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Simple Summary: In this work, we evaluated the need for frequent laboratory assessments in patients with metastatic renal cell carcinoma treated with nivolumab and nivolumab+ipilimumab during the TITAN-RCC clinical trial. We analysed how often reached criteria for dose delay or permanent discontinuation of therapy would have been missed if the frequency of laboratory testing had been reduced, in order to avoid over-sampling patients and to optimise clinical workflow and staffing. Our study showed that if the frequency of laboratory tests had been reduced, reached dose delay criteria would hardly have been missed. This would have affected up to 1% (2/207) of patients. An exception was dose delay due to the elevation of lipase blood levels which would have been missed in up to 7% (15/207) of patients. However, these patients presented with symptoms and would have been identified based thereupon. Discontinuation criteria would have only been overlooked for lipase (2% [4/207] of patients) and amylase (0.5% [1/207] of patients). Again, these patients would have been identified, since only symptomatic patients would have needed to discontinue treatment due to amylase or lipase laboratory values. In conclusion, in asymptomatic patients in our setting, laboratory analyses do not seem to be necessary before every treatment application. In clinical trials, laboratory values are assessed with high frequency. This can be stressful for patients, resource intensive, and difficult to implement, for example in office-based settings. In the prospective, multicentre phase 2 TITAN-RCC trial (NCT02917772), we investigated how many relevant changes in laboratory values would have been missed if laboratory values had been assessed less frequently. Patients with metastatic renal cell carcinoma (n = 207) received a response-based approach with nivolumab and nivolumab+ipilimumab boosts for non-response. We simulated that laboratory values were obtained before every second dose instead of every dose of the study drug(s). We assessed elevated leukocyte counts, alanine aminotransferase, aspartate aminotransferase, bilirubin, creatinine, amylase, lipase, and thyroid-stimulating hormone. Dose delay and discontinuation criteria were defined according to the study protocol. With the reduced frequency of laboratory analyses, dose delay criteria were rarely missed: in a maximum of <0.1% (3/4382) of assessments (1% [2/207] of patients) during nivolumab monotherapy and in a maximum of 0.2% (1/465) of assessments (1% [1/132] of patients) during nivolumab+ipilimumab boosts. An exception was lipase-related dose delay which would have been missed in 0.6% (25/4204) of assessments (7% [15/207] of patients) during nivolumab monotherapy and in 0.8% (4/480) of assessments (3% [4/134] of patients) during nivolumab+ipilimumab boosts, but would have required the presence of symptoms. Discontinuation criteria would have only been missed for amylase (<0.1% [1/3965] of assessments [0.5% (1/207) of patients] during nivolumab monotherapy, none during nivolumab+ipilimumab boosts) and lipase (0.1% [5/4204] of assessments [2% (4/207) of patients] during nivolumab monotherapy; 0.2% [1/480] of assessments [0.7% (1/134) of patients] during nivolumab+ipilimumab boosts). However, only symptomatic patients would have had to discontinue treatment due to amylase or lipase laboratory values. In conclusion, a reduced frequency of laboratory testing appears to be acceptable in asymptomatic patients with metastatic renal cell carcinoma treated with nivolumab or nivolumab+ipilimumab. [ABSTRACT FROM AUTHOR]

Background: According to European Centre for Disease Prevention and Control (ECDC) reports, women and migrants are more likely to have delayed HIV diagnosis (CD4 <350 cells/mm3). As a follow‐up to a previously published systematic review revealing a range of barriers to HIV testing among migrant women, the aim of the present study was to identify barriers to HIV testing from the perspective of service providers and to formulate possible interventions to improve access to HIV healthcare among migrants in Europe, with an emphasis on migrant women. Methods: Between November 2021 and February 2022 an online survey, consisting of 20 questions, was forwarded to 178 stakeholders and non‐governmental organizations (NGOs) working with migrant populations in 33 countries from the World Health Organization (WHO) European region. Results: Forty‐three responses from 14 countries were analysed. Most respondents (70%) judged migrants' access to healthcare as worse than that for the resident native population. Only 2/11 prevention interventions were available to all in at least 50% of participating countries. The three main barriers to accessing healthcare for migrant women and reasons for late HIV diagnosis among migrant women were stigma and discrimination, language barriers, and cultural barriers. Conclusions: Many HIV prevention interventions are not free of charge for all within Europe. The results of this survey show that migrant women face many barriers to accessing healthcare and that these might contribute to late HIV diagnosis. Simplification of access to free healthcare for all, more awareness raising about HIV screening and prevention among migrant women, and more migrant‐focused outreach programmes are suggested to improve migrant women's access to HIV healthcare in Europe. [ABSTRACT FROM AUTHOR]

Traditional process monitoring control charts (CCs) focused on sampling methods using fixed sampling intervals ( $ \mathrm {FSI} $ FSI s). The variable sampling intervals ( $ \mathrm {VSI} $ VSI s) scheme is receiving increasing attention, in which the sampling interval ( $ \mathrm {SI} $ SI ) length varies according to the process monitoring statistics. A shorter $ \mathrm {SI} $ SI is considered when the process quality indicates the possibility of an out-of-control (OOC) situation; otherwise, a longer $ \mathrm {SI} $ SI is preferred. The $ \mathrm {VSI} $ VSI multivariate exponentially moving average for compositional data ( $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa ) CC based on a coordinate representation using isometric log-ratio ( $ \operatorname {ilr} $ ilr) transformation is proposed in this study. A methodology is proposed to obtain the optimal parameters by considering the zero-state ( $ \mathrm {ZS} $ ZS ) average time to signal ( $ \mathrm {ZATS} $ ZATS ) and the steady-state (SS) average time to signal ( $ \mathrm {SATS} $ SATS ). The statistical performance of the proposed CC is evaluated based on a continuous-time Markov chain ( $ \mathrm {CTMC} $ CTMC ) method for both cases, the $ \mathrm {ZS} $ ZS and the SS using a fixed value of in-control (IC) $ \mathrm {ATS}_0 $ ATS 0 . Simulation results demonstrate that the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC has significantly decreased the OOC average time to signal ( $ \mathrm {ATS} $ ATS ) than the $ \mathrm {FSI}\,\mathrm {MEWMA}\,\mathrm {CoDa} $ FSI MEWMA CoDa CC. Moreover, it is found that the number of variables (d) has a negative impact on the $ \mathrm {ATS} $ ATS of the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC, and the subgroup size (n) has a mildly positive impact on the $ \mathrm {ATS} $ ATS of the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC. At the same time, the $ \mathrm {SATS} $ SATS of the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC is less than the $ \mathrm {ZATS} $ ZATS of the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC for all the values of n and d. The proposed $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC under steady-State performs effectively compared to its competitors, such as the $ \mathrm {FSI} $ FSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC, the $ \mathrm {VSI} $ VSI - $ T^2\,\mathrm {CoDa} $ T 2 CoDa CC and the $ \mathrm {FSI} $ FSI - $ T^2\,\mathrm {CoDa} $ T 2 CoDa CC. An example of an industrial problem from a plant in Europe is also given to study the statistical significance of the $ \mathrm {VSI} $ VSI - $ \mathrm {MEWMA}\,\mathrm {CoDa} $ MEWMA CoDa CC. [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]

