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Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online., (© 2022 European Society of Cardiology This article has been co-published with permission in European Heart Journal (published by Oxford University Press on behalf of European Society of Cardiology) and European Journal of Heart Failure (published by John Wiley & Sons Ltd on behalf of European Society of Cardiology).)

The synthetic cannabinoid receptor agonist (SCRA) market is transnational, and the availability of individual SCRAs changes regularly in response to national and international legislative controls. This generates a cyclic pattern and near constant evolution of SCRA compounds. This study reports toxicology-based and/or seized sample-based prevalence data relating to SCRA use in prisons from Germany, the United Kingdom (UK; Scotland and Wales), and the United States (US), representing 4427 individual test results. The study examines SCRA detections in prisons from July 2018 to September 2020, and where possible, prison-based data are compared with SCRA prevalence data in the wider population. The relative influence of Chinese, other international, and national drug legislation on the prevalence of individual SCRAs in prisons is also considered. tert-Leucinate- and valinate-indole- and indazole-3-carboxamides were the most common SCRA detections, and MDMB-4en-PINACA was one of the most commonly detected SCRAs in all jurisdictions by September 2020. However, despite there being a global production and supply market, there were notable regional differences. Analog controls in German and US legislation may have led to increased compound diversity that is not reflected in the UK which has both analog controls and a blanket ban on psychoactive substances. While there were regional differences, SCRA prevalence in prisons closely aligned with the SCRAs detected on the local market, demonstrating that SCRA (and possibly other NPS) monitoring programs in prisons can act as early warning systems for the wider population in that given jurisdiction., (© 2021 The Authors. Drug Testing and Analysis published by John Wiley & Sons Ltd.)

Purpose: Normative utility scores represent the health related quality of life of the general population, are of utmost importance in cost-effectiveness studies and should reflect relevant sexes and age groups. The aim of this study was to estimate EQ-5D-5L normative utility scores in a population of Dutch females, stratified by age, and to compare these scores to those of female populations of three other countries., Methods: Dutch women completed the EQ-5D-5L online between January and July 2020. Mean normative utilities were computed using the Dutch EQ-5D-5L value set, stratified by age, tested for differences using the Kruskall-Wallis test, and compared to normative utility scores of female populations elsewhere. Additionally, to support the use of the Dutch EQ-5D-5L data in other settings, normative utility scores were also calculated by applying the value sets of Germany, United Kingdom and USA., Results: Data of 9037 women were analyzed and the weighted mean utility score was 0.911 (SD 0.155, 95% CI 0.908-0.914). The mean normative utility scores differed between age groups, showing lower scores in older females. Compared to other normative utility scores of female populations, Dutch mean utilities were consistently higher except for age groups 18-24 and 25-34. With the three country-specific value sets, new age-specific mean normative utility scores were provided., Conclusion: This study provides mean normative utility scores of a large cohort of Dutch females per age group, which were found to be lower in older age groups. Utility scores calculated with three other value sets were made available., (© 2022. The Author(s).)

Background: The current standard of care for multiple myeloma requires several regimens of treatment, with patients experiencing high symptom burden and side effects, which negatively impact health-related quality of life (HRQoL). Thus, it is crucial to understand patient perceptions of multiple myeloma and how patients value different treatment options., Objective: The purpose of this study was to conduct an exploratory investigation into concepts that could form attributes that influence treatment choices for patients with multiple myeloma and to identify trade-offs that patients are willing to make between treatment attributes., Methods: In total, 30 patients with newly diagnosed or relapsed/refractory multiple myeloma from the UK, France, and Germany participated in semistructured interviews talking about their disease experience and symptoms, treatment benefits, treatment burden, perceived side effects, and benefit/risk trade-offs in treatment. The interview audio recordings were transcribed and analyzed using content analysis to identify treatment and disease aspects relevant to patients., Results: Symptoms of fatigue and bone pain and treatment side effects of peripheral neuropathy, diarrhea, and constipation were cited by patients as the most disruptive to their HRQoL. Treatment duration was reported most frequently as a major treatment burden, and patients emphasized the importance of increased life expectancy as a treatment benefit. All patients showed good understanding of benefit/risk trade-offs in treatment, and some patients expressed a preference for more convenient modes of treatment administration., Conclusions: Qualitative interviews identified key aspects of multiple myeloma treatment that are most important to patients. These findings will inform a wider patient-preferences study, which could improve treatment choice and HRQoL for patients with multiple myeloma., (© 2021. The Author(s).)

In addition to improving quality of life, higher subjective wellbeing leads to fewer health problems and higher productivity, making subjective wellbeing a focal issue among researchers and governments. However, it is difficult to estimate how happy people were during previous centuries. Here we show that a method based on the quantitative analysis of natural language published over the past 200 years captures reliable patterns in historical subjective wellbeing. Using sentiment analysis on the basis of psychological valence norms, we compute a national valence index for the United Kingdom, the United States, Germany and Italy, indicating relative happiness in response to national and international wars and in comparison to historical trends in longevity and gross domestic product. We validate our method using Eurobarometer survey data from the 1970s and demonstrate robustness using words with stable historical meanings, diverse corpora (newspapers, magazines and books) and additional word norms. By providing a window on quantitative historical psychology, this approach could inform policy and economic history.

Health-related quality of life (HRQoL) assessment is recognized as an important outcome in the evaluation of different therapeutic regimens for persons with haemophilia. The Canadian Haemophilia Outcomes-Kids' Life Assessment Tool (CHO-KLAT) is a disease-specific measure of HRQoL for 4 to 18-year-old boys with haemophilia. The purpose of this study was to extend this disease-specific, child-centric, outcome measure for use in international clinical trials. We adapted the North American English CHO-KLAT version for use in five countries: France, Germany, the Netherlands, Spain and the United Kingdom (UK). The process included four stages: (i) translation; (ii) cognitive debriefing; (iii) validity assessment relative to the PedsQL (generic) and the Haemo-QoL (disease-specific) and (iv) assessment of inter and intra-rater reliability. Cognitive debriefing was performed in 57 boys (mean age 11.4 years), validation was performed in 144 boys (mean age 11.0 years) and reliability was assessed for a subgroup of 64 boys (mean age 12.0 years). Parents also participated. The mean scores reported by the boys were high: CHO-KLAT 77.0 (SD = 11.2); PedsQL 83.8 (SD = 11.9) and Haemo-QoL 79.6 (SD = 11.5). Correlations between the CHO-KLAT and PedsQL ranged from 0.63 in Germany to 0.39 in the Netherlands and Spain. Test-retest reliability (concordance) for child self-report was 0.67. Child-parent concordance was slightly lower at 0.57. The CHO-KLAT has been fully culturally adapted and validated for use in five different languages and cultures (in England, the Netherlands, France, Germany and Spain) where treatment is readily available either on demand or as prophylaxis., (© 2014 John Wiley & Sons Ltd.)

