Search

It has been decades since inclusive education was introduced as the most favourable approach to educating students with special educational needs and disabilities. Still, according to research and practice, teachers' attitudes are seen as the most important key factor for its successful implementation. Therefore, there is an ongoing process of researchers investigating teachers' attitudes towards inclusive schooling. The aim of the current study was to do a follow-up of previous reviews on primary schoolteachers' attitudes (Avramidis and Norwich 2002; de Boer, Pijl, and Minnaert 2011). In total, 36 studies were analysed. The results indicate that primary school teachers tend to hold rather neutral or ambivalent attitudes towards inclusive education. Similar to previous review results, inclusion still seems to be a matter of students' type of disability. Therefore, regular primary school teachers do not favour the inclusion of all students when it comes to the concept of inclusion for all students. Directions for improving teachers' attitudes are widely missing in the studies of the last years.

This article explores future scenarios regarding the integration of European higher education (HE) in light of the European Universities Initiative which has been unfolding since 2017. Its aim is to understand potential development paths in light of the established intergovernmental Bologna Process, which has been diversified through international and supranational practices since its launch at the end of the 1990s. By way of European integration theories, we approach potential integration scenarios - a hitherto underutilized framework in HE studies. Our heuristic analysis of HE integration is based on secondary data; subsequently we construct and discuss four scenarios. Finally, we explore the implications of the scenarios from the perspective of the evaluation of the integration process of European HE.

Regulatory frameworks for artificial intelligence (AI) are needed to mitigate risks while ensuring the ethical, secure, and effective implementation of AI technology in healthcare and population health. In this article, we present a synthesis of 141 binding policies applicable to AI in healthcare and population health in the EU and 10 European countries. The EU AI Act sets the overall regulatory framework for AI, while other legislations set social, health, and human rights standards, address the safety of technologies and the implementation of innovation, and ensure the protection and safe use of data. Regulation specifically pertaining to AI is still nascent and scarce, though a combination of data, technology, innovation, and health and human rights policy has already formed a baseline regulatory framework for AI in health. Future work should explore specific regulatory challenges, especially with respect to AI medical devices, data protection, and data enablement. [ABSTRACT FROM AUTHOR]

Aim s : Community‐ and school‐based lifestyle interventions are an efficient method of preventing type 2 diabetes in vulnerable populations. Many participants, however, fail to complete the necessary follow‐ups. We investigated factors affecting the continuous participation in follow‐up evaluations during the Feel4Diabetes‐study, a multilevel intervention programme implemented across Europe. Methods: Socioeconomic, sociodemographic and clinical factors were assessed for 2702 participants within six participating countries: Bulgaria and Hungary (low‐to‐middle‐income countries, LMIC), Belgium and Finland (high‐income countries, HIC) and Greece and Spain (high‐income countries under austerity measures, HICAM). Results: Statistically significant differences were detected with respect to sex, control group, education level, employment status, BMI and blood pressure measurements (systolic and diastolic blood pressure). Post hoc analysis revealed significant differences within socioeconomic regions. Higher levels of education were associated with significantly lower attrition in HIC (p < 0.05) and HICAM (p < 0.001), higher employment status was associated with lower attrition in HICAM (p < 0.001) and being female was associated with lower attrition in LMIC (p < 0.001). Surprisingly, the intervention group exhibited higher‐than‐expected attrition in HIC (p < 0.001) and HICAM (p = 0.003), and lower attrition in LMIC (p = 0.007). When tested together in the same multivariable predictive model, all sociodemographic and socioeconomic variables along with higher BMI retained their statistical significance, while systolic and diastolic blood pressure failed to remain significant. Conclusions: Key socioeconomic and sociodemographic factors along with BMI play a significant role in determining continuous participation in follow‐up evaluations during school‐ and community‐based intervention programmes. [ABSTRACT FROM AUTHOR]

The genus Sidera (Hymenochaetales, Basidiomycota) comprises white-rot, mono- or dimitic fungi with poroid or hydnoid hymenophore. It has a worldwide distribution albeit with fewer species present in the Southern Hemisphere. Although recent studies revealed the existence of several new Sidera species, there are still taxonomic inconsistencies and obscure phylogenetic relationships amongst certain taxa of the genus. In this work, a large number of Sidera collections were used to obtain an updated phylogeny, based on ITS and 28S rDNA sequences by including new material from Mediterranean Europe. The monophyly of the genus was strongly supported and all species with poroid hymenophore formed a highly-supported lineage with two major subclades. In total, 23 putative species were recognised. Amongst those, five are considered to possibly represent entities new to science, but further work is required since they are represented by single specimens or environmental sequences. Examined collections originally named S. lenis from southern Europe were grouped within S. vulgaris. Similarly, several collections under various names were hereby identified as S. vulgaris, including those of the recently described species S. tibetica. Furthermore, a critical discussion (based on morphoanatomical findings) is made on the key features that could be used to distinguish S. lenis from S. vulgaris. [ABSTRACT FROM AUTHOR]

The shortage of organs for transplantations is increasing in Europe as well as globally. Many initiatives to the organ shortage, such as opt-out systems for deceased donation and expanding living donation, have been insufficient to meet the rising demand for organs. In recurrent discussions on how to reduce organ shortage, financial incentives and removal of disincentives, have been proposed to stimulate living organ donation and increase the pool of available donor organs. It is important to understand not only the ethical acceptability of (dis)incentives for organ donation, but also its societal acceptance. In this review, we propose a research agenda to help guide future empirical studies on public preferences in Europe towards the removal of disincentives and introduction of incentives for organ donation. We first present a systematic literature review on public opinions concerning (financial) (dis)incentives for organ donation in European countries. Next, we describe the results of a randomized survey experiment conducted in the United States. This experiment is crucial because it suggests that societal support for incentivizing organ donation depends on the specific features and institutional design of the proposed incentive scheme. We conclude by proposing this experiment's framework as a blueprint for European research on this topic. [ABSTRACT FROM AUTHOR]

