Biomass-derived carbon dots as emerging visual platforms for fluorescent sensing

Biomass-derived carbon dots (CDs) are non-toxic and fluorescently stable, making them suitable for extensive application in fluorescence sensing. The use of cheap and renewable materials not only improves the utilization rate of waste resources, but it is also drawing increasing attention to and interest in the production of biomass-derived CDs. Visual fluorescence detection based on CDs is the focus of current research. This method offers high sensitivity and accuracy and can be used for rapid and accurate determination under complex conditions. This paper describes the biomass precursors of CDs, including plants, animal remains and microorganisms. The factors affecting the use of CDs as fluorescent probes are also discussed, and a brief overview of enhancements made to the preparation process of CDs is provided. In addition, the application prospects and challenges related to biomass-derived CDs are demonstrated.

Health and Care Data: Approaches to data linkage for evidence-informed policy

An indispensable prerequisite for answering research questions in health services research is the availability and accessibility of comprehensive, high-quality data. It can be assumed that health services research in the coming years will be increasingly based on data linkage, i.e., the linking, or connecting, of several data sources based on suitable common key variables. A range of approaches to data collection, storage, linkage and availability exists across countries, particularly for secondary research purposes (i.e., the use of data initially collected for other purposes), such as health systems research. The main goal of this review is to develop an overview of, and gain insights into, current approaches to linking data sources in the context of health services research, with the view to inform policy, based on existing practices in high-income countries in Europe and beyond. In doing so, another objective is to provide lessons for countries looking for possible or alternative approaches to data linkage. Thirteen country case studies of data linkage approaches were selected and analysed. Rather than being comprehensive, this review aimed to identify varied and potentially useful case studies to showcase different approaches to data linkage worldwide. A conceptual framework was developed to guide the selection and description of case studies. Information was first identified and collected from publicly available sources and a profile was then created for each country and each case study; these profiles were forwarded to appropriate country experts for validation and completion. The report presents an overview of the included countries and their case studies (Chapter 2), with key data per country and case study in the appendices. This is followed by a closer look at the possibilities of using routine data (Chapter 3); the different approaches to linkage (Chapter 4); the different access routes for researchers (Chapter 5); the use of data for research from electronic patient or health records (Chapter 6); foundational considerations related to data safety, privacy and governance (Chapter 7); recent developments in cross-border data sharing and the European Health Data Space (Chapter 8); and considerations of changes and responses catalysed by the COVID-19 pandemic as related to the generation and secondary use of data (Chapter 9). The review ends with overall conclusions on the necessary characteristics of data to inform research relevant for policy and highlights some insights to inspire possible future solutions - less or more disruptive - for countries looking to expand their use of data (Chapter 10). It emphasises that investing in data linkage for secondary use will not only contribute to the strengthening of national health systems, but also promote international cooperation and contribute to the international visibility of scientific excellence.

France: Health System Review

This review of the French health system analyses recent developments in health organisation and governance, financing, healthcare provision, recent reforms and health system performance. Overall health status continues to improve in France, although geographic and socioeconomic inequalities in life expectancy persist. The health system combines a social health insurance (SHI) model with an important role for tax-based revenues to finance healthcare. The health system provides universal coverage, with a broad benefits basket, but cost-sharing is required for all essential services. Private complementary insurance to cover these costs results in very low average out-of-pocket (OOP) payments, although there are concerns regarding solidarity, financial redistribution and efficiency in the health system. The macroeconomic context in the last couple of years in the country has been affected by the Covid-19 pandemic, which resulted in subsequent increases of total health expenditure in France in 2020 (3.7%) and 2021 (9.8%). Healthcare provision continues to be highly fragmented in France, with a segmented approach to care organization and funding across primary, secondary and long-term care. Recent reforms aim to strengthen primary care by encouraging multidisciplinary group practices, while public health efforts over the last decade have focused on boosting prevention strategies and tackling lifestyle risk factors, such as smoking and obesity with limited success. Continued challenges include ensuring the sustainability of the health workforce, particularly to secure adequate numbers of health professionals in medically underserved areas, such as rural and less affluent communities, and improving working conditions, remuneration and career prospects, especially for nurses, to support retention. The Covid-19 pandemic has brought to light some structural weaknesses within the French health system, but it has also provided opportunities for improving its sustainability. There has been a notable shift in the will to give more room to decision-making at the local level, involving healthcare professionals, and to find new ways of funding healthcare providers to encourage care coordination and integration.

