Artificial intelligence (AI) was introduced to develop and create “thinking machines” that are capable of mimicking, learning, and replacing human intelligence. Since the late 1970s, AI has shown great promise in improving human decision-making processes and the subsequent productivity in various business endeavors due to its ability to recognize business patterns, learn business phenomena, seek information, and analyze data intelligently. Despite its widespread acceptance as a decision-aid tool, AI has seen limited application in supply chain management (SCM). To fully exploit the potential benefits of AI for SCM, this paper explores various sub-fields of AI that are most suitable for solving practical problems relevant to SCM. In so doing, this paper reviews the past record of success in AI applications to SCM and identifies the most fruitful areas of SCM in which to apply AI.

Purpose: The global pandemic COVID-19 unveils transforming the supply chain (SC) to be more resilient against unprecedented events. Identifying and assessing these risk factors is the most significant phase in supply chain risk management (SCRM). The earlier risk quantification methods make timely decision-making more complex due to their inability to provide early warning. The paper aims to propose a model for analyzing the social media data to understand the potential SC risk factors in real-time.Design/methodology/approach: In this paper, the potential of text-mining, one of the most popular Artificial Intelligence (AI)-based data analytics approaches for extracting information from social media is exploited. The model retrieves the information using Twitter streaming API from online SC forums.Findings: The potential risk factors that disrupt SC performance are obtained from the recent data by text-mining analyses. The outcomes carry valuable insights about some contemporary SC issues due to the pandemic during the year 2021. The most frequent risk factors using rule mining techniques are also analyzed.Originality/value: This study presents the significant role of Twitter in real-time risk identification from online SC platforms like “Supply Chain Dive”, “Supply Chain Brain” and “Supply Chain Digest”. The results indicate the significant role of data analytics in achieving accurate decision-making. Future research will extend to represent a digital twin for identifying potential risks through social media analytics, assessing risk propagation and obtaining mitigation strategies.

It has been more than a year since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) “eruption” on the world scene and the coronavirus disease 2019 (COVID-19) pandemic engulfed all lives on all continents. And quite the year, was 2020! Physicians from all specialties have been affected, both personally and professionally; from screening for and treating patients with COVID-19, which did not fall in their area of expertise, or from delaying care of patients with acute and chronic disorders with other pathologies. Moreover, COVID-19 created new pathologies and several patients with chronic conditions are at higher risk. Further complicating the picture; most non-acute care has been moved on and off from in-person clinic visits to remote telemedicine visits, while elective surgeries have been also on hold during several “pause” waves. Pituitary diseases and several disease components, such as acute visual loss, tumor mass effects, or chronic conditions such as adrenal insufficiency (AI), hypopituitarism, Cushing’s disease (CD) or growth hormone (GH) excess (acromegaly) have had tremendous interplay with COVID-19. Several recommendations from international experts published by the Pituitary Society (1) or the European Journal of Endocrinology, affiliated with European Society of Endocrinology (2–5) were published early in the course of the pandemic; notably, a re-evaluation every few months in light of emerging data, was suggested (1, 6). Unfortunately, at this time, despite an ongoing unprecedented vaccination campaign, the risk of viral infection load in many countries is the highest it has been and local rules for “lockdown” have been intensified rather than relaxed overall. Furthermore, many patients without a history of pituitary disorders who have had severe SARS-CoV-2 are being treated with high dose glucocorticoids (GC). This is based on data suggesting that abnormal immune reactivity could cause additional lung damage and progression to severe respiratory failure rather than uncontrolled viral replication. Notably, dexamethasone was shown to reduce intermediate (28-day) mortality among patients on either invasive mechanical ventilation or oxygen alone in the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial (7). However, administration of anti-retroviral drugs and high dose GC use could trigger drug–drug interactions and enhance exposure to drugs that are metabolized through the CYP450/CYP3A pathway, impacting the hypothalamic-pituitary-adrenal HPA axis (8) and highlighting a need for HPA axis monitoring at discharge from the hospital. Another interplay between COVID-19 and pituitary disorders is linked to the suggestion that many patients with fractures should start, in addition to calcium and vitamin D supplementation, early bone-targeted treatment, even while in hospital (9). This can prove complicated due to limited resources that prompt early discharge during the COVID-19 pandemic. As such, a communication plan regarding the importance of anti-osteoporosis treatment post-discharge is essential (10). Many patients with pituitary disorders who are at higher risk of fractures such as CD, acromegaly, hypopituitarism (11–14), and central AI could thus possibly need anti-resorptive treatments (15). Here, we focus on updates on the risks associated with COVID-19 in patients with pituitary disorders. We also discuss management of patients with either new or long-standing pituitary disorders in the setting of limited healthcare delivery due to the pandemic. Patients with CD can experience many comorbidities, which can in turn increase complication(s) risk if patients with CD become infected with COVID-19 (1, 5). It has been recognized that the severity of COVID-19 is higher in patients with diabetes mellitus (DM) and hypertension (16) Moreover, COVID-19 might increase the risk of hyperglycemia, which can modulate immune and inflammatory responses, thus worsening the risk of severe disease (17). Complicating the picture even more, many medications used for COVID-19 treatment can affect glucose metabolism, particularly with preexisting DM; thus, both glucose monitoring and individualized management are usually needed for patients with DM and/or hypertension (16). Patients with cardiovascular or kidney disease have been also shown to have a poorer prognosis than those without these diseases and COVID-19 (18, 19). Obesity reduces respiratory system compliance, expiratory reserve volume, and functional capacity. Sleep apnea is more frequent and further impairment of pulmonary function is noted with reduced excursion of diaphragm. Several other comorbidities, including thrombosis, also have a great impact in COVID-19 infected patients’ outcomes (18). However, currently, there are no studies that answer an essential question; are these comorbidities in patients with pituitary disorders having a different impact on outcomes when compared with patients without pituitary function abnormalities (either excess or deficiency)? One could extrapolate that a high burden of cardiovascular, metabolic and respiratory comorbidities would increase overall disease severity in patients with pituitary disorders if they become infected with COVID-19. For patients with active CD who develop COVID-19, risk of severe thromboembolism on already heightened hypercoagulability due to CS could be compounded (20), thus anticoagulation treatment per se, not just preventive doses should be recommended in all hospitalized patients with CS, which can decrease mortality overall (21). Presently, there is limited data on treating patients with CS and COVID-19. Yuno et al., described a 27-year-old female with CD who was awaiting pituitary surgery when she developed COVID-19 pneumonia (22). She was treated with a “block-and-replace” regimen using a steroidogenesis inhibitors combination (high dose metyrapone, 4,000 mg/day and trilostane) and hydrocortisone, and a multimodal treatment that included antiviral therapy. The patient improved clinically and underwent curative surgery 1 month later (after testing negative for COVID-19) (22). Beretta et al., reported on a case of a 67-year-old male with CD, who presented with signs and symptoms of AI; (persistent hypotension and hypoglycemia) after he became infected with COVID-19 (23). Pasireotide and metyrapone and DM treatment were halted, and injectable GC was started. Furthermore, unexpected hyperkalemia in CS patients under treatment with heparin, as was the case in this patient, might be a signal of aldosterone suppression and increased awareness for electrolyte abnormalities is needed (23). Titration and/or temporary halting medical therapies in the treatment of patients with CS in the context of COVID-19 infection should be considered; adjustments dependent on drug regimen and symptom severity. If patients are COVID-19 positive, but asymptomatic, an attempt should be made to keep patients eucortisolemic and avoid AI (1, 5). Patients should have at home already and available oral and injectable GC, but administration is probably not needed preemptively unless a patient develops symptoms. In our experience, we have stopped CS medication in two patients with severe COVID-19 symptoms and administered high dose GC for a few days with no long-term complications, and complete recovery in both patients (unpublished data). For patients who are not on a “block-and-replace” regimen, during the height of the pandemic when emergency department and urgent care visits were limited, mild