This paper introduces three new scales to measure left- and right-wing radical as well as general extremist attitudes that can be applied across Western European countries. We therefore propose a thorough conceptualization of extremist attitudes that consists of two dimensions: general extremism, by which we understand attitudes that oppose the constitutional democratic state, and another dimension that differentiates between right- and left-wing radicalism by which we understand people who take far-reaching but often one-sided positions on political issues (e.g., on nationalism or anti-imperialism) by advocating fundamental socio-political change. Based on data from Germany, Great Britain, and the Netherlands (n = 6,201) we created short indices for general extremism and left- and right-wing radicalism. We check for convergence validity by assessing the psychometric properties of the extracted indices, i.e. their internal coherence and the degree to which a scale is able to distinguish strongly extremist and non-extremist individuals. Finally, we correlate the scales with various constructs that are likely related to extremist attitudes in order to assure external or construct validity. The results indicate that the three scales are highly valid and applicable across three Western European countries. Overall, we find that about two to four percent of citizens in each country hold left-wing or right-wing extremist attitudes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Jungkunz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Interactions in the healthcare system today involve an important new set of actors: evaluative health platforms (EHPs). These platforms are not neutral intermediaries, but active moderators of how patients express opinions, choose providers, and consume health-related information. This paper adds to our understanding of the varied and evolving commercial interests of EHPs and the implications these have for patient voice. We analyze 71 platforms in the USA, UK, and Germany and identify five ideal types: subscribers, analyzers, advertisers, regulators, and scammers. Each platform type enacts a unique competitive strategy through an evaluative infrastructure which constrains but also generates possibilities for patient voice. Based on our typology, we develop three contributions. First, we nuance universalizing claims about the consequences of platform capitalism by specifying the diverse strategies underpinning competition between EHPs in different countries, and showing how each strategy leads evaluative infrastructures to develop in ways that impact patient voice. Second, we show how patients can navigate the challenges of a complex EHP space by exercising their ability to choose between platforms. Finally, we outline the conditions platforms need to fulfil to become empowering. Overall, this study highlights the varied and complex relationship between platform business models and user voice, which exists not only in healthcare, but also in many other fields., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Hardly any value frameworks exist that are focused on provider-facing digital health technologies (DHTs) for managing chronic disease with diverse stakeholder participation in their creation. Our study aimed to 1) understanding different stakeholder opinions on where value lies in provider-facing technologies and 2) create a comprehensive value assessment framework for DHT assessment., Methods: Mixed-methods comprising both primary and secondary evidence were used. A scoping review enabled a greater understanding of the evidence base and generated the initial indicators. Thirty-four indicators were proposed within 6 value domains: health inequalities (3), data rights and governance (6), technical and security characteristics (6), clinical characteristics (7), economic characteristics (9), and user preferences (3). Subsequently, a 3-round Web-Delphi was conducted to rate the indicators' importance in the context of technology assessment and determine whether there was consensus., Results: The framework was adapted to 45 indicators based on participant contributions in round 1 and delivered 16 stable indicators with consensus after rounds 2 and 3. Twenty-nine indicators showed instability and/or dissensus, particularly the data rights domain, in which all 5 indicators were unstable, showcasing the novelty of the concept of data rights. Significant instability between important and very important ratings was present within stakeholder groups, particularly clinicians and policy experts, indicating they were unsure how different aspects should be valued., Conclusions: Our study provides a comprehensive value assessment framework for assessing provider-facing DHTs incorporating diverse stakeholder perspectives. Instability for specific indicators was expected due to the novelty of data and analytics integration in health technologies and their assessment. Further work is needed to ensure that, across all types of stakeholders, there is a clear understanding of the potential impacts of provider-facing DHTs., Highlights: Current health technology assessment (HTA) methods may not be well suited for evaluating digital health technologies (DHTs) because of their complexity and wide-ranging impact on the health system.This article adds to the literature by exploring a wide range of stakeholder opinions on the value of provider-facing DHTs, creating a holistic value framework for these technologies, and highlighting areas in which further discussions are needed to align stakeholders on DHTs' value attributes.A Web-based Delphi co-creation approach was used involving key stakeholders from throughout the digital health space to generate a widely applicable value framework for assessing provider-facing DHTs. The stakeholders include patients, health care professionals, supply-side actors, decision makers, and academia from the United States, United Kingdom, and Germany.High levels of instability among stakeholders and value domains are demonstrated, indicating the novelty of assessing provider-facing DHTs and their impact on the health system., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this paper was provided by a contract with Sanofi S.A. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Prominent theoretical positions in sociology and labor economics disagree whether educational expansion has outstripped the demand for qualified labor (overexpansion), or whether economies face a skill shortage despite increases in education (underexpansion). Focusing on the United Kingdom and West Germany, two countries with dissimilar skill formation institutions, patterns of expansion, and labor markets, this paper asks to what degree expansion of education has been absorbed. I point out shortcomings of wage-centered analyses and develop an approach that focuses on trends in self-assessed over- and underqualification. Using repeated surveys among workers and official labor market statistics, I estimate regression models that link the cohort-level expansion of education to the cohort-level prevalence of mismatch. Results suggest overexpansion in the United Kingdom, with overqualification increasing and underqualification decreasing over historical times and cohorts. West Germany, on the other hand, shows signs of underexpansion. While dominant theoretical accounts focus on the under-/overexpansion of tertiary education, my results show that mismatch-dynamics in both contexts are strongest for workers without university degrees., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Using two case studies from Europe, this paper illustrates that there is a need to understand the role of pharmacists' professional practice relating to traditional and complementary medicine. Especially in countries, where there is a strong ongoing tradition of using most notably herbal medicines and at the same time a limited focus on pharmacy practice research, there is a need for further studies. Comparing the role of community pharmacists in the context of herbal medicines and their use, two contrasting approaches emerge, and we exemplify this using a case study approach with two countries, which show the different approaches in the context of healthcare and specifically community pharmacy. In Germany (as in many other European countries) herbal medicines have remained a core element of community pharmacy, and are an important healthcare resource, while in the UK, these products are no longer primarily sourced through community pharmacies. This case study also highlights different regulatory approaches and classification in these countries to identical healthcare/medical products. Pharmacy practice research should endeavour to systematically compare the regulatory framework of this class of products and their importance in community settings., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Socioeconomic inequalities in childhood Body Mass Index (BMI) are becoming increasingly more pronounced across the world. Although countries differ in the direction and strength of these inequalities, cross-national comparative research on this topic is rare. This paper draws on harmonized longitudinal cohort data from four wealthy countries-Germany, the Netherlands, the United Kingdom (UK), and the United States (US)-to 1) map cross-country differences in the magnitude of socioeconomic inequalities in childhood BMI, and 2) to examine cross-country differences in the role of three energy-balance-related behaviors-physical activity, screen time, and breakfast consumption-in explaining these inequalities. Children were aged 5-7 at our first timepoint and were followed up at age 8-11. We used data from the German National Educational Panel Study, the Dutch Generation R study, the UK Millennium Cohort Study and the US Early Childhood Longitudinal-Kindergarten Study. All countries revealed significant inequalities in childhood BMI. The US stood out in having the largest inequalities. Overall, inequalities between children with low versus medium educated parents were smaller than those between children with high versus medium educated parents. The role of energy-balance-related behaviors in explaining inequalities in BMI was surprisingly consistent. Across countries, physical activity did not, while screen time and breakfast consumption did play a role. The only exception was that breakfast consumption did not play a role in the US. Cross-country differences emerged in the relative contribution of each behavior in explaining inequalities in BMI: Breakfast consumption was most important in the UK, screen time explained most in Germany and the US, and breakfast consumption and screen time were equally important in the Netherlands. Our findings suggest that what constitutes the most effective policy intervention differs across countries and that these should target both children from medium as well as low educated families., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This paper discusses fourteen letters that Heinrich Will (1812-1890), Justus Liebig's (1803-1873) successor at the University of Giessen, sent to Robert Warington (1807-1867), the chemical operator at Apothecaries' Hall in London, between 1842 and 1854. The correspondence illuminates a range of topics related to the development of the British chemical community in mid-Victorian Britain - its organisations, networks, and commercial opportunities, as well as offering insights into the importance of family, friendship, and collegiality in sustaining scientific careers. Studying such an exchange of material and textual knowledge helps to further understand how science was organised and ideas disseminated in a key period for institutional development in chemistry.