30 years of primary health care reforms in Estonia: The role of financial incentives to achieve a multidisciplinary primary health care system

Estonia has a legacy of hospital-focused service provision, but since the 1990s, has introduced a series of reforms to strengthen primary health care (PHC). The recent PHC reforms have placed an increasing focus on multidisciplinary care, involving home nurses, midwives, and physiotherapists, and emphasize PHC centres over single physician practices. These incremental reforms, without a supporting legal basis nor explicitly defined timelines and targets, nonetheless demonstrated the ability of financial incentives to drive change. EU structural funds in particular provided essential funding for infrastructure investments in PHC. Yet not all stakeholders supported these initiatives, largely due to the uncertain sustainability of funding. The EHIF also adjusted contract and payment terms to support PHC reforms, with some concessions to PHC providers operating as single practitioners. Despite substantial progress over the last three decades to shift the focus to PHC, there are some important bottlenecks that hinder the progress. These include PHC providers' hesitance to give up their freedom as single practitioners, low interest from specialists to start working at the PHC level, and a lack of financial incentives and adequate funding for a broader scope of PHC services. This looks to become more challenging in the future, as nearly half of family physicians are 60 years old or older. The development of the new PHC strategy in 2023 is very timely to comprehensively address these bottlenecks and to set the vision for the future of PHC in Estonia.

Beyond Pristine Metal-Organic Frameworks: Preparation of Hollow MOFs and Their Composites for Catalysis, Sensing, and Adsorption Removal Applications

Metal-organic frameworks (MOFs) have been broadly applied to numerous domains with a substantial surface area, tunable pore size, and multiple unsaturated metal sites. Recently, hollow MOFs have greatly attracted the scientific community due to their internal cavities and gradient pore structures. Hollow MOFs have a higher tunability, faster mass-transfer rates, and more accessible active sites when compared to traditional, solid MOFs. Hollow MOFs are also considered to be candidates for some functional material carriers. For example, composite materials such as hollow MOFs and metal nanoparticles, metal oxides, and enzymes have been prepared. These composite materials integrate the characteristics of hollow MOFs with functional materials and are broadly used in many aspects. This review describes the preparation strategies of hollow MOFs and their composites as well as their applications in organic catalysis, electrochemical sensing, and adsorption separation. Finally, we hope that this review provides meaningful knowledge about hollow-MOF composites and their derivatives and offers many valuable references to develop hollow-MOF-based applied materials.

Primary health care reforms in Estonia: using financial incentives to encourage multidisciplinary care

Estonia has a historical legacy of large hospital networks and municipality-owned specialist clinics, with a low emphasis on primary health care (PHC). Since the 1990s, a transition towards PHC has occurred, delivering PHC in family physician practices rather than in specialist clinics. The transition has been underpinned by a series of comprehensive healthcare system reforms starting in the late 1990s. The most recent reforms, although lacking a legal basis, have been accompanied by financial incentives including EU structural funds to encourage change. These financial incentives were designed to improve quality of care, encourage working in remote areas, and more. A key focus of PHC reforms has been an emphasis on multidisciplinary care, and the reforms have aimed at increasing the involvement of home nurses, midwives, and physiotherapists in PHC. The reforms have also prioritized PHC centres, with multiple practicing physicians, over single physician practices. Although EU structural funds have supported building the infrastructure for expanded scope of services at PHC level, the uncertainty of long-term funding of expanded services remained a key challenge limiting the success of the reform. Further, the supply of family physicians will be problematic in the future, as the number of permanently vacant positions has quadrupled in the last five years and almost half are 60 years of age or older. As the PHC reform process in Estonia continues until today, it can serve as a case study for other countries interested in strengthening their PHC systems.