Camera traps have revolutionized how ecologists monitor wildlife, but their full potential is realized only when the hundreds of thousands of collected images can be readily classified with minimal human intervention. Deep learning classification models have allowed extraordinary progress towards this end, but trained models remain rare and are only now emerging for European fauna. We report on the first milestone of the DeepFaune initiative (https://www.deepfaune.cnrs.fr), a large-scale collaboration between more than 50 partners involved in wildlife research, conservation and management in France. We developed a classification model trained to recognize 26 species or higher-level taxa that are common in Europe, with an emphasis on mammals. The classification model achieved 0.97 validation accuracy and often > 0.95 precision and recall for many classes. These performances were generally higher than 0.90 when tested on independent out-of-sample datasets for which we used image redundancy contained in sequences of images. We implemented our model in a software to classify images stored locally on a personal computer, so as to provide a free, user-friendly, and high-performance tool for wildlife practitioners to automatically classify camera trap images. The DeepFaune initiative is an ongoing project, with new partners joining regularly, which allows us to continuously add new species to the classification model. [ABSTRACT FROM AUTHOR]

Background: In order to support the ongoing research across Europe to facilitate access to novel radionuclides, the PRISMAP consortium (European medical radionuclides programme) was established to offer the broadest catalog of non-conventional radionuclides for medical and translational research. The aim of this article is to introduce readers with current status of novel radionuclides in Europe. Main body: A consortium questionnaire was disseminated through the PRISMAP consortium and user community, professional associations and preclinical/clinical end users in Europe and the current status of clinical end-users in nuclear medicine were identified. A total of 40 preclinical/clinical users institutions took part in the survey. Clinical end users currently use the following radionuclides in their studies: 177Lu, 68 Ga, 111In, 90Y, other alpha emitters, 225Ac, 64Cu and Terbium isotopes. Radionuclides that would be of interest for users within the next 2–5 years are 64Cu, Terbium radionuclide "family" and alpha emitters, such as 225Ac. Conclusions: Thanks to a questionnaire distributed by the PRISMAP consortium, the current status and needs of clinical end-users in nuclear medicine were identified. [ABSTRACT FROM AUTHOR]

This article introduces a new dataset on regionalist actors' territorial demands and frames in Europe. The FraTerr dataset advances on existing datasets by proposing a more fine-grained understanding of regionalist actors' territorial demands, and is the first to provide comparative data on how these are framed. Methodologically, it develops an original coding scheme for the qualitative content analysis of political documents. Empirically, this approach is applied to a comparative study of regionalist parties and civil society actors in twelve European regions. A preliminary analysis of the data provides new evidence of the complexity of regionalist actors' territorial demands and the multi-dimensional nature of their framing strategies. The dataset has implications for the study of regionalist actors and issues, and for broader scholarly efforts at estimating political actors' territorial issue positions and framing strategies. [ABSTRACT FROM AUTHOR]

Environmental justice ('EJ') receives a lot of attention in the environmental social sciences and in U.S. law. But in Europe, it has so far been largely ignored in legal literature and policy debates, which seems difficult to reconcile with an anthropocentric understanding of current environmental law. This article focuses on distributive and procedural dimensions of EJ and on considerations of intragenerational fairness within the EU. General features of EU environmental law are examined in search of 'hidden' elements that might help or frustrate this goal. Themain finding is that other fields of law and policy are likely more significant enablers of EJ in Europe. To the extent that EU environmental law contributes, it seems largely an accidental result that is not guaranteed by its design. Substantive EU environmental law pursues a territorially uniform level of environmental protection and seems to have, with the possible exception of environmental impact assessments, no direct mechanisms to consider inequities between human populations. Examples are found of rules that even have clearly adverse consequences for underprivileged populations. The Aarhus Convention provides theoretical opportunities for procedural justice, but the current implementation in practice fails to achieve those and might even operate counterproductively as a mechanism that further benefits the already powerful. Primary EU environmental law largely mirrors these findings. Nevertheless, a correct interpretation of sustainable development in Article 11 of the Treaty on the Functioning of the European Union (TFEU) is identified as a potential key to better integrate EJ in EU policy. [ABSTRACT FROM AUTHOR]

Background: No data on healthcare utilisation and associated costs for the many rare entities of children's interstitial lung diseases (chILD) exist. This paper portrays healthcare utilisation structures among individuals with chILD, provides a pan-European estimate of a 3-month interval per-capita costs and delineates crucial cost drivers.Methods: Based on longitudinal healthcare resource utilisation pattern of 445 children included in the Kids Lung Register diagnosed with chILD across 10 European countries, we delineated direct medical and non-medical costs of care per 3-month interval. Country-specific utilisation patterns were assessed with a children-tailored modification of the validated FIMA questionnaire and valued by German unit costs. Costs of care and their drivers were subsequently identified via gamma-distributed generalised linear regression models.Results: During the 3 months prior to inclusion into the registry (baseline), the rate of hospital admissions and inpatient days was high. Unadjusted direct medical per capita costs (€19 818) exceeded indirect (€1 907) and direct non-medical costs (€1 125) by far. Country-specific total costs ranged from €8 713 in Italy to €28 788 in Poland. Highest expenses were caused by the disease categories 'diffuse parenchymal lung disease (DPLD)-diffuse developmental disorders' (€45 536) and 'DPLD-unclear in the non-neonate' (€47 011). During a follow-up time of up to 5 years, direct medical costs dropped, whereas indirect costs and non-medical costs remained stable.Conclusions: This is the first prospective, longitudinal study analysing healthcare resource utilisation and costs for chILD across different European countries. Our results indicate that chILD is associated with high utilisation of healthcare services, placing a substantial economic burden on health systems. [ABSTRACT FROM AUTHOR]

