European Countries Research Articles

European guidelines recommend transcatheter aortic valve implantation (TAVI; class IA) for symptomatic severe aortic stenosis (sSAS) in patients aged ≥75 years, if a transfemoral approach is possible. Recent cost-utility analyses based on the PARTNER 3 trial have suggested that TAVI with the SAPIEN 3 device is cost effective versus surgical aortic valve replacement (SAVR) in patients at low risk of surgical mortality in several European countries. This cost-utility analysis compares TAVI with SAPIEN 3 versus SAVR in patients with sSAS at low risk of surgical mortality from the UK healthcare system perspective, using 5-year PARTNER 3 trial data. A two-stage, Markov-based, cost-utility analysis was performed using published and validated methodology to estimate changes in both direct healthcare costs and health-related quality of life for TAVI with SAPIEN 3 versus SAVR in patients with sSAS at low surgical risk from the perspective of the UK healthcare system. The model used a lifetime horizon with a 3.5% yearly discounting factor. Uncertainty was addressed using deterministic and probabilistic sensitivity analyses. Transcatheter aortic valve implantation with SAPIEN 3 generated an incremental health benefit of 0.47 (90% credible interval 0.35-0.60) quality-adjusted life-years per patient compared with SAVR, at an increased cost of £7999 (£852-£15,035 90% credible interval) per patient over a lifetime horizon (incremental cost-effectiveness ratio: £16,979 per quality-adjusted life-year gained). Transcatheter aortic valve implantation has a 63-90% probability of cost effectiveness based on a £20,000-£30,000 willingness-to-pay threshold. Transcatheter aortic valve implantation remained cost effective across most deterministic sensitivity analyses, confirming the relative robustness of the results. Transcatheter aortic valve implantation with SAPIEN 3 has a 63-90% probability of being cost effective compared with SAVR for low-surgical-risk patients with sSAS. These findings may inform policy decision making in the management of this patient group.

The spread of the COVID-19 pandemic, along with government interventions, significantly reshaped economic activity, leading to abrupt shifts in household consumption behavior. This paper offers an empirical analysis of how the rollout of COVID-19 vaccines influenced consumer spending, using high-frequency debit and credit card transaction data from three European countries. The findings indicate that vaccinations, in conjunction with other policy measures, helped mitigate the pandemic's severe economic impact and supported a recovery in consumer spending. First, the deployment of vaccines had a statistically and economically significant positive effect on private consumption. Second, additional policy responses-aimed at containing the virus and providing financial support to households and businesses-also had notable effects on both the volume and composition of card-based transactions. Third, the stimulative impact of vaccinations on consumer spending was more pronounced in contact-intensive sectors, such as services, compared to goods.

Epidemiological and microbiological characteristics of endogenous endophthalmitis (EE) can vary by population and geographical area, with different risk factors. This study from a tertiary care centre aimed to provide additional data from one European country in the field of EE. This retrospective study was conducted on patients diagnosed with EE at the University Hospital of Grenoble-Alpes, France, between 2014 and 2023. General and ocular clinical data, along with microbiological findings, were collected at baseline and on follow-up. Thirty-three patients were diagnosed with EE in this study with a mean age of 70 ± 17.7 years, and 51.5% were male. Most cases were unilateral. Common health conditions included cancer, and diabetes mellitus, with endocarditis being the leading source of infection. Baseline visual acuity ranged from 20/20 to no light perception. Blood cultures were positive in 87.8% of the cases. Gram-positive bacteria, especially Staphylococcus aureus, were the most common pathogens, followed by Candida albicans. Pars plana vitrectomy was performed in 33% of the patients. At the end of the follow-up, four patients had lost vision, two developed phthisis, and mortality was reported in 24% of the patients. This study on endogenous endophthalmitis highlights that, in Europe, the primary risk factors are cancer and diabetes, with endocarditis being the most common source of infection. According to our findings, Gram-positive bacteria, particularly Streptococcus species and Staphylococcus aureus, are the most frequently identified pathogens in Europe. These findings differ significantly from reports originating from the USA and Asia.

While the Eosinophilic Esophagitis (EoE) has become the second most common disease entity causing esophageal dysfunction, there is currently a lack of data reporting on pediatric EoE from Germany. This monocentric longitudinal study seeks to fill this gap by investigating treatment success, atopic comorbidities and potential blood parameters in a real-world setting. This study analyzed data on children with EoE (n=50), gastroesophageal reflux disease (GERD, n=13) and controls (n=5). Evaluated characteristics included clinical manifestations, atopy and treatment success during disease progress. We defined the primary endpoint as histological remission in all esophageal locations (proximal, mid, distal). Secondary endpoints were histological-clinical, histological-endoscopic and histological-clinical-endoscopic remission. Of 50 patients (0.5-16.9 years), 26% (n=13) responded to proton-pump-inhibitors (PPI-R) and 74% (n=37) needed other forms of treatment (PPI-NR). Atopic comorbidities were observed in 46% (PPI-NR) and 23% (PPI-R). Primary PPI treatment resulted in histological remission in 13 patients (median: 2 [2;4.5] months), only one (8%) achieved complete endoscopic-clinical-histological remission. 32 PPI-NR (84%) reached histological remission after a median of 7 [4;11] months, but only eleven (34%) acquired complete histological-clinical-endoscopic remission. Absolute blood eosinophil count (AEC) was increased within active EoE (420 [250;550] cells/µL). It distinguished EoE from controls (cut-off 90 cells/µL, sensitivity/specificity: 95.7%/80%) and from GERD (180 cells/µL, 87.5%/66.7%). Eosinophilic cationic protein (ECP) differed between children with active EoE and controls (10 µg/L, 86.7%/100%). Patients' characteristics are comparable to those from other European countries. AEC and ECP were increased in EoE patients. Achieving complete remission required an intensified therapy regime.