What have European countries done to prevent the spread of COVID-19? Lessons from the COVID-19 Health System Response Monitor

Although some European countries imposed measures that successfully slowed the transmission of Covid-19 during the first year of the pandemic, others struggled, either because they acted slowly or implemented measures ineffectively. In this paper we consider the European experience with public health measures designed to prevent transmission of COVID-19. Based on literature and country responses described in the COVID-19 Health System Response Monitor from March 2020 to December 2020, we consider some critical aspects of public health policy responses. These include the importance of public health capacity that can scale up surveillance and outbreak control, including effective testing and contract tracing, of clear messaging based on an understanding of human behaviour, policies that address the undesirable consequences of necessary measures, such as support for those isolating or unable to earn, and the ability to implement at pace and scale a major vaccine rollout. We conclude that for countries to be successful at preventing COVID-19 transmission, there is a need for a clear strategy with explicit goals and a whole systems approach to implementation.

An analytical framework for assessing data for health services research

This presentation will provide an overview of the conceptual framework we used as a basis for the analysis of the case studies. The framework distinguishes between data sets with care-relevant data i) at the individual level (i.e. microdata) and ii) at the non-individual level, and iii) from three or four large content blocks (health data, health care data, socio-demographic or economic data, environmental data). Using health data as an example, individual-level health data includes individual patient data, such as laboratory and clinical results, vital signs (body temperature, pulse rate, and respiration date), as well as diagnoses and health behavior. Non-individual level data includes aggregated data in areas such as life expectancy, years of life lost (YLL), years lost to disability (YLD), disability-adjusted life years (DALY), as well as population characteristics such as prevalence of risk factors and chronic illness. The framework we have developed shows linking possibilities that are available by either storing the data in common databases (e.g., based on an electronic health record) or by linking them via a unique personal characteristic (e.g., patient identifier). The country case studies selected in the research - largely within the European region but also Australia, Canada, the Republic of Korea, New Zealand, and the United States - are all evaluated using the same conceptual framework.

Delivering health and social services

Dual delivery of COVID-19 and non-COVID-19 services proved to be the core challenge of the service delivery response. Health systems responded by implementing strategies to manage a surge in demand for both health and social services, while continuing to provide other necessary health care services. These involved adapting or transforming patient care approaches, including the coordination of care across levels (e.g., acute vs. outpatient) and settings (e.g., PHC vs. long-term care), and coordinating response measures with social services provided outside of health system. The initial capacities and available reserves of physical infrastructure, such as hospital and intensive care unit (ICU) beds, the organization and coordination of service delivery and previous experience of responding to epidemics such as SARS or MERS or other health system shocks, influences a country's ability to anticipate and cope with surges in demand for health and social services. This presentation will provide an overview of strategies on ensuring the ability to cope with surge in demand for and managing provision of services for COVID and non-COVID patients, including social services. It will also cover strategies on increasing capacity to cope with surges of need for physical resources, such as infrastructure, equipment and medical supplies. A brief overview of key metrics to assess resilience in delivery of health and social services will also be provided.

A cross-country comparison on providing health services effectively during the first wave of COVID-19

At the onset of the COVID-19 pandemic, health care providers had to abruptly change their way of providing care in order to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Even the most well-resourced health systems faced pressures from new challenges brought on by COVID-19, and every country had to make difficult choices about how to maintain access to essential care while treating a novel communicable disease. Using the information available on the HSRM platform from the early phases of the pandemic, we analyze how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and outpatient settings. Many country responses displayed striking similarities despite very real differences in the organization of health and care services. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Many countries expect to operate at lower capacity for routinely provided care, which will impact patient access and waiting times. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

Primary Health Care during the COVID-19 pandemic: an analysis based on the HSRM

The COVID-19 pandemic has had a dramatic impact on workload and responsibilities for those working at primary health care (PHC) level in the European region - much of which has gone unnoticed relative to the focus on hospitals. Based on the PHC-relevant data extracted from the HSRM, we describe PHC models of care and the political and system levers that supported them. Three key themes emerged: (1) varied forms of PHC multidisciplinary collaboration were developed to manage the emergency response - supported by the movement of staff to areas requiring support; (2) vulnerable patients were identified and prioritized for medical outreach within PHC, and were supported through financial incentives and complementary action from centralized and local governments that used much broader definitions of vulnerability; and (3) digital solutions for remote triage, medical advice and treatment enhanced the effectiveness of the PHC response and were facilitated through centralized investment in digital technologies. Based on our analysis, we raise opportunities for the future of PHC, namely that multidisciplinary approaches to PHC service delivery are essential to future infectious and non-infectious outbreaks, and the agility and rapid pace of change that took place among PHC providers should continue. PHC providers lacked visibility during the pandemic and should work together to develop a strong voice in all health systems.

