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Golden everlasting paper daisies (Xerochrysum , Gnaphalieae, Asteraceae) were some of the earliest Australian native plants to be cultivated in Europe. Reputedly a favourite of Napoléon Bonaparte and Empress Joséphine, X. bracteatum is thought to have been introduced to the island of St Helena in the South Atlantic during Napoléon's exile there. Colourful cultivars were developed in the 1850s, and there is a widely held view that these were produced by crossing Xerochrysum with African or Asian Helichrysum spp. Recent molecular phylogenetic analyses and subtribal classification of Gnaphalieae cast doubt on this idea. Using single-nucleotide polymorphism (SNP) data, we looked for evidence of gene flow between modern cultivars, naturalized paper daisies from St Helena and four Xerochrysum spp. recorded in Europe in the 1800s. There was strong support for gene flow between cultivars and X. macranthum. Paper daisies from St Helena were genotypically congruent with X. bracteatum and showed no indications of ancestry from other species or from the cultivars, consistent with the continuous occurrence of naturalized paper daisies introduced by Joséphine and Napoléon. We also present new evidence for the origin of colourful Xerochrysum cultivars and hybridization of congeners in Europe from Australian collections. [ABSTRACT FROM AUTHOR]

Morbidity and mortality from ischaemic heart disease (IHD) and heart failure (HF) remain significant in Europe and are increasing worldwide. Patients with IHD or HF might benefit from novel therapeutic strategies, such as cell-based therapies. We recently discussed the therapeutic potential of cell-based therapies and provided recommendations on how to improve the therapeutic translation of these novel strategies for effective cardiac regeneration and repair. Despite major advances in optimizing these strategies with respect to cell source and delivery method, the clinical outcome of cell-based therapy remains unsatisfactory. Major obstacles are the low engraftment and survival rate of transplanted cells in the harmful microenvironment of the host tissue, and the paucity or even lack of endogenous cells with repair capacity. Therefore, new ways of delivering cells and their derivatives are required in order to empower cell-based cardiac repair and regeneration in patients with IHD or HF. Strategies using tissue engineering (TE) combine cells with matrix materials to enhance cell retention or cell delivery in the transplanted area, and have recently received much attention for this purpose. Here, we summarize knowledge on novel approaches emerging from the TE scenario. In particular, we will discuss how combinations of cell/bio-materials (e.g. hydrogels, cell sheets, prefabricated matrices, microspheres, and injectable matrices) combinations might enhance cell retention or cell delivery in the transplantation areas, thereby increase the success rate of cell therapies for IHD and HF. We will not focus on the use of classical engineering approaches, employing fully synthetic materials, because of their unsatisfactory material properties which render them not clinically applicable. The overall aim of this Position Paper from the ESC Working Group Cellular Biology of the Heart is to provide recommendations on how to proceed in research with these novel TE strategies combined with cell-based therapies to boost cardiac repair in the clinical settings of IHD and HF. [ABSTRACT FROM AUTHOR]

Background The value equation of value-based healthcare (VBHC) as a single figure remains ambiguous, closer to a theoretical framework than a useful tool for decision making. The challenge lies in the way patient-centred outcomes (PCOs) might be combined to produce a single value of the numerator. This paper aims to estimate the weights of PCOs to provide a single figure in the numerator, which ultimately will allow a VBHC figure to be reached. Methods A cohort of patients diagnosed with breast cancer (n  = 690) with a 6-month follow-up recruited in 2019–20 across six European hospitals was used. Patient-reported outcomes (PROs), clinical-related outcomes (CROs), and clinical and socio-demographic variables were collected. The numerator was defined as a composite indicator of the PCOs (CI-PCO), and regression analysis was applied to estimate their weights and consequently arrive at a single figure. Results Pain showed as the highest weight followed by physical functioning , emotional functioning , and ability to work , and then by a symptom, either arm or breast. PCOs weights were robust to sensitivity analysis. The CI-PCO value was found to be more informative than the health-related quality of life (HRQoL) value. Conclusions To the best of our knowledge, this is the first research to combine the PCOs proposed by ICHOM to provide a single figure in the numerator of the value equation. This figure shows a step forward in VBHC to reach a holistic benchmarking across healthcare centres and a value-based payment. This research might also be applied in other medical conditions as a methodological pathway. [ABSTRACT FROM AUTHOR]

Smart Specialization policy, Europe's place-based innovation policy, is transitioning into an innovation policy for sustainability inspired by academic debate and the urgency of societal challenges. The implications in terms of policy design remain underexplored. This paper studies the policy implications of this transition on the design of monitoring indicators. First, a theoretical framework based on the literature is created. Then, monitoring indicators used in the first policy phase are summarized into categories and themes through inductive and deductive document analysis. The indicators' strengths and limitations are discussed. By highlighting how monitoring indicators need to adjust to the policy transition, this paper contributes to the literature on innovation policy and Smart Specialization. It also provides guidance to policymakers by developing a framework on indicator design and providing practical recommendations on aspects that need to be considered, captured, and analysed through the indicators. [ABSTRACT FROM AUTHOR]

Social clinics are grassroots health initiatives characterized by the development of mutualist practices of healthcare provision and the articulation of their action at territorial and community level. The present paper explores the development and implementation of community participation practices across three social clinics in Europe: social clinic of solidarity KIA in Greece, Village2Santé in France, and Microclinica Fatih in Italy. Drawing on findings collected through qualitative methods, our paper reflects on three overlapping themes of community participation highlighting its collective and eminently political character. Inspired by the frameworks of health promotion, comprehensive Primary Health Care and community development, we analyze three levels of community participation in the social clinics: participatory medical practices, the co-creation of health services, and the connection with broader social movements. Our paper contributes to the literature on community development by stressing the urge to reimagine the principles and practices of community participation through the creation of alternative forms of organizing and of radical empowerment. At the same time, it can inspire practitioners in experimenting with community participation initiatives from a more critical perspective, resisting the worst elements of neoliberalism. [ABSTRACT FROM AUTHOR]

Background The issue of reluctance towards vaccination is becoming more worrisome. Health care workers (HCWs) are the primary point of contact with individuals who make decisions about vaccination. Therefore, it is crucial that HCWs receive sufficient training and periodic updates. The main objective of this systematic review is to evaluate the HCWs' training needs in vaccination and vaccine uptake. Methods In February 2022, a search was conducted on MEDLINE, Scopus and Google Scholar databases. The search included papers written in English, Italian, Portuguese, Spanish, French and Romanian, with a publication date ranging from 1 January 2011 to 24 February 2022 and conducted in Europe. To assess the methodological quality of the papers, the Appraisal tool for Cross-Sectional Studies was utilized. Results The search of scientific literature yielded 640 outcomes on PubMed, 556 on Scopus and 15 on Google Scholar, for a total of 1211 records. After eliminating duplicates, screening titles and abstracts and evaluating the full text of the articles, only 25 of them were found suitable for inclusion. The studies' overall quality ranged from moderate to good. The majority of the research emphasized the need for improved knowledge of vaccine-preventable diseases, vaccine efficacy, immunization schedules and vaccine adverse effects. Conclusions It is vital to prioritize educational programmes on vaccinology and vaccine hesitancy for HCWs, with the objective of improving their knowledge, awareness and attitudes. Addressing the diversity of educational backgrounds, roles and training requirements of HCWs involved in vaccination across Europe is a critical issue that must be tackled for future initiatives. [ABSTRACT FROM AUTHOR]

