The Helsinki Declaration 2020: Europe that protects

Human health and the health of Planet Earth go together

The emergence of the planetary health approach was highlighted by the report of The Rockefeller Foundation-Lancet Commission on Planetary Health in 2015 and changed how we comprehend human well-being. The report advocates integrating the health of other living beings and Earth's natural systems as intrinsic components of human health. Drawing on over three decades of experience in respiratory epidemiology and environmental health, this article outlines how my perspective on human health underwent a transformative shift upon reading the abovementioned report. The planetary health approach offers a lens through which human health issues and potential solutions can be understood within the context of the Anthropocene. It addresses the pressing existential challenges arising from humanity's transgression of planetary limits. Embracing the planetary health paradigm within the field of health sciences can catalyze transformative changes essential for cultivating a sustainable and equitable future.

A comparative ethical analysis of the Egyptian clinical research law

BACKGROUND

In this study, we examined the ethical implications of Egypt's new clinical trial law, employing the ethical framework proposed by Emanuel et al. and comparing it to various national and supranational laws. This analysis is crucial as Egypt, considered a high-growth pharmaceutical market, has become an attractive location for clinical trials, offering insights into the ethical implementation of bioethical regulations in a large population country with a robust healthcare infrastructure and predominantly treatment-naïve patients.

METHODS

We conducted a comparative analysis of Egyptian law with regulations from Sweden and France, including the EU Clinical Trials Regulation, considering ethical human subject research criteria, and used a directed approach to qualitative content analysis to examine the laws and regulations. This study involved extensive peer scrutiny, frequent debriefing sessions, and collaboration with legal experts with relevant international legal expertise to ensure rigorous analysis and interpretation of the laws.

RESULTS

On the rating of the seven different principles (social and scientific values, scientific validity, fair selection of participants, risk-benefit ratio, independent review, informed consent and respect for participants) Egypt, France, and EU regulations had comparable scores. Specific principles (Social Value, Scientific Value, and Fair selection of participants) were challenging to directly identify due to certain regulations embodying 'implicit' principles more than explicitly stated ones.

CONCLUSION

The analysis underscores Egypt's alignment with internationally recognized ethical principles, as outlined by Emanuel et al., through its comparison with French, Swedish, and EU regulations, emphasizing the critical need for Egypt to continuously refine its ethical regulations to safeguard participant protection and research integrity. Key issues identified include the necessity to clarify and standardize the concept of social value in research, alongside concerns regarding the expertise and impartiality of ethical review boards, pointing towards a broader agenda for enhancing research ethics in Egypt and beyond.

Construction and application of the core competence course training system for infectious disease specialist nurses

OBJECTIVES

This study aims to construct and apply a training course system which was scientific and comprehensive to foster the core competence of infectious disease specialist nurses.

DESIGN

A two-round Delphi consultation survey was carried out to collect feedback from experts on constructing the training course system of core competence for infectious disease specialist nurses. Besides, a non-randomized controlled experimental study was adopted to check the application effect of the courses.

METHODS

This study adopted a series of methods including group discussion, theoretical analysis and Delphi consultation to draft the training course content of core competence of infectious disease specialist nurses. Twenty-one Chinese experts were invited to participate in the Delphi consultation from November 2021 to December 2021. From October 2022 to January 2023, a total of 105 infectious disease specialist nurses from two training bases were selected by the convenience sampling method, of which the nurses in one training base were the control group and the nurses in the other training base were the observation group. The observation group was trained by the constructed core competence training course. Questionnaire evaluation was used to compare the core competence of infectious disease specialist nurses and the training effect.

RESULTS

The experts, regarded as the authorities on the subject, were highly motivated in this study. Besides, they reached a consensus on the results. The final training course system of core competence for infectious disease specialist nurses focused on 5 competence modules and was composed of 12 categories of courses with 66 classes and corresponding objectives. The core competence scores of the observation group were significantly higher than those in the control group after training (P < 0.05), which proved the training system can effectively enhance the core competence of infectious disease specialist nurses.

CONCLUSIONS

The research methods embodied scientific and precise properties. The course system was comprehensive in content and reliable in results. It could serve as a reference for training infectious disease specialist nurses.