A reversal of fortune: Comparison of health system responses to COVID-19 in the Visegrad group during the early phases of the pandemic

This paper analyses the health policy response to the COVID-19 pandemic in the four Visegrad countries – Czechia, Hungary, Poland, and Slovakia – in spring and summer 2020. The four countries implemented harsh transmission prevention measures at the beginning of the pandemic and managed to effectively avoid the first wave of infections during spring. Likewise, all four relaxed most of these measures during the summer and experienced uncontrolled growth of cases since September 2020. Along the way, there has been an erosion of public support for the government measures. This was mainly due to economic considerations taking precedent but also likely due to diminished trust in the government. All four countries have been overly reliant on their relatively high bed capacity, which they managed to further increase at the cost of elective treatments, but this could not always be supported with sufficient health workforce capacity. Finally, none of the four countries developed effective find, test, trace, isolate and support systems over the summer despite having relaxed most of the transmission protection measures since late spring. This left the countries ill-prepared for the rise in the number of COVID-19 infections they have been experiencing since autumn 2020.

Data availability for health system comparisons and assessments in the WHO African Region

Background

Describing and assessing health systems is a challenging but essential task for researchers and policy makers striving to perform cross-country comparisons and to ensure evidence-based global health policy. The European Observatory on Health Systems and Policies has developed a template for country health system reviews (HiT) to systematically describe and assess health systems. To date, the HiT template has been used for countries in Europe, Asia and North America. This study reviews to what extent data for the indicators in the HiT template are available for the 47 countries of the WHO African Region.

Methods

After identifying indicators in the HiT template, we explored the databases highlighted in the HiT template, as well as additional international and regional databases, to determine data availability. We extracted the country coverage and availability of indicators over time, noting gaps in data availability. Internationally available socio-demographic, macroeconomic, and mortality and health indicators were most frequently available for all 47 countries included in the study; data on the provision of services had the lowest availability. Data on human and physical resources and service provision had the most geographic and temporal variability. Information related to health system assessment, including issues around quality of care and access, if available, were geographically and temporally limited and found only in regional surveys or national sources.

Conclusions

This project provides a comprehensive overview of health system-related data availability for the African Region. Regional or country group databases with regular updates, such as those managed by OECD and Eurostat, are less common in the African region, leading to a dearth of information. More work is needed to determine the most appropriate indicators and data sources for health system comparisons and assessments in the region.

Key messages

We evaluated the data availability of health system indicators in the WHO African Region using indicators from the HiT template of the European Observatory on Health Systems and Policies. Socio-demographic, macroeconomic, and mortality indicators had highest availability for all 47 countries included in the study, while data on the provision of services had the lowest availability.

MRI provision for patients with cardiac implantable electronic devices: understanding the real-world administrative requirements of service delivery

Introduction

Patients with cardiac implantable electronic devices (CIEDs) should have access to Magnetic Resonance Imaging (MRI) but are less likely to be referred and hospitals lack provision. A major barrier to service delivery is the administrative demand required to obtain accurate CIED details prior to scheduling. We aimed to understand the administrative requirements of a high-volume Cardiac Device-MRI service to inform the design of an electronic referrals platform that can facilitate workflow.

Methods

Single centre retrospective audit of a high-volume Cardiac Device-MRI service in a tertiary unit in the UK. Six months of referrals were reviewed for patient and CIED details and barriers met. Referrals were stratified by source, indication, MR-Conditional labelling and referrer.

Results

Administrative barriers were reviewed for 116 patients with CIEDs referred for MRI (48% cardiac, 52% non-cardiac) between September 2020 and March 2021 (Table 1). Referrers were 47% cardiologists and 53% other specialties. Referral to scan time was 15 days (interquartile range, 8–32). There were no scan-related complications.

34% of referrals contained complete CIED details and 30% stated the MR labelling of the CIED. None incorrectly labelled a CIED as MR-Conditional, but 8% incorrectly labelled as non-MR Conditional. 7 additional days were required to obtain complete CIED details where not provided (involving information requests from two device clinics in 27%), 10% had delays over 2 weeks (maximum 145 days). 35% required 3 or more repeat discussions with referrers after initial referral. Obtaining CIED information for external referrals required 17 days (11–42), compared to 14 (6–35) days for internal referrals (p=0.25).