Background Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems. Methods In the VOICE community—a European healthcare centre cluster intending to address VBHC from theory to practice—information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics. Results Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers. Conclusions To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions. [ABSTRACT FROM AUTHOR]

Analysis of phylogenetic trees has become an essential tool in epidemiology. Likelihood-based methods fit models to phylogenies to draw inferences about the phylodynamics and history of viral transmission. However, these methods are often computationally expensive, which limits the complexity and realism of phylodynamic models and makes them ill-suited for informing policy decisions in real-time during rapidly developing outbreaks. Likelihood-free methods using deep learning are pushing the boundaries of inference beyond these constraints. In this paper, we extend, compare, and contrast a recently developed deep learning method for likelihood-free inference from trees. We trained multiple deep neural networks using phylogenies from simulated outbreaks that spread among 5 locations and found they achieve close to the same levels of accuracy as Bayesian inference under the true simulation model. We compared robustness to model misspecification of a trained neural network to that of a Bayesian method. We found that both models had comparable performance, converging on similar biases. We also implemented a method of uncertainty quantification called conformalized quantile regression that we demonstrate has similar patterns of sensitivity to model misspecification as Bayesian highest posterior density (HPD) and greatly overlap with HPDs, but have lower precision (more conservative). Finally, we trained and tested a neural network against phylogeographic data from a recent study of the SARS-Cov-2 pandemic in Europe and obtained similar estimates of region-specific epidemiological parameters and the location of the common ancestor in Europe. Along with being as accurate and robust as likelihood-based methods, our trained neural networks are on average over 3 orders of magnitude faster after training. Our results support the notion that neural networks can be trained with simulated data to accurately mimic the good and bad statistical properties of the likelihood functions of generative phylogenetic models. [ABSTRACT FROM AUTHOR]

Focuses on the financial limitations of establishing massive conventional forces to defend Western Europe, while highlighting the relation between the 1952 British Global Strategy Paper (GSP) and the Eisenhower New Look of 1953. What was emphasized by both papers; Basis for the North Atlantic Treaty Organization (NATO); Information on the factors which influenced the GSP; Recommendations made by the GSP.

This paper examines existing methods of evaluating sample quality, showing that their practical utility and applicability to large-scale cross-project comparisons depends on whether they require auxiliary individual-level data. Among those methods that do not demand any such additional data, we differentiate between two approaches that rely on (i) external criteria, that is, comparisons of sample estimates to benchmarks derived from external population statistics, and (ii) internal criteria, that is, comparisons of subsample estimates to a theoretically derived aprioristic value. Our analyses demonstrate the advantages and limitations of both approaches based on an evaluation of 1,125 national surveys carried out in Europe between 2002 and 2016 within four survey projects: the Eurobarometer, European Quality of Life Survey, European Social Survey, and International Social Survey Programme. We show that the prevailing absence of design weights in cross-national survey datasets severely limits the applicability of external criteria evaluations. In contrast, using internal criteria without any weights proves acceptable because incorporating design weights in calculations of internal sample quality has only minor consequences for estimates of sample bias. Furthermore, applying internal criteria, we find that around 75 percent of samples in the four analyzed projects are not significantly biased. We also identify surveys with extremely high sample bias and investigate its potential sources. The paper concludes with recommendations regarding future research, which are directed at secondary data users, as well as producers of cross-national surveys. [ABSTRACT FROM AUTHOR]

Objectives Research among older adults reveals that the loss of core network members is a risk factor for loneliness. Still, it is not clear whether all such losses induce similar levels of loneliness, particularly as network members are distributed at varied geographic distances. Neither is it clear whether tie addition—the other ubiquitous aspect of network turnover in later life—offsets the loneliness that arises from different network loss scenarios. Methods This paper scrutinized core network losses across multiple relationship–distance scenarios. We used the fourth and sixth waves of data from the Survey of Health, Ageing, and Retirement in Europe and estimated fixed-effect models. Results The loss of a child from a core network increases feelings of loneliness across variant distances, especially when not complemented by additional connections. Losing relatives or nonkin core connections in proximity (within 1 km and 5 km radius, respectively) is also associated with increased loneliness, yet such effects are also largely mitigated by the addition of new core network members. Discussion The relationship between core network member losses and loneliness can significantly differ based on the nature of the lost connection and its geographic distance. Active rebalancing of one's core network following losses and proactive network expansion can serve as pivotal strategies to prevent loneliness for the aging population. [ABSTRACT FROM AUTHOR]

In recent years, public policymakers in Europe have become increasingly aware of the need to support Europe's failing semiconductor industry. This is an emerging policy area, and this paper examines the current state of the industry in Europe and assesses its potential future. It contends that the competitiveness of the industry will be related to its innovative capacity, especially its capability to engage in processes of open innovation. The industry in Europe is largely located in a number of discrete regional clusters, and the analysis focuses on data collected from a series of interviews with lead representatives of these clusters. The analysis indicates that the challenges facing the industry stem from the structure of the industry in Europe and the structure of the wider European technology industry. It is concluded that policies, such as the introduction of the European Chips Act, are likely to have a limited, or even negative, impact on the types of open innovation–led growth that will improve long-term competitiveness. [ABSTRACT FROM AUTHOR]

Nothing puzzles sociologists of religion more than the reasons and the patterns behind religious change. In the literature on secularization processes, it is broadly accepted that ongoing modernization has undermined many of the pillars of institutional religions, leading to widespread religious decline. While a considerable body of research investigates the "why(s)" of this decline, the main focus of this paper is on the "how." Drawing on CARPE, a harmonized dataset concerning church attendance with almost 2 million observations spanning over 40 years in 39 European countries, this article disentangles the contributions of period change and cohort replacement to the general religious decline. It shows that this decline reflects a real population dynamic based on generational replacement. It is not historical events or developments affecting everyone that undermine religion: new and less religious cohorts are replacing old and more religious ones. Like many other population dynamics, this process is described by an S-shaped curve and applies—with different speeds and levels—to almost all the European countries considered herein. These findings suggest that the effects of the processes of modernization on the mechanisms of religious socialization should be scrutinized more carefully when studying the reasons behind religious decline. [ABSTRACT FROM AUTHOR]

Background Early reports on the pandemic nature of coronavirus disease 2019 (COVID-19) directed the nephrology community to develop infection prevention and control (IPC) guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave. Methods We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between 1 March 2020 and 31 July 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in dialysis centres. Results Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting. Conclusions Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2. [ABSTRACT FROM AUTHOR]

The GECEM Project Database stands out as a new Digital Humanities solution to accurately order and analyse the new historical Big Data gathered in Chinese and European historical archives. Traditional challenges such as capture, storage, analysis, data curation, searching, sharing, transfer, visualization, querying, updating, and information privacy are being tackled and solved within the design of this new multi-relational database. The implementation of this database has as its main innovative elements the capability of coding and cross-referring historical data in Chinese and Western languages. Thus, we present a new database as a digital solution to solve the long-lasting problem in historical research: the maximization and optimization of data collection when analysing historical sources and how to make use of a large amount of registers and information when developing case studies and work hypotheses for historical research. In this paper, we present a solution for data collection and analysis of probate inventories and trade records which is a relevant source when determining changes in patterns of consumption and global trade through the introduction of Chinese goods into Europe and vice versa during the early modern period. [ABSTRACT FROM AUTHOR]