Abstract Introduction The COVID-19 pandemic disrupted oncological services globally, with elective surgeries postponed or limited across many healthcare systems. For hormone receptor-positive (HR+) breast cancer defined by estrogen receptor (ER) and/or progesterone receptor (PR) expression, neoadjuvant endocrine therapy (NET) emerged as a strategy to delay surgery and reduce hospital exposure. While NET has traditionally been reserved for metastatic or high-stage disease in countries like the UK, other European and non-European settings adapted treatment protocols differently. Aim To evaluate endocrine therapy adaptations, specifically NET, for HR+ breast cancer patients during the COVID-19 pandemic, and to assess the changes in treatment, delays, and outcomes within the European region and non-European region countries. Methodology A systematic literature review was conducted using PRISMA 2020 guidelines. PubMed and CINAHL were searched from March 2020 to August 2024, yielding 130 records; 13 studies were included after screening and eligibility assessment. All 13 articles were non-randomised and assessed using Risk of Bias in Non-randomised Studies - of Exposure (ROBINS-E). As this study is a systematic review of previously published research, ethical approval was not required. Results In European region countries, endocrine therapy was implemented proactively to mitigate surgical delays. For instance, van Dam et al. reported that 23% of EUSOMA-certified centres (Belgium, Italy, Spain, Portugal) modified NET protocols in response to COVID-19 [1]. Similarly, Eijkelboom et al. (2023) in the Netherlands observed increased NET uptake across stages I–III [2], supporting tumour downsizing to enable later surgery. Ribeiro et al. (2024) showed a significant increase in NET initiation (16% vs. 6%, p = 0.021) [3]. These adaptations helped maintain treatment quality, defined as minimising tumour progression, upstaging, and maintaining alignment with multidisciplinary care plans. In the UK, NET adoption remained limited, reflecting pre-pandemic practice norms, though a temporary rise in aromatase inhibitor prescriptions was observed in early-stage cases. Out of the 13 included studies, 12 were assessed as having some concerns regarding risk of bias, and only 1 was at high risk of bias. In contrast, non-European region countries also increased NET use but often on a case-by-case basis. Habbous et al. (2022) found a 3.17-fold increased likelihood of NET use as a surgical bridge [4], while Hawrot et al. (2021) reported NET initiation rose from 4.0% (2018) to 23.2% (2020) [5]. However, inconsistent implementation and interruptions in planned transitions from NET to surgery were more frequently noted outside Europe. Discussion This review shows that hormonal therapy played a critical role in pandemic era care continuity for HR+ breast cancer, particularly in stage II and III cases where tumour downstaging improved surgical planning. European responses were generally coordinated at the system level, while non-European adaptations were often reactive and individualised. Treatment quality in terms of efficacy, continuity, and maintenance of intended outcomes was largely preserved in both regions. Limitations include heterogeneity in HR definitions and lack of long-term outcome data. These findings highlight the resilience of hormonal strategies during healthcare crises and support their role in future contingency planning.

This study aims to provide an overview of evidence on factors affecting Mediterranean Diet (MD) adherence across socio-ecological levels (individual, interpersonal, and environmental) in Mediterranean countries, which can be target points for future interventions to promote MD adherence. A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines and registered in the Prospero database (CRD42020189337). Literature was searched in PubMed, Web of Science and PsycINFO. The MD is one of the healthiest dietary patterns, reducing risk of chronic disease while promoting better health outcomes. However, adherence to the MD remains challenging, even in Mediterranean countries. Healthy adults aged 18 years and older, living in a Mediterranean country. A total of 37 cross-sectional studies were included, with 190 to 13,262 participants. Most studies (30/37) were conducted in European Mediterranean countries, primarily Italy (n=14), Spain (n=9) and Greece (n=6). All studies involved community-based samples; two studies included only women. Individual-level determinants were the most frequently examined. Higher socioeconomic status (SES), regular breakfast consumption, being unemployed, a job seeker, or retired were linked to better MD adherence. Socio-cognitive and interpersonal factors were underexplored. At the environmental level, COVID-19 confinement boosted adherence, whereas the effects of economic crises were inconsistent. Effect sizes were mostly very small to small, and findings are based on low-quality studies. This systematic review highlighted several socio-economic and environmental factors potentially influencing MD adherence. However, more robust research is needed to better understand socio-cognitive and ecological factors.

