Massive Pressure Research Articles

Hemoptysis due to severe obstructive sleep apnea

Although OSA is rarely mentioned as a clinically relevant differential diagnosis of hemoptysis in the literature, we report on a patient with chronic hemoptysis, which was caused by repetitive intrathoracic negative pressures due to severe upper airway obstruction.A 56-year-old overweight patient (BMI 32 kg/m2), with a long history of smoking (40 PY) and who complained of pronounced daytime sleepiness, was referred 2 years ago in March and last year in the summer to our emergency room because of long lasting mild hemoptysis.Sedation during bronchoscopies induced hypopharyngeal collapse accompanied by severe obstructive apneas and massive inspiratory negative pressure. Simultaneously, multiple petechial and larger flat mucosal bleeding as fresh blood coverings occurred on the bronchial mucosa. At the first presentation, the patient wished no further diagnosis. During the second presentation, polysomnography including transcutaneous CO2 measurement showed a severe OSA in combination with hypoventilation (AHI of 76/h, desaturation index: 128/h; medium PCO2 value of 56 mmHg). OSA was treated effectively with oronasal positive pressure.With this case report we underline the generally underestimated implication of strong intrathoracic negative pressures in severe OSA as a clinically relevant differential diagnosis of hemoptysis.

‘It's not for the children's sake’: A qualitative inquiry into the barriers and facilitators underlying parents' decision-making for vaccinating children against influenza in Denmark

Recently, the Danish Health Authority began recommending vaccinating children aged 2–6 years against seasonal influenza, underscoring the pivotal role of children in its transmission dynamics within the wider population and the need to protect vulnerable population groups after COVID-19. Under a third followed the recommendation. For the routine Danish childhood vaccine program coverage is usually well above 90%.Through a qualitative in-depth study with 28 key informants during the 2022/2023 influenza season, we investigated the barriers and facilitators of parents' decision-making for vaccinating their children against influenza. We found that parents' decision-making was influenced by a range of factors that present barriers or facilitators at the individual or collective levels, depending on personal antecedents and family situations. We also gained insights on how COVID-19 mass vaccination shaped parents’ attitudes and awareness toward influenza vaccination, explaining why many parents who fully complied with the COVID-19 recommendations elected to opt out of influenza.The implications of these findings extend beyond the concrete context of parent's decision-making regarding influenza vaccination, contributing to our understanding of vaccine confidence in at least two ways. First, the limited public controversy regarding childhood influenza vaccination allows for a perspective onto low vaccine uptake that does not resort to the usual framing of a well-defined “crisis”. Second, the interaction between COVID-19 vaccination and the childhood influenza vaccination reveals how the massive pressure on parents to vaccinate themselves and their children against COVID-19 contributed to an erosion of vaccine confidence in general.

Travel Restrictions in Siargao: An Intervention for the Island’s Long-Term Sustainability

An overwhelming influx of tourists to a destination can create massive pressure. Siargao, a tourism-first island known as "Asia's Best Island" and the "Surfing Capital of the Philippines", is one of the favorite spots and has captivated the hearts of tourists around the world. This study investigated the efficacy of travel restrictions to ensure the island’s long-term sustainability. This descriptive research, using a quantitative approach, utilized snowball sampling. Data were gathered from 400 respondents from the National Capital Region. The findings revealed that Siargao is popularly known as one of the top attractions in the Philippines, and respondents are aware that excessive tourism may lead to site deterioration. Restrictions could be an effective intervention to achieve island conservation. Stakeholders can make a substantial contribution to conservation efforts by closely observing tourist demand and behavior to incorporate the current travel restrictions into strategies and, thereby, prevent traffic and destruction of natural sites when visitation levels return to normal. These restrictions could be an effective environmental conservation intervention; therefore, implementing these travel limitations is an effective way to ensure long-term gains that contribute to Siargao’s conservation goals. Considering this additional intervention, a thorough intervention, and its impact will greatly help determine the significance of the improvement. Thus, this pioneering study provides supporting statements to help Siargao rise to the top Philippine destination and ensure the long-term sustainability of tourism.