Although firmly established as a global norm, the Women, Peace and Security Agenda (WPS) has been largely driven by the global North attempting to solve insecurities in the global South. Postcolonial feminist research shows that this western-centrism and colonial legacies continue to dominate both WPS practices and knowledge production. This article focuses on WPS in central Europe, a previously ignored 'non-region' that remains outside the North–South divide. Combining postcolonial and decolonial approaches with feminist institutionalism, we interrogate what WPS becomes in the Czech, Polish and Slovakian contexts characterized by illiberal populist and anti-gender governance and politics. Building on interviews with key stakeholders, on document analysis and our own encounters, we argue that the three countries understand WPS as key to their western belongingness and reliability as international partners. As a result, they replicate rather than challenge 'western' WPS thinking. The resulting National Action Plans are centred around women's participation and security problems 'out there'. This lack of localization enables them to stay immune to the anti-gender alliances, but limits the engagement of feminist civil society. Amidst Russian imperial aggression, central Europe's WPS agendas serve as mere paper tigers and are failing to address the multitude of domestic and regional gendered insecurities. [ABSTRACT FROM AUTHOR]

Magnetic minerals form or alter in the presence of hydrocarbons, making them a potential magnetic proxy for identifying hydrocarbon migration pathways. In this paper, we test this idea by magnetically measuring core samples from the Tay Fan in the Western Central Graben in the Central North Sea. In a companion paper, 3-D petroleum systems modelling has been carried out to forward model migration pathways within the Tay Fan. Rock magnetic experiments identified a range of magnetite, maghemite, iron sulphides, siderite, goethite and titanohematite, some of which are part of the background signal, and some due to the presence of hydrocarbons. Typical concentrations of the magnetic minerals were ∼10–200 ppm. Importantly, we have identified an increasing presence of authigenic iron sulphides (likely pyrite and greigite) along the identified lateral hydrocarbon migration pathway (east to west). This is likely caused by biodegradation resulting in the precipitation of iron sulphides, however, though less likely, it could alternatively be caused by mature oil generation, which subsequently travelled with the migrating oil to the traps in the west. These observations suggest mineral magnetic techniques could be a rapid alternative method for identifying the severity of biodegradation or oil maturity in core sample, which can then be used to calibrate petroleum systems models. [ABSTRACT FROM AUTHOR]

Civil society organizations (CSOs) are a cornerstone of democracy in Europe. Nonetheless, "civil society" and "political society" should not be equated as membership-based organizations are not necessarily politically engaged. This paper theorizes and empirically examines which membership-based CSOs engage in interest representation through sustained advocacy activity. We propose an incentive-theoretical framework on CSO investments in advocacy activities—a collective, non-exclusive incentive from which also non-members can profit—by organizations fundamentally dependent on member support. Theorizing how CSOs' own structural characteristics, resource dependencies, and government demand for CSO input affect how CSOs reconcile selective and collective incentive provision, we test our hypotheses using new data from four recent surveys conducted in four European democracies. In line with our framework, CSOs organizing individual citizens rather than corporate actors and those pursuing member interests are less likely to engage in advocacy, while CSO professionalization and state funding access enhance CSOs' propensities to do so. Furthermore, the analysis shows that the former structural CSO characteristics are similarly relevant for CSO advocacy across distinct country settings, while the role of resource variables is mediated by institutional context revealing an important source of inequality in democratic interest representation. [ABSTRACT FROM AUTHOR]

Scientists who work on bioinspired systems may see the potential for products resulting from their research, but are often unaware of the various steps or issues related to commercialization or product development. Commercialization topics lie outside the usual training of a basic biologist, and therefore much of their exposure to these topics is adventitious, such as from casual conversations at meetings. Thus, the information gleaned may be somewhat piecemeal. In this paper, I briefly summarize some of what I have learned over the last 10 years about commercialization from a variety of different sources, related to a bioinspired project in which I am involved. My collaborators and I have invented and patented a technology to entrap insect pests by a purely physical mechanism (a "physical insecticide" that does not involve a chemical insecticide). This bioinspired technology is based on a historical control method, in which leaves from bean plants were used to capture bed bugs for hundreds of years in parts of eastern Europe. Sharp recurved microstructures (nonglandular trichomes) on the leaf surfaces irreversibly impale the tarsi (feet) of the bed bugs as they walk over the surfaces, trapping them in place. Pest professionals have identified bed bugs as the most difficult pest to control; there is a clear need for new methods of control for this pest. There are societal benefits and consumer demand for products that are sustainable, without regulatory constraints, and that minimize insecticide exposure for humans. But how would these products be developed from this starting point of a bioinspired invention? I will briefly share some of our experiences in the early and ongoing product development of entrapping surfaces, with the hope that this might interest or aid others who are considering entrepreneurial activities. Unfamiliar topics such as intellectual property, customer segmentation, value propositions, business models, conflict of interest, and conflict of commitment may require some attention from prospective entrepreneurs. This brief and introductory overview is intended for those academic scientists with little to no experience or knowledge in the area of commercialization. [ABSTRACT FROM AUTHOR]

To develop students' critical thinking is one of the primary goals of a modern democratic school system. However, what is to be developed has been the matter of long‐standing debate. One particular area of conflict has been what role is played by the knowledge concerning the object to be critically thought about. The 'specifists' have asserted that knowledge about the object is the core. The 'generalists' have claimed that there is no need for any actual profound knowledge. Typically, this debate has been held at a theoretical and philosophical level. In this paper, I will make an empirically based contribution to the debate. In a unique approach, I will use a number of student essay responses to argue in favour of a specifist view, and at the same time to question some of the generalists' basic assumptions. The paper ends with an appeal to the generalists to provide us with proper clarification regarding the questions I raise. This is important as they hold the dominant position in the field. If they are to continue to do so, we need to be clear about the accuracy of their basic assumptions. This becomes even more essential as the generalist research has been severely criticised for producing inconclusive results, as well as the fact that the generalist view on critical thinking has been adopted by major policymakers both in Europe and the United States. [ABSTRACT FROM AUTHOR]

Ulipristal acetate (UPA) is a medical treatment for uterine fibroids and was authorized for surgical pre-treatment in 2012 after the conduct of the PEARL I and II randomized controlled trials and for intermittent treatment after the observational PEARL III and IV trials. However, UPA came into disrepute due to its temporary suspension in 2017 and 2020 because of an apparent association with liver injury. This clinical opinion paper aims to review the process of marketing authorization and implementation of UPA, in order to provide all involved stakeholders with recommendations for the introduction of future drugs. Before marketing authorization, the European Medicines Agency (EMA) states that Phase III registration trials should evaluate relevant outcomes in a representative population, while comparing to gold-standard treatment. This review shows that the representativeness of the study populations in all PEARL trials was limited, surgical outcomes were not evaluated and intermittent treatment was assessed without comparative groups. Implementation into clinical practice was extensive, with 900 000 prescribed treatment cycles in 5 years in Europe and Canada combined. Extremely high costs are involved in developing and evaluating pre-marketing studies in new drugs, influencing trial design and relevance of chosen outcomes, thereby impeding clinical applicability. It is vitally important that the marketing implementation after authorization is regulated in such way that necessary evidence is generated before widespread prescription of a new drug. All stakeholders, from pharmaceutical companies to authorizing bodies, governmental funding bodies and medical professionals should be aware of their role and take responsibility for their part in this process. [ABSTRACT FROM AUTHOR]