Forecasts predict a growing shortage of skilled nursing staff in countries worldwide. Nurse migration is already a common strategy used to address nursing workforce needs. Germany, the UK, and Australia are reviewed here as examples of destination countries for nurse migrants. Agreements exist between countries to facilitate nurse migration; however, it is not evident how nurse migrants have contributed to data on which these arrangements are based. We examined existing primary research on nurse migration, including educational needs and initiatives to support policymakers', stakeholders', and health professions educators' decisions on measures for ethical and sustainable nurse migration. We conducted a rapid evidence assessment to review available empirical research data which involved, was developed with, or considered migrant nurses to address the research question: what are the findings of research that directly involves migrant nurses in producing primary research data? A total of 56 papers were included. Four main themes were identified in this research data: Research does not clearly define what is meant by the term migrant nurses; discrimination is often reported by migrant nurses; language and communication competencies are important; and structured integration programs are highly valued by migrant nurses and destination healthcare employers.Migrant nurses continue to experience discrimination and reduced career opportunities and therefore should be included in research about them to better inform policy. Structured integration programs can improve the experience of migrant nurses by providing language support (if necessary), a country-specific bridging program and help with organisational hurdles. Not only researching migrant nurses but making them active partners in research is of great importance for successful, ethical, and sustainable migration policies. A broader evidence base, especially with regard to the views and experiences of migrant nurses and their educational support needs, should be promoted to make future immigration policy more needs-based, sustainable and ethically acceptable.

Since December 2019, a novel coronavirus (COVID-19) has spread all over the world, causing unpredictable economic losses and public fear. Although vaccines against this virus have been developed and administered for months, many countries still suffer from secondary COVID-19 infections, including the United Kingdom, France, and Malaysia. Observations of COVID-19 infections in the United Kingdom and France and their governance measures showed a certain number of similarities. A further investigation of these countries' COVID-19 transmission patterns suggested that when a turning point appeared, the values of their stringency indices per population density (PSI) were nearly proportional to their absolute infection rate (AIR). To justify our assumptions, we developed a mathematical model named VSHR to predict the COVID-19 turning point for Malaysia. VSHR was first trained on 30-day infection records prior to the United Kingdom, Germany, France, and Belgium's known turning points. It was then transferred to Malaysian COVID-19 data to predict this nation's turning point. Given the estimated AIR parameter values in 5 days, we were now able to locate the turning point's appearance on June 2 nd , 2021. VSHR offered two improvements: (1) gathered countries into groups based on their SI patterns and (2) generated a model to identify the turning point for a target country within 5 days with 90% CI. Our research on COVID-19's turning point for a country is beneficial for governments and clinical systems against future COVID-19 infections., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2022 Xiang Yu et al.)

The COVID-19 pandemic is an unprecedented global crisis in which governments had to act in a situation of rapid change and substantial uncertainty. The governments of Germany, Sweden and the UK have taken different paths allowing learning for future pandemic preparedness. To help inform discussions on preparedness, inspired by resilience frameworks, this paper reviews governance structures, and the role of science and the media in the COVID-19 response of Germany, Sweden and the UK in 2020. We mapped legitimacy, interdependence, knowledge generation and the capacity to deal with uncertainty.Our analysis revealed stark differences which were linked to pre-existing governing structures, the traditional role of academia, experience of crisis management and the communication of uncertainty-all of which impacted on how much people trusted their government. Germany leveraged diversity and inclusiveness, a 'patchwork quilt', for which it was heavily criticised during the second wave. The Swedish approach avoided plurality and largely excluded academia, while in the UK's academia played an important role in knowledge generation and in forcing the government to review its strategies. However, the vivant debate left the public with confusing and rapidly changing public health messages. Uncertainty and the lack of evidence on how best to manage the COVID-19 pandemic-the main feature during the first wave-was only communicated explicitly in Germany. All country governments lost trust of their populations during the epidemic due to a mix of communication and transparency failures, and increased questioning of government legitimacy and technical capacity by the public., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Notable cross-country differences exist in the diffusion of the Covid-19 and in its lethality. Contact patterns in populations, and in particular intergenerational contacts, have been argued to be responsible for the most vulnerable, the elderly, getting infected more often and thus driving up mortality in some context, like in the southern European one. This paper asks a simple question: is it between whom contacts occur that matters or is it simply how many contacts people have? Due to the high number of confounding factors, it is extremely difficult to empirically assess the impact of single network features separately. This is why we rely on a simulation exercise in which we counterfactually manipulate single aspects of countries' age distribution and network structures. We disentangle the contributions of the kind and of the number of contacts while holding constant the age structure. More precisely, we isolate the respective effects of inter-age contact patterns, degree distribution and clustering on the virus propagation across age groups. We use survey data on face-to-face contacts for Great Britain, Italy, and Germany, to reconstruct networks that mirror empirical contact patterns in these three countries. It turns out that the number of social contacts (degree distribution) largely accounts for the higher infection rates of the elderly in the Italian context, while differences in inter-age contacts patterns are only responsible for minor differences. This suggests that policies specifically targeting inter-age contacts would be little effective., Competing Interests: The authors have declared that no competing interests exist.