Single cell RNA-seq identifies a FOS/JUN-related monocyte signature associated with clinical response of heart failure patients with mesenchymal stem cell therapy

Heart failure (HF) is a serious global health issue that demands innovative treatment approaches. In this study, we collected samples from 4 HF patients before and after MSC therapy and performed scRNA-seq. After the MSC therapy, the proportion of CD14+ monocytes decreased significantly in both the treatment response and non-response groups, with a more pronounced decrease in the treatment response group. The therapy-response and non-response group were clearly separated in the UMAP plot, while the CD14+ monocytes in the therapy-response group before and after MSC therapy were very similar, but there were significant differences in the non-response group. By further performing NMF analysis, we identified 11 subsets of CD14+ monocytes. More importantly, we identified a therapy-related CD14+ monocyte subpopulation. The predictive model based on CD14+ monocytes constructed by machine learning algorithms showed good performance. Moreover, genes such as FOS were highly enriched in the therapy-related CD14+ monocytes. The SCENIC analysis revealed potential regulatory factors for this treatment-responsive CD14+ monocytes, and FOS/JUN were identified as potential core indicators/regulators. Finally, HF patients were divided into three groups by NMF analysis, and the therapy-responsive CD14+ monocyte characteristics were differentially activated among the three groups. Together, this study identifies treatment-responsive CD14+ monocytes as a crucial biomarker for assessing the suitability of MSC therapy and determining which HF patients could benefit from it. This provides new clues for further investigating the therapeutic mechanisms of MSC therapy, offering beneficial insights for personalized treatment and improving prognosis in HF patients.

Green Roof Gardens - Selecting Allergy-Friendly Vegetation: A Global Allergy and Asthma Excellence Network (GA²LEN) Position Paper

Green roof gardens are important for planetary health by mitigating the effects of urbanization. Because of the nature of green roof gardens, only particular plants can be used. The allergologic impact of these plants remains ill-characterized and guidance on building allergy-friendly green roof gardens is missing. To address this gap, we investigated the plant spectrum of several German green roof companies and categorized plants based on their primary pollination mechanism. Except for grasses, most plants were insect-pollinated and of low allergenicity. In addition, we conducted a review on the allergologic impact of plants used for green roof gardens. Our aim was to provide landscape architects with guidance on how to develop allergy-friendly green roof gardens. We highlight the need for universally accepted standards for assessing the allergenicity of roof top plants. Also, we recommend the joint development, by green roof producers and allergists, of criteria for allergy-friendly roof gardens. Their implementation may help to reduce the risk of allergen sensitization and allergy exacerbation, such as by avoiding the use of wind-pollinated plants of proven allergenicity including grasses. Green infrastructure, such as green roofs, should benefit planetary health without increasing the prevalence and burden of allergies.

From biodiversity to nature deficiency in human health and disease

Nature (biodiversity) loss is the loss or decline of the state of nature taking place in the wider environment. We present a novel concept, nature deficiency, referring to nature loss in the human body influencing health. Humans are connected with the natural environment and its microbes and biogenic chemicals through eating (drinking), breathing, and touching. The mental and sociocultural links to the environment are also strong. With medical and ecological research and guidelines, the diagnosis, prevention, and treatment of nature deficiency may become part of the clinical practice. Nature prescription is likely to find plausible forms in patient care and inspire preventive actions at the society level. Health professionals are in a key position to integrate public health promotion and environmental care.

Holistic Nursing and Quran Recitation and its Impact on Floods Survivors in Indonesia

Purpose: The purpose of the study was aimed to explore the trajectory of thoughts and feelings related to religiosity and spirituality using a holistic approach following attendance at group-Quran Recitation (QR) sessions among annual flood victims. Design: This is a qualitative study with an in-depth retrospective interview conducted data in 2019. Methods: The purposive sampling was applied to conduct face-to-face individual video-recorded semistructured interviews. Seventeen participants followed six QR chanting sessions in Bandung, Indonesia. Data were transcribed verbatim and analyzed using inductive analysis. Findings: After extracting evidence expressions of participants, the research team generated the central theme of "Holism of Religiosity and Spirituality," using three influential sub-themes, including obedience to God's will, growing a positive mindset through spirituality and life started to be delighting from nine categories. Conclusion: The relationship of body-mind concepts of holism through QR among flood sufferers was explored. The effect of QR chanting is beneficial to change awareness about the wisdom of spirituality. The holistic approach of religiosity and spirituality in nursing care is recommended to promote all service settings, especially community and disaster nursing in the Indonesian context. Future research is needed to develop QR chanting activities among multiethnic and socio-cultural groups as alternative therapy quantitatively.