Copyright of Bauphysik is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Quadruple and Quintuple Helix Innovation Systems aim to optimize the design and operation of modern, democratic societies and economies in a smart, sustainable, inclusive, resilient and efficacious manner via the cyber-physical ecosystems that align with Industry 5.0 and Society 5.0 precepts. In this context, the Quintuple Innovation Helix Framework (which is part of the Quadruple/Quintuple Innovation Helix or Q2IH) represents the most comprehensive, meaningful and valuable construct and modality as it encompasses the five key core dimensions of modern, sustainable and democratic knowledge economies and societies. These are the Environment, the Civil Society as well as the Government, University and Industry dimensions. We strongly feel that it is appropriate and even critical, given current events in Europe that starkly highlight the conflict and struggle between democracies and autocracies, to enable, facilitate and even accelerate the further development of an Emerging Unified Theory of Helical Architectures (EUTOHA). The objective would be to bring clarity, coherence and consistency to the process of leveraging the helical architectures to advance and enhance the design of solutions for the digital transformation of modern knowledge economies and societies towards more democratic and sustainable (green) ones. [ABSTRACT FROM AUTHOR]

Pontederia cordata L. (Pontederiaceae) is an emerging aquatic plant native to the American continent that has been introduced to various continents through long-distance commerce as an ornamental plant. Individuals growing in the wild belonging to Pontederia L. genus where found in South Spain. The analysis of diagnostic characters of the collected specimens and their comparison to those represented in herbarium vouchers allowed us to distinguish them from its closest relative, P. sagittata C. Presl and to assign all the specimens found at the locality to P. cordata L. This is the southernmost European record of the species. It was clear that the origin of the introduction was the use as ornamental aquatic plant in the area. Its invasion risk was assessed for Europe, firstly, by analysing the suitability of European climate for the species, secondly, by assessing the potential impact. Results showed that from 92.5 to 92.9% of the meteorological stations analysed showed climate conditions that were compatible with the species’ climatic requirements. The ecological characteristics of the species and the climatic features of the area analysed suggest a great risk of invasion that could lead to the species’ spread in Europe. These findings suggest that P. cordata could threaten European wetlands. [ABSTRACT FROM AUTHOR]

As Europe is faced with increasing droughts and extreme precipitation, countries are taking measures to adapt to these changes. It is challenging, however, to navigate through the wide range of possible measures, taking into account the efficacy, economic impact and social justice aspects of these measures, as well as the governance requirements for implementing them. This article presents the approach of selecting and analysing adaptation measures to increasing extreme weather events caused by ongoing climate change that was developed and applied in the H2020 project BINGO (Bringing Innovation to Ongoing Water Management). The purpose of this project is (a) to develop an integrated participatory approach for selecting and evaluating adaptation measures, (b) to apply and evaluate the approach across six case-study river basins across Europe, and (c) to support decision-making towards adaptation capturing the diversity, the different circumstances and challenges river basins face across Europe. It combines three analyses: governance, socio-economic and social justice The governance analysis focuses on the requirements associated with the measures and the extent to which these requirements are met at the research sites. The socio-economic impact focuses on the efficacy of the measures in reducing the risks and the broad range of tools available to compare the measures on their societal impact. Finally, a tentative social justice analysis focuses on the distributive impacts of the adaptation measures. In the summary of results, we give an overview of the outcome of the different analyses. In the conclusion, we briefly assess the main pros and cons of the different analyses that were conducted. The main conclusion is that although the research sites were very different in both the challenges and the institutional context, the approach presented here yielded decision-relevant outcomes. [ABSTRACT FROM AUTHOR]

Obesity is a risk factor for severe respiratory diseases, including COVID-19 infection. Meta-analyses on mortality risk were inconsistent. We systematically searched 3 databases (Medline, Embase, CINAHL) and assessed the quality of studies using the Newcastle-Ottawa tool (CRD42020220140). We included 199 studies from US and Europe, with a mean age of participants 41.8–78.2 years, and a variable prevalence of metabolic co-morbidities of 20–80 %. Exceptionally, one third of the studies had a low prevalence of obesity of <20 %. Compared to patients with normal weight, those with obesity had a 34 % relative increase in the odds of mortality (p -value 0.002), with a dose-dependent relationship. Subgroup analyses showed an interaction with the country income. There was a high heterogeneity in the results, explained by clinical and methodologic variability across studies. We identified one trial only comparing mortality rate in vaccinated compared to unvaccinated patients with obesity; there was a trend for a lower mortality in the former group. Mortality risk in COVID-19 infection increases in parallel to an increase in BMI. BMI should be included in the predictive models and stratification scores used when considering mortality as an outcome in patients with COVID-19 infections. Furthermore, patients with obesity might need to be prioritized for COVID-19 vaccination. [Display omitted] • COVID-19 patients with obesity face a 20–50 % higher risk of mortality compared to those with normal weight. • Higher obesity class is associated with increasing relative risk of COVID-19 mortality, denoting a dose-response relationship. • Obese COVID-19-patients in high-income countries have a lower mortality risk than those in middle or low income countries. [ABSTRACT FROM AUTHOR]