hypercortisolemia, especially for a short period of time is preferable versus AI/adrenal crisis. On the other hand, Etomidate treatment might also be needed for patients with severe newly diagnosed CD in the context of COVID-19 if hyperglycemia is uncontrolled, hypertension and infections are present, and imaging and/or definitive treatment(s) with tumor removal are postponed. A study by Mirani et al., showed that glucose level at hospital admission and ongoing anti-diabetic drugs may influence the outcome of COVID-19 in patients with DM2 (24). Interestingly, patients on insulin therapy at admission had a more severe evolution of COVID-19 (a more than three times increased mortality risk). Patients taking Dipeptidyl peptidase-4 inhibitors (DDP4-I) had better outcomes. However, the number of patients taking DDP4-I was small. A clear conclusion cannot be determined, but this raises an interesting hypothesis, one which was also suggested in another observational study in patients with type 2 diabetes taking Sitagliptin (25). Specific data in patients with endogenous CS is lacking, but one can assume that if there is no contraindication DDP4-I should be considered in the treatment armamentarium if a COVID-19 hospitalization ensues. Lastly, one should consider many possible interactions between the pharmacological treatment of CS and medications used to treat COVID-19 that have the potential for QTc prolongation, liver toxicity, and hypo- and hyperkaliemia (8, 23). Patients with acromegaly have several characteristics that could potentially worsen their outcome if they develop COVID-19 (26). Patient baseline comorbidities and treatment management may also be impacted due to drug-drug interactions with some medications used to treat COVID-19. Some studies have shown a higher risk of arrhythmias in patients with acromegaly, and an increase of QTc interval is a possible side effect of octreotide, lanreotide, and pasireotide, (long-acting somatostatin receptor ligands; SRLs) treatment (26). Prevalence of glucose abnormalities (prediabetes and diabetes) in patients with acromegaly is high, up to 50% (27), and hypertension is reported in approximately 30% of patients (27). There are no available studies in patients with acromegaly, however, data shows that fasting blood glucose (FBG) ≥ 7.0 mmol/l at admission is an independent predictor for 28-day mortality in patients with COVID-19 without a previous diagnosis of diabetes (28). This highlights the need for close monitoring and glycemic control in all COVID-19 patients. Interestingly, a new study showed that risk is considerably decreased in patients treated with metformin prior to COVID-19 diagnosis, thus raising the idea that metformin could be somewhat protective in this high-risk population (29). Another co-morbidity; bone disease with vertebral fractures (VFs), which could influence cardiorespiratory function and disease outcomes has a high prevalence in patients with both controlled and uncontrolled acromegaly (27, 30). A recent Italian study (114 patients admitted with COVID-19 and no known pituitary disorders) found thoracic VFs in 41 patients (36%) (31). Patients with VFs here were older and more frequently affected by hypertension and coronary artery disease, were hospitalized and more frequently required noninvasive mechanical ventilation compared with those without VFs. Furthermore, mortality was higher in patients with VFs compared to patients without VFs, and was higher in patients with severe VFs compared to those with moderate and mild VFs (31). As VF seems to be a good marker of patient fragility and poor prognosis, it will be important to continue to study patients with acromegaly who develop COVID-19 and subsequent outcomes. Epidemiological studies showed a sex dimorphism (with male preponderance) and age-dependent disease susceptibility to the severity of COVID-19 disease, with young individuals experiencing overall a milder illness. The progressive functional decline and dysregulation in the immune system in both sexes with age could be the culprit (32). Brandi and Giustina (32), suggest that sex-specific measures be considered in a comprehensive management plan for patients with COVID-19; adjusting testosterone replacement doses in men to avoid a pro-inflammatory response of hypogonadism and increased venous thromboembolism (VTE) typical of higher testosterone levels. For women, stopping oral contraceptives, but continuing menopausal hormone replacement therapy, preferably transdermal estrogen is recommended (32). While evidence of hypothalamic-pituitary involvement by SARS in a study of 61 survivors has emerged following the 2003 outbreak (33), there is no evidence of a direct COVID-19 effect on the pituitary or hypothalamic axis. Interestingly, 40% of SARS survivors had biochemical evidence of central AI, which mostly resolved within a year (33). Historical data on impaired immune function may suggest higher risk of complications and mortality in patients with AI. A large retrospective case-control study undertaken in Lombardy, Italy, (one of the most affected areas in Italy, in the Spring of 2020) by Carosi et al., analyzed data collected with a standardized telephone questionnaire from 279 patients with primary and secondary AI and 112 controls (with benign pituitary lesions with normal pituitary function (34). Prevalence of symptomatic patients (complaining at least 1 symptom of viral infection) was similar between the two groups (24% in AI and 22.3% in controls, p = 0.79). The exact prevalence of infections is, however, unknown as testing was undertaken in just 12 patients. However, highly suggestive COVID-19 symptoms (at least two including fever and/or cough) occurred equally in AI and controls (12.5% in both groups). No hospitalization and no adrenal crisis were reported (34). It is reassuring that patients with AI who are on adequate GC replacement and appropriately adjust stress doses do not have higher rates of COVID-19-suggestive symptoms and/or disease severity compared with controls (34). Treatment of patients with AI under major stress to avoid adrenal crisis has been studied (35) and should be considered when treating critically ill patients with COVID-19 (2). Expert consensus has recommended oral stress-dose coverage of 20 mg hydrocortisone (HC) every 6 h to maintain a more continuous level of steroid support in a patient with known AI; given the known associated persistent inflammation and stress associated with either suspected or confirmed acute COVID-19 infection (2). The Italian Society of Endocrinology Expert opinion (36) has taken a different approach; suggesting doubling the usual steroid dose in patients with suspected COVID-19 who have mild symptoms, but increasing to 100 mg HC (parenteral preferred) if there is progresses to what is defined as moderate COVID-19, and finally a high-dose 200 mg/24 h continuous infusion if COVID-19 is defined as severe. Due to known coagulation abnormalities associated with GC use and coagulopathies observed with severe COVID-19 anticoagulation has been suggested in all of these patients (36). Several possible pathophysiologic mechanisms linking alterations in GH/IGF-1 axis and severity of COVID-19, including links to obesity have been suggested, but more research is needed (37). A single center retrospective study has shown that COVID-19 may be associated with a high risk of thyrotoxicosis due to systemic immune activation by the SARS-CoV-2 infection. This can potentially complicate the management of partial central hypothyroidism in some patients with COVID-19, thus close monitoring and thyroid replacement adjustment is advisable (38). Patients with pre-existing conditions, including endocrine disorders may be vulnerable to plasma sodium abnormalities in more severe cases of COVID-19 (3). There have been no specific published reports, just yet. Patients with DI who develop respiratory complications of COVID-19, especially those with adispic DI are at significantly increased risk of dysnatremia and desmopressin should be administered parenterally (3). A recent expert opinion review advises how endocrinologists can optimally care for ambulatory patients with central DI and hyponatremia, when regular visits and biochemical assessments are delayed (3). There are several highlight points; 1) priority of routine treatment of central DI should be to avoid hyponatremia, thus physicians and patients should be aware of the importance of delaying desmopressin doses to allow proper free water clearance, and 2) preference of 0.9% sodium chloride use as volume restoration in patients with COVID-19 hypovolemic shock, even if there is hypernatremia. The authors suggest that in the absence of hypovolemic shock, patients with DI and severe dehydration should be treated with hypotonic fluids (3). The precise impact and measure of pandemic restrictions, even for patients who do not contract COVID-19, such as delays in diagnosis and care due to resource alteration by healthcare institutions is not known. However, a few investigators, using surveys, are attempting to determine the direct and indirect impact of the COVID-19 on patients with pituitary disease from a patient and a physician perspective. In a large study that included 412 patients (412/586; 70.3% answered a survey) in a single center cross sectional survey in the UK (interestingly few patients actually had COVID per se); 66 patients (66/412; 16.0%) reported having suspected COVID-19 infection, and from 10 patients tested, just three had a positive test (39). Furthermore, no deaths due to COVID-19 were identified. Blood tests planned to assess or monitor pituitary hormone levels were not performed in almost half of patients, while few had imaging (12.4%) or delayed and planned endocrine dynamic test (1.7%). Of note is that despite only a small percentage of patients having confirmed or suspected COVID-19 infection, over half were still indirectly impacted by the pandemic through a delay or change to