The European pharmaceutical industry uses the alleged efficacy of self-regulation to question the need for transparency laws similar to the US Physician Payment Sunshine Act. We conducted a comparative analysis of 20 large companies' payment disclosures in seven European countries in 2017-2019. The data was extracted as part of eurosfordocs.eu, a novel transparency project that scrapes and integrates publicly available databases and disclosures. Our analysis of EUR 735 million showed marked differences in country payment patterns. For example, payment totals per registered doctor were substantially larger in Spain and lowest in Sweden. There were significant country and company differences in individualized data completeness. Only 19% of totals were reported with recipient names in Germany, compared to Ireland (59%), the United Kingdom (60%), Italy (67%), Switzerland (73%), Sweden (79%) and Spain (100%), with little or no improvement over time. Payment data in Spain was particularly difficult to extract. Thus, in no country did self-regulation generate comprehensive individualized data allowing for building an accurate picture of financial relationships between the industry and healthcare professionals. We conclude that the cultures and policies of countries and companies create structural problems of data inaccessibility and incompleteness within the self-regulatory framework. Therefore, this study supports calls for a Europe-wide "Sunshine Act" to achieve real transparency of drug company payments., Competing Interests: Declaration of Competing Interest SM's partner is employed by PRA Health Sciences, a global Contract Research Organization whose costumers include many pharmaceutical companies. LM and PAJ are members of Euros for Docs, a non-profit organization registered in France that seeks to promote transparency of drug company funding in the healthcare sector by making payment data accessible and complete across Europe. PAJ is employed by Haute Autorité de Santé, the French independent health technology assessment organisation. PO's PhD student was supported by a grant from Sigma Pharmaceuticals, a UK pharmacy wholesaler and distributor (not a pharmaceutical company). The PhD work funded by Sigma Pharmaceuticals is unrelated to the subject of this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

The development and enhancement of occupational health services (OHS) at the national level is central to ensuring the sustainable health, well-being and work engagement of the working population. However, due to differences in national health, social security and occupational safety and health systems, the content, capacity, coverage and provisions of OHS vary considerably across national contexts. Obtaining a better understanding in terms of such similarities and variations internationally is essential as such comparative information can help inform evidenced-based decision-making on OHS at both policy and practice levels. This paper therefore reviews and analyses the key policies, standards and approaches in OH systems and services, using both academic and grey literature, across 12 industrialised countries (Australia, Canada, Finland, France, Germany, Ireland, Italy, Japan, The Netherlands, Poland, United Kingdom and the United States of America). It provides a detailed overview and categorization of OHS in these selected countries in terms of the legal and policy context, organisation and financing and coverage and staffing while specifically discussing variations aimed at psychosocial risk management and the promotion of mental health and well-being at work. It draws conclusions on key development needs of OHS internationally to ensure psychosocial risk management and mental health promotion are prioritised effectively in a preventive manner.

With the implementation of European integration policies such as the single market, the Euro and the Schengen Visa, the EU member states are developing closer economic ties through tourism, and their level of tourism integration is constantly improving. Taking the 28 EU member states as research objects, this paper constructs a tourism economic connection network among them, measures the strength of their tourism economic connections from 1995 to 2018 by using the modified gravity model and social network method, and analyzes the spatial structure characteristics and effects of the EU tourism economy. The results are as follows: (1) The tourism economic ties of EU member states are growing increasingly close, enhancing network stability. (2) Germany, France, Italy, Austria and the United Kingdom are the top five countries in the degree centrality and closeness centrality rankings, meaning that they are located in the center of the network and have great influence, and the network is becoming increasingly concentrated. Germany, Italy, Sweden, Austria and France play an important intermediary role in the network, and the centrality of most member states has increased. (3) The core areas are mainly concentrated in Western Europe, Southern Europe, Mediterranean mainland countries and Central Europe, while the marginal areas are mainly concentrated in Eastern Europe, Northern Europe and Mediterranean island countries; the network connection density of the core area, the network connection density of the marginal area, and the network connection density between the core and marginal area overall show an increasing trend. (4) Improvements in the complete network connectedness and a reduction in graph efficiency can significantly reduce differences in EU tourism economic development levels and improve spatial equity.

Studying weekend-weekday variation in ground-level ozone (O 3 ) allows one to better understand O 3 formation conditions, with a potential for developing effective strategies for O 3 control. Reducing inappropriately the O 3 precursors emissions can either produce no reduction or increase surface O 3 concentrations. This paper analyzes the weekend-weekday differences of O 3 at 300 rural and 808 urban background stations worldwide from 2005 to 2014, in order to investigate the O 3 weekend effect over time and assess the effectiveness of the precursors emissions control policies for reducing O 3 levels. Data were analyzed with the non-parametric Mann-Kendall test and Theil-Sen estimator. Rural sites typically did not experience a weekend-weekday effect. In all urban stations, the mean O 3 concentration on the weekend was 12% higher than on weekdays. Between 2005 and 2014, the annual mean of daily O 3 concentrations increased at 74% of urban sites worldwide (+ 0.41 ppb year -1 ) and decreased in the United Kingdom (- 0.18 ppb year -1 ). Over this time period, emissions of O 3 precursors declined significantly. However, a greater decline in nitrogen oxides (NO x ) emissions caused an increase in Volatile Organic Compounds (VOCs) to NO x ratios leading to O 3 formation. In France, South Korea and the United Kingdom, most urban stations showed a significant upward trend (+ 1.15% per year) for O 3 weekend effect. Conversely, in Canada, Germany, Japan, Italy and the United States, the O 3 weekend effect showed a significant downward trend (- 0.26% per year). Further or inappropriate control of anthropogenic emissions in Canada, Southern Europe, Japan, South Korea and the United States might result in increased daily O 3 levels in urban areas., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Wheat is one of the main dietary sources for mycotoxins that can cause adverse health effects in humans. Here we report results of a 3-year survey which compared the effects of flour type (whole-grain vs white), wheat species (common vs spelt), and farming system (organic vs conventional) on mycotoxin concentrations in UK and German wheat flour brands. Wholegrain, conventional and organic flour contained 124, 31 and 9% higher concentrations of T-2/HT-2, DON and ZEA respectively, but concentrations of the three Fusarium mycotoxins assessed were ~10 times lower than the EC-maximum contamination levels (MCL). Thirty one percent of flour samples had Ochratoxin A (OTA) concentrations above the MCL (3 µg/kg), but OTA levels were no affected by wheat species, farming system and flour type. Results suggest that both organic and conventional primary production methods and postharvest quality assurance systems are effective for maintaining Fusarium mycotoxins, but not OTA concentrations, below the MCL., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Scientific and/or technical breakthroughs require the exploration of novel ideas and technologies. Yet, it has not been studied quantitatively how national institutional contexts either facilitate or stifle organizational support for exploration. Available qualitative evidence suggests that institutional contexts that exert weak control over universities and research organizations strengthen their capabilities to achieve scientific breakthroughs, while contexts with strong control constrain them. The paper is based on an analysis of the population of Nobel laureates in Physics, Chemistry and Physiology or Medicine. We examine to what extent existing qualitative findings for the biomedical sciences, which are partly based on Nobel laureates in Physiology or Medicine, can be substantiated both quantitatively and across the three Nobel Prize fields of science. We find that for most of the 20th century and the early 21st century, countries with weak institutional control (United Kingdom, United States) have outperformed those exerting strong control (France, Germany). These results are further corroborated when controlled by population sizes and by GDP per capita. In addition, these results hold not only for the biomedical sciences, but also for Physics and Chemistry. Furthermore, countries with weak institutional control have attracted many future Nobel laureates from countries with strong environments. In this regard, the United States appears to be a particularly attractive setting for conducting innovative research, and thus has been a magnet for young and promising scientists. However, future laureates working in institutional environments exerting weak control are not faster in accomplishing their prize-winning work compared to those laureates working in more restrictive institutional settings., Competing Interests: The authors have declared that no competing interests exist.