Simple Summary: About 30% of patients with medulloblastoma experience recurrence, which is usually incurable despite intensive chemotherapy. The aim of our retrospective study was to evaluate a novel combinatorial metronomic antiangiogenic approach ("MEMMAT-like") for recurrent medulloblastoma consisting of five oral drugs, an intravenous antibody against vascular endothelial growth factor, and intrathecal therapy. The study, conducted between 2006 and 2016, included 29 consecutive patients with first or multiple recurrences treated according to this "MEMMAT-like" strategy and confirmed a significantly longer median overall survival than in previously reported studies. As of 07/2022, 9/29 patients are alive 86 to 164 months after recurrence. Treatment was primarily out-patient and well-tolerated. Toxicities did occur but were manageable. The novel combination significantly improved overall and progression-free survival for patients with recurrent medulloblastoma. A formal study (MEMMAT; ClinicalTrials.gov Identifier: NCT01356290) has been completed and is currently being evaluated. Medulloblastoma (MB) recurrence is usually incurable despite intensive therapy including high-dose chemotherapy. An evolving alternative approach to conventional chemotherapy aims at interfering with tumor angiogenesis at different levels. We report on a novel combinatorial metronomic antiangiogenic approach. The study is a retrospective observational study of 29 consecutive patients with first or multiple recurrences prospectively treated according to the MEMMAT strategy ("MEMMAT-like") before the formal protocol (MEMMAT; ClinicalTrials.gov Identifier: NCT01356290) started. The study period was 11/2006 to 06/2016. Treatment consisted of daily oral thalidomide, fenofibrate, celecoxib, and alternating 21-day cycles of low-dose oral etoposide and cyclophosphamide supplemented by IV bevacizumab and intraventricular therapy consisting of alternating etoposide and liposomal cytarabine. Median overall survival (OS) after recurrence for the whole group was 29.5 months, OS was 48.3 ± 9.3% at three years and 34.5 ± 8.8% at five years, and progression-free survival was 42.0 ± 9.5% at three years and 29.4 ± 9% at five years. As of 07/2022, 9/29 patients are alive 86 to 164 months after the recurrence that prompted the "MEMMAT-like" therapy. Treatment was primarily out-patient and generally well-tolerated. Toxicities did occur but were manageable. In conclusion, antiangiogenic therapy according to the MEMMAT strategy increased median OS of patients with recurrent MB and may lead to long-term survival. Adherence to the protocol, including intraventricular therapy, appears important. [ABSTRACT FROM AUTHOR]

Background: Maternal perception of child weight status in children with overweight or obesity has received a lot of attention but data on paternal perception of children from presumably healthy cohorts are lacking. Objective: We aimed to investigate paternal and maternal perception of child weight status at the age of 8 years in a cohort of 591 children from 5 European countries. Material and Methods: Included were 8-year-old children and their parents participating in the European Childhood Obesity Project (EU CHOP). Weight and height of children and parents were measured and Body Mass Index (BMI, kg/m2) was calculated. Both parents were asked to assess their perception of child weight status using Eckstein scales and their concern about child overweight. The agreement between mother and father perceptions was assessed by Cohen kappa coefficient and their relationship was analyzed by linear mixed effects models based on ordinal logistic regression, accounting for country, child gender and BMI, parental BMI, level of education, concern and type of feeding during first year of life. Results: Data from children and both parents were available for 432 girls and boys. Mean BMI was comparable in boys and girls (16.7 ± 2.31 vs. 16.9 ± 2.87 kg/m2, P = 0.55). In total, 172 children (29.3%) were overweight or obese. There was a high degree of agreement between mother and father perceptions of their child's weight status (Cohen kappa 0.77). Multivariate modelling showed that perception levels significantly increased with child BMI but were globally lower than assessed. They differed between countries, gender and types of feeding during first year of life, were influenced by education level of the father but were not related to parental BMI and concern about childhood overweight. Conclusions: The study showed no overall differences between mothers and fathers in rating their child's weight status but both parents had a propensity to underestimate their child's actual weight, particularly in boys. The EU CHOP trial registered at clinicaltrials.gov as NCT00338689. [ABSTRACT FROM AUTHOR]

ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. None. The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27–86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0–41 %). There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand. [ABSTRACT FROM AUTHOR]