Background To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe. Methods SILNE-R school survey data, which was collected in 2016–17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N  = 5088, age 13–19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL. Results Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83–5.49], alcohol use (OR: 2.94, 95% CI: 2.34–3.68) and cannabis use (OR: 2.56, 95% CI: 1.89–3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (β = 1.04, 95% CI: 0.89–1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL. Conclusions Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use. [ABSTRACT FROM AUTHOR]

Background Access to various kidney replacement therapy (KRT) modalities for patients with end-stage kidney disease differs substantially within Europe. Methods European adults on KRT filled out an online or paper-based survey about factors influencing and experiences with modality choice (e.g. information provision, decision-making and reasons for choice) between November 2017 and January 2019. We compared countries with low, middle and high gross domestic product (GDP). Results In total, 7820 patients [mean age 59 years, 56% male, 63% on centre haemodialysis (CHD)] from 38 countries participated. Twenty-five percent had received no information on the different modalities, and only 23% received information >12 months before KRT initiation. Patients were not informed about home haemodialysis (HHD) (42%) and comprehensive conservative management (33%). Besides nephrologists, nurses more frequently provided information in high-GDP countries, whereas physicians other than nephrologists did so in low-GDP countries. Patients from low-GDP countries reported later information provision, less information about other modalities than CHD and lower satisfaction with information. The majority of modality decisions were made involving both patient and nephrologist. Patients reported subjective (e.g. quality of life and fears) and objective reasons (e.g. costs and availability of treatments) for modality choice. Patients had good experiences with all modalities, but experiences were better for HHD and kidney transplantation and in middle- and high-GDP countries. Conclusion Our results suggest European differences in patient-reported factors influencing KRT modality choice, possibly caused by disparities in availability of KRT modalities, different healthcare systems and varying patient preferences. Availability of home dialysis and kidney transplantation should be optimized. [ABSTRACT FROM AUTHOR]

Online platforms can support health and educational professionals in their daily work; however, it is challenging to keep online platforms sustainable. This paper aims to indicate the most important factors of platform sustainability from the perspective of professionals involved in online platforms. Further, it aims to understand how these factors operate. A mixed methods study was carried out among professionals from Europe, Australia, the USA and Canada. In the first phase, the importance of 54 factors from the literature was assessed with a questionnaire among 17 professionals. The relative importance of the factors and the consensus regarding this importance were calculated using median scores and interquartile deviations. In total, 19 factors were selected representing general characteristics, characteristics related to the platform, communication, visitor and context. In the second phase, insight was gained regarding the experiences with those factors through 12 individual Skype interviews. The most frequently mentioned important factors of platform sustainability were (i) having sufficient time, resources and expertise, (ii) user friendliness and (iii) creating a sense of belonging. Platforms should use a planned approach to address a combination of factors directly from platform development. Gaining long-term resources is challenging and should be considered from the start of a project by building partnerships. To promote user friendliness, platforms should be simple, have a clear set-up and provide high-quality tools. Finally, establishing a sense of belonging could be supported by branding and face-to-face networking activities. For all aspects, involving visitors and stakeholders is essential. [ABSTRACT FROM AUTHOR]

This paper is focused on the implications of a collaborative digital storytelling project on student engagement in the higher education context. The empirical study is conducted with an interdisciplinary group of bachelor students in a Nordic University (N  = 22) and a university in Southern Europe (N  = 21), and the data are collected through an online student survey. The results demonstrate that the digital storytelling project supported students' behavioral, emotional, and cognitive engagement. In general, the students had positive emotional experiences with the project. This assignment format was found less stressful than a frontal presentation in the classroom, allowing the students to express their perspectives more freely and confidently. The digital storytelling format also opened up for more creative ways to approach the task. It was important for the participants to have the project assignment split up in several checkpoints with feedback from the instructor. At the same time, the students suggested several areas for further improvement. Those are mainly related to the guidance on the use of technology and scripting the learning process within the small groups. Based on the results of the study, a range of practical implications for teaching practice is formulated. [ABSTRACT FROM AUTHOR]

Genetic variants disrupting DNA methylation at CpG dinucleotides (CpG-SNP) provide a set of known causal variants to serve as models to test fine-mapping methodology. We use 1716 CpG-SNPs to test three fine-mapping approaches (Bayesian imputation-based association mapping, Bayesian sparse linear mixed model, and the J-test), assessing the impact of imputation errors and the choice of reference panel by using both whole-genome sequence (WGS), and genotype array data on the same individuals (n = 1166). The choice of imputation reference panel had a strong effect on imputation accuracy, with the 1000 Genomes Project Phase 3 (1000G) reference panel (n = 2504 from 26 populations) giving a mean nonreference discordance rate between imputed and sequenced genotypes of 3.2% compared to 1.6% when using the Haplotype Reference Consortium (HRC) reference panel (n = 32,470 Europeans). These imputation errors had an impact on whether the CpG-SNP was included in the 95% credible set, with a difference of ~23% and ~7% between the WGS and the 1000G and HRC imputed datasets, respectively. All of the fine-mapping methods failed to reach the expected 95% coverage of the CpG-SNP. This is attributed to secondary cis genetic effects that are unable to be statistically separated from the CpG-SNP, and through a masking mechanism where the effect of the methylation disrupting allele at the CpG-SNP is hidden by the effect of a nearby SNP that has strong linkage disequilibrium with the CpG-SNP. The reduced accuracy in fine-mapping a known causal variant in a low-level biological trait with imputed genetic data has implications for the study of higher-order complex traits and disease. [ABSTRACT FROM AUTHOR]

Background in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems. [ABSTRACT FROM AUTHOR]

Background in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems. [ABSTRACT FROM AUTHOR]