their planned care. Furthermore, the study included data up until summer 2020 after a “first wave” and we can assume that now in a “third wave” and with ongoing lockdowns, delay in regular care combined with number of patients affected by COVID-19 could be actually much worse. An additional worrisome trend was the spontaneously reported comments on the negative impact of the COVID-19 pandemic on their mental health (39). While the negative psychological effects of quarantine have been recognized (40) ongoing research and mitigation efforts are needed. An international survey, focused on patients with acromegaly included endocrinologists, patients, nurses and neurosurgeons; data from endocrinologists was published (41) and interim patient data recently presented (42). Questions focused on five broad categories; 1) impact on evaluation and diagnosis, 2) access to treatment and management, 3) impact on monitoring, 4) role of technology and remote communication, and 5) future management. The majority of endocrinologists who responded (n = 84) were based in Europe (67.9%) (41). In terms of patient-perceived risk, 76.2% of endocrinologists indicated that patients had approached them asking if they had increased COVID-19 risk. Forty-one-point seven percent (41.7%) of respondents reported that their patients had actively sought advice regarding acromegaly management under pandemic conditions, and 59.5% reported that patients had sought help regarding medical therapy. Half indicated that they believed that the role of self/partner-administered SRLs plays increased role under pandemic conditions, with 33.5% of respondents recommending a switch to self/partner-administered SRLs in patients lacking biochemical control and just 9.5% of respondents recommended delaying monthly SRLs to avoid possible patient exposure to COVID-19. These results suggested the COVID-19 pandemic is substantially affecting the care of patients with acromegaly. However, 55.9% noted that remote methods improved communication with patients. The goal of these changes must be both to improve care while safeguarding patients from more severe involvement in concomitant acute illnesses such COVID-19. Effects of the pandemic on patients living with acromegaly were similarly broad in the survey (42) with more than one-quarter of patients from 182 interviewed reporting difficulties accessing therapy; 39.0% respondents agreed or strongly agreed that the COVID-19 pandemic had affected their ability to provide samples for regular laboratory testing. Twenty-six-point nine percent (26.9%) of respondents reported limited access to injectable drug therapies and 22.0% reported access to care-team members who administer injectable therapies were affected. Just 2.8% respondents had tested positive for the SARS-CoV-2, highlighting again how much care has been affected for all patients. More than half (51.1%) agreed or strongly agreed that the pandemic had made managing their condition more challenging (42). The number of community cases and inpatients with COVID-19, and staffing shortages (43) should play a role in calculating a staged volume limiting approach to scheduling patients’ surgeries. Fortunately, the personal protective equipment (PPE) shortage has improved since the start of the pandemic, when due to severe limitations, elective surgeries were put on hold and only emergent cases were prioritized and performed, but now there are new challenges due to magnitude of COVID-19 cases overall. The type of pituitary disease is also an important consideration to determine need for surgery. The Pituitary Society (1) proposed stratifying cases as emergent, urgent, or elective. Pituitary apoplexy with acute severe visual loss, or other significant mass effect, or possible malignant pathology should be considered emergent or urgent. The approach in pituitary apoplexy differs from center to center and country to country; for example, initial use of high-dose dexamethasone has been suggested even in non-pandemic times in patients without severe visual loss (4, 6). Involution of a pituitary adenoma after pituitary apoplexy has also been reported in a patient whose surgery was delayed during the COVID pandemic (44). A case-by-case basis decision for urgent surgery should be made for patients with slowly progressive visual loss, functioning tumors with aggressive clinical features, if not controlled by medical therapy. Other types of tumors, either functioning ones, well controlled on medical therapy or nonfunctioning adenomas can be scheduled as elective cases (6). Testing for COVID-19 at 48–72 h prior to any surgery is advised (45, 46), especially for pituitary surgery where risks are higher for patients, but also for staff (43, 47). Intensified preoperative screening, even in asymptomatic patients, reverse transcription polymerase chain reaction (rRT-PCR) for all symptomatic cases, and an increased use of airborne PPE was reported in a large international survey to associated with decreased reports of COVID-19 transmission during transsphenoidal surgery (TSS) (45). Interestingly in the survey, patients were reportedly asymptomatic 32% of the time in cases of healthcare transmission (45). A postoperative outcomes study of patients diagnosed with COVID-19 peri-operatively, found 14/51 (27.5%) postoperative mortality rate and severe mostly pulmonic complications, as well as high medical staff exposure and transmission (46). If a patient is positive for SARS-CoV-2, surgery is usually delayed at least 30–45 days unless needs are urgent or there is worsening clinical status that cannot be medically controlled. Interestingly, safe TSS has been reported in a COVID-19 positive patient presenting with pituitary apoplexy few days after inducted vaginal delivery (48). In patients with high suspicion of hypercortisolemia, testing should be performed accordingly. While initially postponing some tests in the height of the pandemic was recommended (1, 5), the longer duration of the status quo could be detrimental to patients who typically, have already experienced a long delay in diagnosis. Overall step-wise testing, screening, confirmation and localization is still suggested. However, a few tests can be performed at the same time rather than sequentially. At our Center, for patients evaluated by telemedicine with high suspicion of CS, two salivary cortisol and urinary free cortisol (UFC) are ordered. When a patient drops them at the laboratory, adrenocorticotropic hormone (ACTH) and other testing can be checked as needed. Initial concerns related to risk of COVID-19 transmission with salivary cortisol kits (5) were assuaged. Salivary cortisol remains an important screening test with proper precautions (1). Once a CS diagnosis is made, because immunosuppression and thromboembolic disorders are common CS features, cortisol-lowering medical therapy, osilodrostat, ketoconazole, metyrapone, which are usually rapid acting (within hours or days), or etomidate, when immediate cortisol control is required, should be temporarily used (5). Treatment should be individualized and selected based on patients’ clinical features, comborbidities, drug availability and drug-drug interactions (49). Patients should have disease and treatment education/teaching online, preferably by video and numerous follow-up visits are needed initially to up-titrate doses until eucortisolemia is achieved. “Block-and-replace” has been suggested as a possible better suited treatment regimen for some patients when there is a high risk of COVID-19 in the region (1, 5). With a prolonged pandemic, periods in between peaks with more access to operating rooms and beds should be actively sought out. Patients who do not tolerate or are not controlled on medical therapy should be further selected for referral planning to surgery, especially for adrenal CS, but also CD. For ectopic CS, initial recommendations suggested a possible wait of 3–6 months for low grade neuroendocrine tumors (pancreatic or lung) (5). However, these timelines have passed now and an active plan for surgery at the same time restrictions are partially lifted is advisable. Patients with acromegaly have frequently associated comorbidities such as cardiovascular complications, DM, restrictive pulmonary disease, and obstructive sleep apnea (27, 50), all of which are associated with higher risk of complications if COVID-19 infected (see above). Furthermore, delay in diagnosis is already very long in these patients even in non-pandemic circumstances, up to 11 years in some cases. A diagnosis could be made via telemedicine evaluation (preferably by video) and screening/confirmatory laboratory work-up. An elevated IGF-1 in a patient with clinical features of GH excess should promptly trigger the need for imaging and treatment. Correspondingly, for any patients with newly diagnosed pituitary adenoma, hormonal laboratory work-up should include IGF-1 to rule out GH excess (6). If imaging shows a pituitary tumor that is not compressing optic chiasm, while planning for surgery (see above) depending on hospital and region characteristics, medical therapy should be at least considered. During the pandemic, at our Center, we have treated many patients with newly diagnosed GH excess with primary therapy, either SRLs or pegvisomant. Most patients treated with SRLs had overall larger tumors and did not have severe DM; patients were started on injections at higher doses (rather than the usual slow up-titration), lanreotide 120 mg or octreotide 30 mg. While octreotide requires nurse administration, lanreotide can be safely self- or partner-administered at home in most cases. Nurse teaching for injections either in clinic or by video has been helpful for patients to increase their confidence and to supervise a first injection. A few patients with small tumors and comorbidities, as diabetes for example, could be treated initially with pegvisomant (1, 2, 6, 50, 51), which has a subcutaneous administration. For patients on long-term