Background: In-hospital cardiac arrest is a major cause of death in European countries, and survival of patients remains low ranging from 20% to 25%. Aims: The purpose of this study was to assess healthcare professionals' knowledge on cardiopulmonary resuscitation among university hospitals in 12 European countries and correlate it with the return of spontaneous circulation rates of their patients after in-hospital cardiac arrest. Methods and results: A total of 570 healthcare professionals from cardiology, anaesthesiology and intensive care medicine departments of European university hospitals in Italy, Poland, Hungary, Belgium, Spain, Slovakia, Germany, Finland, The Netherlands, Switzerland, France and Greece completed a questionnaire. The questionnaire consisted of 12 questions based on epidemiology data and cardiopulmonary resuscitation training and 26 multiple choice questions on cardiopulmonary resuscitation knowledge. Hospitals in Switzerland scored highest on basic life support (P =0.005) while Belgium hospitals scored highest on advanced life support (P <0.001) and total score in cardiopulmonary resuscitation knowledge (P =0.01). The Swiss hospitals scored highest in cardiopulmonary resuscitation training (P <0.001). Correlation between cardiopulmonary resuscitation knowledge and return of spontaneous circulation rates of patients with in-hospital cardiac arrest demonstrated that each additional correct answer on the advanced life support score results in a further increase in return of spontaneous circulation rates (odds ratio 3.94; 95% confidence interval 2.78 to 5.57; P <0.001). Conclusion: Differences in knowledge about resuscitation and course attendance were found between university hospitals in 12 European countries. Education in cardiopulmonary resuscitation is considered to be vital for patients' return of spontaneous circulation rates after in-hospital cardiac arrest. A higher level of knowledge in advanced life support results in higher return of spontaneous circulation rates. [ABSTRACT FROM AUTHOR]

Background Influenza vaccine effectiveness (VE) varies by season, circulating influenza strain, age, and geographic location. There have been few studies of influenza VE among hospitalized children, particularly in Europe and the Middle East. Methods We estimated VE against influenza hospitalization among children aged 6 months to 8 years at Clalit Health Services hospitals in Israel in the 2015–2016, 2016–2017, and 2017–2018 influenza seasons, using the test-negative design. Estimates were computed for full and partial vaccination. Results We included 326 influenza-positive case patients and 2821 influenza-negative controls (140 case patients and 971 controls from 2015–2016, 36 case patients and 1069 controls from 2016–2017, and 150 case patients and 781 controls from 2017–2018). Over all seasons, VE was 53.9% for full vaccination (95% confidence interval [CI], 38.6%–68.3%), and 25.6% for partial vaccination (−3% to 47%). In 2015–2016, most viruses were influenza A(H1N1) and vaccine lineage–mismatched influenza B/Victoria; the VE for fully vaccinated children was statistically significant for influenza A (80.7%; 95% CI, 40.3%–96.1%) but not B (23.0%; −38.5% to 59.4%). During 2016–2017, influenza A(H3N2) predominated, and VE was (70.8%; 95% CI, 17.4%–92.4%). In 2017–2018, influenza A(H3N2), H1N1 and lineage-mismatched influenza B/Yamagata cocirculated; VE was statistically significant for influenza B (63.0%; 95% CI, 24.2%–83.7%) but not influenza A (46.3%; −7.2% to 75.3%). Conclusions Influenza vaccine was effective in preventing hospitalizations among fully vaccinated Israeli children over 3 influenza seasons, but not among partially vaccinated children. There was cross-lineage protection in a season where the vaccine contained B/Victoria and the circulating strain was B/Yamagata, but not in a season with the opposite vaccine-circulating strain distribution. [ABSTRACT FROM AUTHOR]

Background: Understanding how nursing students in European countries perceive their future professional role is an important step in creating awareness of the diversity and similarities between countries. Investigating nursing students' perceptions of their future profession could help in the design of education and the retention of nurses. Aim: To compare nursing students' perceptions of the professional nurse's role between Belarus, Lithuania, Poland and Sweden. Method: A cross‐sectional design was implemented. The study used two scales of the Professional Nursing Image Survey, which has questions about 10 skills and abilities and 14 functions and duties of a nurse. Results: A total of 392 final‐year nursing students in four countries participated in the study. Statistically significant differences were found between countries in terms of all 10 skills and abilities and in the distribution of responses concerning functions and duties of a nurse. Conclusions: Nursing students in Belarus, Lithuania, Poland and Sweden perceive differently the role of a nurse in terms of some functions and responsibilities. This may influence the adaptation of nurses who enjoy freedom of movement among the countries. Implications for nursing policy: The knowledge gained in this study could be beneficial in improving nursing education, as it could illuminate the discrepancy between educational goals and students' perceptions of their future professional role. [ABSTRACT FROM AUTHOR]

Purpose: The efficacy of assertive community treatment for children and adolescents is proven in the United States, but remains controversial in Europe. Moreover, most studies showing positive outcomes of assertive community treatment are limited to statistically significant differences and do not consider whether the treatment is also subjectively clinically meaningful for the patient. Using a naturalistic sample, the present study aims to assess statistical and clinical significance of an assertive community treatment unit for adolescents in Europe.Methods: Linear mixed-effects models and reliable change indices were used to respectively assess the statistical and clinical significance of assertive community treatment in 179 adolescents (mean age = 15.76, SD = 1.76) with severe mental illnesses.Results: Difficulties related to mental health (measured by the Health of the Nation Outcome Scales for Children and Adolescents, HoNOSCA) and overall functioning (measured by the Global Assessment of Functioning scale) statistically improved (all ps < 0.001) from admission to discharge. Additionally, a considerable proportion of patients (from 14% to 21%) clinically recovered to functional levels.Conclusion: Our results support the fact that assertive community treatment can have convincing and positive clinical outcomes in European settings. [ABSTRACT FROM AUTHOR]