Background: In patients with hepatic cystic echinococcosis (CE), treatment effectiveness, outcomes, complications, and recurrence rate are controversial. Endocystectomy is a conservative surgical approach that adequately removes cyst contents without loss of parenchyma. This conservative procedure has been modified in several ways to prevent complications and to improve surgical outcomes. This systematic review aimed to evaluate the intraoperative and postoperative complications of endocysectomy for hepatic CE as well as the hepatic CE recurrence rate following endocystectomy. Methods: A systematic search was made for all studies reporting endocystectomy to manage hepatic CE in PubMed, Web of Science, and Cochrane CENTRAL databases. Study quality was assessed using the methodological index for non-randomized studies (MINORS) criteria and the Cochrane revised tool to assess risk of bias in randomized trials (RoB2). The random-effects model was used for meta-analysis and the arscine-transformed proportions were used to determine complication-, mortality-, and recurrence rates. This study is registered with PROSPERO (number CRD42020181732). Results: Of 3,930 retrieved articles, 54 studies reporting on 4,058 patients were included. Among studies reporting preoperative anthelmintic treatment (31 studies), albendazole was administered in all of them. Complications were reported in 19.4% (95% CI: 15.9–23.2; I2 = 84%; p-value <0.001) of the patients; biliary leakage (10.1%; 95% CI: 7.5–13.1; I2 = 81%; p-value <0.001) and wound infection (6.6%; 95% CI: 4.6–9; I2 = 27%; p-value = 0.17) were the most common complications. The post-endocystectomy mortality rate was 1.2% (95% CI: 0.8–1.8; I2 = 21%; p-value = 0.15) and the recurrence rate was 4.8% (95% CI: 3.1–6.8; I2 = 87%; p-value <0.001). Thirty-nine studies (88.7%) had a mean follow-up of more than one year after endocystectomy, and only 14 studies (31.8%) had a follow-up of more than five years. Conclusion: Endocystectomy is a conservative and feasible surgical approach. Despite previous disencouraging experiences, our results suggest that endocystectomy is associated with low mortality and recurrence. Author summary: Cystic echinococcosis (CE) is a parasitic zoonosis caused by the larval stage of Echinococcus granulosus sensu lato, which can invade several organs including the brain, lungs, and liver. Liver involvement through hepatic cystic echinococcosis has been reported in up to 75% of CE cases. Although it is a rare disease in Europe, migrations from endemic regions to European countries have increased the prevalence of hepatic CE. Several medical and surgical treatment options have been introduced for hepatic CE. Of these, endocystectomy is a conservative approach which avoids radical surgeries and liver resections. In this systematic review and single-arm meta-analysis, we synthesized evidence on the short- and long-term outcomes of endocystectomy in treating patients with hepatic CE. We searched for relevant articles in PubMed, Embase, and Cochrane databases that were published until May 2020 without any language restriction. Of 3930 articles, 54 were included in the systematic review. A summarized analysis of the study findings suggested that endocystectomy is an effective and safe alternative to radical resection or the PAIR procedure in hepatic CE patients. [ABSTRACT FROM AUTHOR]

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010-15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs. [ABSTRACT FROM AUTHOR]

The so-called 'Eurozone' and 'migration' crises mark critical moments in Europe's recent political history and share similarities to the extent that they both have increased political conflict, mobilised large parts of civil society, and put renewed attention upon the notion of 'solidarity'. Focusing on the specific case of solidarity with migrants, this articles argues that times of crises have increasingly blurred the lines between contentious and non-contentious forms of civil society engagement. Scrutinising these dynamics of hybridisation, we bridge diverse, yet largely disconnected literatures, including social movement, civil society and humanitarian studies. In particular, we suggest that the disciplinary and analytical distinction between volunteering and non-profit activities on the one hand and social movements and political activism on the other is too rigid and does obscure parts of a complex phenomenon, which is characterised by activities that often intersect between humanitarian practices and contentious politics. [ABSTRACT FROM AUTHOR]

Purpose: Transarterial chemoembolisation (TACE) using irinotecan-eluting beads is an additional treatment option for colorectal cancer liver metastases (CRLM) patients that are not eligible for curative treatment approaches. This interim analysis focuses on feasibility of the planned statistical analysis regarding data distribution and completeness, treatment intention, safety and health-related quality of life (HRQOL) of the first 50 patients prospectively enrolled in the CIrse REgistry for LifePearl™ microspheres (CIREL), an observational multicentre study conducted across Europe. Methods: In total, 50 patients ≥ 18 years diagnosed with CRLM and decided to be treated with irinotecan-eluting LifePearl™ microspheres TACE (LP-irinotecan TACE) by a multidisciplinary tumour board. There were no further inclusion or exclusion criteria. The primary endpoint is the categorisation of treatment intention, and secondary endpoints presented in this interim analysis are safety, treatment considerations and HRQOL. Results: LP-irinotecan TACE was conducted in 42% of patients as salvage therapy, 20% as an intensification treatment, 16% as a first-line treatment, 14% a consolidation treatment and 8% combination treatment with ablation with curative intent. Grade 3 and 4 adverse events were reported by 4% of patients during procedure and by 10% within 30 days. While 38% reported a worse, 62% reported a stable or better global health score, and 54% of patients with worse global health score were treated as salvage therapy patients. Conclusion: This interim analysis confirms in a prospective analysis the feasibility of the study, with an acceptable toxicity profile. More patients reported a stable or improved HRQOL than deterioration. Deterioration of HRQOL was seen especially in salvage therapy patients. Trial Registration: NCT03086096. [ABSTRACT FROM AUTHOR]

As Europe is faced with increasing droughts and extreme precipitation, countries are taking measures to adapt to these changes. It is challenging, however, to navigate through the wide range of possible measures, taking into account the efficacy, economic impact and social justice aspects of these measures, as well as the governance requirements for implementing them. This article describes and evaluates an approach to selecting and analysing climate change adaptation measures that was applied at six research sites across Europe. It describes the steps that were taken in collecting, selecting and analysing adaptation measures, in a process with local stakeholders, with concrete examples from the case studies. The governance analysis focuses on the requirements associated with the measures and the extent to which these requirements are met at the research sites. The socio-economic impact focuses on the efficacy of the measures in reducing the risks and the broad range of tools available to compare the measures on their societal impact. Finally, the social justice analysis focuses on the distributive impacts of the adaptation measures. In the discussion, we identify some key findings with regard to the different kind of measures. In the conclusion we briefly assess the main pros and cons of the different analyses that were conducted. The main conclusion is that although the research sites were very different in both the challenges and the institutional context, the approach presented here yielded decision relevant outcomes. [ABSTRACT FROM AUTHOR]

Sweden is one of the most forested countries in Europe, and it has one of the highest shares of productive forest. Production in forestry is largely reliant on the private non-industrial forest owners, who own half of the forest land. As in many countries, however, forest ownership is changing towards a higher extent of urban, female or non-forestry-background owners. This poses a challenge for the forestry services sector, mainly forest owners' associations and companies, but also broadly the sector at large. By exploring the sales and marketing processes, this paper analyses the service logics and strategies of Swedish forestry under changing forest ownership, drawing on an interview study covering all the large actors in the Swedish forestry sector. The study illustrates an increased focus of forestry organizations on services from a strategic and managerial perspective, in customer-oriented relationship development and in value creation and sales processes, specifically in order to manage "new" forest owners and the demand of forest industries. The results highlight the domination of service logics associated with timber production and the challenges for the service market and the provision of diversified services to forest owners. [ABSTRACT FROM AUTHOR]