Study Question: How many twins are born in human populations and how has this changed over recent decades?Summary Answer: Since the 1980s, the global twinning rate has increased by a third, from 9.1 to 12.0 twin deliveries per 1000 deliveries, to about 1.6 million twin pairs each year.What Is Known Already: It was already known that in the 1980s natural twinning rates were low in (East) Asia and South America, at an intermediate level in Europe and North America, and high in many African countries. It was also known that in recent decades, twinning rates have been increasing in the wealthier parts of our world as a result of the rise in medically assisted reproduction (MAR) and delayed childbearing.Study Design, Size, Duration: We have brought together all information on national twinning rates available from statistical offices, demographic research institutes, individual survey data and the medical literature for the 1980-1985 and the 2010-2015 periods.Participants/materials, Setting, Methods: For 165 countries, covering over 99% of the global population, we were able to collect or estimate twinning rates for the 2010-2015 period. For 112 countries, we were also able to obtain twinning rates for 1980-1985.Main Results and the Role Of Chance: Substantial increases in twinning rates were observed in many countries in Europe, North America and Asia. For 74 out of 112 countries the increase was more than 10%. Africa is still the continent with highest twinning rates, but Europe, North America and Oceania are catching up rapidly. Asia and Africa are currently home to 80% of all twin deliveries in the world.Limitations, Reasons For Caution: For some countries, data were derived from reports and papers based on hospital registrations which are less representative for the country as a whole than data based on public administrations and national surveys.Wider Implications Of the Findings: The absolute and relative number of twins for the world as a whole is peaking at an unprecedented level. An important reason for this is the tremendous increase in medically assisted reproduction in recent decades. This is highly relevant, as twin deliveries are associated with higher infant and child mortality rates and increased complications for mother and child during pregnancy and during and after delivery.Study Funding/competing Interest(s): The contribution of CM was partially supported by the European Research Council (ERC) under the European Union's Horizon 2020 Research and Innovation Programme (grant No 681546, FAMSIZEMATTERS), Nuffield College, and the Leverhulme Trust. The contribution of GP was partially supported by the French Agence Nationale de la Recherche (grant No ANR-18-CE36-0007-07). The authors declare no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background: While risk of outdoor transmission of respiratory viral infections is hypothesized to be low, there are limited data on SARS-CoV-2 transmission in outdoor compared to indoor settings.Methods: We conducted a systematic review of peer-reviewed papers indexed in PubMed, EMBASE, and Web of Science and preprints in Europe PMC through 12 August 2020 that described cases of human transmission of SARS-CoV-2. Reports of other respiratory virus transmission were included for reference.Results: Five identified studies found a low proportion of reported global SARS-CoV-2 infections occurred outdoors (<10%) and the odds of indoor transmission was very high compared to outdoors (18.7 times; 95% confidence interval, 6.0-57.9). Five studies described influenza transmission outdoors and 2 adenovirus transmission outdoors. There was high heterogeneity in study quality and individual definitions of outdoor settings, which limited our ability to draw conclusions about outdoor transmission risks. In general, factors such as duration and frequency of personal contact, lack of personal protective equipment, and occasional indoor gathering during a largely outdoor experience were associated with outdoor reports of infection.Conclusions: Existing evidence supports the wide-held belief that risk of SARS-CoV-2 transmission is lower outdoors but there are significant gaps in our understanding of specific pathways. [ABSTRACT FROM AUTHOR]

The authors discuss the area to address concerns in phenological data- collection procedures in Europe in 2016. They mention that the risk of a collapse of the network may be avoided and the citizen science (CS) technologies will have completely replaced traditional phenological data-collection. They say that the CS technologies facilitate data collection that the range of phases and species can be extended easily.

Background Natural disasters are increasing in their frequency and complexity. Understanding how their cascading effects can lead to infectious disease outbreaks is important for developing cross-sectoral preparedness strategies. The review focussed on earthquakes and floods because of their importance in Europe and their potential to elucidate the pathways through which natural disasters can lead to infectious disease outbreaks. Methods A systematic literature review complemented by a call for evidence was conducted to identify earthquake or flooding events in Europe associated with potential infectious disease events. Results This review included 17 peer-reviewed papers that reported on suspected and confirmed infectious disease outbreaks following earthquakes (4 reports) or flooding (13 reports) in Europe. The majority of reports related to food- and water-borne disease. Eleven studies described the cascading effect of post-disaster outbreaks. The most reported driver of disease outbreaks was heavy rainfall, which led to cross-connections between water and other environmental systems, leading to the contamination of rivers, lakes, springs and water supplies. Exposure to contaminated surface water or floodwater following flooding, exposure to animal excreta and post-disaster living conditions were among other reported drivers of outbreaks. Conclusions The cascade effects of natural disasters, such as earthquakes and floods, include outbreaks of infectious disease. The projection that climate change-related extreme weather events will increase in Europe in the coming century highlights the importance of strengthening preparedness planning and measures to mitigate and control outbreaks in post-disaster settings. [ABSTRACT FROM AUTHOR]

This paper reports on a study undertaken to determine what progress has been made in the uptake and impact of the CompHP Core Competencies on Health Promotion practice, education and training in Europe since their publication in 2011. The study used a purposive sample comprising health promoters who had contributed to the development of the CompHP Competencies was augmented by snowball sampling across European Health Promotion practitioners. An online survey tool was employed to elicit information on respondents' attitudes to the Competencies, levels of current and intended use, and opinions on their impact. A total of 81 responses were received from 25 European countries. Findings on factors considered likely to influence the use of the Competencies were generally positive, as were respondents' attitudes to them. However, only 53% of respondents reported that the CompHP Competencies were used in their country and 54% that they used them in their practice. The Competencies were most frequently used in Health Promotion education, where their impact was also most apparent. A lack of support and recognition of the Competencies by key organizations and stakeholders at country level emerges as a potentially critical factor influencing their uptake and use. The survey findings provide an insight into the uptake and impact of the CompHP Core Competencies to date and begin to address the gap in empirical evidence on the use and impact of Health Promotion competencies. However, further research is required to explore the factors influencing implementation of the CompHP Core Competencies at a country level. [ABSTRACT FROM AUTHOR]

Summary: Background: Topical photodynamic therapy (PDT) using methyl aminolaevulinate is a noninvasive treatment option suitable to treat clinical and subclinical actinic keratosis (AK) over a large area (field cancerization). The most widely used, conventional protocol in Europe includes illumination with a red‐light lamp. This illumination commonly causes pain, and patients often cannot complete the treatment. Objectives: The aims of this paper are twofold. The first aim is to introduce a novel protocol, the Phosistos protocol (P‐PDT), which includes illumination with a fabric‐based biophotonic device. The second and major aim is to assess the noninferiority, in terms of efficacy for PDT of AK, of P‐PDT compared with the conventional protocol (C‐PDT). Methods: A randomized, controlled, multicentre, intraindividual clinical study was conducted. Forty‐six patients with grade I–II AK of the forehead and scalp were treated with P‐PDT on one area (280 AK lesions) and with C‐PDT on the contralateral area (280 AK lesions). The primary end point was the lesion complete response (CR) rate at 3 months, with an absolute noninferiority margin of −10%. Secondary end points included pain scores, incidence of adverse effects and cosmetic outcome. Results: Three months following treatment, the lesion CR rate of P‐PDT was noninferior to that of C‐PDT (79·3% vs. 80·7%, respectively; absolute difference −1·6%; one‐sided 95% confidence interval −4·5% to infinity). The noninferiority of P‐PDT to C‐PDT in terms of the lesion CR rate remained at the 6‐month follow‐up (94·2% vs. 94·9%, respectively; absolute difference −0·6%; one‐sided 95% confidence interval −2·7% to infinity). Moreover, the pain score at the end of illumination was significantly lower for P‐PDT than for C‐PDT (mean ± SD 0·3 ± 0·6 vs. 7·4 ± 2·3; P < 0·001). Conclusions: P‐PDT is noninferior to C‐PDT in terms of efficacy for treating AK of the forehead and scalp and resulted in much lower pain scores and fewer adverse effects. What's already known about this topic? Topical photodynamic therapy using methyl aminolaevulinate is effective for treating actinic keratosis.In Europe, the conventional protocol involves illumination with a red‐light lamp. Unfortunately, pain is often experienced by patients undergoing this protocol.An alternative protocol that uses daylight illumination has recently been shown to be as effective as the conventional protocol while being nearly painless. However, this alternative protocol can be conducted only in suitable weather conditions. What does this study add? The Phosistos protocol is demonstrated to be as effective as the conventional protocol, nearly as painless as the daylight protocols and suitable year round for treatment of actinic keratosis. Plain language summary available online Linked Comment: Gilaberte. Br J Dermatol 2020; 182:11–12. [ABSTRACT FROM AUTHOR]