Does corporate social sustainability influence on business environment? Impact of corporate governance on distance to default of Sukuk issuers in Islamic banks

Malaysia has emerged as a global hub for Sukuk. But on the parallel, the Malaysian sukuk market has undergone many defaults and facing massive competitive pressure. In this scenario, the precautionary tools to mitigate the default risk must be explored. This study analyzed the impact of corporate governance (CG) on corporate social sustainability (CS) and the distance to default of Sukuk issuers (DD) to investigate the mitigating effect of these variables and the mediating role of CS. The results are robust across alternative measures for the variables and robust against different econometric tests. The implication of this study encouraged the inclusion of female directors and their empowerment due to their positive impact on DD and CS.

The human-wildlife conflict in Musk Deer National Park, Neelum Gureze Valley, Azad Jammu & Kashmir, Pakistan.

Growing human population is a solemn risk to biodiversity at a global level. Massive anthropogenic pressure and invasion in the natural habitats initiated the human-wildlife conflict in rural areas. Present study aimed to assess human-wildlife conflict in Musk Deer National Park (MDNP) from 2013 to 2018. Results revealed an estimated 241784 nomadic and 5589 residential livestock heads grazed in different areas of MDNP during the summer season. A total of 126 heads were depredated by carnivores during the study period. Majority (n=39) of livestock heads were killed in May (n=29). Livestock depredation resulted in economic losses worth 3.115 million PKRs (25744 US$) to the herder community while farmers received 1.629 million PKRs (13466 US$) losses due to crop raiding. Most (64%) of the respondents believed human-wildlife conflict heightened due to scarcity of food or prey in the natural habitats of carnivores. Majority (92%) of the respondents did not like the presence of predators in MDNP. Loss compensation schemes could turn this negative attitude into the positive one and increase tolerance about the presence of carnivores in their vicinity. This study provides an insight into the human-wildlife conflict in MDNP and paves a way for understanding the conflict and conservation of carnivore species in the study area.

Pravoslavna crkva u raljama aktuelnih globalnih geopolitičkih promena - kanonska i socio-politička analiza

This paper points to processes that have been going on for a century and aim to change the modern image of the Orthodox Church. One patriarchy, the first in honour, is trying to impose itself as the supreme interpreter of traditions and theological narratives, as well as to change the canonical structure and ecclesial identity of all other autocephalous Orthodox Churches. The prehistory of the devastating processes starts with the restoration of national and church self-consciousness in the 19th century in the Balkans, which led to the emergence of the brainchild of restoring the autocephalous status of church communities in the liberated territories. The procedures for church independence were not initially approved by the Patriarchate of Constantinople. The leading patriarchate in honour, faced with the actual church situation on the Balkan Peninsula, confirmed the independence of the Athens Archdiocese and the Metropolitanate of Belgrade in the second half of the 19th century. However, the 20th century brought massive changes. The Balkan Wars, the Great War, the communist revolution in Russia, the disappearance of the Ottoman and Austrian empires, and the great tragedy of the Orthodox Greeks in Constantinople and Asia Minor led to changes in theological paradigms in the Patriarchate of Constantinople, which also initiated a change in its church position from Primus inter pares (The first among equals) to Primus sine paribus (The first without equals). This fact leads to the pretensions of this patriarchate to the entire Orthodox diaspora, as well as to the exclusive right to form criteria for granting autocephalous status to church communities that request it. However, the representatives of the Patriarchate of Constantinople very consistently continue to develop the theological assumptions of the new ecclesiological matrix, especially in the decades after the Second World War. Quite consciously and with the expected outcome, they are approaching the levers of power of the US political elite with the desire to strengthen their position in front of the repressive regime in Turkey. Soon, they began to use the established connections and increased political potential to impose their ecclesiological and canonical views on other Orthodox churches, especially since the fall of the Iron Curtain and the demolition of the Berlin Wall. The resistance of the new ecclesiological narratives of the Patriarchate of Constantinople, which give it a priority place in relation to all other churches and in the processes of accomplishing canonical and spiritual authority, not just honour, to all reasoned theological and historical criticism from Orthodox theologians, canonists, and archbishops, points to the fact that the theological turnover of this Patriarchate is well and studiously prepared. It is apparent that this church expects essential benefits from it, but also that the shaped narratives have a reflective effect on anticipated political situations that have been preparing for decades under the guise of the pseudo-ideological supremacy of the West. Since it is under massive transformative pressure from the Western power centres, it's evident that the Orthodox Church is in great turmoil, with painful uncertainty about its resolution. The processes that are mentioned are part of global geopolitical change. Rational interpretation of reality suggests they are synchronized from the same centre of power and political decision-making, as well as mutually compatible and complementary. This fact tells us that the mutual relations of the Orthodox churches are in a crisis that seems to be designed and managed for the purpose of more comprehensive intervention in the self-consciousness of the Orthodox peoples and their ecclesial, national, ethical, and political identity.