Background: The International Classification of Functioning, Disability and Health is the international standard for describing and monitoring functioning. While the categories, the units of the classification, were not designed with measurement in mind, the hierarchical structure of the classification lends itself to the possibility of summating categories into some higher order domain. Focusing on the chapters of d4 Mobility, d5 Self-Care and d6 Domestic Life, this study seeks to ascertain if qualifiers rating of categories (0-No problem to 4-Complete problem) within those chapters can be summated, and whether such derived measurement is consistent with estimates obtained from well-known instruments which purport to measure the same constructs. Methods: The current study applies secondary analysis to data previously collected in the context of validating Core Sets for stroke, rheumatoid arthritis, and osteoarthritis. Data included qualifier-based ratings of the categories in the Core Sets, and the physical functioning sub-scale of the Short-Form 36, and the World Health Organization Disability Assessment Schedule 2.0. To examine qualifier-comparator scale item agreement Kappa statistics were used. To identify whether appropriate gradients of the comparator scales were observed across qualifier levels, an Independent Sample Median Test of the ordinal scores was deployed. To investigate the internal validity of the summated ICF categories, the Rasch model was applied. Results: Data from 2,927 subjects from Europe, Australasia, Middle East and South America were available for analysis; 36.3% had experienced a stroke, 35.8% osteoarthritis, and 27.9% had rheumatoid arthritis. The items from the Short-Form 36 could not match directly the qualifier categories as the former had only 3 response options. The Kappa between World Health Organization Disability Assessment Schedule 2.0 items and categories was low. For all qualifiers, a significant (<0.001) overall gradient was observed across the comparator scales. Only in few of the World Health Organization Disability Assessment Schedule 2.0 items could no discrete level be detected. The aggregation of the qualifiers at the Chapter and higher order levels mostly revealed fit to the Rasch model. Almost all ICF qualifiers showed ordered thresholds suggesting that the current structure and response options of the qualifiers worked as intended. Conclusions: The findings of this study provide supporting evidence for the use of the professionally rated categories and associated qualifiers to measure functioning. Implication for Rehabilitation: This study provides evidence that functioning data can be collected directly with the International Classification of Functioning, Disability and Health (ICF) by using the ICF categories as items and the ICF qualifiers as rating scale. The findings of this study show the aggregated ratings of ICF categories from the chapters d4 Mobility, d5 Self-care, and d6 Domestic life capture a broader spectrum of the construct than the corresponding summated items from the SF36-Physical Function sub-scale and the corresponding items of the World Health Organization Disability Assessment Schedule 2.0. This study illustrates the potential of building quantitative measurement by aggregating ICF categories and their qualifier ratings into meaningful domains. [ABSTRACT FROM AUTHOR]

The link between greater wellbeing and longevity is well documented. The aim of the current study was to test whether this association is consistent across individualistic and collectivistic cultures. The sample consisted of 13,596 participants from 11 European countries, each of which was assigned an individualism score according to Hofstede et al.'s (Cultures and organizations: software of the mind, McGraw Hill, New York, 2010) cultural dimension of individualism. We tested whether individualism moderated the cross-sectional association between wellbeing and self-rated health or the longitudinal association between wellbeing and mortality risk. Our analysis revealed a significant interaction between individualism and wellbeing such that the association between wellbeing and self-rated health or risk of mortality from cardiovascular disease was stronger in more individualistic countries. However, the interaction between wellbeing and individualism was not significant in analysis predicting all-cause mortality. Further prospective studies are needed to confirm our finding and to explore the factors responsible for this culturally dependent effect. [ABSTRACT FROM AUTHOR]

This study examines disparities in subjective well-being (SWB) among older migrants and natives across several European countries using data from the Survey of Health, Aging and Retirement in Europe (SHARE). Our results show a significant SWB gap between migrants and non-migrants that diminishes with increasing age. While migrants from Northern and Central Europe have similar SWB levels as natives, Southern European, Eastern European, and Non-European migrants have significantly lower levels of SWB than the native population. The immigrant-native gap becomes smaller but remains significant after controlling for sociodemographic characteristics and health, the financial situation, citizenship, age at migration, and length of residence. Additionally, we find that the size of the SWB gap varies largely across countries. Current family reunion policies as measured by the Migrant Integration Policy Index (MIPEX) correlate with these country differences. The immigrant-native gap is bigger in countries with restrictive and smaller in countries with open policies. [ABSTRACT FROM AUTHOR]

The starting point of this contribution is the potential risk to health and performance from the combination of elite sporting careers with the pursuit of education. In European sport science and politics, structural measures to promote dual careers in elite sports have been discussed increasingly of late. In addition to organisational measures, there are calls for educational-psychological intervention programmes supporting the successful management of dual careers at the individual level. This paper presents an appropriate intervention programme and its evaluation: stress-resistance training for elite athletes (SRT-EA). It comprises 10 units, each lasting 90 minutes. It is intended for athletes and aims to improve their resistance to chronic stress. The evaluation was carried out in a quasi-experimental design, with three points of measurement (baseline, immediately after, and three months after) and two non-randomised groups: an intervention group (n = 128) and an untreated control group (n = 117). Participants were between 13 and 20 years of age (53.5% male) and represented various Olympic sports. Outcome variables were assessed with questionnaires. Significant short- and mid-term intervention effects were explored. The intervention increased stress-related knowledge, general self-efficacy, and stress sensitivity. Chronic stress level, stress symptoms, and stress reactivity were reduced. In line with the intention of the intervention, the results showed short- and mid-term, small to medium-sized effects. Accordingly, separate measurements at the end of the intervention and three months later showed mostly positive subjective experiences. Thus, the results reinforce the hope that educational-psychological stress-management interventions can support dual careers. [ABSTRACT FROM PUBLISHER]

Chronic diseases are the leading cause of morbidity and mortality and are considered to be at epidemic levels worldwide. This is a cross-sectional multi-country study based on data from the European Social Survey round 7, 2014, comprising 30,826 participants (14,813 men) with mean age 50.4 ± 18.0. Physical activity and chronic diseases were self-reported. Men and women who practiced physical activity more often had lower odds of having heart problems, breathing problems, type 2 diabetes, and obesity. Engaged in physical activity 2–4 times/week and ≥5 times/week decrease the odds of having heart problems, high blood pressure, breathing problems, type 2 diabetes, and obesity, compared with men and women who engaged in physical activity 1 or less times per week. For the women, the practice of physical activity ≥5 times/week was significantly and negatively associated with having cancer, when compared with women who engaged in physical activity 1 or less times per week. Physical activity is associated with a lower risk of chronic diseases, in particular: heart problems, high blood pressure, breathing problems, allergies, type 2 diabetes, and obesity. Furthermore, even small amounts of weekly physical activity seem to decrease the risk of chronic diseases. [ABSTRACT FROM PUBLISHER]