Patients with non-MR Conditional CIEDs required on average 14 days longer to obtain complete referral details than patients with MR-Conditional CIEDs. Even when referrers were aware of non-MR Conditional labelling and received information on risk, 41% required further discussion between patient and referrer regarding risks and benefits of MRI scanning. For cancer referrals, obtaining correct details took 1 day longer than other referrals (p=0.074) and required 2 extra emails to maintain provision within the national time-to-treatment target of 62 days. Missing data was similarly present in referrals from Cardiologists and non-Cardiologists (59% versus 61% respectively), but non-Cardiologists recorded more incorrect CIED details (8% vs 0%).

Conclusions

Referral for MRI in patients with CIEDs demands significant administrative input to obtain correct device information, leading to delays. These delays are greater for patients with non-MR conditional CIEDs, and data provided is often incorrect or incomplete. This may explain why some patients are not referred for MRI. An online referrals platform has been developed to streamline this process, initially deployed through a network of 60 centres registered in the UK.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work is supported by British Heart Foundation Innovations funding (HFHF_016).

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Transformations in the landscape of primary health care during COVID-19: Themes from the European region

The COVID-19 pandemic has dramatically impacted primary health care (PHC) across Europe. Since March 2020, the COVID-19 Health System Response Monitor (HSRM) has documented country-level responses using a structured template distributed to country experts. We extracted all PHC-relevant data from the HSRM and iteratively developed an analysis framework examining the models of PHC delivery employed by PHC providers in response to the pandemic, as well as the government enablers supporting these models. Despite the heterogenous PHC structures and capacities across European countries, we identified three prevalent models of PHC delivery employed: (1) multi-disciplinary primary care teams coordinating with public health to deliver the emergency response and essential services; (2) PHC providers defining and identifying vulnerable populations for medical and social outreach; and (3) PHC providers employing digital solutions for remote triage, consultation, monitoring and prescriptions to avoid unnecessary contact. These were supported by government enablers such as increasing workforce numbers, managing demand through public-facing risk communications, and prioritising pandemic response efforts linked to vulnerable populations and digital solutions. We discuss the importance of PHC systems maintaining and building on these models of PHC delivery to strengthen preparedness for future outbreaks and better respond to the contemporary health challenges.

European countries' responses in ensuring sufficient physical infrastructure and workforce capacity during the first COVID-19 wave

The COVID-19 pandemic has placed unprecedented pressure on health systems’ capacities. These capacities include physical infrastructure, such as bed capacities and medical equipment, and healthcare professionals. Based on information extracted from the COVID-19 Health System Reform Monitor, this paper analyses the strategies that 45 countries in Europe have taken to secure sufficient health care infrastructure and workforce capacities to tackle the crisis, focusing on the hospital sector. While pre-crisis capacities differed across countries, some strategies to boost surge capacity were very similar. All countries designated COVID-19 units and expanded hospital and ICU capacities. Additional staff were mobilised and the existing health workforce was redeployed to respond to the surge in demand for care. While procurement of personal protective equipment at the international and national levels proved difficult at the beginning due to global shortages, countries found innovative solutions to increase internal production and enacted temporary measures to mitigate shortages. The pandemic has shown that coordination mechanisms informed by real-time monitoring of available health care resources are a prerequisite for adaptive surge capacity in public health crises, and that closer cooperation between countries is essential to build resilient responses to COVID-19.

A comparison of 2020 health policy responses to the COVID-19 pandemic in Canada, Ireland, the United Kingdom and the United States of America

This paper compares health policy responses to COVID-19 in Canada, Ireland, the United Kingdom and United States of America (US) from January to November 2020, with the aim of facilitating cross-country learning. Evidence is taken from the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, which has documented country responses to COVID-19 using a structured template completed by country experts. We show all countries faced common challenges during the pandemic, including difficulties in scaling-up testing capacity, implementing timely and appropriate containment measures amid much uncertainty and overcoming shortages of health and social care workers, personal protective equipment and other medical technologies. Country responses to address these issues were similar in many ways, but dissimilar in others, reflecting differences in health system organization and financing, political leadership and governance structures. In the US, lack of universal health coverage have created barriers to accessing care, while political pushback against scientific leadership has likely undermined the crisis response. Our findings highlight the importance of consistent messaging and alignment between health experts and political leadership to increase the level of compliance with public health measures, alongside the need to invest in health infrastructure and training and retaining an adequate domestic health workforce. Building on innovations in care delivery seen during the pandemic, including increased use of digital technology, can also help inform development of more resilient health systems longer-term.