Identification of necessity behind the construction of the third Shitalakhya bridge based on level of service (LOS) measurement parameters applicable for developing countries

With the expansion of industrial activities in developing countries like Bangladesh, the purchase of motorized vehicles is also growing in recent days. This increased number of motorized vehicles is creating massive pressure on the logistic movement in industrial areas, and the performance level of roadways is deteriorating day by day. It has become quite difficult to meet the need for a reliable transportation system that can provide good compatibility for road users and logistical operations. Kanchpur Industrial Area can be classified as an industrial hub of Narayanganj District due to the presence of jute trading and plant processing industries. Over the years two bridges have been constructed in the proximity of this area named, the Kanchpur Bridge and Sultana Kamal Bridge to decrease the pressure on N2 National Highway; however, the situation is still not satisfactory and construction of a third bridge over the Shitalakhya River is under consideration by the Government of Bangladesh (GOB). Dhaka-Sylhet Highway is a section of the N2 National Highway system which connects the industrial district Kanchpur with Dhaka City. The main objectives of the study were to develop a methodology which can be used to measure the Level of Service (LOS) of roadways located in developing countries and use it to understand the necessity of the construction of the third Shitalakhya Bridge. LOS measurement procedures suitable for developed countries are not useable for developing countries due to the difference in road geometry, presence of non-motorized vehicles, and control delay at intersections. A procedure has been developed to measure LOS by combining standards of the National Institute of Technical Teachers Training and Research, Chandigarh, India; Highway Capacity Manual (HCM), USA; and Roads and Highway Department (RHD), Bangladesh. LOS measurement was based on four parameters: Peak Hour Factor (PHF), Travel Speed, Load Factor, and Volume/Capacity Ratio (VCR). The data analysis shows that the LOS value of the Dhaka-Sylhet Highway varies within the range from “E" to “F", and construction of the third Shitalakhya Bridge will significantly improve the roadway condition.

Heterogeneous Effects of a Means-Tested Benefit on Income of Older Adults: Evidence from the Basic (Old-Age) Pension in South Korea

In response to severe old-age poverty in South Korea, the Basic Pension has been operated since 2008 for 70% of low-income older adults as a means-tested benefit. It has become an important income supplement for them; however, its expenditure has sharply increased due to rapid population aging. This study analyzed the Korea Household Income and Expenditure Survey using changes-in-changes to examine heterogeneous effects at different income deciles among its development phases in 2008, 2014, 2018, and 2019–2021. First, the largest benefit increase in 2014 records greater income support effects. Second, in terms of heterogeneous effects, the bottom 10th percentile has insignificant effects in 2018 compared to 2014 because it can select another means-tested programme for general citizens, which provides more extensive benefits since 2015. The 20th–50th percentiles presented significant income increase effects. Although the benefits are distributed for the 60th–70th percentiles, who are positioned above the poverty threshold, they consistently displayed insignificant effects. Practically, obtaining a sufficient increase effect like in 2014 may be difficult considering population aging and massive budget pressure. Therefore, it is necessary to collaborate with other social service programmes and concentrate on vulnerable population to provide sustainable welfare services.

Voices of Black and Asian minority ethnic postgraduate students post the COVID-19 pandemic: Are higher education institutions listening?

The COVID-19 pandemic significantly affected students studying in higher education (HE) institutions in the UK and international contexts. Black and Asian Minority Ethnic (BAME) university students faced massive pressure during and post COVID-19 pandemic, alongside trying to meet their education goals. Our research project was with postgraduate students from two HE institutions, and this paper highlights participants' lived experiences and perspectives, including emotional stress, the need for greater support to access learning resources, financial issues and physical and mental health issues. Our paper suggests that HE institutions need to provide democratic spaces to encourage all students, including BAME students, to engage in dialogues among themselves and with other key players in HE, such as policymakers, and local and international communities, to address issues of inequality. It is important for HE institutions to listen to students' voices, reflect on the impact of the pandemic on their lives and make strategic planning for mitigating negativities and uplifting quality learning experiences post the pandemic.