medical treatment when the pandemic started, some adjustments have been also helpful, for example increasing SRLs doses, which allowed for a longer injection interval (5–6 weeks or even more) (1, 2, 6, 51) for patients who could not have injections at home. In the US, oral octreotide has been Food and Drug Administration approved and available since the Fall of 2020, thus allowing some patients controlled on injectable SRLs (but requiring nurse visits for administration) to switch to an oral therapy (52). Close monitoring is needed for all patients, either on stable therapy or especially after changes are made; serial IGF-1 and GH (except for patients on pegvisomant), safety testing in conjunction with signs or symptoms elicited during a telemedicine visit. Many investigations required for screening of acromegaly related complications (27, 30) have been almost completely arrested. It is essential that patients are advised and even scheduled in advance wherever possible, to undergo screening when hospital systems open up, or even in between COVID-19 low and high infection rates. Most patients with prolactin-secreting tumors can be medically treated with dopamine agonists (DAs) (50). However, these drugs are now recognized to increase risk of depression and impulse control disorders (ICDs) (53, 54) and mental health is understandably, more so affected during a pandemic. It is critical that both comprehensive psychiatric history and concomitant medications are acquired before starting DAs (1); specific questions might be needed to elicit response, especially if visits are undertaken virtually. Patients with larger tumors who need treatment and have severe depression at baseline would require multidisciplinary management with psychiatry and close monitoring. Serial virtual visits every 2 weeks have been helpful for clinical monitoring and dose adjustments in the authors’ personal experience. Counseling on sick-day rules and to start GC stress dose treatment immediately at the onset of symptoms suspicious for COVID-19 (even if not confirmed) in patients with known AI is essential. Furthermore, these doses should be continued until symptom resolution. If a COVID-19 infection is confirmed, depending on severity of symptoms doses will vary (see above). Confirming with patients at every visit their home supply of both oral and injectable GC increases compliance and reinforces the importance of adrenal crisis prevention with patients and their family (1, 2, 6, 51). Relatively surprisingly, data shows that most patients with GH deficiency of all ages, including children and adults, but also transition patients had overall good adherence to GH therapy during the COVID-19 pandemic (55). The authors’ explanation of this better than expected adherence in the pandemic compared with previous data was linked to home confinement despite the disruption of clinical care for many patients. Reduced access to day-to-day regular clinical services for patients with suspected or confirmed pituitary disease, could create delays in both diagnosis and treatment plans. A modified management approach is needed for patients who require regular/routine monitoring, which likely will vary from country to country depending on health care systems and virus load. Patients with pituitary disorders should be stratified by risk and virtual follow-ups generally recommended to further evaluate any changes. Many of these patients have hypopituitarism including secondary AI, requiring stress-dose GC. For patients with hyper-functioning tumors; acromegaly, CD, and prolactinomas, laboratory testing, though initially postponed for few months at the beginning of the pandemic is needed to ensure patients are well controlled on therapy or that the disease did not recur. Dose adjustments can be made based on clinical assessment and telemedicine virtual visits in the interim. A tight balance between minimizing frequency to reduce infection risk and monitoring for tumor growth is also required for pituitary imaging in patients with more aggressive tumors. A year into the pandemic, change in how patients are treated is still needed. To prevent an increase in complications and patient satisfaction, motivation, but also adherence, care delivery standardization for pituitary disorders is advised in this crisis. Hope is, however, on the way with multiple vaccination programs. 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Eur J Endocrinology (2019) 180(1):31–40. doi: 10.1530/EJE-18-0682 CrossRef Full Text | Google Scholar 55. Giavoli C, Profka E, Giancola N, Rodari G, Giacchetti F, Ferrante E, et al. Growth hormone therapy at the time of Covid-19 pandemic: adherence and drug supply issues. Eur J Endocrinol (2020) 183(4):L13–5. doi: 10.1530/EJE-20-0481 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: COVID–19, pituitary, SARS–CoV–2, medical treatment, risk Citation: Fleseriu M (2021) Pituitary Disorders and COVID-19, Reimagining Care: The Pandemic A Year and Counting. Front. Endocrinol. 12:656025. doi: 10.3389/fendo.2021.656025 Received: 20 January 2021; Accepted: 15 February 2021; Published: 12 March 2021. Edited by: Reviewed by: Copyright © 2021 Fleseriu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Maria Fleseriu, [email protected]

The Covid-19 pandemic has swept the world in fewer than 3 months, and there remains no end in sight. Approximately 6.1% of Covid-19 cases were classified as critical—defined as respiratory failure, shock, and multiple organ dysfunction or failure (1). Among the critically ill Covid-19 patients, ~6–47% of them were intubated in China (2–7), 71–75% were intubated in the United States (8, 9), and 88% were intubated in Italy (10). The sheer volume of patients who require invasive mechanical ventilation support entails that anesthesia professionals have been put under significant pressure during this pandemic. This pressure is exacerbated by the fact that many urgent and emergent surgeries must proceed, even in situations in which patients have confirmed or suspected Covid-19. Clearly, anesthesia providers are playing a fundamental role in the frontline efforts to fight against this formidable pandemic. This paper discusses the impact Covid-19 is having on contemporary anesthesia practice through different phases and highlights some of the lessons we can learn to inform future practice (Figure 1). Figure 1. Impact of the Covid-19 pandemic on anesthesia practice through different phases. Be it as a measure of precaution, resource-saving, better manpower allocation, or ensuring availability of hospital beds, many hospitals throughout the world have canceled or postponed elective and semi-elective surgeries amid the current pandemic. While the reduction in the volume of surgical procedures being performed varies across different hospitals, it can be as high as 70–90%. This move suddenly relieves most anesthesia providers from perioperative care, with only a small portion being deployed to provide anesthesia for urgent or emergent surgeries. At the same time, as a result of the rapidly expanding number of patients admitted to hospitals and intensive care units (ICUs), anesthesiologists are being mobilized and re-deployed to serve outside the perioperative setting. During this pandemic, anesthesia providers are typically being asked to provide the following services: (1) to intubate critically ill patients who require invasive mechanical ventilatory support; (2) to work in the ICU in the roles of intensivists, respiratory therapists, or nurses; (3) to place intra-arterial catheters and peripheral or central intravenous catheters; and (4) to work in the emergency departments or fever clinics to ensure the gaps in resources created by the sudden increase in symptomatic patients are filled (11). This is the overall global picture; however, the type and load of the work assigned to anesthesia providers outside the perioperative environment primarily depend on the number of cases encountered by individual hospitals and vary by country. Various issues that directly impact anesthesia providers have arisen in the midst of providing care to critically ill Covid-19 patients. These issues are related to self-protection, best practices of intubation and ventilation, and professional liability in delivering care to patients outside any specialist scope of practice. In mid-March 2020, an article was published documenting the intubation and ventilation experiences in one of the epicenters—Wuhan, China (11). In this paper, the authors described the personal protective equipment (PPE) used by the Chinese healthcare workers. Of note, when performing invasive procedures in Covid-19 patients, including intubation and ventilation, all healthcare workers in China were required to follow Level III protective measures. Put simply, this mandates coverage of the entire body (11). This practice has caused a wide-range discussion outside China. In comparison, in the United States, standard protective practice does not involve covering the neck or leg below the knee. Although we agree that neither under-protection nor over-protection are warranted, the most ideal approach to self-protection is unclear. We hope this information will come to light with future analyses of worldwide practice data. Regardless of what level of protection is most efficient, the shortage of PPE has caused some significant concerns. Especially at the early stage of the pandemic, there is a global shortage of almost every piece of PPE that is deemed necessary when performing invasive procedures in Covid-19 patients. Many medical practitioners are scrambling to identify methods of sterilizing and reusing N95 masks and/or making their own face shields. Reports of doctors and nurses using unconventional self-protection innovations, such as transparent plastic bags to cover the head and neck, have flooded social media and newspapers. The shortage of PPE and the difference in the availability of self-protection resources across