Providing health services effectively during the first wave of COVID-19: A cross-country comparison on planning services, managing cases, and maintaining essential services

The COVID-19 pandemic triggered abrupt challenges for health care providers, requiring them to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Since March 2020, the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, has documented country responses to COVID-19 using a structured template which includes a section on provision of care. Using the information available on the platform, this paper analyzes how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and ambulatory settings. Despite very real differences in the organization of health and care services, there were many similarities in country responses. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

The 2020 reform of the employment status of Hungarian health workers: Will it eliminate informal payments and separate the public and private sectors from each other?

Hungary, like many countries, features a complex mix of the public and private sector in the financing and provision of health care services. At the same time, the health system also faces challenges related to shortages of health professionals, low public financing, and informal payments. With the added pressure from the COVID-19 pandemic, Hungarian policymakers acted rapidly to pass a sweeping regulation aimed at these issues. Over two days, the Hungarian parliament introduced and unanimously approved a new regulation, Act C of 2020 on the Employment Status of Health Workers, that replaces the existing public employment relationship between health professionals, public providers and their controlling authorities. The Act, passed on 6 October 2020, brings the employment of health workers under strict central control by introducing a new employment status similar to that of the armed forces. The Act also provides doctors with an unprecedented 120% salary increase and criminalizes informal payments. The reception has been overwhelmingly negative, with thousands of health professionals indicating that they would not sign the new contracts, and the policy also contains serious technical and feasibility concerns. Although the first statistics show that only about 3-5% of the active workforce did not sign the contract by 1 March 2021, the implementation of the reform still faces serious challenges.

New criteria for efficient Raman and Brillouin amplification of laser beams in plasma

Raman or Brillouin amplification of a laser beam in plasma has long been seen as a way to reach multi-PW powers in compact laser systems. However, no significant plasma-based Raman amplification of a laser pulse beyond 0.1 TW has been achieved in nearly 20 years, and only one report of Brillouin amplification beyond 1 TW. In this paper, we reveal novel non-linear criteria for the initial seed pulse that will finally open the door to efficient Raman and Brillouin amplification to petawatt powers and Joule-level energies. We show that the triple product of the coupling constant [Formula: see text], seed pulse duration [Formula: see text] and seed pulse amplitude a for the Raman seed pulse (or [Formula: see text] for Brillouin) must exceed a specific minimum threshold for efficient amplification. We also analyze the plasma-based Raman and Brillouin amplification experiments to date, and show that the seed pulses used in nearly all experiments are well below our new threshold, which explains the poor efficiency obtained in them. Finally, we analyze a recent Brillouin amplification experiment that used increased seed pulse power to obtain Joule-level amplification, and find excellent agreement with our theory.

Gaps in coverage and access in the European Union

Background

At the request of the European Commission, the Observatory on Health Systems and Policies and the HSPM network have undertaken a study to explore gaps in universal health coverage in the European Union and increase the level of granularity in terms of areas or groups where accessibility is sub-optimal.

Methods

To explore these gaps more systematically a survey was developed based on the so-called cube model that comprises different dimensions determining health coverage, including population coverage, service coverage and cost coverage. In addition, access can also be hampered by other factors, which relate more to the physical availability of care, a person's ability to obtain necessary care or the attitude of the provider. The survey was sent to country contacts from the Health Systems and Policy Monitor network.

Results

Within the diversity of country cases found in the survey, the most significant barriers for accessing health care still seem to be associated with social and income status, rather than specific medical conditions. However, groups like mentally ill, homeless, frail elderly, undocumented migrants are more likely to face multiple layers of exclusion and complex barriers to access.

