contribute to determining our academic success and our educational institutions' economic viability.

Practical Tips for HyFlex Undergraduate Teaching During a Pandemic

Many universities in the United States have resumed campus-based learning during the coronavirus disease of 2019 (COVID-19) pandemic. Under these special circumstances, many instructors have considered the HyFlex approach to redesign their undergraduate courses. However, a HyFlex teaching model that one adopts in reaction to a global pandemic significantly differs from HyFlex teaching that one adopts under normal conditions. In this paper, we provide actionable practical tips that will allow fellow instructors to better prepare themselves for running a COVID-19 HyFlex classroom. First, we explain how the COVID-19 HyFlex model has some key distinctions from the regular HyFlex teaching model. Then, in the COVID-19 HyFlex classroom, we focus specifically on how to effectively use group work as the learning instrument in these types of classrooms. We consciously seek to go narrow and deep on the dimension of group work as it has the most potential to yield beneficial outcomes while also being fraught with logistical challenges in the COVID-19 HyFlex context. Our collective success with undergraduate HyFlex teaching in future academic terms during COVID-19 will determine our universities' economic success and our jobs' security.

A single center evaluation of applicant experiences in virtual interviews across eight internal medicine subspecialty fellowship programs.

Due to the COVID-19 pandemic, most graduate medical education (GME) training programs conducted virtual interviews for prospective trainees during the 2020-2021 application cycle. Many internal medicine (IM) subspecialty fellowship programs hosted virtual interviews for the first time with little published data to guide best practices.To evaluate how IM subspecialty fellowship applicants perceived the virtual interview day experience.We designed a 38-item questionnaire that was sent via email to applicants in eight IM subspecialty programs at a single tertiary academic medical center (University of California, San Francisco) from September-November, 2020.Seventy-five applicants completed the survey (75/244, 30.7%), including applicants from all eight fellowship programs. Most survey respondents agreed that the length of the virtual interview day (mean = 6.4 hours) was long enough to gather the information they needed (n = 65, 86.7%) and short enough to prevent fatigue (n = 55, 73.3%). Almost all survey respondents agreed that they could adequately assess the clinical experience (n = 71, 97.3%), research opportunities (n = 72, 98.6%), and program culture (n = 68, 93.2%). Of the respondents who attended a virtual educational conference, most agreed it helped to provide a sense of the program's educational culture (n = 20, 66.7%). Areas for improvement were identified, with some survey respondents reporting that the virtual interview day was too long (n = 11) or that they would have preferred to meet more fellows (n = 10).Survey respondents indicated that the virtual interview was an adequate format to learn about fellowship programs. These findings can inform future virtual interviews for GME training programs.

A Phase II Safety and Efficacy Study on Prognosis of Moderate Pneumonia in Coronavirus Disease 2019 Patients With Regular Intravenous Immunoglobulin Therapy.

BACKGROUND: Currently, there is no specific drug for the treatment of coronavirus disease 2019 (COVID-19). Therapeutic benefits of intravenous immunoglobulin (IVIG) have been demonstrated in wide range of diseases. The present study is conducted to evaluate the safety and efficacy of IVIG in the treatment of COVID-19 patients with moderate pneumonia. METHODS: An open-label, multicenter, comparative, randomized study was conducted on COVID-19 patients with moderate pneumonia. One hundred eligible patients were randomized in 1:1 ratio either to receive IVIG + standard of care (SOC) or SOC. RESULTS: Duration of hospital stay was significantly shorter in the IVIG group compared with that of SOC alone (7.7 vs 17.5 days). Duration for normalization of body temperature, oxygen saturation, and mechanical ventilation were significantly shorter in IVIG compared with SOC. Percentages of patients on mechanical ventilation in 2 groups were not significantly different (24% vs 38%). Median time to reverse-transcription polymerase chain reaction negativity was significantly shorter with IVIG than SOC (7 vs 18 days). There were only mild to moderate adverse events in both groups except for 1 patient (2%), who died in SOC. CONCLUSIONS: Intravenous immunoglobulin was safe and efficacious as an adjuvant with other antiviral drugs in the treatment of COVID-19.