This paper examines the principles of benchmarking in healthcare and how benchmarking can contribute to practice improvement and improved health outcomes for patients. It uses the Deepening our Understanding of Quality in Australia (DUQuA) study published in this Supplement and DUQuA's predecessor in Europe, the Deepening our Understanding of Quality improvement in Europe (DUQuE) study, as models. Benchmarking is where the performances of institutions or individuals are compared using agreed indicators or standards. The rationale for benchmarking is that institutions will respond positively to being identified as a low outlier or desire to be or stay as a high performer, or both, and patients will be empowered to make choices to seek care at institutions that are high performers. Benchmarking often begins with a conceptual framework that is based on a logic model. Such a framework can drive the selection of indicators to measure performance, rather than their selection being based on what is easy to measure. A Donabedian range of indicators can be chosen, including structure, process and outcomes, created around multiple domains or specialties. Indicators based on continuous variables allow organizations to understand where their performance is within a population, and their interdependencies and associations can be understood. Benchmarking should optimally target providers, in order to drive them towards improvement. The DUQuA and DUQuE studies both incorporated some of these principles into their design, thereby creating a model of how to incorporate robust benchmarking into large-scale health services research. [ABSTRACT FROM AUTHOR]

Inspired by the growing cries from young climate crisis activists, and noting that net-zero emission legislation is growing in frequency across Europe and globally, this paper briefly discuses some ways in which marine science might respond. Marine science can provide governments support and advice for emission-reducing policies and actions, as well as tackling our own emissions. Supporting government actions will require new and innovative science. While implementing this science, as a community, we can lead by example in bringing about change in the way professionals do business and hence reducing business's overall carbon footprint. After all, if environmental science cannot change, why should the rest of society? [ABSTRACT FROM AUTHOR]

Aims: The European Society of Cardiology (ESC) guidelines state that heart failure nurse specialists (heart-failure nurses) with specific competences are essential for a successful heart-failure-management programme. Thus, the Heart Failure Association (HFA) of the ESC developed the heart failure nurse curriculum (HFA curriculum). Several ESC member states developed cardiovascular education programmes to enable nurses to deliver high specialist care, but little is known of whether these curricula are in line with the HFA curriculum. Therefore, this paper describes the extent to which cardiovascular education programmes in Belgium, The Netherlands and Germany correspond to the HFA curriculum. Methods and results: A case study approach was adopted to obtain an in-depth understanding of the programme contents in relation to the HFA curriculum. For this purpose, representatives of the educational programmes and/or delegates of the national cardiovascular nursing organization shared their educational curricula. All of the studied cardiovascular education programmes aim to provide heart failure and/or cardiovascular nurses with essential competences for implementation of evidence based and guideline derived care. However, every cardiovascular education programme has a different focus/area of attention. Cardiovascular education in Belgium discusses aspects of all core-learning objectives of the HFA curriculum and emphasizes mostly knowledge aspects of these. Learning objectives in cardiovascular education in The Netherlands focus on chronic diseases in general and on learning objectives concerning patient education, support in self-care and management of device and pharmacological therapy. Cardiovascular education in Germany discusses most learning objectives; however, not all learning objectives receive equal attention. Conclusions: Although local cardiovascular education programmes adopt certain aspects of the HF curriculum, the curriculum as a whole is not adopted. [ABSTRACT FROM AUTHOR]

Background As digitalization is progressively permeating all aspects of society, how can be it fruitfully employed to sustain the public health goals of quality, accessibility, efficiency and equity in health care and prevention? In this paper, we reflect on the potential of applying digital tools to public health and discuss some key challenges. Methods We first define 'digitalization' in its broader sense, as well as applied to public health. We then build a conceptual framework where key public health domains are associated to available digital technologies in a matrix that help to identify digital features that bolster public health action. We also provide illustrative data and evidence on the application of digital solutions on selected public health areas. In the second part, we identify the strategic pillars for a successful European strategy for public health digitalization and we outline how the approach being pursued by the European Public Health Association (EUPHA) applies to digital health. Results From a public health perspective, digitalization is being touted as providing several potential benefits and advantages, including support for the transition from cure to prevention, helping to put people and patients at the center of care delivery, supporting patient empowerment and making healthcare system more efficient, safer and cheaper. These benefits are enabled through the following features of digital technologies: (i) Personalization and precision; (ii) Automation; (iii) Prediction; (iv) Data analytics and (v) Interaction. Conclusion A successful European strategy for public health digitalization should integrate the following pillars: political commitment, normative frameworks, technical infrastructure, targeted economic investments, education, research, monitoring and evaluation. EUPHA acknowledges digitalization is an asset for public health and is working both to promote the culture of "public health digitalization", as well as to enable its planning, implementation and evaluation at the research, practice and policy level. [ABSTRACT FROM AUTHOR]

The article provides updates on issues related to the European Public Health Association (EUPHA) as of October 2019. Topics covered include opportunity of the World Health Organization to renew its vision for health in Europe beyond 2020, a white paper published by the European Commission in March 2017 setting out five possible paths for the future of Europe, and EUPHA's statement on what European political parties are stating on health.

Background: Within the European Union (EU), substantial efforts are being made to achieve economic and social cohesion, and the reduction of health inequalities between EU regions is integral to this process. This paper is the first to examine how self-reported conditions and non-communicable diseases (NCDs) vary spatially between and within countries. Methods: Using 2014 European Social Survey (ESS) data from 20 countries, this paper examines how regional inequalities in self-reported conditions and NCDs vary for men and women in 174 regions (levels 1 and 2 Nomenclature of Statistical Territorial Units, 'NUTS'). We document absolute and relative inequalities across Europe in the prevalence of eight conditions: general health, overweight/obesity, mental health, heart or circulation problems, high blood pressure, back, neck, muscular or joint pain, diabetes and cancer. Results: There is considerable inequality in self-reported conditions and NCDs between the regions of Europe, with rates highest in the regions of continental Europe, some Scandinavian regions and parts of the UK and lowest around regions bordering the Alps, in Ireland and France. However, for mental health and cancer, rates are highest in regions of Eastern European and lowest in some Nordic regions, Ireland and isolated regions in continental Europe. There are also widespread and consistent absolute and relative regional inequalities in all conditions within countries. These are largest in France, Germany and the UK, and smallest in Denmark, Sweden and Norway. There were higher inequalities amongst women. Conclusion: Using newly available harmonized morbidity data from across Europe, this paper shows that there are considerable regional inequalities within and between European countries in the distribution of self-reported conditions and NCDs. [ABSTRACT FROM AUTHOR]