Conclusions

Health system interventions can close access gaps for these vulnerable groups and address inequities in access to care. Through detailed coverage design countries can indeed determine the extent to which financial hardship and catastrophic out-of-pocket spending can be prevented. Furthermore, scope exists to improve current data collection practice.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Physical activity accrued as part of public transport use in England

BACKGROUND

Walking and cycling for transport (active travel) is an important source of physical activity with established health benefits. However, levels of physical activity accrued during public transport journeys in England are unknown.

METHODS

Using the English National Travel Survey 2010-14 we quantified active travel as part of public transport journeys. Linear regression models compared levels of physical activity across public transport modes, and logistic regression models compared the odds of undertaking 30 min a day of physical activity.

RESULTS

Public transport users accumulated 20.5 min (95% confidence interval=19.8, 21.2) a day of physical activity as part of public transport journeys. Train users accumulated 28.1 min (26.3, 30.0) with bus users 16.0 min (15.3, 16.8). Overall, 34% (32%, 36%) of public transport users achieved 30 min a day of physical activity in the course of their journeys; 21% (19%, 24%) of bus users and 52% (47%, 56%) of train users.

CONCLUSION

Public transport use is an effective way to incorporate physical activity into daily life. One in three public transport users meet physical activity guidelines suggesting that shifts from sedentary travel modes to public transport could dramatically raise the proportion of populations achieving recommended levels of physical activity.

Sustainability Indicators for Biobased Product Manufacturing: A Systematic Review

Indicators are effective decision-supporting tools to assess and evaluate progress toward sustainability for a given system. This paper reviews the literature on the four pillars of sustainability (environmental, economic, technical, and social) and relevant indicators used in the agricultural, manufacturing, and materials sectors to determine a framework for manufacturing biobased products as only individual sectors have been studied in detail. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology is used to select 40 papers for review in this study. This paper suggests 22 categories encompassing 33 core measurable indicators with respective units for biobased manufacturing sectors to determine the sustainability of an end product while holistically understanding the standpoint of biomaterial industries in assessing a sustainable supply chain.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Use of impedance ratios to assess hand swelling in lymphoedema

Objectives

To determine whether bioimpedance spectroscopy was suitable for detection of hand lymphoedema.

Methods

The hands of 50 participants without a history of lymphoedema were measured with perometry and bioimpedance spectroscopy after positioning two ways for three minutes: (a) both hands rested at heart height and (b) the dominant hand at heart height and the non-dominant hand at head height. In addition, 10 women with secondary hand lymphoedema were also measured.

Results

Impedance and volume measurements were found to be strongly related (dominant hand r = −0.794). Both measurements were reliable (ICC2,1 = 0.900–0.967 and 0.988–0.996, respectively). Impedance was more sensitive to small changes in hand volume due to the postural change (position × device interaction: F = 23.9, P < 0.001). Finally, impedance measurements had better discrimination of women with lymphoedema than volume measurements.

Conclusions

Bioimpedance spectroscopy is a promising tool for the detection of secondary hand lymphoedema.

Minireview: Regulatory T Cells and Ovarian Cancer

In the last 15 years, it has become apparent that ovarian cancer is recognized by the immune system, taking into account that T cell infiltration can be associated with increased overall survival. Several studies indicate that a correct combination of cluster of differentiation 8 and cluster of differentiation 4 T cells is key to fight tumor progression and that the presence of regulatory T cells (Tregs) infiltrating ovarian solid tumors (or present in ascites) is deleterious. Several markers that characterize Tregs include glucocorticoid-induced tumor necrosis factor receptor, cytotoxic T lymphocyte antigen-4, and forkhead box protein 3 (Foxp3). Research has shown that Tregs can infiltrate cancerous tissue and contribute to tumor growth by secreting immunosuppressive cytokines such as transforming growth factor beta and interleukin (IL)-10. Importantly, these cells might hamper the efficacy of immunotherapeutic approaches, thus strategies involving depletion or regulation of this population have been proposed and tested in experimental models. In this Minireview, we will discuss the relevance of Tregs in ovarian cancer and the experimental approaches destined to impair their immunosuppressive effects.