Although Europe has experienced unprecedented numbers of refugee arrivals in recent years, there exists almost no causal evidence regarding the impact of the refugee crisis on natives' attitudes, policy preferences, and political engagement. We exploit a natural experiment in the Aegean Sea, where Greek islands close to the Turkish coast experienced a sudden and massive increase in refugee arrivals, while similar islands slightly farther away did not. Leveraging a targeted survey of 2,070 island residents and distance to Turkey as an instrument, we find that direct exposure to refugee arrivals induces sizable and lasting increases in natives' hostility toward refugees, immigrants, and Muslim minorities; support for restrictive asylum and immigration policies; and political engagement to effect such exclusionary policies. Since refugees only passed through these islands, our findings challenge both standard economic and cultural explanations of anti-immigrant sentiment and show that mere exposure suffices in generating lasting increases in hostility. [ABSTRACT FROM AUTHOR]

Background: The revised 2017 European LeukemiaNet (ELN) classification (ELN-2017) of acute myeloid leukemia (AML) divides patients into 3 prognostic risk categories, with additional factors such as the fms-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD) allele ratio (AR) considered for risk stratification. To the best of the authors' knowledge, the prognostic usefulness of ELN-2017 in comparison with ELN-2010 in younger patients with AML has not been validated to date.Methods: The authors performed a retrospective study on patients aged <60 years who received idarubicin plus cytarabine (IA)-based induction chemotherapy for newly diagnosed AML.Results: According to ELN-2017 criteria, the number of patients in the favorable (Fav), intermediate (Int), and adverse (Adv) risk categories was 192 patients (27%), 331 patients (46%), and 192 patients (27%), respectively. Overall survival probabilities at 5 years in the Fav, Int, and Adv groups were 57%, 37%, and 18%, respectively. In comparison, the 5-year overall survival probabilities in the Fav (169 patients), intermediate (IR)-1 (80 patients), IR-2 (306 patients), and Adv (160 patients) ELN-2010 categories were 59%, 32%, 40%, and 14%, respectively. Although ELN-2010 historically distinguishes prognosis into IR-1 and IR-2 categories in younger patients, this difference was nullified in the current study cohort. When comparing patients with a low FLT3-ITD AR with those with a high FLT3-ITD AR, no significant differences in survival were noted among patients with nucleophosmin 1 (NPM1)-mutated AML (P = .28) or wild-type NPM1 (P = .35), and in those treated with IA alone (P = .79) or those treated with IA and a FLT3 inhibitor (P = .10).Conclusions: The ELN-2017 more accurately distinguishes prognosis in patients with newly diagnosed AML. The lack of prognostic significance for the FLT3-ITD AR needs further evaluation in different treatment settings. [ABSTRACT FROM AUTHOR]

Colorectal cancer is a leading cause of death both in Europe and worldwide. Unfortunately, 20-25% of patients with colorectal cancer already have metastases at the time of diagnosis, while 50-60% of the remainder will develop metastases later during the course of the disease. Although hepatic excision is the first-line treatment for patients with liver-limited colorectal metastases and is reported to prolong the survival of these patients, few patients are candidates. Locoregional therapy encompasses minimally invasive techniques practiced by interventional radiology. Most widely used locoregional therapies include ablative treatments (radiofrequency ablation, microwave ablation) and transcatheter intra-arterial therapies (transarterial chemoembolization, and radioembolization with yttrium-90). [ABSTRACT FROM AUTHOR]

Medical devices are estimated to account for 6 percent of health expenditures in the US and 7 percent in European Union (EU) countries. Cardiac implants are a large segment of the market, but little is known about their prices. Using 2006-14 data from a large hospital panel survey, this article provides a systematic comparison of prices of cardiac implants between the US and four EU countries. The data reveal that prices were two to six times higher in the US than in Germany, where cardiac implants were generally the cheapest. Prices also varied between EU countries. Prices of coronary stents and pacemakers were higher in France and Italy than in the UK, where prices were similar to those in Germany. The data also confirmed findings of prior studies that found significant price variation between hospitals within a given country. This study found that within- and between-country variations were similar in magnitude. While these findings can help assess whether technology-related policies effectively control the prices of cardiac devices, future research is necessary to establish a causal relationship between prices and several possible explanatory factors and help policy makers understand which mechanisms are available to control device prices. [ABSTRACT FROM AUTHOR]

Agricultural productivity varies greatly among agricultural systems and among regions in Europe. A multilevel logistic regression model was applied to investigate the labour productivity of the six main agricultural systems across European NUTS2 regions. K -means and two-step clustering methods were used to classify European regions based on the agricultural systems’ standard output per annual work unit. We analysed the effect of environmental (soil erosion, rainfed yield potential), structural (farm education, age, pluriactivity, diversification, rented agricultural land), technical (yield ratio) and contextual (gross domestic product per capita, population density) factors on labor productivity. Significant differences were revealed between northern-central regions and the continental peripheries (Mediterranean, Eastern). Soil erosion negatively affects agricultural labour productivity; for each one ton/ha increase in the modelled annual soil erosion rate the odds of regions to attain high labour productivity decreased by 28%. The importance of technical efficiency in crop production was also identified. Observed low wheat yields, relative to modelled potential yields, in the southern, eastern and northern European regions indicate a large unexploited gap. The positive effect of the regional gross domestic product per capita and the low population density confirmed the importance of contextual factors on labour productivity. A second analysis of a composite indicator of the labour productivity of the European agricultural systems, which accounted for the productivity of each system without considering its size, revealed the positive effect of farm education and the negative effect of pluriactivity on agricultural labour productivity. The analyses indicate the importance of compensatory allowances for areas facing natural constraints, while investing in farm training schemes and advisory services could increase the adoption of new technologies and improve the performance of farmers in both economic and environmental terms. Finally, the significance of contextual factors indicates the importance of a better harmonisation of rural development policy with regional policy. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB).Materials and Methods: This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates.Results: The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years.Conclusions: TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy. [ABSTRACT FROM AUTHOR]