Objective: To understand the predominant topics of discussion, stance and associated language used on social media platforms relating to maternal vaccines in 15 countries over a six-month period., Background: In 2019, the World Health Organisation prioritised vaccine hesitancy as a top ten global health threat and recognized the role of viral misinformation on social media as propagating vaccine hesitancy. Maternal vaccination offers the potential to improve maternal and child health, and to reduce the risk of severe morbidity and mortality in pregnancy. Understanding the topics of discussion, stance and language used around maternal vaccines on social media can inform public health bodies on how to combat vaccine misinformation and vaccine hesitancy., Methods: Social media data was extracted (Twitter, forums, blogs and comments) for six months from 15 countries (Australia, Brazil, Canada, France, Germany, India, Italy, Korea, Mexico, Panama, South Africa, Spain, United Kingdom and United States). We used stance, discourse and topic analysis to provide insight into the most frequent and weighted keywords, hashtags and themes of conversation within and across countries., Results: We exported a total of 19,192 social media posts in 16 languages obtained between 1st November 2018 and 30th April 2019. After screening all posts, 16,000 were included in analyses, while excluding retweets, 2,722 were annotated for sentiment. Main topics of discussion were the safety of the maternal influenza and pertussis vaccines. Discouraging posts were most common in Italy (44.9%), and the USA (30.8%)., Conclusion: The content and stance of maternal vaccination posts from November 2018 to April 2019 differed across countries, however specific topics of discussion were not limited to geographical location. These discussions included the promotion of vaccination, involvement of pregnant women in vaccine research, and the trust and transparency of institutions. Future research should examine the relationship between stance (promotional, neutral, ambiguous, discouraging) online and maternal vaccination uptake in the respective regions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

This paper examines the linkages in financial markets during coronavirus disease 2019 (COVID-19) pandemic outbreak. For this purpose, daily stock market returns were used over the period of December 31, 2019-April 20, 2020 for the following economies: USA, Spain, Italy, France, Germany, UK, China, and Romania. The study applied the autoregressive distributed lag (ARDL) model to explore whether the Romanian stock market is impacted by the crisis generated by novel coronavirus. Granger causality was employed to investigate the causalities among COVID-19 and stock market returns, as well as between pandemic measures and several commodities. The outcomes of the ARDL approach failed to find evidence towards the impact of Chinese COVID-19 records on the Romanian financial market, neither in the short-term, nor in the long-term. On the other hand, our quantitative approach reveals a negative effect of the new deaths' cases from Italy on the 10-year Romanian bond yield both in the short-run and long-run. The econometric research provide evidence that Romanian 10-year government bond is more sensitive to the news related to COVID-19 than the index of the Bucharest Stock Exchange. Granger causality analysis reveals causal associations between selected stock market returns and Philadelphia Gold/Silver Index.

Background: Obtaining a sample that is representative of the group of interest is of utmost importance in questionnaire studies. In a survey using a state authorized web-portal for citizen communication with authorities, we wanted to investigate the view of adult men on patient involvement in health care decision-making regarding Prostate-Specific Antigen test for prostatic cancer. In this paper, we report on sample characteristics and representativeness of our sample in terms of personality and baseline involvement preferences., Methods: We compared personality profiles (BFI-10) and baseline healthcare decision-making preferences (CPS) in our sample (n = 6756) to internationally available datasets. Pooled data from a) US, UK, Canada, Australia, and New Zealand (n = 1512), b) Germany, Netherlands, Switzerland, and Belgium (n = 1136), and c) Norway, Sweden, Finland, and Denmark (n = 1313) were used for BFI-10 comparisons. Regarding CPS, we compared our sample with three previous datasets relating to decision-making in cancer (n = 425, 387, and 199)., Results: Although statistically significant differences particularly appeared in large dataset comparisons, sample BFI-10 and CPS profiles mostly were within the range of those previously reported. Similarity was greatest in BFI-10 comparisons with group a) where no statistically significant difference could be established in factors 'agreeableness' and 'neuroticism' (p = .095 and .578, respectively)., Conclusion: Despite some variation, our sample displays personality and baseline preference profiles that are generally similar to those described in previous international studies. For example, this was the case with the BFI-10 'agreeableness' measure (incl. trust and fault-finding items), an important factor in healthcare decision-making.

The high price of new generations of vaccines relative to their predecessors has become an important consideration in debates over whether the benefits of the new vaccines justify their costs. An increasingly central line of inquiry in the literature on valuing vaccination surrounds accounting for the full social and economic benefits of vaccination. This paper applies this emerging perspective to the particular case of vaccination against serogroup B meningococcal disease (MenB). We explore key issues involved in health technology assessments of MenB vaccination, which have led to pronounced heterogeneity in evaluation methods and recommendation outcomes across countries such as France, Germany, the US, and the UK. Accounting for typically neglected sources of socioeconomic benefit could potentially impact recommendation and reimbursement decisions. We propose a taxonomy of such benefits built around four dimensions: (i) internalized health benefits, (ii) internalized non-health benefits, (iii) externalized health benefits, and (iv) externalized non-health benefits. This approach offers a systematic, comprehensive evaluation framework that can be used in future assessment of MenB vaccines as well as other health technologies., (Copyright © 2020 Stawasz, Huang, Kirby and Bloom.)

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of "failure to warn", i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on "failure to warn" and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550-555.