High muscular fitness (MF) and high adherence to the Southern European Atlantic Diet (the SEADiet) have been associated with several positive metabolic outcomes. The purpose of the present study was two-fold: (i) to explore the independent associations between MF and C-reactive protein (CRP) levels; and (ii) to investigate the combined impact of MF and SEADiet on the CRP levels in a sample of adolescents. A cross-sectional school-based study was conducted on 463 adolescents (272 girls) aged 15–18 years, from the Portuguese Azorean Archipelago. Anthropometric indicators (stature, body mass, waist circumference (WC)) were measured by standardized protocols and pubertal stages were assessed by Tanner criteria. Blood samples were taken after an overnight fast. MF was assessed by the curl-up and push-up tests (from the Fitnessgram test battery). Adherence to the SEADiet was assessed with a semi-quantitative food frequency questionnaire. Linear regression models showed that MF was inversely associated with hs-CRP (unstandardizedB = −0.127;p < .009), after adjustments for age, sex, and pubertal stage, adherence of SEADiet, total energy intake and low-energy reporter and WC. Analysis of covariance (ANCOVA) showed a significant difference between the low adherence of SEADiet with low MF group and those with a high adherence of SEADiet and high MF (p < .05) (F(5, 453) = 2.238,p = .040). Our results showed that MF is inversely associated with hs-CRP. In addition, the adolescents with Low adherence of SEADiet/Low MF group had high levels of hs-CRP compared those who with high adherence of SEADiet/high MF group. [ABSTRACT FROM AUTHOR]

The study aims to examine the individual and combined association of early life factors (birth weight, birth length, and any and exclusive breastfeeding) with attention capacity in adolescents. The study included 421 European adolescents (243 girls), aged 12.5-17.5 years, who participated in the Healthy Lifestyle in Europe by Nutrition in Adolescence Study. Body weight and length at birth of adolescents were collected from parental records. The duration of any and exclusive breastfeeding were self-reported. The d2 Test of Attention was administered to assess attention capacity. The main results showed that birth weight, birth length, breastfeeding, and exclusive breastfeeding were related to attention capacity in boys ( β ranging from 0.144 to 0.196; all p < .05) after adjustment for age, centre, gestational age, maternal education, family affluence scale, and body mass index. Among boys, differences in attention capacity were found according to tertiles of birth weight and birth length ( p < .05), as well as borderline significant differences across groups of any and exclusive breastfeeding ( p = 0.055 and p = 0.108, respectively) after adjusting for potential confounders. In addition, boys with 3 early life risk factors (low birth weight, low birth length, and <3 months of breastfeeding) had significantly lower scores in attention capacity compared with boys with 0 risk factors (percentile score − 15.88; p = 0.009). In conclusion, early life factors, both separately and combined, may influence attention capacity in male European adolescents. Importantly, the combination of the 3 early life risk factors, low birth weight, low birth length, and <3 months of breastfeeding, even in normal ranges, may provide the highest reduction in attention capacity. [ABSTRACT FROM AUTHOR]

Background. This intercontinental study aimed to study gram-negative rod (GNR) resistance in hematopoietic stem cell transplantation (HSCT). Methods. GNR bacteremias occurring during 6 months post-HSCT (February 2014-May 2015) were prospectively collected, and analyzed for rates and risk factors for resistance to fluoroquinolones, noncarbapenem anti-Pseudomonas β-lactams (noncarbapenems), carbapenems, and multidrug resistance. Results. Sixty-five HSCT centers from 25 countries in Europe, Australia, and Asia reported data on 655 GNR episodes and 704 pathogens in 591 patients (Enterobacteriaceae, 73%; nonfermentative rods, 24%; and 3% others). Half of GNRs were fluoroquinolone and noncarbapenem resistant; 18.5% carbapenem resistant; 35.2% multidrug resistant. The total resistance rates were higher in allogeneic HSCT (allo-HSCT) vs autologous HSCT (auto-HSCT) patients (P < .001) but similar in community-acquired infections. Noncarbapenem resistance and multidrug resistance were higher in auto-HSCT patients in centers providing vs not providing fluoroquinolone prophylaxis (P < .01). Resistance rates were higher in southeast vs northwest Europe and similar in children and adults, excluding higher fluoroquinolone- and β-lactam/β-lactamase inhibitor resistance rates in allo-HSCT adults. Non-Klebsiella Enterobacteriaceae were rarely carbapenem resistant. Multivariable analysis revealed resistance risk factors in allo-HSCT patients: fluoroquinolone resistance: adult, prolonged neutropenia, breakthrough on fluoroquinolones; noncarbapenem resistance: hospital-acquired infection, breakthrough on noncarbapenems or other antibiotics (excluding fluoroquinolones, noncarbapenems, carbapenems), donor type; carbapenem resistance: breakthrough on carbapenem, longer hospitalization, intensive care unit, previous other antibiotic therapy; multidrug resistance: longer hospitalization, breakthrough on β-lactam/β-lactamase inhibitors, and carbapenems. Inappropriate empiric therapy and mortality were significantly more common in infections caused by resistant bacteria. Conclusions. Our data question the recommendation for fluoroquinolone prophylaxis and call for reassessment of local empiric antibiotic protocols. Knowledge of pathogen-specific resistance enables early appropriate empiric therapy. Monitoring of resistance is crucial. Clinical Trials Registration. NCT02257931 [ABSTRACT FROM AUTHOR]