Why have European large parties lost electoral ground in recent decades? Whereas most explanations draw on theories of dealignment, this article advances a novel, institutional, argument by focusing on the introduction of direct elections to the European Parliament (EP) in 1979. Archetypes of second-order elections, EP elections are characterized by lower vote shares for (a) large and (b) incumbent parties. Bridging the second-order elections theory with theories of political socialization, we posit that voting patterns in EP elections spill over onto national elections, especially among voters not yet socialized into patterns of habitual voting. In so doing, they increase the national vote shares of small parties. This proposition is examined using an instrumental variables approach. We also derive a set of testable propositions to shed light on the underlying mechanisms of this pattern. Our findings show that EP elections decrease support for big parties at the national arena by inculcating voting habits. [ABSTRACT FROM AUTHOR]

The article provides information on the Women Against Viruses in Europe (WAVE) Work Group dedicated to health and wellbeing promotion among women living with HIV (WLWH) through workshops and conferences. It focuses on priority areas for optimizing care of WLWH including psychosocial aspects of HIV diagnosis, mental health, and antiretroviral therapy.

We study the implications of the Great Recession for voting for antiestablishment parties, as well as for general trust and political attitudes, using regional data across Europe. We find a strong relationship between increases in unemployment and voting for nonmainstream parties, especially populist ones. Moreover, unemployment increases in tandem with declining trust toward national and European political institutions, though we find only weak or no effects of unemployment on interpersonal trust. The correlation between unemployment and attitudes toward immigrants is muted, especially for their cultural impact. To explore causality, we extract the component of increases in unemployment explained by the precrisis structure of the economy, in particular the share of construction in regional value added, which is strongly related both to the buildup preceding and the bursting of the crisis. Our results imply that crisis-driven economic insecurity is a substantial determinant of populism and political distrust. [ABSTRACT FROM AUTHOR]

The impact of the economic crisis has been highly asymmetric across the European regions. The objective of this paper is to investigate the determinants of resilience to economic crisis across European regions. Regional economic resilience was assessed based on employment changes during 2008-2013, while socioeconomic determinants were analysed pre-crisis (2002-2007). A highly heterogeneous pattern of resilience was observed within countries, while significant differences were also revealed between the continental northern-central regions and the southern periphery. A multilevel logistic regression model indicated the magnitude of country-effects on the performance of regional employment during crisis periods. Both EU-referenced and country-referenced regional resilience identified the positive effect of accessibility and the negative effect of a large manufacturing sector in the ability of regions to withstand recessionary shocks. Education and economic development level positively affected the resilience of both large and small regional European economies. Investing in education enhances the spatial homogeneity across Europe in terms of its ability to react to economic shocks. The results reveal the importance of narrowing disparities among regions and formulating targeted and differentiated regional development policies at country level, taking into consideration the size of the economy of the regions. [ABSTRACT FROM AUTHOR]

We argue that an important determinant of voters' support for economic reform is the strength of family ties. While the 'crisis hypothesis' predicts that crises facilitate reform, we show in a political economy model that this relation can break down, and even reverse, when agents take into account the effect of reform on their family members. Applied to southern European countries with strong family ties, the model rationalizes why the extremely high (youth) unemployment following the Great Recession has not led to more substantial labor market reforms. In such countries austerity might block rather than foster additional structural reforms. ( JEL D64, D72, J48) [ABSTRACT FROM AUTHOR]

Old-age survival is a good indicator of population health and regional development. We evaluated the spatial distribution of old-age survival across Porto neighbourhoods and its relation with physical (biogeophysical and built) and socioeconomic factors (deprivation). Smoothed survival rates and odds ratio (OR) were estimated using Bayesian spatial models. There were important geographical differentials in the chances of survival after 75 years of age. Socioeconomic deprivation strongly impacted old-age survival (Men: least deprived areas OR=1.31(1.05-1.63); Women OR=1.53(1.24-1.89)), explaining over 40% of the spatial variance. Walkability and biogeophysical environment were unrelated to old-age survival and also unrelated to socioeconomic deprivation, being fairly evenly distributed through the city. [ABSTRACT FROM AUTHOR]

Background Further increases in life expectancy in high-income countries depend to a large extent on advances in old-age survival. We aimed to characterise the spatial distribution of old-age survival across small areas of Europe, and to identify areas with significantly high or low survivorship. Methods This study incorporated 4404 small areas 1 from 18 European countries. We used a 10-year survival rate to express the proportion of population aged 75-84 years who reached 85-94 years of age (beyond average life expectancy). This metric was calculated for each gender using decennial census data (1991, 2001 and 2011) at small geographical areas. To address problems associated with small areas, rates were smoothed using a Bayesian spatial model. Excursion sets were defined to identify areas with significantly high (>95th centile) and low (<5th) survival. Results In 2011, on average, 47.1% (range: 22.5- 71.5) of the female population aged 75-84 years had reached 85-94 years of age, compared to 34.2% (16.4- 49.6) of the males. These figures, however, hide important and time-persistent spatial inequalities. Higher survival rates were concentrated in northern Spain, Andorra and northeastern Italy, and in the south and west of France. Lower survival was found in parts of the UK, Scandinavia and the Netherlands, and in some areas of southern Europe. Within these regions, we detected areas with significantly high and low old-age survival. Conclusions Clear and persistent spatial inequalities in old-age survival exist, suggesting that European social unity is still to be accomplished. These inequalities could arise from a myriad of population health determinants (eg, poverty, unhealthy lifestyles), which merit further study. [ABSTRACT FROM AUTHOR]