This paper contributes to the growing literature regarding the role of Information and Communication Technologies as well as Innovation on driving the level of carbon dioxide emissions and economic growth in context of the 21st conference of the Parties to the Climate convention (COP21). Drawing the data from 13 selected G-20 countries (including Argentina, Canada, China, France, Germany, Italy, Japan, Mexico, Republic of Korea, Russian Federation, Turkey, United Kingdom, United States) during the period of 15 years, our study achieves significant results. First, only five factors impede the carbon emissions namely energy price, foreign direct investment, technology, spending on innovation and trade openness while the remainder of determinants contribute to contamination of environment, including financial development. Second, when it comes to economic growth, information and communication technological and financial development are positive driving factors. Our results do reject the absence of Environmental Kuznets Curve (EKC) from our sample. Finally, our study empirically suggests that the work of controlling consumption of oil and environmentally friendly process including manufacture-trading in these economies will limit the amount of pollution., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

We developed a method to better estimate the carbon stocks of in-use harvested wood products (HWP) by using the Eora multiregional input-output tables to link global HWP production and end uses, compared to existing global-scale studies that focused on semifinished HWP. Using the new method, we allocated global HWP to country-specific end uses, including solid HWP used in (1) construction, (2) furniture production, and (3) other end uses, and as (4) household and sanitary paper and (5) other paper and paper products, while the HWP carbon stocks in these end uses were estimated using the Stock Change Approach. We reported that HWP produced globally contained an annual average of 277.7 teragram carbon in 1992-2015, of which 63.0, 12.6, 76.7, 9.1, and 116.3 teragram carbon were consumed by the above five end uses, respectively. By 2015, the carbon stocks of global in-use HWP produced since 1992 accumulated to 2938 teragrams of carbon, of which the above five HWP end uses accounted for 1489, 268, 890, 0, and 291 teragrams of carbon, respectively. Country-specific HWP production and consumption varied significantly, with the eight leading consuming countries (United States, China, Japan, Canada, Germany, Russia, United Kingdom, and France) accounting for 69% of the global in-use HWP carbon stocks.

Objective: To be fit-for-purpose, oral health-related quality of life instruments must possess a range of psychometric properties which had not been fully examined in the 16-item Short Form Child Perceptions Questionnaire for children aged 11 to 14 years (CPQ 11-14 ISF-16). We used advanced statistical approaches to determine the CPQ's measurement accuracy, precision, invariance and dimensionality and analyzed whether age range could be extended from 8 to 15 years., Methods: Fit to the Rasch model was examined in 6648 8-to-15-year-olds from Australia, New Zealand, Brunei, Cambodia, Hong Kong, Malaysia, Thailand, Germany, United Kingdom, Brazil and Mexico., Results: In all but two items, the initial five answer options were reduced to three or four, to increase precision of the children's selection. Items 10 (Shy/embarrassed) and 11 (Concerned what others think) showed an 'extra' dependency between item scores beyond the relationship related to the underlying latent construct represented by the instrument, and so were deleted. Without these two items, the CPQ was unidimensional. The three oral symptoms items (4 Food stuck in teeth, 3 Bad breath and 1 Pain) were required for a sufficient person-item coverage. In three out of 14 items (21 %), Europe and South America showed regional differences in the patterns of how the answer options were selected. No differential item functioning was detected for age., Conclusion: Except for a few modifications, the present analysis supports the combination of items, the cross-cultural validity of the CPQ with 14 items and the extension of the age range from 8 to 15 years., Clinical Significance: The valid, reliable, shortened and age-extended version of the CPQ resulting from this study should be used in routine care and clinical research. Less items and a wider age range increase its usability. Symptoms items are needed to precisely differentiate between children with higher and lower quality of life., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Since 2015, a series of papers which describe the systems for the provision of health and oral healthcare in nine European Union (EU) countries (France, Germany, Greece, Ireland, Italy, Poland, Romania, Spain and Sweden) have been published in this journal. This tenth and final paper in the series compares aspects of the systems for each country, with each other and with that in the United Kingdom (UK). The topics which have been covered are the organisation and funding of oral healthcare, national populations and oral healthcare workforce, education of dentists, uptake of oral healthcare, expenditure on oral healthcare and oral epidemiology. The comparison shows that there are wide differences between the care provision systems between the individual countries. In all of them, oral healthcare continues to operate outside the mainstream healthcare systems. In particular, the proportion of costs paid for them from public funds, raised through taxation or through compulsory social insurances, and those paid for by individual patients varies greatly. No comparable data exist on quality of care.

Objective: Auditory research and complaints about environmental noise indicate that there exists a significant, small subgroup within the population which is sensitive towards infra- and low-frequency or ultra- and high-frequency sounds (ILF/UHF). This paper reports on the development, factorization and validation of measures of sensitivity towards frequencies outside the common hearing range., Design: A multinational, cross-sectional survey study was run. Principal component analyses and exploratory factor analyses were conducted in a sample of 267 Europeans (from the UK, Slovenia, and Germany)., Results: The factor analyses suggested that ILF versus UHF sensitivity constitute different factors, each characterized by sensory perception, stress-responsivity, and behavioral avoidance. A third factor comprising beliefs of dangerousness of ILF and UHF emerged. The factors explained 72% of the variance. The factor-solution was replicated separately for the English (n = 98) and German (n = 169) versions of the questionnaire (Slovenians and UK residents filled out the English version). Acceptable to excellent reliability was found. ILF and UHF sensitivity were moderately related to noise sensitivity in the normal hearing range, suggesting the new measures are not redundant. Correlations with psychiatric and somatic symptoms were small to moderate. ILF sensitivity correlated with neuroticism (small effect) and daytime sleepiness (moderate effect). ILF and UHF sensitivity were related to agreeableness (small effects). Overall, the novel ILF and UHF sensitivity scales seems to provide a solid tool for conducting further research on the role of sensitivity concerning adverse effects of ILF and UHF sound (e.g. health outcomes, annoyance ratings). The questionnaire consortium recommends using the new scales in combination with established measures of normal hearing range sensitivity., Competing Interests: None

This study charts the evolution of the scientific literature on Parkinson's disease (PD) from 1983 to 2017 to inform communities of scientists, physicians, patients, caregivers and politicians concerned with PD. Articles published in journals indexed in the Science Citation Index-Expanded database of the Web of Science were retrieved and analyzed in seven five-year periods: 1983-1987, 1988-1992, 1993-1997, 1998-2002, 2003-2007, 2008-2012 and 2013-2017. Over 35 years the number of research papers on PD increased 33-fold: 885 papers in 1983-1987 to 29,972 in 2013-2017. At the same time the number of countries contributing to PD research increased from 37 to 131. The USA was the most prolific country throughout, followed by several European (UK, Germany, Italy and France) and English-speaking (Canada and Australia) countries. By 2003, several Asian countries (China, South Korea, India and Turkey) emerged with rapid increases in publications related to PD. By 2013-2017, China surpassed all but the USA to rank 2nd globally in productivity. Despite an increase from 4 to 22 African countries publishing PD research from 1983 to 2017, most were either unproductive or contributed ≤5 papers in each five-year period. There has also been a 12-fold increase in the number of journals (232-2824) containing papers on PD. In 2013-2017 three PD-focused journals (Parkinsonism & Related Disorders, Movement Disorders and Journal of Parkinson's Disease) contained 6.8% of all PD papers while a large majority (82.5%) of journals published ≤ 10 papers. This quantitative study complements the numerous extant qualitative reviews to provide a global perspective on PD research., (Copyright © 2018. Published by Elsevier Ltd.)