different hospitals, regions, and countries have caused concern and confusion, and this has even resulted in some providers refraining from attending work (12). Moving forward, ensuring adequate PPE supply at all times with a robust production and supply chain capability is a priority. In regards to the best practice when intubating and ventilating Covid-19 patients, there is no universal agreement, but the experiences of different countries should be considered (11, 13–16). Most anesthesia providers typically perform the following steps during intubation: (1) maintain the oxygenation and ventilatory support that has already been used in the patient; (2) avoid bag-mask ventilation if possible; (3) use 100% oxygen for 5 min during pre-oxygenation; (4) cover the patient's nose, mouth, and face; (5) perform rapid sequence induction; (6) aim for complete muscle relaxation; (7) avoid coughing and bucking; (8) perform video laryngoscope guided intubation; and (9) avoid chest auscultation. When delivering ventilatory support, most providers adhere to the following processes. They should avoid non-invasive ventilation, including continuous positive airway pressure and bilevel positive airway pressure, if there are enough ventilators and manpower for invasive mechanical ventilation. This is supported by reports from Lombardy region, Italy, where 11% of cases received non-invasive ventilation and 88% invasive mechanical ventilation during the first 24 h of ICU admission;(10) and in California, United States, 4% of ICU cases received high-flow nasal cannula, 1% non-invasive ventilation, and 91% invasive mechanical ventilation (17). They should adopt lung-protective ventilation strategies; set an ideal oxygenation goal; deliver early prone position ventilation; ensure adequate sedation and analgesia; and provide muscle relaxation when needed (11, 18). Lastly, the best approach to extubation is equally important as it may generate infectious aerosols as a result of patient coughing, and agitation (11). Most anesthesia providers are not credentialled to work outside the perioperative environment, especially in the United States. Although it appears that the Covid-19 crisis is a scenario in which the Good Samaritan principle would apply, there is still a requirement to rapidly authorize anesthesia providers to care for patients in the ICUs, emergency departments, and clinics. Depending on the local policy and practice, credentialing committees should quickly facilitate the process to legally authorize anesthesia providers to deliver necessary services in settings outside the perioperative environment as appropriate. The Covid-19 pandemic presents some unprecedented challenges to anesthesiology departments. The environment is sporadic, chaotic, and unpredictable, with the situation changing daily, if not hourly, especially at the early stage of the pandemic. While every effort is made to ensure all practitioners are updated on the current status via timely communications, confusion and anxiety are commonplace. While it is understandable that almost all practitioners are witnessing a crisis of this severity for the first time in their lives, it is imperative that efforts are invested in streamlining the communication process so things proceed in the most smooth and effective fashion (19). Most anesthesiology departments have quickly established a task force that is specifically responsible for dealing with the Covid-19 crisis. Organized, centralized, clear, and timely communication is essential. The leader of this task force or the individual to whom the leader delegates responsibility needs be in charge of the departmental communication. The message needs be as clear and transparent as possible to avoid any confusion. Reports from front-line staff go to the task force, not the entire department, for collection, summary, and dissemination. Daily conference calls with clinical leadership serve to keep everyone informed and delivering a consistent message to their teams. Every effort needs be made to protect frontline providers (19). The anesthesiology department needs work aggressively with hospital partners to seek alternative sources of supplies when facing a shortage of critical PPE and medications. Counseling for mental health and wellbeing needs be provided to department members (20). Lodging can be considered for individuals who are particularly concerned about risks of contamination of their home environment. Departmental leaders are role models for the team members by offering courage, acting as a source of inspiration, and encouraging a spirit of caring for each other. As of mid-April 2020, the current pandemic appears starting to head into a transition phase, with the progress varying from country to country. The transition phase is characterized by a dramatic decrease, but not complete elimination, of cases and risks of infection. During this phase, regular work order is gradually resumed while continuing to care for varying numbers of Covid-19 patients. During the transition phase, it may be tempting to maximize the capacity of the operating rooms to address the cases that were postponed or rescheduled at the height of the pandemic. However, it is prudent to open the operating rooms more gradually for several reasons. First, the infection risk is lower but still lingers. Infection control requires time and energy and consumes resources. The need to ensure adequate protection and maintain control over the virus should be treated as a higher priority than maximizing caseload, given the potential for severe unintended consequences. Second, perioperative personnel, including anesthesia providers, have relearned and redesigned their approach to patient care to emphasize caution over throughput. Short of a vaccine that abolishes the future risk of Covid-19, there cannot be an immediate return to business as usual. Practitioners likely cannot achieve the necessary level of caution from an infection prevention standpoint, while achieving high throughput surgical volume, without neglecting other aspects of patient care and safety. Third, as we have learned now, some critically ill patients will continue to occupy the ICU beds, even weeks into the transition phase. Therefore, if a surgical case would typically require ICU admission after surgery, there will be a need to coordinate resource management with the hospital bed flow management team. Finally, the spread of the disease (hopefully through community spread and not at-work exposure/infection) will reduce the available workforce unpredictably. Contact tracing and temporary quarantine further reduce the numbers of available workers. Vigilance is needed as the risk of infection still exists during the transition phase. It has been suggested that all surgical patients undergo SARS-CoV-2 nucleic acid (typically a PCR test) and antibody tests and chest x-rays or CTs even if they are clinically asymptomatic. False negative rates are non-zero but poorly defined (2–29% estimated based on current data June 2020) (21). The preoperative preparation during the transition phase requires standardized approaches and policies. At a minimum, anesthesia providers need to be cautious during preoperative patient preparation. It is prudent to do the following: (1) wear a surgical mask and eye protection (goggles or face shield) when visiting, interviewing, and examining patients; (2) wash hands before and after each visit; (3) wear gloves when touching and examining patients; (4) consider avoiding chest auscultation if not clinically indicated; (4) be vigilant for the signs of infection; (5) follow up on pertinent labs; (6) follow up on chest x-ray or computed tomography results if ordered; (7) always remember to screen the patient for a history of Covid-19 and/or close contact with confirmed cases; and (8) consider testing for Covid-19 and the presence of an antibody response. Moreover, data regarding the protection provided by an immune response to prior Covid-19 infection and the duration of immunity are desperately needed. In the operating rooms, full self-protection including N95 masks or power air purifying respirators (PAPRs), goggles or face shields, and waterproof gowns needs be worn if the patient has confirmed or suspected Covid-19; otherwise, wearing a surgical mask with a face shield should be the minimum for patients without evidence of Covid-19. If a Covid-19 patient is undergoing surgery, the following recommendations are advised: 1) perform the surgery in a dedicated Covid-19 negative-pressure operating room; (2) follow the consensus PPE guidelines during intubation and ventilation; (3) ensure smooth emergence and extubation; (4) use filters that are capable of preventing virus transmission/contamination to the anesthesia machine; (5) try to use disposable supplies when possible; and (6) thoroughly clean/sterilize any non-disposable equipment after surgery. Even after the pandemic has been officially declared over, things will not go back to how they used to be (even if there is an effective vaccine). The impact of Covid-19 on anesthesia practice will be deeply embedded. As the adage goes: what does not kill us makes us stronger. The lessons that can be learned from this pandemic are summarized below. The most effective methods of protecting providers against virus transmission need to be identified (22–24). Different hospitals, regions, and countries have adopted different approaches. Evidence regarding the relationship between the various self-protection mandates that are available and the risk of cross-contamination is needed; neither under-protection nor over-protection is warranted. Different viruses have different behaviors, virulence, and modes of transmission; therefore, preparedness to adjust the approach to self-protection when confronting a novel virus and a new outbreak will be needed. A related issue concerns the adequacy of PPE supplies. Regular stockpile checking needs to be mandated. Methods of sterilizing