Compared to many manufacturing industries, there have been few major improvements over the past few decades in the productivity, profitability, or the environmental impact of construction. However, driven by institutional changes, promotion campaigns, and technological development in the 1990s, novel industrial wood-frame multi-story construction (WMC) practices have been emerging in some European countries. The aim of the study is to explore the WMC market potential in Europe by combining two complementary approaches: Top-down scenario analysis and bottom-up innovation diffusion analysis. The results show that the WMC diffusion is heavily dependent on the regulatory framework and the structure of the construction industry. The risk-averse nature of the construction value chain resisting the uptake of new practices appears to be a more significant hindrance for the future market potential of WMC, compared to the possible competition from alternative construction practices. It would require both increasing competition within the WMC sector and increasing co-operation between wood product suppliers and the construction sector to attract investments, to reduce costs, and to make the WMC practices more credible throughout the construction value chain. [ABSTRACT FROM AUTHOR]

The successive reforms of the Common Agricultural Policy (CAP), the enlargements of the European Union (EU) and the impacts of climate change have amplified the diversity of European agriculture. These rapid changes have resulted in the intensification of agricultural activities in some regions, while they have led to the marginalization of agriculture and its eventual abandonment in others. The objective of this paper is to investigate the factors that are behind the differential performance of agriculture across the EU-27 countries. Ward's, k -means and two-step clustering methods were used to classify European agriculture based on gross-value-added farm, land and labour productivity indicators. Significant differences were revealed between the Northern-Central counties and the continental peripheries (Mediterranean, Eastern, Northern Scandinavian). An exact logistic regression model was used to analyse the factors behind this differential performance. Agricultural sectors characterized by a young and better trained farm population are more likely to attain high economic performance. The odds to attain high economic performance are almost 9 times greater for countries with a highly trained farm population, namely, the Netherlands (72%) and Germany (69%), than for countries with poor farm training, while an ageing farm population such as in Portugal (72%) and Bulgaria (66%) is 92% less likely to be high performing. The importance of investments in agriculture was also identified. The significance of the wheat yield variable highlights the importance of both environmental conditions and technical efficiency on farm economic performance. Similarly, countries with a high share of utilized agricultural land in less favoured areas, such as in the Mediterranean, are 94% less likely to attain high economic performance. The redesign of CAP direct payments between old and new member states after 2013 combined with the impacts of agricultural trade liberalization and climate change are expected to deteriorate the position of low performing agricultural sectors further. [ABSTRACT FROM AUTHOR]

Fabrizio Faggiano and colleagues discuss how a central, transparent, and evidence-based approval process is needed for behavioral prevention interventions in Europe and propose a way forward. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

Public opinion is considered a major obstacle to changing the status quo of welfare state policies. Yet some far-reaching reforms and gradual changes of European welfare states prompt the reverse question: Have increased reform pressures and restructuring efforts led to changes in individual attitudes? In line with previous research, I found that the strong support for a public provision of healthcare remains unchanged. But what about the structure of attitudes? Testing core assumptions of the new politics theory and power resources theory, I looked at conflict lines within society and how they change in times of retrenchment. Analysing individual attitudes in 14 European countries between 1996 and 2002, I moved beyond static comparisons across countries to provide a dynamic account of trends over time. Observing stability, not change, I found no evidence that the relevance of old cleavages is in decline. Both old and new cleavages shape individual attitudes. [ABSTRACT FROM AUTHOR]

The European Water Framework Directive establishes a framework for the protection of water resources. However, common water management tools demand common understanding of assessment methods, so quality goals are equally met. Intercalibration of methods ensures the comparability of biological elements across similar geographical areas. Many aspects can influence the outcome of intercalibration: data sampling, treatment methods, taxonomic reliability of databases, choice of metrics for ecological quality status classification, and criteria for selecting reference sites. This study describes the potentials and constraints of the intercalibration of indices using diatoms for assessment of Mediterranean rivers. Harmonisation of diatom taxonomy and nomenclature was based on a previous ring test which took place at the European level. Four diatom indices (Indice de Polluosensibilité Spécifique—IPS, Indice Biologique Diatomées—IBD 2007, Intercalibration Common Metric Italy—ICMi and Slovenian Ecological Status assessment system) were intercalibrated using data from six European Mediterranean countries (Cyprus, France, Italy, Portugal, Slovenia and Spain). Boundaries between High/Good and Good/Moderate quality classes were harmonised by means of the Intercalibration Common Metric (ICM). Comparability between countries was assured through boundary bias and class agreement. The national boundaries were adjusted when they deviated more than a quarter of a class equivalent (0.25) from the global mean. All national methods correlated well with the ICM, which was sensitive to water quality (negatively correlated to nutrients). Achnanthidium minutissimum sensu lato was the most discriminative species of Good ecological status class. Planothidium frequentissimum, Gomphonema parvulum and Nitzschia palea were the most contributive to Moderate ecological status class. Some taxa were discriminative for both Good and Moderate ecological status classes due to low indication and ecological discriminative power but also due to differences in taxonomy between countries. This intercalibration exercise allowed establishment of common water quality goals across Mediterranean Europe, which is substantiated with the ICM. [ABSTRACT FROM AUTHOR]

The aim of this article is to explain commonalities and differences in the responses of four national educational science communities to the same external stimulus, namely international comparative large scale student assessments that offered vastly improved comparability of national results from the beginning of the 1990s. The comparison shows the epistemic traditions of educational research in the four countries and properties of the data produced by the international comparative studies to be the central explanatory factors for commonalities and differences of responses to the new studies. [ABSTRACT FROM AUTHOR]