Treatment with new and/or innovative drugs with uncertain safety and efficacy profile is associated with substantial ethical concerns. The main objective of this paper is to present guidance on the use of such drugs contained in: (i) major international codes and guidelines pertaining to medical ethics and biomedical research; (ii) national codes of medical ethics and professional conduct of the USA, Canada, Australia, New Zealand, the UK, Ireland, France and Germany. Out of the four international codes and guidelines analysed, only the Declaration of Helsinki addresses the question of the use of unproven drugs. Among national codes, only two (USA and New Zealand) explicitly allow for use of new or innovative drugs. Moreover, treatment with unproven drugs seems to be permissible under the French code, though this is not stated explicitly. The remaining codes do not contain any articles on the use of new and innovative drugs. An update of existing articles, as well as the addition of new guidelines to the codes, should be considered in view of the rapid pace of development and introduction to clinical practice of new drugs. This work is relevant to innovative off-label applications of approved drugs and expanded access to investigational drugs., (© 2018 The British Pharmacological Society.)

Background: Within (European) healthcare systems, the predominant goal for pharmaceutical expenditure is cost containment. This is due to a general belief among healthcare policy makers that pharmaceutical expenditure-driven by high prices-will be unsustainable unless further reforms are enacted., Objective: The aim of this paper is to provide more realistic expectations of pharmaceutical expenditure for all key stakeholder groups by estimating pharmaceutical expenditure at 'net' prices. We also aim to estimate any gaps developing between list and net pharmaceutical expenditure for the EU5 countries (i.e. France, Germany, Italy, Spain, and the UK)., Methods: We adjusted an established forecast of pharmaceutical expenditure for the EU5 countries, from 2017 to 2021, by reflecting discounts and rebates not previously considered, i.e. we moved from 'list' to 'net' prices, as far as data were available., Results: We found an increasing divergence between expenditure measured at list and net prices. When the forecasts for the five countries were aggregated, the EU5 (unweighted) average historical growth (2010-2016) rate fell from 3.4% compound annual growth rate at list to 2.5% at net. For the forecast, the net growth rate was estimated at 1.5 versus 2.9% at list., Conclusions: Our results suggest that future growth in pharmaceutical expenditure in Europe is likely to be (1) lower than previously understood from forecasts based on list prices and (2) below predicted healthcare expenditure growth in Europe and in line with long-term economic growth rates. For policy makers concerned about the sustainability of pharmaceutical expenditure, this study may provide some comfort, in that the perceived problem is not as large as expected.

Background: Faecal incontinence (FI) is a substantial health problem with a prevalence of approximately 8% in community-dwelling populations. Sacral neuromodulation (SNM) is considered the first-line surgical treatment option in adults with FI in whom conservative therapies have failed. The clinical efficacy of SNM has never been rigorously determined in a trial setting and the underlying mechanism of action remains unclear., Methods/design: The design encompasses a multicentre, randomised, double-blind crossover trial and cohort follow-up study. Ninety participants will be randomised to one of two groups (SNM/SHAM or SHAM/SNM) in an allocation ratio of 1:1. The main inclusion criteria will be adults aged 18-75 years meeting Rome III and ICI definitions of FI, who have failed non-surgical treatments to the UK standard, who have a minimum of eight FI episodes in a 4-week screening period, and who are clinically suitable for SNM. The primary objective is to estimate the clinical efficacy of sub-sensory SNM vs. SHAM at 32 weeks based on the primary outcome of frequency of FI episodes using a 4-week paper diary, using mixed Poisson regression analysis on the intention-to-treat principle. The study is powered (0.9) to detect a 30% reduction in frequency of FI episodes between sub-sensory SNM and SHAM stimulation over a 32-week crossover period. Secondary objectives include: measurement of established and new clinical outcomes after 1 year of therapy using new (2017 published) optimised therapy (with standardised SNM-lead placement); validation of new electronic outcome measures (events) and a device to record them, and identification of potential biological effects of SNM on underlying anorectal afferent neuronal pathophysiology (hypothesis: SNM leads to increased frequency of perceived transient anal sphincter relaxations; improved conscious sensation of defaecatory urge and cortical/subcortical changes in afferent responses to anorectal electrical stimulation (main techniques: high-resolution anorectal manometry and magnetoencephalography)., Discussion: This trial will determine clinical effect size for sub-sensory chronic electrical stimulation of the sacral innervation. It will provide experimental evidence of modifiable afferent neurophysiology that may aid future patient selection as well as a basic understanding of the pathophysiology of FI., Trial Registration: International Standard Randomised Controlled Trial Number: ISRCTN98760715 . Registered on 15 September 2017.

An important, yet unsettled, question in public health policy is the extent to which unemployment causally impacts mental health. The recent literature yields varying findings, which are likely due to differences in data, methods, samples, and institutional settings. Taking a more general approach, we provide comparable evidence for four countries with different institutional settings-Australia, Germany, the UK, and the United States-using a nonparametric bounds analysis. Relying on fairly weak and partially testable assumptions, our paper shows that unemployment has a significant negative effect on mental health in all countries. Our results rule out effects larger than a quarter of a standard deviation for Germany and half a standard deviation for the Anglo-Saxon countries. The effect is significant for both men and women and materialises already for short periods of unemployment. Public policy should hence focus on early prevention of mental health problems among the unemployed., (Copyright © 2017 John Wiley & Sons, Ltd.)

This paper proposes a new method to distinguish structural from exchange mobility in status attainment models with interval endogenous variables. In order to measure structural mobility, the paper proposes to trace occupational and educational changes across generations using information provided by children about their fathers. The validity of the method is assessed by comparing the effects of father's socio-economic status and education on son's status and educational attainments, net of occupational upgrading and educational expansion, in five European countries: Britain, Denmark, Germany, Norway, and Spain, using data from the 2005 EU-SILC survey. The results show that the effect of father's on son's ISEI weakens greatly in all countries after considering occupational upgrading, and that much of father's influence over sons occurs by directing them towards occupations with good economic prospects. Useful extensions to the method are discussed in the conclusions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Obesity and type 2 diabetes (T2D) are highly prevalent among African migrants compared with European descent populations. The underlying reasons still remain a puzzle. Gene-environmental interaction is now seen as a potential plausible factor contributing to the high prevalence of obesity and T2D, but has not yet been investigated. The overall aim of the Research on Obesity and Diabetes among African Migrants (RODAM) project is to understand the reasons for the high prevalence of obesity and T2D among sub-Saharan Africans in diaspora by (1) studying the complex interplay between environment (eg, lifestyle), healthcare, biochemical and (epi)genetic factors, and their relative contributions to the high prevalence of obesity and T2D; (2) to identify specific risk factors within these broad categories to guide intervention programmes and (3) to provide a basic knowledge for improving diagnosis and treatment., Methods and Analysis: RODAM is a multicentre cross-sectional study among homogenous sub-Saharan African participants (ie, Ghanaians) aged >25 years living in rural and urban Ghana, the Netherlands, Germany and the UK (http://rod-am.eu/). Standardised data on the main outcomes, genetic and non-genetic factors are collected in all locations. The aim is to recruit 6250 individuals comprising five subgroups of 1250 individuals from each site. In Ghana, Kumasi and Obuasi (urban stratum) and villages in the Ashanti region (rural stratum) are served as recruitment sites. In Europe, Ghanaian migrants are selected through the municipality or Ghanaian organisations registers., Ethics and Dissemination: Ethical approval has been obtained in all sites. This paper gives an overview of the rationale, conceptual framework and methods of the study. The differences across locations will allow us to gain insight into genetic and non-genetic factors contributing to the occurrence of obesity and T2D and will inform targeted intervention and prevention programmes, and provide the basis for improving diagnosis and treatment in these populations and beyond.