Is Denmark a green entrepreneurial state?


 This article is based on digital methods research using the tools Hyphe, Gephi and CorText to map the relations between public Danish actors – from informal civil society groups and NGO’s to business and state actors - and their “matters of concern” (cf. Latour 2004) in the heated political situation around the development of green transition policies following the enactment of the Climate Act in 2019. The Act was, according to the newly elected social democratic government, the “most ambitious Climate Act in the world”. It included such political innovations as the Citizens’ Assembly on Climate Change, a group of 99 randomly selected citizens mandated to give recommendations to parliament, and a series of Climate Partnerships, business and industry collaborations tasked with developing recommendations and frameworks for the business community’s engagement in the green transition. The Climate Act was passed after massive popular pressure from the civic climate movement leading up to the election. Despite these efforts and the apparent political will to engage with multiple voices and interests, our network mapping shows that the business community, with an emphasis on “innovative and technological solutions”, were soon to become dominant in the network and align themselves more closely with the political system than the civil society actors were able to with their repeated calls for more radical and political action on climate change. 

In Search for Soul: The Contribution of Analytical Psychology to Heal Human Rights Violations

Humanity continues to experience serious violations of human rights, and the recent critical events, like the COVID‐19 pandemic and the war in Ukraine, seem to have directly or indirectly intensified the occurrence of violations of human rights like torture, enforced disappearances, human trafficking, gender‐based violence and war crimes. Can analytical psychology make a significant contribution to the prevention, treatment, remedying such violations, from the individual level to the most macro level of socio‐political systems? I will support the thesis that the Jungian concept of soul has a special role in such an endeavour. My proposal is that when a social terrifying threat, like in the case of widespread social violence, is perceived at the social level, the functioning of the individual Self and society may change dramatically. In particular, both lose their containing function and are subjected to an unconscious massive collective pressure to align themselves to a specific kind of functioning that I call monolithic functioning. It is the splintering of what I call the reflective triangle, which is illustrated here, and has an effect on societal, groupal, interpersonal and intrapsychic levels. Some vignettes from a clinical case of a patient who suffered torture and gender‐based violence are presented to illustrate how these human rights violations affect the three levels mentioned.

Intelligence Information Intervention in Emergency Management of Emergencies: The Case of the “7.20 Zhengzhou Rainstorm”

Public emergencies can be divided into four categories: natural disasters, accidents and disasters, public health and social security. This paper discusses government countermeasures and measures in natural disaster emergency management, public health emergency management and information intervention management, and summarises and analyses them. In July 2021, a significant rainstorm and flooding disaster occurred in Zhengzhou, causing substantial damage to the area and attracting national attention. However, the development of emergency management and intelligence intervention in emergencies has gradually become chaotic, with problems such as “slow updates”, “one-sided reporting” and “low quality”; this has put massive pressure on the handling of intelligence information and online public opinion. Therefore, it is of great theoretical value and practical significance to explore the management of information interventions in emergency management of emergencies. Taking the “Zhengzhou 7.20” incident as the object of study, this paper uses literature analysis and case study methods to explore the shortcomings of the Zhengzhou municipal government in emergency management and information intervention, as well as the serious social losses and negative social impacts caused by the incident. The paper uses crisis theory, life cycle theory, coordination theory and membrane technology to analyse the emergency management and information intervention in this emergency. In response to the problems encountered in the Zhengzhou incident and the reasons for the shortcomings of information intervention in emergency management, corresponding suggestions and countermeasures for improvement are put forward. Moreover, suggestions and model diagrams are given on how to build a perfect information system, hoping to provide some reference values for better-solving emergency events in the future.

The Shaking of America: September 11th Becomes History

J. Samuel Walker’s new book focuses on why the United States failed to prevent the terrorist attacks of September 11, 2001, as well as the experiences of that day and the U.S. policy response. This study efficiently summarizes this history and makes some important arguments, but its lack of historical contextualization and failure to differentiate itself within the extensive scholarship on this topic limit its usefulness. Walker’s most interesting arguments examine pre-2001 counterterrorism policy and intelligence, including the shortcomings that made September 11th possible. For instance, he offers a compelling defense of U.S. President Bill Clinton’s administration’s counterterrorism policies. He shows that Clinton devoted more resources than any previous president to counterterrorism, doubling federal spending between 1995 and 2000. He launched missile strikes on targets in Afghanistan and Sudan, took effective financial action against terrorist groups, and put massive diplomatic pressure on Afghanistan to give up Osama Bin Laden and on Pakistan to pressure Afghanistan to cut ties to al-Qaeda. However, Clinton’s counterterrorism efforts bumped against constraints such as vague intelligence about al-Qaeda, the limits of U.S. ability to influence Pakistani foreign policy, and the lack of political support for bolder military action.