Background. Surveys in the United States and Europe have shown a plateau of new HIV cases, with certain regions and populations disproportionately affected by the disease. Ethnic minority women and socioeconomically disadvantaged groups are disproportionately affected by HIV. Previous reviews have focused on prevention interventions targeting ethnic minority men who have sex with men, have not accounted for socioeconomic status, or have included only interventions carried out in clinical settings. Objectives. To review and assess the effectiveness of HIV prevention interventions targeting socioeconomically disadvantaged ethnic minority women in member states of the Organisation for Economic Co-operation and Development (OECD). Search Methods. On March 31, 2014, we executed a search using a strategy designed for the MEDLINE (Ovid), CINAHL, Embase, Scopus, and Web of Knowledge databases. Additional searches were conducted through the Cochrane Library, CRD Databases, metaRegister of Controlled Trials, EURONHEED, CEA Registry, and the European Action Program for Health Inequities as well as in gray literature sources. No language or date restrictions were applied. Selection Criteria. We selected studies assessing the effectiveness of interventions to prevent HIV among ethnic minority women of low socioeconomic status in which at least 80% of participants were reported to belong to an ethnic minority group and to have a low income or be unemployed. We included only studies that were conducted in OECD member states and were randomized controlled trials or quasi-experimental investigations with a comparison group. Data Collection and Analysis. A data extraction form was developed for the review and used to collect relevant information from each study. We summarized results both qualitatively and quantitatively. The main outcomes were categorized into 3 groups: improved knowledge regarding transmission of HIV, behavior changes related to HIV transmission, and reductions in the incidence of sexually transmitted infections (STIs). We then performed meta-analyses to assess the effectiveness of the prevention interventions in terms of the 3 outcome categories. Main Results. A total of 43 interventions were included, and 31 were judged to be effective, 7 were partially effective, and 5 were ineffective. The most frequently recurring characteristics of these interventions were cultural adaptation, a cognitive– behavioral approach, the use of small groups and trained facilitators, and a program duration of between 1 and 6 weeks. Our meta-analyses showed that the interventions improved knowledge of HIV transmission (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.43, 0.75), increased the frequency of condom use (OR= 1.60; 95% CI = 1.16, 2.19), and significantly reduced the risk of STI transmission by 41% (relative risk = 0.59; 95% CI = 0.46, 0.75). Conclusions. Our study demonstrates the feasibility and effectiveness of HIV prevention interventions targeting socioeconomically deprived ethnic minority women. [ABSTRACT FROM AUTHOR]

Purpose: Milk provides a significant source of calcium, protein, vitamins and other minerals to Western populations throughout life. Due to its widespread use, the metabolic and health impact of milk consumption warrants further investigation and biomarkers would aid epidemiological studies. Methods: Milk intake assessed by a validated food frequency questionnaire was analyzed against fasting blood metabolomic profiles from two metabolomic platforms in females from the TwinsUK cohort ( n = 3559). The top metabolites were then replicated in two independent populations (EGCUT, n = 1109 and KORA, n = 1593), and the results from all cohorts were meta-analyzed. Results: Four metabolites were significantly associated with milk intake in the TwinsUK cohort after adjustment for multiple testing ( P < 8.08 × 10) and covariates (BMI, age, batch effects, family relatedness and dietary covariates) and replicated in the independent cohorts. Among the metabolites identified, the carnitine metabolite trimethyl-N-aminovalerate ( β = 0.012, SE = 0.002, P = 2.98 × 10) and the nucleotide uridine ( β = 0.004, SE = 0.001, P = 9.86 × 10) were the strongest novel predictive biomarkers from the non-targeted platform. Notably, the association between trimethyl-N-aminovalerate and milk intake was significant in a group of MZ twins discordant for milk intake ( β = 0.050, SE = 0.015, P = 7.53 × 10) and validated in the urine of 236 UK twins ( β = 0.091, SE = 0.032, P = 0.004). Two metabolites from the targeted platform, hydroxysphingomyelin C14:1 ( β = 0.034, SE = 0.005, P = 9.75 × 10) and diacylphosphatidylcholine C28:1 ( β = 0.034, SE = 0.004, P = 4.53 × 10), were also replicated. Conclusions: We identified and replicated in independent populations four novel biomarkers of milk intake: trimethyl-N-aminovalerate, uridine, hydroxysphingomyelin C14:1 and diacylphosphatidylcholine C28:1. Together, these metabolites have potential to objectively examine and refine milk-disease associations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Epidemiological evidence on the association between ambient air pollution and breast cancer risk is inconsistent. OBJECTIVE: We examined the association between long-term exposure to ambient air pollution and incidence of postmenopausal breast cancer in European women. METHODS: In 15 cohorts from nine European countries, individual estimates of air pollution levels at the residence were estimated by standardized land-use regression models developed within the European Study of Cohorts for Air Pollution Effects (ESCAPE) and Transport related Air Pollution and Health impacts - Integrated Methodologies for Assessing Particulate Matter (TRANSPHORM) projects: particulate matter (PM) ≤2:5 μm, ≤10 μm, and 2:5-10 μm in diameter (PM2.5, PM10, and PMcoarse, respectively); PM2.5 absorbance; nitrogen oxides (NO2 and NOx); traffic intensity; and elemental composition of PM. We estimated cohort-specific associations between breast cancer and air pollutants using Cox regression models, adjusting for major lifestyle risk factors, and pooled cohort-specific estimates using random-effects meta-analyses. RESULTS: Of 74,750 postmenopausal women included in the study, 3,612 developed breast cancer during 991,353 person-years of follow-up. We found positive and statistically insignificant associations between breast cancer and PM2.5 {hazard ratio (HR)=1:08 [95% confidence interval (CI): 0.77, 1.51] per 5 μg = m3}, PM10 [1.07 (95% CI: 0.89, 1.30) per 10 μg = m3], PMcoarse [1.20 (95% CI: 0.96, 1.49 per 5 μg = m3], and NO2 [1.02 (95% CI: 0.98, 1.07 per 10 μg = m3], and a statistically significant association with NOx [1.04 (95% CI: 1.00, 1.08) per 20 μg = m3, p = 0:04]. CONCLUSIONS: We found suggestive evidence of an association between ambient air pollution and incidence of postmenopausal breast cancer in European women. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe gender and region differences in the prevalence of binge drinking and in the association between binge drinking and well-being, among older adult Europeans. Methods: This is a cross-sectional study using the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 4, conducted between 2011 and 2012, including 58 489 individuals aged 50 years or older. Sixteen European countries were grouped in four drinking culture regions: South, Central, North and East. We categorized drinking patterns as: never, former, no-binge and binge drinkers. We used the CASP-12 questionnaire to measure well-being. To assess the association between binge drinking and well-being, we fitted two-level mixed effects linear models. Results: The highest percentage of binge drinkers was found in Central Europe (17.25% in men and 5.05% in women) and the lowest in Southern Europe (9.74% in men and 2.34% in women). Former, never and binge drinkers had a significant negative association with well-being as compared with no-binge drinkers. There was a significant interaction in this association by gender and region. Overall, associations were generally stronger in women and in Southern and Eastern Europe. The negative association of binge drinking with well-being was especially strong in Southern European women (β = -3.80, 95%CI: -5.16 to -2.44, P value <0.001). Conclusion: In Southern and Eastern European countries the association between binge drinking and well-being is stronger, especially in women, compared with Northern and Central Europe. Cultural factors (such as tolerance to drunkenness) should be further explored. [ABSTRACT FROM AUTHOR]