Penicillin is often considered one of the greatest discoveries of 20th century medicine. However, the revolution in therapeutics brought about by sulphonamides also had a profound effect on British medicine, particularly during World War II (WWII). Sulphonamides were used to successfully treat many infections which later yielded to penicillin and so their role deserves wider acknowledgement. The sulphonamides, a pre-war German discovery, were widely used clinically. However, the revolution brought about by the drugs has been either neglected or obscured by penicillin, resulting in less research on their use in Britain during WWII. By examining Medical Research Council records, particularly war memorandums, as well as medical journals, archives and newspaper reports, this paper hopes to highlight the importance of the sulphonamides and demonstrate their critical role in the medical war effort and their importance in both the public and more particularly, the medical, sectors. It will present evidence to show that sulphonamides gained importance due to the increased prevalence of infection which compromised the health of servicemen during WWII. The frequency of these infections led to an increase in demand and production. However, the sulphonamides were soon surpassed by penicillin, which had fewer side-effects and could treat syphilis and sulphonamide-resistant infections. Nevertheless, despite these limitations, the sulphonamides drugs were arguably more important in revolutionising medicine than penicillin, as they achieved the first real success in the war against bacteria.

Background: Public health researchers are increasingly encouraged to establish international collaborations and to undertake cross-national comparative studies. To-date relatively few such studies have addressed migration, ethnicity and health, but their number is growing. While it is clear that divergent approaches to such comparative research are emerging, public health researchers have not so far given considered attention to the opportunities and challenges presented by such work. This paper contributes to this debate by drawing on the experience of a recent study focused on maternal health in Canada, Germany and the UK., Discussion: The paper highlights various ways in which cross-national comparative research can potentially enhance the rigour and utility of research into migration, ethnicity and health, including by: forcing researchers to engage in both ideological and methodological critical reflexivity; raising awareness of the socially and historically embedded nature of concepts, methods and generated 'knowledge'; increasing appreciation of the need to situate analyses of health within the wider socio-political setting; helping researchers (and research users) to see familiar issues from new perspectives and find innovative solutions; encouraging researchers to move beyond fixed 'groups' and 'categories' to look at processes of identification, inclusion and exclusion; promoting a multi-level analysis of local, national and global influences on migrant/minority health; and enabling conceptual and methodological development through the exchange of ideas and experience between diverse research teams. At the same time, the paper alerts researchers to potential downsides, including: significant challenges to developing conceptual frameworks that are meaningful across contexts; a tendency to reify concepts and essentialise migrant/minority 'groups' in an effort to harmonize across countries; a danger that analyses are superficial, being restricted to independent country descriptions rather than generating integrated insights; difficulties of balancing the need for meaningful findings at country level and more holistic products; and increased logistical complexity and costs., Summary: In view of these pros and cons, the paper encourages researchers to reflect more on the rationale for, feasibility and likely contribution of proposed cross-national comparative research that engages with migration, ethnicity and health and suggests some principles that could support such reflection.

Background: Nonmedical determinants of medical decision making were investigated in an international research project in the United States, the United Kingdom, and Germany. The key question in this paper is whether and to what extent doctors' diagnostic and therapeutic decisions in coronary heart disease (CHD) are influenced by patient gender., Methods: A factorial experiment with a videotaped patient consultation was conducted. Professional actors played the role of patients with symptoms of CHD. Several alternative versions were taped featuring the same script with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to a randomly selected sample of 128 primary care physicians in each country. Using an interview with standardized and open-ended questions, physicians were asked how they would diagnose and treat such a patient after they had seen the video., Results: Results show gender differences in the diagnostic strategies of the doctors. Women were asked different questions, CHD was mentioned more often as a possible diagnosis for men than for women, and physicians were less certain about their diagnosis with female patients. Gender differences in management decisions (therapy and lifestyle advice) are less pronounced and less consistent than in diagnostic decisions. Magnitude of gender effect on doctors' decisions varies between countries with smaller influences in the United States., Conclusion: Although patients with identical symptoms were presented, primary care doctors' behavior differed by patients' gender in all 3 countries under study. These gender differences suggest that women may be less likely to receive an accurate diagnosis and appropriate treatment than men.

The variations of dose response with X ray energy observed with the human lymphocyte dicentric assay is examined. In order to determine reliably the initial slopes (RBEm) many cells need to be analysed at low doses. Insufficient analysis may explain some reported interlaboratory differences in fitted dose-response coefficients. One such discrepancy at 150 kVp, E = 70 keV is examined. Data are also presented for an X ray spectrum of 80 kVp, E = 58 keV. Over the photon energy range 20 keV X rays to 1.25 MeV gamma rays RBEm varies by about a factor of 5, with the lower energies being more effective. This is consistent with microdosimetric theory. By contrast, in radiological protection a radiation weighting factor of 1.0 is assumed for all photons when assessing the risk of inducing cancer at low doses. The measured variations of biological effect with photon energy have led to suggestions that the lower energies, as used for some diagnostic radiology, carry a greater risk per unit dose than is normally assumed by those involved in radiological protection. Interpretation of the data reported in this paper does not support this view.

The improvement of the quality of life of people with a severe mental illness is a key policy objective and an important outcome for clinical services. Drawing on cases assessed using the Lancashire Quality of Life Profile and its German translation (The Berliner Lebensqualitatprofil), this paper explores the relationship between personal characteristics, objective well being, subjective well being and overall well being. These variables are compared in two large data sets of people with severe mental illness, one from the UK (n = 1279) and the other from Germany (n = 386). The comparison shows that UK cases have significantly lower subjective well-being in almost all life domains (except safety, living situation and employment). UK cases reported slightly but not significantly higher levels of satisfaction with employment but German cases are more often employed than their UK counterparts. The German samples reported substantially better subjective well-being ratings for health, finances, family, leisure and social life. Exploration of the predictors of overall well-being shows that in both countries depression has the effect of reducing subjective well-being scores, except in relation to work (both samples), religion (UK), finance and safety (Germany). Regression analysis confirms that age, depression and objective circumstances make a small contribution to overall well-being but that subjective ratings in individual life domains make the major contribution. The most important individual predictors of overall well-being for the two samples combined include being a victim of crime, depression and satisfaction with leisure, work, health and mental health, family, living situation, finance and social contacts. Factor analysis indicates that the variance in global well-being explained in both samples combined is 36% (31% in the German samples and 38% in the UK sample).