Taliban's war on educating girls and women must end now: A call for global actions

Taliban's war on educating girls and women must end now: A call for global actions

РИНОК ЖИТЛОВОГО БУДІВНИЦТВА РЕГІОНІВ УКРАЇНИ: ПРОБЛЕМИ ТА ПЕРСПЕКТИВИ ВІДНОВЛЕННЯ У ПОВОЄННИЙ ПЕРІОД

The article analyzes the housing construction market and identifies the main factors restraining its growth. First, the author confirms that the housing construction market suffered a significant blow during the spread of COVID-19, as the decrease in construction volumes amounted to 12.4% compared to the previous year, and the second, more massive pressure was felt by the market after the start of armed warfare in Ukraine (a drop of almost 50%). It was determined that despite rather attractive mortgage lending conditions, the housing market is not experiencing a significant recovery. Secondly, in the regional context, such changes were uneven, for example, during the "covid" period, some regions managed to maintain positive dynamics, such as Poltava and Vinnytsia regions, where the growth was more than 25%, while some regions, on the contrary, "fell rapidly", losing up to 30% of housing construction volumes compared to the previous year (for example, Luhansk region - the fall was more than 60%). At the same time, the correlation between the volume of housing construction and the gross regional product per capita, which were adjusted for the price index, was confirmed, but there is a basic level of income that should ensure "objective quality" of living for households so that they can invest in housing construction. The study shows that, in addition to household incomes, there are other important factors that can become demotivators for the state and dynamics of the housing market. These include the ability of the state and the banking and financial sector to freely dispose of significant amounts of free funds that can be used for construction. At the same time, the risks of economic instability limit the investment potential of the financial institution (as evidenced by the low activity of citizens in participating in the eHouse program). In addition, economic instability has a significant impact on the development ofconstruction. Thus, it was noted that the greater the fluctuations, the worse the results of the industry. Therefore, the key factors restraining the positive dynamics of this market are the following:low investment capacity of the population, economic instability, external factors (the war factor) and expectations of market participants. Demonstrating the differentiation of indicators of development of the housing construction market by region, it is stated that there has been a change in the "landscape" of growth centers - the western regions of Ukraine have been included in them, which is associated with migration processes (relocation of internally displaced persons), and thus contributes to the restoration of the growth rate of the housing construction market in these regions. Therefore, the further development of the housing market will be associated with the search for and attraction of new investors, for example, European governments, implementation of joint projects and grants to restore energy-saving territorial development (including through the construction of social housing), etc.

Conditional Anonymous Remote Healthcare Data Sharing Over Blockchain.

As an important carrier of healthcare data, Electronic Medical Records (EMRs) generated from various sensors, i.e., wearable, implantable, are extremely valuable research materials for artificial intelligence and machine learning. The efficient circulation of EMRs can improve remote medical services and promote the development of the related healthcare industry. However, in traditional centralized data sharing architectures, the balance between privacy and traceability still cannot be well handled. To address the issue that malicious users cannot be locked in the fully anonymous sharing schemes, we propose a trackable anonymous remote healthcare data storing and sharing scheme over decentralized consortium blockchain. Through an "on-chain & off-chain" model, it relieves the massive data storage pressure of medical blockchain. By introducing an improved proxy re-encryption mechanism, the proposed scheme realizes the fine-gained access control of the outsourced data, and can also prevent the collusion between semi-trusted cloud servers and data requestors who try to reveal EMRs without authorization. Compared with the existing schemes, our solution can provide a lower computational overhead in repeated EMRs sharing, resulting in a more efficient overall performance.