We studied the associations of leukocyte telomere length (LTL) with all-cause, cardiovascular disease, and cancer mortality in 12,199 adults participating in 2 population-based prospective cohort studies from Europe (ESTHER) and the United States (Nurses' Health Study). Blood samples were collected in 1989-1990 (Nurses' Health Study) and 2000-2002 (ESTHER). LTL was measured by quantitative polymerase chain reaction. We calculated z scores for LTL to standardize LTL measurements across the cohorts. Cox proportional hazards regression models were used to calculate relative mortality according to continuous levels and quintiles of LTLz scores. The hazard ratios obtained from each cohort were subsequently pooled by meta-analysis. Overall, 2,882 deaths were recorded during follow-up (Nurses' Health Study, 1989-2010; ESTHER, 2000-2015). LTL was inversely associated with age in both cohorts. After adjustment for age, a significant inverse trend of LTL with all-cause mortality was observed in both cohorts. In random-effects meta-analysis, age-adjusted hazard ratios for the shortest LTL quintile compared with the longest were 1.23 (95% confidence interval (CI): 1.04,1.46) for all-cause mortality, 1.29 (95% CI: 0.83, 2.00) for cardiovascular mortality, and 1.10 (95% CI: 0.88, 1.37) for cancer mortality. In this study population with an age range of 43-75 years, we corroborated previous evidence suggesting that LTL predicts all-cause mortality beyond its association with age. [ABSTRACT FROM AUTHOR]

Objectives. The arachidonate 5-lipoxygenase activating protein (ALOX5AP) regulates synthesis of leuko-trienes (LTs), which are important mediators of inflammation and connective tissue remodelling. The aim of this study was to evaluate if single nucleotide polymorphisms (SNPs) of ALOX5AP confer risk of SSc and/ or SSc-related organ involvement. Methods. Seven SNPs of ALOX5AP (rs17222814, rs17216473, rs10507391, rs4769874, rs9551963, rs9315050 and rs7222842) were genotyped in a cohort of 977 patients with SSc and 558 healthy controls from centres collaborating within the European Scleroderma Trials and Research group. In 22 SSc patients, concentrations of cysteinyl LTs and LT B4 (LTB4) were measured in the supernatants of ionophore-stimulated peripheral blood mononuclear cells (PBMCs) by means of commercially available enzyme immunoassay kits. Results. Significant association was found between rs10507391 polymorphism (T/A) of ALOX5AP and the risk of SSc [odds ratio (OR) 1.27 (95% CI 1.07, 1.50), P < 0.05 vs controls], the presence of SSc-related interstitial lung disease on high-resolution CT of the lungs [OR 1.45 (95% CI 1.17, 1.79), P < 0.05 vs patients without SSc-related interstitial lung disease] as well as with restrictive ventilatory defect [forced vital capacity <70% of predicted; OR 1.51 (95% CI 1.16, 1.97), P < 0.05 vs SSc patients without pulmonary restriction]. PBMCs from SSc carriers of rs10507391 allele A synthesized greater amounts of cysteinyl LTs as compared with SSc patients with rs10507391 TT genotype (P < 0.05). Synthesis of LTB4 did not differ significantly between the two groups. Conclusion. The results of our study indicate that the genetic variants of ALOX5AP might play a role in the development of SSc-related pulmonary fibrosis. [ABSTRACT FROM AUTHOR]

Purpose: Supplementation with dietary forms of vitamin D is commonplace in clinical medicine, elite athletic cohorts, and the general population, yet the response of all major vitamin D metabolites to high doses of vitamin D is poorly characterized. We aimed to identify the responses of all major vitamin D metabolites to moderate- and high-dose supplemental vitamin D3. Methods: A repeated-measures design was implemented in which 46 elite professional European athletes were block randomized based on their basal 25[OH]D concentration into two treatment groups. Athletes received either 35,000 or 70,000 IU⋅wk-1 vitamin D3 for 12 wk, and 42 athletes completed the trial. Blood samples were collected for 18 wk to monitor the response to supplementation and withdrawal from supplementation. Results: Both doses led to significant increases in serum 25[OH]D, and 1,25[OH]2D3. 70,000 IU⋅wk-1 also resulted in a significant increase of the metabolite 24,25[OH]2D at weeks 6 and 12 that persisted after supplementation withdrawal at week 18, despite a marked decrease in 1,25[OH]2D3. Intact parathyroid hormone was decreased in both groups by week 6 and remained suppressed throughout the trial. Conclusions: High-dose vitamin D3 supplementation (70,000 IU⋅wk-1) may be detrimental for its intended purposes because of increased 24,25[OH]2D production. Rapid withdrawal from high-dose supplementation may inhibit the bioactivity of 1,25[OH]2D3 as a consequence of sustained increases in 24,25[OH]2D that persist as 25[OH]D and 1,25[OH]2D concentrations decrease. These data imply that lower doses of vitamin D3 ingested frequently may be most appropriate and gradual withdrawal from supplementation as opposed to rapid withdrawal may be favorable. [ABSTRACT FROM AUTHOR]