The effects of a structured communication tool in patients with medically unexplained physical symptoms: a cluster randomized trial

Background

Medically Unexplained Physical Symptoms (MUPS) are prevalent among primary care patients and frequently lead to diminished quality of life, increased healthcare costs, and decreased work participation. We aimed to examine the effects of a work-focused structured communication tool based on cognitive-behavioral therapy in patients with MUPS.

Methods

In a Norwegian two-arm cluster randomized trial, the effectiveness of the structured communication tool Individual Challenge Inventory Tool (ICIT) was compared to usual care for patients with MUPS using a two-arm cluster randomized design. Enrollment period was between March 7 and April 1, 2022. Ten groups (clusters) of 103 General Practitioners (GPs) were randomized to provide the ICIT or usual care for 11 weeks. Patients received two or more sessions with their GP, and outcomes were assessed individually. Primary outcome was patient-reported change in function, symptoms, and quality of life measured by the Patient Global Impression of Change (PGIC). Secondary outcomes included sick leave, work-related self-efficacy (RTW-SE), health-related quality of life (RAND-36), and patient experiences with consultants (PEQ). The trial was registered on ClinicalTrials.gov (NCT05128019).

Findings

A total of 541 patients with MUPS were enrolled in the study. In the intervention group 76% (n = 223) showed a significant overall improvement in function, symptoms, and quality of life as measured by the PGIC, compared to 38% (n = 236) in the usual care group (mean difference -0.8 ([95% CI -1.0 to -0.6]; p < 0.0001). At 11 weeks, the intervention group had a 27-percentage point decrease in sick leave (from 52.0 to 25.2), compared to 4-percentage point decrease (from 49.7 to 45.7) in the usual care group. Furthermore, compared to usual care, the intervention group reported significant improvements in work-related self-efficacy, health-related quality of life, and greater satisfaction with the communication during the consultations. No adverse events were reported.

Interpretation

The implementation of the structured communication tool ICIT in primary care significantly improved patient outcomes and reduced sick leave among patients with MUPS.

Funding

The study was funded by The Norwegian Research Fund for General Practice.

A short history from Karelia study to biodiversity and public health interventions

Contact with natural environments enriches the human microbiome, promotes immune balance and protects against allergies and inflammatory disorders. In Finland, the allergy &amp; asthma epidemic became slowly visible in mid 1960s. After the World War II, Karelia was split into Finnish and Soviet Union (now Russia) territories. This led to more marked environmental and lifestyle changes in the Finnish compared with Russian Karelia. The Karelia Allergy Study 2002–2022 showed that allergic conditions were much more common on the Finnish side. The Russians had richer gene-microbe network and interaction than the Finns, which associated with better balanced immune regulatory circuits and lower allergy prevalence. In the Finnish adolescents, a biodiverse natural environment around the homes associated with lower occurrence of allergies. Overall, the plausible explanation of the allergy disparity was the prominent change in environment and lifestyle in the Finnish Karelia from 1940s to 1980s. The nationwide Finnish Allergy Programme 2008–2018 implemented the biodiversity hypothesis into practice by endorsing immune tolerance, nature contacts, and allergy health with favorable results. A regional health and environment programme, Nature Step to Health 2022–2032, has been initiated in the City of Lahti, EU Green Capital 2021. The programme integrates prevention of chronic diseases (asthma, diabetes, obesity, depression), nature loss, and climate crisis in the spirit of Planetary Health. Allergic diseases exemplify inappropriate immunological responses to natural environment. Successful management of the epidemics of allergy and other non-communicable diseases may pave the way to improve human and environmental health.

Latent profile analysis of security among patients with COVID-19 infection in mobile cabin hospitals and its relationship with psychological capital

Aim

COVID-19 patients' security is related to their mental health. However, the classification of this group's sense of security is still unclear. The aim of our research is to clarify the subtypes of security of patients infected with COVID-19, explore the factors affecting profile membership, and examine the relationship between security and psychological capital for the purpose of providing a reference for improving patients' sense of security and mental health.