and reusing different components of PPE need to be investigated and established. The supply chain needs to be bolstered, with contacts regularly maintained. All providers should be trained on the appropriate use of PPE, including the donning and doffing processes. The best practices regarding intubation and ventilation need to be elucidated. Although there is some consensus, most of the actions that have been taken thus far amid this pandemic are opinion-based. Evidence to support or revise these is needed. One example is the non-invasive ventilatory support in critically ill Covid-19 patients. Bilevel positive airway pressure ventilation support was popularly used in the epicenter in Wuhan, China (11). Continuous positive airway pressure ventilation support has been used in the United Kingdom (25). However, non-invasive ventilation support has not been widely recommended for use in both Italy and the United States (10, 17). The three primary factors that determine which one to choose are clinical effectiveness, risk of cross-contamination, and the availability of resources. Clearly, the best practices concerning care for critically ill patients in situations like this pandemic need to be further investigated and discussed. The scopes of the clinical skills that future anesthesia providers should possess need to be clarified. This crisis has taught us that, during pandemics of this nature, anesthetists are not only needed for surgical procedures and airway management but also for work in the ICUs, emergency departments, and clinics. It is plausible to quickly teach practitioners immediately before and during the required activities; however, it would be better if the potential need in any future situation similar to this Covid-19 pandemic is anticipated and our providers are proactively trained so that they possess the skills they may need in an emergency situation. The good news is that the skills required outside the perioperative environment (e.g., ventilatory support) are not something unfamiliar to anesthesia providers, as critical care training is a component of anesthesiology residency in most countries. Therefore, regularly updating knowledge and practicing essential skills can be sufficient to ensure preparedness. A mechanism is needed to rally the team when situations similar to this pandemic occur again. This mechanism includes the ability to quickly assemble a task force, identify the available resources, establish a channel for efficient and clear communication, allocate jobs based on the strength and talent of individual team members, deliver counseling to ensure mental health and well-being, and closely collaborate with colleagues from other departments. The goal of this mechanism is to help practitioners efficiently join forces during the fight against a hidden enemy. The success in this great fight against SARS-CoV-2 resides in the resilience of all professionals related to the care for the Covid-19 patients, including nurses and physicians at different levels of training and practices and across different specialties. As we applaud this unprecedented all-out effort, we should also plan further team building to better prepare for any future outbreaks or pandemics. In a crisis like the Covid-19 pandemic, the traditional conduct of education and research are not permissible due to concerns surrounding virus transmission. Many trainees and research personnel have to stay at home for weeks. Instead of staying passive, anesthesia providers should use this period of time to effectively enhance education and research. Doing so also promotes a feeling of enrichment and satisfaction, which is a positive way of promoting well-being. The widely available remote conferencing platforms revolutionize how people are connected with each other in the modern era, making virtual academic activities possible. Contemporary technologies also allow people to gather online, see each other, talk to each other, reconnect with each other, help each other, exchange information, and move forward together as a team. Finally, the coming months during which people are awaiting for a Covid-19 vaccine will hopefully see a true tipping point in the transition to distance learning, expansion of telemedicine, and remote conferencing that will replace destination continuous medical education, non-essential face-to-face patient encounters, and convention center society meetings. The impact of the Covid-19 pandemic on anesthesia practice varies dynamically with the various phases of the pandemic. As we respond, recuperate, and move forward from the Covid-19 pandemic, the impact on anesthesia practice and the lessons learned should be summarized and addressed to ensure better preparedness and results in the future. The areas in which improvements are needed center on self-protection, best practices, scope of practice, organized response, and remote education, research, and gathering. Preparedness may use certain resources and cause financial concern, especially when a crisis is not observed for many years. Therefore, it would be wise to use the process of preparedness to promote a higher quality of patient care, education, research, and culture building. Simulation and quality assurance activities will facilitate “maintenance of preparedness.” Vigilance is the motto of the North American anesthesiology community, and it appears to be more appropriate now than ever. LM helped with the concept and design, administrative and material support, data interpretation, manuscript drafting, and critical revision of the manuscript for important intellectual content. DM helped with the data interpretation and critical revision of the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version. This work was supported by institutional and departmental sources with which the authors are affiliated. 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Med. 7:452. doi: 10.3389/fmed.2020.00452 Received: 07 May 2020; Accepted: 08 July 2020; Published: 21 July 2020. Edited by: Reviewed by: Copyright © 2020 Meng and McDonagh. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Lingzhong Meng, [email protected]

Editorial on the Research TopicToward Consumer 4.0 Insights and Opportunities under the Marketing 4.0 Scenario This Research Topic aims to shed light on the current academic and practical perspectives within the so-called “Consumer 4.0” paradigm. The related perspective on Marketing 4.0 represents new opportunities and concerns for Social Science. Thus, there is a need to find a balance between theoretical frameworks, opinions, and empirical applications, and thereby stimulate dialogues among researchers and professionals. In short, this collection of papers encapsulates the literature on how technological evolution is impacting different actors (companies, consumers, patients, and tourists, etc.) and interacting in various sectors. We also propose research lines based on the combination of two key factors: the advancement of technologies and the impact of the SARS-COV-2 pandemic. This collection builds upon a previous Research Topic, “From consumer experience to affective loyalty: challenges and prospects in the psychology of consumer behavior 3.0,” which influenced subsequent research on the opportunities and challenges inherent to Marketing 4.0. The primary objective of the current Research Topic is to analyze how virtual transformation affects the behavior of very different organizations, industries, and consumers. This Research Topic collection includes 15 research articles spanning diverse publication formats, including 8 Original Research Articles, 4 Opinion Reviews, and 3 Mini-reviews. Although different, the papers have common threads, examining the impact of Information and Communication Technology (ICT) on market demand and business strategy. They are also connected either through the functional scope within the organization or the focal sector in which they are applied. Blazquez-Resino et al. highlight how for companies to be competitive, it is important to establish synergy between Industry 4.0 and Marketing 4.0. Muñoz et al. discuss how investments in technology influence the orientation toward entrepreneurship in SMEs, showing how digital transformation has allowed direct and rapid access to information about consumers in an atomized market, in this case, wine. In an examination of the financial field, Callejas-Albiñana et al. conducted a panel data study among a selected sample of countries to determine the influence of different exogenous factors, aiming to explain stagnation in recent years and outline proposals for new government intervention strategies. In Marketing 4.0, which reflects the impact of the technological revolution on the marketing arena (Jiménez-Zarco et al., 2019), companies face high volumes of information (Big Data) (Lies, 2019) that can be analyzed through data mining techniques (Data Mining) (Sener et al., 2019). Studies on “Big Data” illustrate the importance of capturing and analyzing huge amounts of information and Rubio et al. underscore the importance of virtual communities on the co-creation process. Díaz-Martín et al. analyzed the concept of health e-mavens, showing the importance of conducting investigations with data mining and user-generated content. Through an in-depth review of financial literature, Díaz and Esparcia analyzed investors' risk aversion in terms of different environments, financial products, and temporality, etc. The authors utilized Big Data on financial products to uncover new research lines for risk reduction. Virtual developments also allow scholars to better measure the impact of business strategies on an individual's behavior, namely by monitoring activities in cyberspace, which include search engine queries, social network relationships, and website purchases. In this regard, Wang et al. used behavioral and ERP (event-related potentials) measures to explore the priming effects of monetary and social rewards on