On May 10, 2012, the European Commission issued a conditional marketing authorization valid throughout the European Union for pixantrone for the treatment of adult patients with multiply relapsed or refractory aggressive non-Hodgkin's B-cell lymphoma (NHL). Pixantrone is a cytotoxic aza-anthracenedione that directly alkylates DNAforming stable DNA adducts and cross-strand breaks. The recommended dose of pixantrone is 50 mg/m2 administered on days 1, 8, and 15 of each 28-day cycle for up to 6 cycles. In the main study submitted for this application, a significant difference in response rate (proportion of complete responses and unconfirmed complete responses) was observed in favor of pixantrone (20.0% vs. 5.7% for pixantrone and physician's best choice, respectively), supported by the results of secondary endpoints of median progression- free and overall survival times (increase of 2.7 and 2.6 months, respectively). The most common side effects with pixantrone were bone marrow suppression (particularly of the neutrophil lineage) nausea, vomiting, and asthenia. This article summarizes the scientific review of the application leading to approval in the European Union. The detailed scientific assessment report and product information, including the summary of product characteristics, are available on the European Medicines Agency website (http://www.ema.europa.eu). [ABSTRACT FROM AUTHOR]

Civil society consists of members obligated to respect each other's rights and, hence, trade with each other as equals. What determines the boundary, rather than the nature, of civil society? For Adam Smith, the boundary consists of humanity itself because it is determined by identification: humans identify with other humans because of common humanness. While Smith's theory can explain the emotions associated with justice (jubilance) and injustice (resentment), it provides a mushy ground for the boundary question: Why not extend the common identity to nonhuman animals? Or why not restrict the boundary to one's own dialect, ethnicity or race? For David Hume, the boundary need not consist of humanity itself because it is determined by self-interest: a European need not respect the property of outsiders such as Native Americans, if the European benefits more by exploiting them than including them in the European society. While Hume's theory can provide a solid ground for the boundary question, it cannot explain the emotions associated with justice. This paper suggests a framework that combines the strengths, and avoids the shortcomings, of Smith's and Hume's theories. [ABSTRACT FROM AUTHOR]

• Two types of beet-pulp/starch bricks are investigated: full and hollowed bricks. • The preparation of the mixture and bricks manufacturing are described in details. • The microstructure of the mixture constituents are described and analyzed. • The drying kinetics of the bricks are compared and predicted via mathematical models. • The mechanical behavior of the bricks is studied via compressive tests on each type. Buildings account for a large share of the primary energy and materials use in Europe. Therefore, the EU has set several energy and materials targets for the built environment and other sectors. Novel low-carbon materials can play a major role in the transition towards meeting those targets. Moreover, agriculture produces by- or waste products that could be used as constituent of innovative agro-materials for construction. Recently, beet pulp based-material is being investigated on the material scale and promising results are pointed out regarding its interesting mechanical, hygrothermal and acoustical properties for building insulation use. In this context, the paper aims to study experimentally two types of beet-pulp starch composites: whole bricks and hollowed bricks. The manufacturing of the two types of bricks is detailed. A comparative study is then achieved regarding the drying kinetics, mechanical properties as well as internal structure composition. [ABSTRACT FROM AUTHOR]

This paper discusses historical and technical events in the U.S. and Europe over the last few years that are aimed at modernizing the electric power grid. The U.S. federal government has ratified the “smart grid initiative” as the official policy for modernizing the electricity grid including unprecedented provisions for timely information and control options to consumers and deployment of “smart” technologies. European countries are unified in researching and developing related technologies through various structures supported by the European Union. This paper presents the development of smart grids and an analysis of the methodologies, milestones, and expected evolutions of grid technologies that will transform society in the near future. [ABSTRACT FROM AUTHOR]

Moderating binge drinking among young people remains a major health policy focus of European Union (EU) member states. Risk perceptions toward alcohol are an important predictor of consumption behavior. We analyze how alcohol policies and various sources providing information about alcohol's effects impact adolescents’ risk perceptions about alcohol. We employ the 2008 Flash Eurobarometer survey, ‘Young people and drugs’, with 12,312 (15–24 year old) resident citizens across the 27 EU member states. After adjusting for inter-country variation, most alcohol policies tested had no significant influence on risk perceptions. Only the blood alcohol concentration limit for driving and health warnings on advertisements and/or alcoholic beverage containers showed a significant effect, increasing risk perceptions among adolescents. Three sources of information dissemination about alcohol's risks and effects showed significant influence on risk perceptions. While information about the risks of alcohol from parents increased risk perceptions, information from friends decreased it. The influence of media campaigns was only marginal, though indicating a small decrease in risk perceptions. If the desire is to increase risk perceptions, policy makers should emphasize the short-term effects and externalities of alcohol consumption as well as focus on the clear and salient dissemination of risk information that may influence the normative environment. (JEL code: I18). [ABSTRACT FROM PUBLISHER]

During the last decade, the European asset management industry has undergone a period of unprecedented change. Europe has witnessed ten years of financial integration, driven in particular by various regulatory initiatives. But Europe has also been transformed in the geopolitical sense, with 12 new Member States and millions of new citizens of the European Union. Add to that a decade of rapid globalization and one financial crisis of historical proportions. But while Europe and its financial markets have evolved and the asset management industry has transformed itself, academic research has not kept pace. During the last ten years or so, the lack of systematic research on the structural dimensions of the asset management industry is striking. This article fills this gap by providing a comprehensive overview of the European asset management industry at the end of the first decade of the 21st century. We seek to provide explanations to the various differences observed between European countries. Using prior research as a basis, we also compare the characteristics of the industry to their standing at the turn of the century. This also includes assessing whether and to what extent the forecasts provided in prior research did materialize. We also try to find reasons for cases in which they did not. Finally, we ourselves offer a number of prognoses on the development of the European asset management over the coming years. [ABSTRACT FROM AUTHOR]

The article discusses the importance of evidences in comparative efficacy assessment in drug licensing in Europe. It states that the European Medicines Agency is encouraged to require drug developers to have pre-market studies to establish comparative efficacy and risks, however, such framework is only limited to molecular entities at the time of market authorization. It also mentions the implications of the lack of early comparative efficacy evidence, which can result to the widespread use of potentially less efficacious and unsafe drugs. It advises the need for drug manufacturers to value the comparative risks and benefits of a proposed treatment to help regulatory authorities safeguard public health from inferior and unsafe medical interventions.