Purpose: This cross-sectional study assesses the relationship between consumption frequencies of food items and high-sensitivity C-reactive protein (hs-CRP) in European children. Methods: Out of the baseline sample ( N = 16.228) of the IDEFICS study, 6.403 children (1.315 boys aged 2 to <6, 1.908 boys aged 6 to <10, 1.204 girls aged 2 to <6 and 1.976 girls aged 6 to <10 years) had hs-CRP measured and the Children's Eating Habits Questionnaire filled, including a food frequency questionnaire. Logistic regression adjusted for body mass index z-score, education of the mother, breast-feeding and self-reported hours of physical activity in a sport club per week was conducted. Results: Mean frequency intake of raw vegetable was lower in boys ( p = 0.022 in young and p = 0.020 in old) and older girls ( p = 0.026) with high hs-CRP concentration, while in younger girls ( p = 0.008) the same occurred with the cooked vegetables. The probability of having higher hs-CRP concentration was significantly associated with having low consumption frequency of vegetables ( p = 0.004 in older boys, raw vegetables; and p = 0.0032 in younger girls, cooked vegetables). Also, honey/jam intake decreased the probability of having higher concentration of hs-CRP, whereas soft drinks with sugar, mayonnaise and cereals milled increased this probability. Conclusions: Out of all food items associated with hs-CRP, frequency intake of vegetables presented more associations across all the analysis. Findings suggest that a high-frequency intake of vegetables is inversely related to an inflammatory status in children. More studies are needed to assess the association between diet and inflammation. [ABSTRACT FROM AUTHOR]

Although the statistical significances for the trends of integrated water vapor (IWV) are essential for a correct interpretation of climate change signals, obtaining accurate IWV trend estimates with realistic uncertainties remains a challenge. This study evaluates the feasibility of the IWV trends derived from the newly released fifth generation European Centre for Medium-Range Weather Forecasts (ECMWF) atmospheric reanalysis (ERA5) for climate change analysis in continental Europe. This is achieved by comparing the trends derived from in-situ ground-based Global Positioning System (GPS)'s daily IWV series from 1994 to 2019 at 109 stations. The realistic uncertainties and statistical significances of the IWV trends are evaluated with the time series analysis on their noise characteristics and proper noise models. Results show that autoregressive moving average ARMA(1,1) noise model is preferred rather than the commonly assumed white noise (WN) or first - order autoregressive AR(1) noise for about 68% of the ERA5 and GPS IWV series. An improper noise model would misevaluate the trend uncertainty of an IWV time series, compared with its specific preferred noise model. For example, ARMA(1,1) may misevaluate the standard deviations of their trend estimates (0.1–0.3 kg m−2 decade−1) by 10%. Nevertheless, ARMA(1,1) is recommended as the default noise model for the ERA5 and GPS IWV series. However, the preferred noise model for each ERA5 minus GPS (E -G) IWV series should be specifically determined, because the AR(1)-related models can result in an underestimation on its trend uncertainty by 90%. In contrast, power-law (PL) model can lead to an overestimation by up to nine times. The E -G IWV trends are within −0.2–0.4 kg m−2 decade−1, indicating that the ERA5 is a potential data source of IWV trends for climate change analysis in continental Europe. The ERA5 and GPS IWV trends are consistent in their magnitudes and geographical patterns, lower in Northwest Europe (0–0.4 kg m−2 decade−1) but higher around the Mediterranean Sea (0.6–1.4 kg m−2 decade−1). • Improper noise models would bias the uncertainties of Integrated Water Vapor trends. • ARMA(1,1) model is recommended for daily ERA5 and GPS IWV time series analysis. • Proper noise models for the daily ERA5 minus GPS IWV series analysis are varied. • ERA5 is a potential data source of IWV trends for climate change analysis in Europe. • The IWV trends are generally 0–1.4 kg m−2 decade−1 in Europe and 69% are significant. [ABSTRACT FROM AUTHOR]

The paper presents an alternative approach to analyzing decoupling between municipal solid waste and economic activity production. The methodology consists of generalizing the functional form of the statistical model of the environmental Kuznets curve. To avoid the limitation of one single alternative hypothesis, we developed a small set of alternatives based on the signs and statistical significance of estimates. We tested the model for all available categories of municipal solid waste in Italian provinces. The necessity of developing an alternative approach resulted from inconsistencies in past studies within the same policy context. Conclusions from similar statistical approaches and models provided contradictory findings for Europe and other regions. The results of our approach suggest that there is no linear correlation between economic activity and municipal solid waste, nor are they (yet) decoupled from economic activity: GDP per capita affects MSW production differently in each province, which is reflected through differences in spatial correlation. [ABSTRACT FROM AUTHOR]

End-of-life care in nursing homes holds several risk factors for the use of physical restraints on residents, a practice shown to be neither safe nor effective. To determine the frequency of physical limb and/or trunk restraint use in the last week of life of nursing home residents in six European countries and its association with country, resident and nursing home characteristics. Epidemiological survey study. Proportionally stratified random sample of nursing homes in Belgium (BE), England (ENG), Finland (FI), Italy (IT), the Netherlands (NL), and Poland (PL). Nursing home staff (nurses or care assistants). In all participating nursing homes, we identified all residents who died during the three months prior to measurements. The staff member most involved in each resident's care indicated in a structured questionnaire whether trunk and/or limb restraints were used on that resident during the last week of life 'daily', 'less frequently than daily' or 'not used'. In 322 nursing homes, staff returned questionnaires regarding 1384 deceased residents (response rate 81%). Limb and/or trunk restraints were used "daily" in the last week of life in 8% (BE), 1% (ENG), 4% (FI), 12% (IT), 0% (NL), and 0.4% (PL) of residents; and "less frequently than daily" in 4% (BE), 0% (ENG), 0.4% (FI), 6% (IT), 0% (NL), and 3.5% (PL) of residents. Restraint use was associated with country (p = 0.020) and inversely associated with residents' age (p = 0.017; odds ratio 0.96, 95% confidence interval 0.93 to 0.99). Restraint use was not significantly associated with resident's gender, dementia, functional status, staffing level, or the level of dependency of residents within the nursing home. In all but one of the six countries studied, staff reported that nursing home residents were restrained through limb and/or trunk restraints in the last week of life. The proportion of restrained residents was highest in Italy and Belgium. Organizational and resident characteristics may not be relevant predictors of restraint use at the end of life in this setting. National policy that explicitly discourages physical restraints in nursing home care and suggests alternative practices may be an important component of strategies to prevent their use. [ABSTRACT FROM AUTHOR]