Promoting Positive Psychology in Senior High School

Nowadays, many high school students face massive pressure from studying and have less time for them to sleep, which causes them to have mental issues that need to be solved, such as depression or anxiety. Previous research has established that positive psychology is associated with broad attention, creative thinking, and holistic thinking, whereas negative emotions restrict focus on narrow attention in high school students. Based on positive psychology, this paper discusses an effective method of solving this issue. This paper takes 100 senior high school students as research samples through a questionnaire survey and observation method analysis. It is found that the positive psychology curriculum has played a positive role in the education of senior high school students. It proves that positive psychology is applicable in high school classrooms, although some improvements need to be made. This paper could help high schools and other institutions that educate students under 15 to above 18 to figure out a method for them to reduce the likelihood of high school students having mental problems through positive education.

Preliminary Results of 2022 for the Consolidated Budgets of the Subjects of the Russian Federation. Adaptation or Crisis?

The consolidated budgets of the subjects the Russian Federation execution in 2022 was carried out in conditions of massive sanctions pressure on the domestic economy, significant fluctuations in prices on world commodity markets, radical changes in economic logistics chains and an increase in the need for budget expenditures. In January-November 2022, the growth of regional budget revenues only slightly lagged behind the rate of inflation. At the same time, in a number of regions with a significant role of ferrous metallurgy and related mining industries, there was a marked reduction in tax revenues to regional budgets, and in some cases to the consolidated budget of the country. Receipts of corporate income tax during the year had a pronounced tendency to decrease. Budget revenues from personal income tax played a stabilizing role. The growth in the need for expenditures of regional budgets was reflected in their advanced growth in comparison with revenues. The result was a marked increase in the volume of public debt compared to the beginning of the year. At the same time, there has been a tendency to replace bank loans and bond loans with budget loans. Budget loans for some regions are beginning to play the role of instruments to compensate for the vertical financial imbalance.

Coupling Coordination Degree between Ecological Environment Quality and Urban Development in Chengdu–Chongqing Economic Circle Based on the Google Earth Engine Platform

Rapid urbanization often exerts massive pressure on the resources relied upon by the ecological environment. It is necessary to quickly evaluate the interaction and mutual influence between regional urbanization and the ecological environment. This paper uses the Google Earth Engine (GEE) platform, integrates MODIS and night light remote sensing data sets, and computes the remote sensing-based ecological index (RSEI) and the coupling coordination degree (CCD) to measure the coupling coordination and analyze the spatiotemporal changes in the Chengdu–Chongqing Economic Circle (CCEC) for 2010, 2015, and 2020. Our results demonstrate four key findings. Firstly, the CCD varies spatially; it peaks at the Chengdu and the West Chongqing Plains, decreasing outwards along the mountains, with the lowest degree of coupling in the central, southern, and northern edge areas of the CCEC. Additionally, it has shown a trend of maintaining unchanged first and then increasing, mainly responding to policy decisions. Secondly, the changes between the different coupling levels were almost stable and mainly occurred between adjacent levels. Thirdly, the coupling level of towns spreads outwards from the centers at Chengdu and Chongqing and has an overall upward trend in time. Fourthly, in the most recent year, the coupling types present a distribution pattern of one developing axis connected with two peaks. Specifically, the environment system lagging type aggregates in Chengdu, Chongqing, and their surrounding areas, and the others mainly are economic system lagging type. The high internal coupling type also mainly occurs in the high and low coupling levels. Under this context, constructive suggestions for developmental optimization in the study area were proposed.

Evaluating Portuguese Public Hospitals Performance: Any Difference before and during COVID-19?

COVID-19 is a well-known respiratory disease that has spread worldwide since January 2020, causing many deaths and massive pressure on health systems. This pandemic’s appearance compromised health service sustainability and quality as many procedures were postponed or canceled, with an expected increase of adverse events like nosocomial infections, in-hospital deaths, and the worsening of the patient’s clinical status. For instance, the year 2020 featured an increase in undesirable results in Portugal: a rise of 10% in delayed first medical appointments, 0.02% in avoidable bloodstream infections, and more than 100 post-operative pulmonary embolisms and septicemia cases per 100,000 inpatients. Therefore, assessing whether the healthcare providers’ performance has changed is paramount. In this case, we evaluated public hospitals in Portugal. To this end, we developed a network data envelopment analysis model relating to efficiency and effectiveness. We observed consistent drops in efficiency when the pandemic started, followed by a recovery to levels above the pre-pandemic ones. Regarding effectiveness, we observed a positive trend during the evaluated period. We conclude that, apart from the great resilience of public healthcare providers, the Portuguese state was unprepared for a pandemic like COVID-19, but still the actions taken (including massive vaccination) were beneficial.