Background: It has been suggested that cross-national variation in educational inequalities in health outcomes (e.g. NCDs) is due to cross-national variation in risky health behaviour. In this paper we aim to use highly recent data (2014) to examine educational inequalities in risky health behaviour in 21 European countries from all regions of the continent to map cross-national variation in the extent to which educational level is associated with risky health behaviour. We focus on four dimensions of risky health behaviour: smoking, alcohol use, lack of physical activity and lack of fruit and vegetable consumption. Methods: We make use of recent data from the 7th wave of the European Social Survey (2014), which contains a special rotating module on the social determinants of health. We performed logistic regression analyses to examine the associations between educational level and the risky health behaviour indicators. Educational level was measured through a three-category version of the harmonized International Standard Classification of Education (ISCED). Results: Our findings show substantial and mostly significant inequalities in risky health behaviour between educational groups in most of the 21 European countries examined in this paper. The risk of being a daily smoker is higher as respondents' level of education is lower (Low education (L): OR = 4.24 (95% CI: 3.83^.68); Middle education (M): OR = 2.91 (95% CI: 2.65-3.19)). Respondents have a lower risk of consuming alcohol frequently if they have a low level of education (L: OR = 0.59 (95% CI: 0.54-0.64); M: OR = 0.70 (95% CI: 0.65-0.76)), but a higher risk of binge drinking frequently (L: OR = 1.29 (95% CI: 1.16-1.44); M: OR = 1.15 (95% CI: 1.04-1.27)). People are more likely to be physically active at least 3 days in the past week when they have a higher level of education (M: OR = 1.42 (95% CI: 1.34-1.50); H: OR = 1.67 (95% CI: 1.55-1.80)). Finally, people are more likely to consume fruit and vegetables at least daily if they have a higher level of education (fruit: M: OR = 1.09 (95% CI: 1.03-1.16); H: OR = 1.77 (95% CI: 1.63-1.92); vegetables: M: OR = 1.34 (95% CI: 1.26-1.42); H: OR = 2.35 (95% CI: 2.16-2.55)). However, we also found considerable cross-national variation in the associations between education and risky health behaviour. Conclusions: Our results yield a complex picture: the lowest educational groups are more likely to smoke and less likely to engage in physical activity and to eat fruit and vegetables, but the highest educational groups are at greater risk of frequent alcohol consumption. Additionally, inequalities in risky health behaviour do not appear to be systematically weakest in the South or strongest in the North and West of Europe. [ABSTRACT FROM AUTHOR]

The article reports on four papers published by the European League Against Rheumatism within a year on aspects of systemic lupus erythematosus (SLE). Topics mentioned include the use of direct oral anticoagulant rivaroxaban in patients with triple aPL positivity, incomplete understanding of SLE pathophysiology, and the first positive phase III trial on anifrolumab.

Background Frailty is a common, multi-factorial, age-related syndrome commonly observed in people with diabetes. Although older diabetics are prone to adverse healthcare outcomes and diabetes increases the risk of developing frailty, little is known about the effects of frailty on diabetes. This paper examines the association between diabetes, frailty, and mortality in Europeans aged ≥50 years. Methods Data were included from The Survey of Health, Ageing and Retirement in Europe (SHARE) waves one and six. A participant's first interview was taken as the baseline and subsequent waves were used for mortality follow-up (time and cause). Frailty and pre-frailty were measured using established cut-offs using the Physical Phenotype (SHARE-FI) and a 55-item Frailty Index (FI-55). Kaplan-Meier survival analysis was used to assess the relationship between frailty and mortality in people with diabetes and significance tested using log-rank test. Cox regression was used to adjust for potential confounders (age, sex, education, income, employment, alcohol use, smoking, hypertension, hypercholesterolaemia, myocardial infarction, stroke, metastatic cancer, chronic lung disease, polypharmacy, self-perceived health and depression). Results Data from 8,954 diabetics aged 50-99 years were included with 1,598 deaths (17.8%). According to the SHARE-FI, 1,971 (22.0%) were frail, 4,183 (46.7%) pre-frail and 2,800 (31.3%) robust. According to the Kaplan-Meier log-rank test survival varied significantly across frailty strata according to both indexes (p<0.001). At 10-year follow-up, adjusting for confounders SHARE-FI frailty and pre-frailty were significantly associated with mortality, adjusted Hazard Ratio (HR) 2.19, (95% CI:1.66-2.89), and 1.38 (95% CI:1.09-1.74), respectively. Results were similar using the FI-55, HR for frailty 1.66 (95% CI:1.09-2.54). Causes of mortality were significantly different according to frailty status (p<0.05). Conclusion Frailty and pre-frailty are independent risk factors for mortality in diabetics. The identification of frailty is important for the risk-stratification and management of middle aged and older patients with diabetes and should be included in the routine assessment of these high-risk individuals. [ABSTRACT FROM AUTHOR]

Objectives IgA vasculitis (IgAV, formerly known as Henoch–Schönlein purpura) is the most common cause of systemic vasculitis in childhood. To date, there are no internationally agreed, evidence-based guidelines concerning the appropriate diagnosis and treatment of IgAV in children. Accordingly, treatment regimens differ widely. The European initiative SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) aims to optimize care for children with rheumatic diseases. The aim therefore was to provide internationally agreed consensus recommendations for diagnosis and treatment for children with IgAV. Methods Recommendations were developed by a consensus process in accordance with the EULAR standard operating procedures. An extensive systematic literature review was performed, and evidence-based recommendations were extrapolated from the included papers. These were evaluated by a panel of 16 international experts via online surveys and subsequent consensus meeting, using nominal group technique. Recommendations were accepted when ⩾80% of experts agreed. Results In total, 7 recommendations for diagnosis and 19 for treatment of paediatric IgAV were accepted. Diagnostic recommendations included: appropriate use of skin and renal biopsy, renal work-up and imaging. Treatment recommendations included: the importance of appropriate analgesia and angiotensin-converting enzyme inhibitor use and non-renal indications for CS use, as well as a structured approach to treating IgAV nephritis, including appropriate use of CS and second-line agents in mild, moderate and severe disease along with use of angiotensin-converting enzyme inhibitors and maintenance therapy. Conclusion The SHARE initiative provides international, evidence-based recommendations for the diagnosis and treatment of IgAV that will facilitate improvement and uniformity of care. [ABSTRACT FROM AUTHOR]

Background: Welfare regimes in Europe modify individuals' socioeconomic trajectories over their life-course, and, ultimately, the link between socioeconomic circumstances (SECs) and health. This paper aimed to assess whether the associations between life-course SECs (early-life, young adult-life, middle-age and old-age) and risk of poor self-rated health (SRH) trajectories in old age are modified by welfare regimes (Scandinavian [SC], Bismarckian [BM], Southern European [SE], Eastern European [EE]).Methods: We used data from the longitudinal SHARE survey. Early-life SECs consisted of four indicators of living conditions at age 10. Young adult-life, middle-age, and old-age SECs indicators were education, main occupation and satisfaction with household income, respectively. The association of life-course SECs with poor SRH trajectories was analysed by confounder-adjusted multilevel logistic regression models stratified by welfare regime. We included 24 011 participants (3626 in SC, 10 256 in BM, 6891 in SE, 3238 in EE) aged 50 to 96 years from 13 European countries.Results: The risk of poor SRH increased gradually with early-life SECs from most advantaged to most disadvantaged. The addition of adult-life SECs differentially attenuated the association of early-life SECs and SRH at older age across regimes: education attenuated the association only in SC and SE regimes and occupation only in SC and BM regimes; satisfaction with household income attenuated the association across regimes.Conclusions: Early-life SECs have a long-lasting effect on SRH in all welfare regimes. Adult-life SECs attenuated this influence differently across welfare regimes. [ABSTRACT FROM AUTHOR]