Methods

A total of 650 COVID-19 patients in a mobile cabin hospital were selected for a cross-sectional survey from April to May 2022. They completed online self-report questionnaires that included a demographic questionnaire, security scale, and psychological capital scale. Data analysis included latent profile analysis, variance analysis, the Chi-square test, multiple comparisons, multivariate logistical regression, and hierarchical regression analysis.

Results

Three latent profiles were identified-low security (Class 1), moderate security (Class 2), and high security (Class 3)-accounting for 12.00, 49.51, and 38.49% of the total surveyed patients, respectively. In terms of the score of security and its two dimensions, Class 3 was higher than Class 2, and Class 2 was higher than Class 1 (all P < 0.001). Patients with difficulty falling asleep, sleep quality as usual, and lower tenacity were more likely to be grouped into Class 1 rather than Class 3; Patients from families with a per capita monthly household income <3,000 and lower self-efficacy and hope were more likely to be grouped into Classes 1 and 2 than into Class 3. Psychological capital was an important predictor of security, which could independently explain 18.70% of the variation in the patients' security.

Conclusions

Security has different classification features among patients with COVID-19 infection in mobile cabin hospitals. The security of over half of the patients surveyed is at the lower or middle level, and psychological capital is an important predictor of the patients' security. Medical staff should actively pay attention to patients with low security and help them to improve their security level and psychological capital.

Biodiversity for resilience-What is needed for allergic children

What is needed for our children facing unprecedented challenges of modern time? Biodiversity, both for immunological and psychological well-being and resilience. That is also the keyword for the children with allergies and asthma. The cultural evolution with advanced technology and medicine along with major move to urban environment has profoundly changed our lifestyle and surroundings. We are increasingly disconnected from our evolutionary home, soil, natural waters, and air we used to breathe. The ecosystem of human body and mind has been tested, survived, and evolved closely in relation with other ecosystems. For balance and tolerance, immune regulatory circuits need training by microbes, biogenic chemicals, and close relation to natural environment throughout life. This is addressed by the biodiversity hypothesis of tolerance/resilience for health, supported by the pioneering real-world interventions and a few controlled studies. No need to go "back to nature," but we must take natural elements back to our everyday life to breathe, eat, drink, and touch. The change for better is plausible and cost-effective, as shown by the Finnish and other European initiatives, but needs contribution of the whole society.

Short-term outcomes of Oxford unicompartmental knee arthroplasty with coronal subluxation of the knee: a retrospective case–control study

Background

The goal of this study was to assess short-term outcomes in single compartment osteoarthritis patients associated with the coronal tibiofemoral subluxation (CTFS) of the knee joint after Oxford unicompartmental knee arthroplasty (OUKA), and to establish the potential impact of the degree of CTFS on operative outcomes.

Methods

Data pertaining to 183 patients with medial compartment osteoarthritis that underwent OUKA treatment between February 2016 and June 2019 were retrospectively analyzed. The presence and degree of severity of CTFS were assessed using preoperative weight-bearing anteroposterior X-ray images of the knee. Patients were stratified into three subgroups based upon the observed degree of subluxation: a normal group, a mild subluxation group (CTFS < 0.5 cm), and a severe subluxation group (CTFS ≥ 0.5 cm). Anterior and posterior X-ray examination of the knee was conducted at the time of most recent follow-up for each patient to assess the degree of CTFS correction following OUKA. Clinical function was assessed using Oxford knee score (OKS) and Hospital for Special Surgery score (HSS) values, while pain was rated using visual-analog scale (VAS) scores. The mechanical femoral tibial angle (mFTA), range of motion (ROM), and complication rates in these three groups were additionally compared.

Results

The average follow-up duration for patients in this study was 24.1 months (range: 17–32 months). There were no significant differences in patient age, sex, body mass index (BMI), follow-up duration, mFTA, ROM, OKS, HSS, or VAS scores among these three groups (P > 0.05). After surgery, OKS and HSS scores declined significantly, but no differences in these scores were observed among groups (P > 0.05). Of these patients, 135 (73.8%) were satisfied with the operation, of whom 80 (43.7%) were very satisfied. There were no significant differences in ROM or VAS scores among groups (P > 0.05). The degree of CTFS for patients in the mild and severe subluxation groups was significantly improved following OUKA relative to preoperative values such that the degree of postoperative CTFS did not differ significantly among these groups (P > 0.05). Postoperative mFTA was also significantly improved in these three patient subgroups (P < 0.05). No patients experienced operative complications over the follow-up period.