Opportunities and Challenges in the Design and Analysis of Biomass Supply Chains

The biomass supply chain is one of the most critical elements of large-scale bioenergy production and in many cases a key barrier for procuring initial funding for new developments on specific energy crops. Most productions rely on complex transforming chains linked to feed and food markets. The term 'supply chain' covers various aspects from cultivation and harvesting of the biomass, to treatment, transportation, and storage. After energy conversion, the product must be delivered to final consumption, whether it is in the form of electricity, heat, or more tangible products, such as pellets and biofuels. Effective supply chains are of utmost importance for bioenergy production, as biomass tends to possess challenging seasonal production cycles and low mass, energy and bulk densities. Additionally, the demand for final products is often also dispersed, further complicating the supply chain. The goal of this paper is to introduce key components of biomass supply chains, examples of related modeling applications, and if/how they address aspects related to environmental metrics and management. The paper will introduce a concept of integrated supply systems for sustainable biomass trade and the factors influencing the bioenergy supply chain landscape, including models that can be used to investigate the factors. The paper will also cover various aspects of transportation logistics, ranging from alternative modal and multi-modal alternatives to introduction of support tools for transportation analysis. Finally gaps and challenges in supply chain research are identified and used to outline research recommendations for the future direction in this area of study.

Housing and respiratory health at older ages

BACKGROUND

A large proportion of the population of England live in substandard housing. Previous research has suggested that poor-quality housing, particularly in terms of cold temperatures, mould, and damp, poses a health risk, particularly for older people. The present study aimed to examine the association between housing conditions and objectively measured respiratory health in a large general population sample of older people in England.

DATA AND METHODS

Data on housing conditions, respiratory health and relevant covariates were obtained from the second wave of the English Longitudinal Study of Ageing. Multivariate regression methods were used to test the association between contemporary housing conditions and respiratory health while accounting for the potential effect of other factors; including social class, previous life-course housing conditions and childhood respiratory health.

RESULTS

Older people who were in fuel poverty or who did not live in a home they owned had significantly worse respiratory health as measured by peak expiratory flow rates. After accounting for covariates, these factors had no effect on any other measures of respiratory health. Self-reported housing problems were not consistently associated with respiratory health.

CONCLUSIONS

The housing conditions of older people in England, particularly those associated with fuel poverty and living in rented accommodation, may be harmful to some aspects of respiratory health. This has implications for upcoming UK government housing and energy policy decisions.

Two synchronous non small cell lung carcinomas with different morphologies in the same lobe

We report the case of a sixty one year old female diagnosed with two synchronous primary lung cancers located within the same lobe. Surgical resection was performed, followed by adjuvant chemotherapy. The patient developed distant bone and skin metastases one year post-surgical resection. In this report we discuss the multimodality therapy used to treat this patient.

A large-scale meta-analysis to refine colorectal cancer risk estimates associated with MUTYH variants

Background:

Defective DNA repair has a causal role in hereditary colorectal cancer (CRC). Defects in the base excision repair gene MUTYH are responsible for MUTYH-associated polyposis and CRC predisposition as an autosomal recessive trait. Numerous reports have suggested MUTYH mono-allelic variants to be low penetrance risk alleles. We report a large collaborative meta-analysis to assess and refine CRC risk estimates associated with bi-allelic and mono-allelic MUTYH variants and investigate age and sex influence on risk.

Methods:

MUTYH genotype data were included from 20 565 cases and 15 524 controls. Three logistic regression models were tested: a crude model; adjusted for age and sex; adjusted for age, sex and study.

Results:

All three models produced very similar results. MUTYH bi-allelic carriers demonstrated a 28-fold increase in risk (95% confidence interval (CI): 6.95–115). Significant bi-allelic effects were also observed for G396D and Y179C/G396D compound heterozygotes and a marginal mono-allelic effect for variant Y179C (odds ratio (OR)=1.34; 95% CI: 1.00–1.80). A pooled meta-analysis of all published and unpublished datasets submitted showed bi-allelic effects for MUTYH, G396D and Y179C (OR=10.8, 95% CI: 5.02–23.2; OR=6.47, 95% CI: 2.33–18.0; OR=3.35, 95% CI: 1.14–9.89) and marginal mono-allelic effect for variants MUTYH (OR=1.16, 95% CI: 1.00–1.34) and Y179C alone (OR=1.34, 95% CI: 1.01–1.77).

Conclusions:

Overall, this large study refines estimates of disease risk associated with mono-allelic and bi-allelic MUTYH carriers.