Background This paper examines changes in substance use, and compares the resulting attributable burden of disease in the WHO European Region between 2010 and 2016. Methods Data for 2010 and 2016 on the number of deaths, years of life lost (YLL) and disability-adjusted life years (DALYs) lost were obtained by sex and country from the 2016 Global Burden of Disease (GBD) study. Exposure data for all substances except alcohol were obtained from the same study, while alcohol data were obtained from the WHO. Proportional changes were calculated for the WHO European Region as a whole to identify trends and for sub-regions to identify which regions contributed most to trends. Results In the WHO European Region in 2016, substance use caused 2.1 million deaths, 48.6 million YLL and 57.9 million DALYs lost, representing 22.4, 29.0 and 20.4% of all deaths, YLL and DALYs, respectively. The substance-attributable burden of disease was higher among men than women and highest in the eastern parts of the WHO European Region. Changes in the number of deaths, YLL and DALYs lost between 2010 and 2016 were almost uniformly downward, with the largest proportional changes observed for men. Exposure to tobacco, alcohol and illicit drugs also decreased uniformly. Conclusions Substance use and its attributable mortality and burden of disease have decreased in the WHO European Region since 2010. However, overall levels of substance use and the resulting burden of disease in the Region remain high compared with other regions of the world. [ABSTRACT FROM AUTHOR]

Background Parents' reluctance to vaccinate their children undermines the effectiveness of vaccination programmes in Western Europe. There is anecdotal evidence suggesting a connection between the rise of political populism and vaccine hesitancy. Methods This paper analyses national-level data to examine the link between political populism and vaccine hesitancy in Western Europe. Political populism is operationalised as the percentage of people in a country who voted for populist parties in the 2014 European Parliament elections. Vaccine hesitancy is operationalised as the percentage of people in a country who believe that vaccines are not important, safe and effective according to data from the Vaccine Confidence Project (2015). Results There is a highly significant positive association between the percentage of people in a country who voted for populist parties and who believe that vaccines are not important (R = 0.7923, P = 0.007) and effective (R = 0.7222, P = 0.0035). The percentage of people who think vaccines are unsafe just misses being significant at the 5% level (R = 0.5027, P = 0.0669). Conclusions Vaccine hesitancy and political populism are driven by similar dynamics: a profound distrust in elites and experts. It is necessary for public health scholars and actors to work to build trust with parents that are reluctant to vaccinate their children, but there are limits to this strategy. The more general popular distrust of elites and experts which informs vaccine hesitancy will be difficult to resolve unless its underlying causes—the political disenfranchisement and economic marginalisation of large parts of the Western European population—are also addressed. [ABSTRACT FROM AUTHOR]

Objectives The European Single Hub and Access point for paediatric Rheumatology in Europe initiative aimed to optimize care for children with rheumatic diseases. Kawasaki disease (KD) is the most common cause of acquired heart disease in children and an important cause of long-term cardiac disease into adulthood. Prompt diagnosis and treatment of KD is difficult due to the heterogeneity of the disease but is crucial for improving outcome. To date, there are no European internationally agreed, evidence-based guidelines concerning the diagnosis and treatment of KD in children. Accordingly, treatment regimens differ widely. The aim of this study is to provide consensus-based, European-wide evidence-informed recommendations for diagnosis and treatment of children with KD. Methods Recommendations were developed using the EULAR's standard operating procedures. An extensive systematic literature search was performed, and evidence-based recommendations were extrapolated from the included papers. These were evaluated by a panel of international experts via online surveys and subsequently discussed in three consensus meetings, using nominal group technique. Recommendations were accepted when ⩾80% agreed. Results In total, 17 recommendations for diagnosis and 14 for treatment of KD in children were accepted. Diagnostic recommendations included laboratory and imaging workup for complete as well as incomplete KD. Treatment recommendations included the importance of early treatment in both complete and incomplete KD, use of intravenous immunoglobulin, aspirin, corticosteroids for high-risk cases, and other treatment options for those with resistant disease. Conclusion The Single Hub and Access point for paediatric Rheumatology in Europe initiative provides international evidence-based recommendations for diagnosing and treating KD in children, facilitating improvement and uniformity of care. [ABSTRACT FROM AUTHOR]

Summary: Background: Photodynamic therapy (PDT) is an effective treatment for actinic keratosis (AK), particularly for patients with large areas of field cancerization. Among the approved protocols in Europe, the most widely used requires irradiation with the Aktilite CL 128 lamp. However, pain during irradiation and the suboptimal adaptability of the lamp relative to the treatment area are two limiting factors of this protocol. To overcome these limits, a new protocol (referred to as the Flexitheralight protocol) involving irradiation with a light‐emitting, fabric‐based device was developed. Objectives: This paper aims to assess the noninferiority, in terms of PDT efficacy for treating AK, of the Flexitheralight protocol compared with the conventional protocol, which requires irradiation with the Aktilite CL 128 lamp. Methods: A monocentric, randomized, controlled, phase II clinical study was performed. Twenty‐five patients with grade I–II AKs of the forehead and scalp were treated with methyl aminolaevulinate PDT in two symmetrical areas. One area was treated with the conventional protocol (n = 154 AKs), whereas the other area was treated with the Flexitheralight protocol (n = 156 AKs). The primary end‐point was the lesion complete response (CR) rate at 3 months (an absolute noninferiority margin of –10% was used). The secondary end‐points included patient‐reported pain at the end of the irradiation. Results: At 3 months, the lesion CR rate with the Flexitheralight protocol was noninferior to that obtained with the conventional protocol (66·0% vs. 59·1%, respectively; absolute difference, 6·9%; 95% confidence interval –0·6% to 14·5%). Patient‐reported pain was significantly lower with the Flexitheralight protocol than with the conventional protocol (mean ± SD: 0·4 ± 0·6 vs. 5·0 ± 2·6; P < 0·0001). Conclusions: The Flexitheralight protocol is noninferior in terms of efficacy and superior in terms of tolerability to the conventional protocol for treating AKs of the forehead and scalp. What's already known about this topic? Methyl aminolaevulinate photodynamic therapy (PDT) is an effective and noninvasive treatment for actinic keratosis (AK).Treatment‐associated pain is frequently experienced by patients treated with the conventional protocol, which requires irradiation with the Aktilite CL 128 lamp.PDT using daylight as the activating light source has been confirmed as equally effective and less painful than the conventional protocol, but it cannot be performed in all weather conditions. What does this study add? This study demonstrates that the Flexitheralight protocol, which can be performed in all weather conditions, is equally effective as the conventional PDT protocol for AK and is a less painful technique. Linked Comment:Morton. Br J Dermatol 2019; 180:703–704. Respond to this article Plain language summary available online [ABSTRACT FROM AUTHOR]

Background Family policies have been shown to affect men's and women's health throughout the European Union, though particularly in the case of women. This paper seeks to analyze this effect by creating two Synthetic Health Indicators (SHIs) differentiated by gender applying the P 2 distance method. We also aim to compare the results obtained by means of our SHI and the Self-rated health (SRH) indicator, as it is the most common indicator used to approach individuals' health. Methods The 2012 European Quality of Life Survey was used to construct the SHI. Dimensions such as physical health, mental health, psychosocial resources, the capacity of health services and community health status were included in our SHI. All proved to be relevant when measuring individuals' health. Results Gender health inequalities differed depending on the indicator used in each European country. When considering family policy, we found significant gender health gaps that favoured men in traditional countries, regardless of the indicator used (SHI or SRH). Moreover, with our SHI we found significant gender health inequalities in market-oriented and dual-earner countries that were not revealed by the SRH indicator, highlighting the fact that current equality policies are necessary but insufficient to overcome the gender health gap. Conclusions The SHI was more sensitive to gender differences and evidenced certain advantages compared to the SRH. The SHI includes a wide range of variables that incorporated large amounts of fresh information, allowing men and women to have a personalized design of their own health. [ABSTRACT FROM AUTHOR]