Conclusions

OUKA can successfully improve clinical symptoms in patients with single compartmental osteoarthritis. Moreover, OUKA can effectively correct CTFS of the knee in these patients, and the degree of preoperative CTFS has no impact on surgical efficacy.

Level of evidence

III.

Getting out of crises: Environmental, social-ecological and evolutionary research is needed to avoid future risks of pandemics

The implementation of One Health/EcoHealth/Planetary Health approaches has been identified as key (i) to address the strong interconnections between risk for pandemics, climate change and biodiversity loss and (ii) to develop and implement solutions to these interlinked crises. As a response to the multiple calls from scientists on that subject, we have here proposed seven long-term research questions regarding COVID-19 and emerging infectious diseases (EIDs) that are based on effective integration of environmental, ecological, evolutionary, and social sciences to better anticipate and mitigate EIDs. Research needs cover the social ecology of infectious disease agents, their evolution, the determinants of susceptibility of humans and animals to infections, and the human and ecological factors accelerating infectious disease emergence. For comprehensive investigation, they include the development of nature-based solutions to interlinked global planetary crises, addressing ethical and philosophical questions regarding the relationship of humans to nature and regarding transformative changes to safeguard the environment and human health. In support of this research, we propose the implementation of innovative multidisciplinary facilities embedded in social ecosystems locally: ecological health observatories and living laboratories. This work was carried out in the frame of the European Community project HERA (www.HERAresearchEU.eu), which aims to set priorities for an environment, climate and health research agenda in the European Union by adopting a systemic approach in the face of global environmental change.

Air pollution and COVID-19: clearing the air and charting a post-pandemic course: a joint workshop report of ERS, ISEE, HEI and WHO

Air pollution is now recognised by governments, international institutions and civil society as a major global public health risk factor. The health burden of air pollution is large: 509 000 premature deaths every year in Europe [1] and serious aggravations of heart and lung diseases that affect millions of patients, both children and adults. The European Environmental Agency estimated that in 2018 there were 417 000 premature deaths attributable to particulate matter with diameter <2.5 µm (PM2.5), 55 000 to NO2, and 20 600 to O3 in Europe (table 10.1 in EEA Report 9/2020 [2]). In addition, 4 805 800 years of life lost could be attributed to PM2.5, 623 600 to NO2, and 246 700 to O3 (table 10.2 in [2]). This “silent killer” is one the most important determinants of health, surpassed only by high blood pressure, tobacco use and poor diet. The coronavirus disease 2019 (COVID-19) pandemic has raised concerns about whether air pollution can increase the severity of disease and risk of death after infection, as well as facilitate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Chronic lung disease patients are in the epicentre of the current crisis, as they are more vulnerable to both the adverse effects of a SARS-CoV-2 infection and air pollution exposure, as well as their possible interactions. At the same time, the lockdown measures to control the spread of COVID-19 brought historical short-term reductions in air pollution levels around the globe, and increasing general public interest and demand for clean air policies [3]. The COVID-19 pandemic, an emerging infectious disease probably caused by a spill over from animals, and its possible interactions with air pollution, is an existential reminder that we are a part of a larger ecosystem, and that human health is closely connected with the health of our environment and planet. Here we provide a short summary on the potential role of air pollution in the spread and worsening of health impacts of COVID-19, and on the influence of the pandemic on air pollution levels in Europe. Moreover, we outline the major lessons learned to chart a healthy post-pandemic course. This work summarises the key messages from a workshop that took place on 2 December, 2020, organised by the European Respiratory Society (ERS), the International Society for Environmental Epidemiology (ISEE) and the Health Effects Institute (HEI), endorsed by the World Health Organization (WHO), and hosted by the European Parliament Lung Health Group and the European Commission (table 1).

The potential role of air pollution in the worsening of health impacts of COVID-19, and the influence of the pandemic on air pollution levels in Europe is explored. This editorial outlines the major lessons learned to chart a healthy post-pandemic course. https://bit.ly/3hmbaya

The Finnish Allergy Program 2008-2018: Society-wide proactive program for change of management to mitigate allergy burden

A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education.