e-commerce consumer decisions in China. In their analysis of individual behavior in relation to specific advertising strategies, García-Madariaga et al. reveal the importance of using neurophysiological measures to analyze the appropriate use of visual metaphors, as well as how to maximize impact and ensure that advertising is effective. The extensive use and adoption of technology has not only impacted organizations, it has given rise to a new type of consumer: Consumer 4.0. In an omni-channel context, combining digital and physical media, this type of customer maintains positive and lasting relationships with multiple firms and other actors. However, the characteristics of digital media are particularly impactful on these individual's brand decisions as they complete their brand journey. In this vein, Martinez-Ruiz and Moser analyzed the evolution of the worldwide web and its impact on consumer behavior. As the online environment has evolved, scholars have emphasized the importance of the psychological aspects of consumer behaviour—namely, individual preferences, emotions, and sensory experiences. For instance, Bettiga and Lamberti shed light on the still vague concepts of anticipated and anticipatory happiness. Their results demonstrate the importance of designing visual product communication in a way that elicits positive feelings of anticipated and anticipatory emotions in the viewer. Building upon gratifications theory, Rodriguez-Ardura and Messeguer-Artola developed an integrative and context-specific model that links engagement with enjoyment, self-presentation, and community belonging, which were all identified as motivational factors among Facebook users. Meanwhile, Reinares-Lara et al. measured the experience of people through two dimensions of satisfaction: cognitive (the most studied so far in academic research) and affective (the least analyzed), derived from the analysis of neurophysiological data. According to the previously mentioned category, the tourism industry provides useful case studies for understanding the huge impact of technology. Blazquez-Resino et al. show how ICTs are important for understanding the development of loyalty, making an important distinction between passive attitudinal loyalty, active attitudinal loyalty, and behavioral loyalty. Huete-Alcocer et al. discuss how building an image of a holiday destination is a critical factor in the perceptions and evaluations of that destination by tourists. This study accounts for not only cognitive and affective components but also the unique image component. Moreover, they demonstrate that eWOM is a powerful means of promoting cultural tourism. Focusing on shopping tourism, Muro-Rodríguez et al. highlight its importance for cities, identifying differentiation strategies for cities as shopping destinations and setting out recommendations based on the analysis of key factors for listing a city as a shopping destination. Since the start of the SARS-COV-2 pandemic in early 2020, consumers and companies have faced a new environmental variable that has accelerated the process of digitization and the incorporation of new technologies. This exogenous phenomenon will produce changes in the global economy, organizational management, and consumer habits. Some will be transitory, while others will be permanent. Future papers (and topics) therefore need to investigate how the pandemic will interact with Marketing 4.0 and influence the competitive strategies that allow organizations to obtain competitive advantages and offer adapted products and services to meet these new demands. Notably, disruptive or emerging technologies that companies were previously using as a test have been incorporated in a masive scale into infrastructures in many countries during the pandemic. For example, traditionally, neuroscientific techniques have been used to measure consumer reactions to advertising-related stimuli or to assess the effectiveness of discount coupons or gifts. Easy-to-use neuro-marketing tools are now being implemented to measure the emotions and experiences of consumers from neurophysiological data relating to a wide range of companies from different sectors (including retail, health, and tourism, etc.) and/or diverse purchasing contexts (such as online, offline, and omnichannel, etc.). Scholars with access to longitudinal data (pre- and post- COVID-19), should measure buyer behavior in terms of the variables that influence them before, during, and after the decision-making process. These variables include the impact of perceived risk, which leads consumers to conduct a more systematic and prolonged process of searching for information, mainly on social networks or web pages (Hansen et al., 2018). The relationship between its different components (physical, functional, economic, social, and psychological) may also change based on the product category (Emilien et al., 2017). However, the economic crisis inflicted by the pandemic may produce the opposite effect. Even though the perceived risk is high, certain middle-class segments that were previously financially healthy might be struggling with their basic food shopping. The next variable relates to consumer preferences for different attributes/values and whether they have remained stable or changed. In the mass consumer sector, and particularly in food or personal hygiene, it is worth studying whether consumers are more likely to use safety as a criterion for choosing a product or not. Following on from this, in the future, scholars should explore technological ways of tracking or tracing health or food products. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. This research was conducted under the framework of different research projects and groups: Observatorio de la Innovación en la Distribución Comercial (University of Castilla-La Mancha); TECHNOCONS Consumer Behavior and Technology. (Autónoma University of Madrid); and the I2TIC Research Group (Open University of Catalonia). The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Emilien, G., Weitkunat, R., and Lüdicke, F. (2017). Consumer Perception of Product Risks and Benefits. New York: Springer International Publishing. Google Scholar Hansen, J. M., Saridakis, G., and Benson, V. (2018). Risk, trust, and the interaction of perceived ease of use and behavioral control in predicting consumers' use of social media for transactions. Comput. Hum. Beh. 80, 197–206. Google Scholar Jiménez-Zarco, A. I., Rospigliosi, A., Martínez-Ruiz, M. P., and Izquierdo-Yusta, A. (2019). “Marketing 4.0: Enhancing consumer-brand engagement through big data analysis,” in Web Services: Concepts, Methodologies, Tools, and Applications, ed. Information Resources Management Association (Hershey, PA: IGI Global), 2172–2195. Google Scholar Lies, J. (2019). Marketing intelligence and big data: digital marketing techniques on their way to becoming social engineering techniques in marketing. Int. J. Interact. Multimed. Artif. Intell. 5, 134–144. doi: 10.9781/ijimai.2019.05.002 CrossRef Full Text | Google Scholar Sener, A., Barut, M., Oztekin, A., Avcilar, M. Y., and Yildirim, M. B. (2019). The role of information usage in a retail supply chain: a causal data mining and analytical modeling approach. J. Bus. Res. 99, 87–104. doi: 10.1016/j.jbusres.2019.01.070 CrossRef Full Text | Google Scholar Keywords: marketing 4.0, consumer 4.0, technology, virtual, COVID Citation: Martínez-Ruiz MP, Gómez-Suárez M, Jiménez-Zarco AI and Izquierdo-Yusta A (2021) Editorial: Toward Consumer 4.0 Insights and Opportunities Under the Marketing 4.0 Scenario. Front. Psychol. 11:611114. doi: 10.3389/fpsyg.2020.611114 Received: 28 September 2020; Accepted: 08 December 2020; Published: 11 January 2021. Edited and reviewed by: Darren C. Treadway, Daemen College, United States Copyright © 2021 Martínez-Ruiz, Gómez-Suárez, Jiménez-Zarco and Izquierdo-Yusta. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: María Pilar Martínez-Ruiz, [email protected]

Emerging diseases have significantly impacted the last few decades (1–10). The emergence and re-emergence of vector-borne and zoonotic diseases in Africa, Asia, and Latin America have reshaped the epidemiological landscape of these continents. The impact of these diseases and the establishment of local transmission in traditionally non-endemic areas, due to migration and travel, have been revealed over the last years. Diseases such as Chikungunya (11–16), Zika (17–24), Yellow Fever (25–28), Dengue (29–33), Oropouche, Madre de Dios virus, Iquitos virus (34, 35), Mayaro Fever (36, 37), Ebola (38–42), Nipah virus, arenaviruses such as Lassa (43), Machupo (44, 45), Chapare (45, 46), Junin (47), zoonotic Malaria (48), Severe Fever with Thrombocytopenia Syndrome (49), Plague (50), Crimean-Congo Hemorrhagic Fever, Acute Orally Transmitted Chagas Disease (51–54), Visceral and Diffuse Cutaneous Leishmaniasis (55, 56), Toxoplasmosis (57–59), Tick-Borne Diseases (60, 61), Rift Valley Fever, Tuberculosis (62), Leprosy (63–67), Avian Influenza (68–70), Orthohantavirus (71–75), and Toxocariasis (76, 77) have posed a significant impact to human health. Furthermore, zoonotic epidemics and pandemic coronaviruses, such as the Severe Acute Respiratory Syndrome (SARS), the Middle East Respiratory Syndrome (MERS) (78–82), and the ongoing SARS-CoV-2/COVID-19 (83, 84) pandemic, have caused a profound economical and social disruption threatening to overwhelm public health systems globally (85) (Table 1). Most of these pathogens can even cocirculate and coinfect a significant proportion of inhabitants within the same territories (11, 87–94). For example, in arboviral diseases, the occurrence of coinfections has been widely reported –such as Dengue with Chikungunya and/or with Zika virus– and affects diverse populations, including pregnant women and immunocompromised patients (94–97). This may obscure clinical suspicion, as signs and symptoms for many of these pathogens may overlap. In endemic areas, this becomes a particularly pressing issue that must be taken into account in order to ensure accurate diagnosis and provide appropriate management. The ChikDenMaZika syndrome has been previously adopted as a mnemonic device to include Chikungunya, Dengue, Mayaro, and Zika in the broad differential of acute febrile illnesses due to arboviral agents (95). More recently, emerging coinfections, including bacterial and parasitic diseases, such as tuberculosis and Chagas disease, have also been reported (98). Table 1 Lessons learned from the COVID-19 pandemic in Latin America. Current times call for more comprehensive ecoepidemiological and bioecosocial approaches (20, 99). Scarce funding and the lack of research (39, 43, 61, 81) in tropical medicine are entirely unacceptable. Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), tuberculosis (TB), and malaria combined receive approximately 70% of neglected diseases funding. As mentioned here, emerging tropical diseases, such as those mentioned here, are worldwide in scope, and many have significant regional implications. Therefore, a different funding paradigm that improves their situation is needed (100). The world is no longer a place with distant countries and shielded territories. Instead, ever increasing interconnectivity has turned it into a “small” global village, where the health status of underprivileged areas may undermine not only their lives and development but extend to the wealthiest. The Ebola crisis in 2014 highlighted how high-consequence emerging diseases could spill over to Europe and North America (38, 40). The ongoing 2020-2021 pandemic of COVID-19, which has reached as far as Antarctica, affecting almost all countries worldwide, is another clear example (8, 29, 84, 101–112). As was expected, coinfections between tropical pathogens and COVID-19 are also now increasingly being reported, especially with dengue (30). Dengue affects over 100 countries worldwide and puts about 2.5-3.9 billion people at risk of infection (113, 114). Within the next century, nearly a billion people are at risk of exposure to virus transmission by both main Aedes spp., Ae. aegypti, and Ae. albopictus (also Chikungunya and Zika) in the worst-case scenario (115). The recent first detection of Ae. vittatus in the Dominican Republic and the Americas generated concern in the region, requiring enhanced surveillance to understand the range and public health risks of this potential invasive mosquito species, deserving more studies (116). Most of these emerging tropical diseases are vector-borne, zoonotically transmitted, or environmentally spread through direct contact, food or water ingestion, as well as a consequence of environmental alterations (including the effects of climate change) (117–125), becoming significant sources of mortality and morbidity worldwide (2). The impact of these diseases extends well beyond the acute constellation of symptoms, leading in a considerable proportion of patients to chronic sequelae and complications, which can be long lasting and severely incapacitating, as is the case with Chikungunya (15, 126–132), Zika (17, 133–135), Ebola, Chagas disease (52), and even for COVID-19 (136–139). Many tools have been deployed to counteract emerging infectious diseases. Amongst these are active surveillance (some supported by artificial intelligence) (140–142), leading to the rapid identification of novel pathogens by genome sequencing and phylogenetic tracing studies (36, 105, 107, 143–146) based on computing methods to predict possible interspecies barriers spillover between humans and animals (147). Coupling biotechnological approaches with social sciences—the holistic understanding of humans and their interactions in the disease ecosystems—is also a critical element needed when studying emerging infectious diseases (148, 149). One of the most significant challenges when studying tropical infectious diseases relies on their complexity and heterogeneity, which usually requires a deep understanding not only of the disease itself but its overall context. In order to better approach these diseases one must keep a broader vision of designing proposed interventions, including multilevel ecoepidemiological studies ranging from molecular and omics to satellite epidemiology (use of data and images derived from geospatial technologies, e.g., satellites, for the study of the occurrence and distribution of health-related events in specified populations, and the application of this knowledge to control the health problems) of pathogens, vectors, hosts, abiotic variables, and other socio-environmental factors (125, 150, 151). While more research is required to fill in the numerous gaps in knowledge for many of these diseases, particular attention should be placed in designing strategies to develop methods to forecast these diseases not only in vulnerable and underserved populations from low-income countries but also in those poverty pockets located in high-income countries. A whole chapter to be considered in emerging tropical diseases is vaccines development. Innovative global partnership between public, private, philanthropic, and civil society organisations, such as the Coalition for Epidemic Preparedness Innovations (CEPI), launched in 2017, are important to develop vaccines to stop future epidemics. To accelerate the development of vaccines against emerging infectious diseases and enable equitable access to these vaccines for people during outbreaks is crucial. Nevertheless, more funding to understand biology, pathogenesis, epidemiology, prevention, and treatment of emerging tropical diseases are urgently needed and expected (152–154). Tropical Medicine is no more a clinical specialty of “exotic diseases,” as it was conceived at its beginnings, and is no more about “diseases for those entering the jungle.” One dramatic change is the urban installation of diseases that before were observed only after sylvatic or primary forest exposure. The increase of urban outbreaks of Chagas disease in South America is now a horrific reality in Brazil (155–157), Venezuela (158), and Colombia (159, 160), and it is also a new reality for visceral leishmaniasis (161–164). The integrated work of public health experts, veterinarians, entomologists, and parasitologists is an urgent need to face these new challenges and transformations of tropical diseases. Tropical diseases also include non-infectious diseases, such as animal bites and stings (e.g. myiasis and tungiasis) (165, 166). Snake bites, scorpion stings, and spider bites, account for a significant amount of the morbidity and mortality in tropical countries in these changing scenarios, including ecotourism, rural migration, and other related factors (167–170). There is no doubt that “many things are wrong in the world today”, as the legendary American rock n’roll band Aerosmith has been singing since the 90s. We are “living on the edge”, the edge of neglect and of a surge of many emerging infectious diseases with no hope for resolution in the foreseeable future. Furthermore, “it sure ain’t no surprise” that poverty, inequality, climate change, deforestation, migration, urbanization, wildlife trade, among many other factors, have all contributed to the emergence of novel tropical diseases and the resurgence of other endemic diseases (171). There is no spare place for the arrival of emerging pathogens, and over time pathogens tend to adapt to new environments leading to unforeseen consequences. The next epidemic, the next pandemic, is just around the corner (68). In response to this latent threat, we need to gather real-time information and build collaborative networks aimed to enhance surveillance activities in order to develop high-priority medical countermeasures to prevent and control emerging tropical diseases. Research in Zoonotic and Vector-Borne Emerging Tropical Diseases remains the most critical aspect and the foundation to determine the drivers of emerging and re-emerging infectious diseases. With that vision, our new Section Emerging Tropical Diseases in the journal Frontiers in Tropical Diseases offers to contribute to the scientific advancement and fill in the many knowledge gaps based on a multi and transdisciplinary approach. Our team of Associate Editors is comprised of a diverse group of experts from different countries, diverse backgrounds, and varied interrelated expertises in a wide range of conditions within the tropical diseases spectrum of diseases, following the One Health approach vision (8, 172). Grand challenges exist in the fight against the threat of emerging tropical diseases. In the laboratory, our daily work, in the hospitals, in the field, in the community, and in many other places, our shared goal is to understand the drivers of emergence and address their root-causes. We are working collaboratively in social networks to reduce the impact of emerging tropical diseases. Let’s work on this together! We value your work and welcome your submissions to this new section of Frontiers in Tropical Diseases. All authors contributed to manuscript conception and design, literature review, manuscript preparation, and critical review. All authors contributed to the article and approved the submitted version. RB-M was employed by Laboratorios Lokímica, Spain. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. AR-M is the Specialty Chief Editor in Emerging Tropical Diseases of Frontiers in Tropical Diseases. 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Edited and reviewed by: Jerome Kim, International Vaccine Institute, South Korea Copyright © 2021 Rodriguez-Morales, Paniz-Mondolfi, Faccini-Martínez, Henao-Martínez, Ruiz-Saenz, Martinez-Gutierrez, Alvarado-Arnez, Gomez-Marin, Bueno-Marí, Carrero, Villamil-Gomez, Bonilla-Aldana, Haque, Ramirez, Navarro, Lloveras, Arteaga-Livias, Casalone, Maguiña, Escobedo, Hidalgo, Bandeira, Mattar, Cardona-Ospina and Suárez. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Alfonso J. Rodriguez-Morales, [email protected]