The COVID-19 pandemic and various consequent isolation, quarantine and curfew measures to curb the spread of the virus caused an increase in anxiety, depression, and loneliness among university students. The aim of this study was to assess the association between psychological distress and loneliness among university students in Europe during the COVID-19 pandemic. This cross-sectional study was part of the COVIDiSTRESS global survey conducted during the first wave of COVID-19 pandemic in 2020. We evaluated for psychological stress and loneliness among university students in Europe (n = 11 231) using the Perceived Stress Scale (PSS-10) and the Loneliness Scale (SLON-3). The associations between the students' psychological stress levels, loneliness, and perceived helplessness were analysed using chi-square test, ANOVA, t-test, and regression models. In total, 9737 university students (69.9% female) between 18 and 34 years (mean: 25.3 years from 13 European countries were included in the analyses. Most (89.6%) of the university students experienced moderate stress levels, with women reporting significantly more stress than men (p < 0.001). Differences in stress levels were also associated with geographic region, marital status, and age. Higher levels of psychological stress were associated with the students' loneliness levels; loneliness accounted for 12.9% of the variance in stress. Perceived helplessness was associated with loneliness and gender and country of residence. Majority of the university students in Europe experienced increased level of stress and loneliness during the first wave of COVID-19. Perceived helplessness was significantly associated with stress and correlated with gender, various loneliness factors and country of origin.

ABSTRACT Governments of all European countries vie for international sporting success, with elite athletes typically participating in national elite sport programmes coordinated by both public and private entities. Recent research sheds light on the precarious social conditions that many elite athletes endure, marked by low income and social protection gaps. This article examines athlete welfare within the context of social policy by assessing athletes’ access to income opportunities and social protection coverage. The case-oriented comparative study explores the legal frameworks and policies for athlete welfare in six European countries and inductively establishes five ideal-type governance models of athlete welfare. The classification of cases according to the models reflects the interplay between a country’s welfare regime and its national sport policy system in this specific policy subfield. The findings highlight common effects of the different models on athletes’ social conditions and livelihoods and emphasise employment status as a crucial factor for their welfare.

Background: Breast cancer remains the most diagnosed cancer in European countries, with diverse screening modalities requiring economic evaluation for optimal resource allocation. This systematic review evaluated the cost-effectiveness of breast cancer screening strategies across European healthcare contexts. Methods: We conducted a comprehensive search across PubMed, ScienceDirect, Cochrane Library, Scopus, and Google Scholar following PRISMA guidelines (1990–2024). Studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Economic standardization employed healthcare-specific inflation indices and purchasing power parity adjustments, with costs converted to 2020 EUR. Results: From 1449 studies, 23 met inclusion criteria, with significant geographic imbalance (74% from North-Western/Central Europe, 4% from South-Eastern Europe). Mammography screening for women aged 50–69 years demonstrated consistent cost-effectiveness (EUR 3000–8000 per quality-adjusted life year (QALY)) with high confidence. For women under 50, screening showed substantially higher costs (EUR 105,000 per year of life saved). Magnetic resonance imaging (MRI) screening showed cost-effectiveness for high-risk populations (EUR 18,201–33,534 per QALY) with moderate confidence. Conclusions: Biennial mammography screening for women aged 50–69 demonstrates consistent cost-effectiveness across European contexts. Findings have highest applicability to North-Western and Central European healthcare systems, with limited generalizability to Southern and Eastern Europe due to evidence gaps.

The article examines the relationship between excessive alcohol consumption, social context and perceived cultural norms in three European countries from the perspective of young adults. This generation is the first to come of age in a globalized world, frequently discussed in terms of diminishing national and regional differences. Several scholars have argued that these transformations have contributed to an increasing homogenization of European drinking cultures. The article seeks to analyse how young adults from different sociocultural backgrounds define and interpret excessive drinking, emphasizing both similarities and divergences in drinking practices. In doing so, it demonstrates how such practices are embedded in broader historical developments and contemporary cultural attitudes. Drawing on 24 focus group interviews conducted with young adults in Denmark, Estonia and Italy, the analysis is structured along three dimensions: the perceived (un)acceptability of excessive alcohol use, processes of ‘othering’ in explaining excessive drinking and gender-specific drinking norms.

Trends in physical fitness among children and adolescents in Europe: A systematic review and meta-analyses during and after the COVID-19 pandemic.

Ecosystem service valuation (ESV) provides a scientific basis for balancing ecological conservation and socioeconomic development. With the rapid progress of Earth observation technologies, remote sensing has become an essential tool for quantifying and mapping ecosystem services at multiple spatial and temporal scales. However, a comprehensive understanding of the global research landscape on ecosystem service valuation using remote sensing remains limited. In this study, this study conducted a bibliometric analysis of publications retrieved from the Web of Science Core Collection between 1990 and 2024. A total of 1172 articles were identified through a systematic search strategy integrating ecosystem service valuation and remote sensing keywords. The analysis employed performance indicators (e.g., publication output, citation trends, and core journals), collaboration networks (countries, institutions, and authors), and keyword co-occurrence to reveal research hotspots and emerging frontiers. The results show a steady growth of publications, with a significant surge after 2010 driven by the application of MODIS, Landsat, and Google Earth Engine in large-scale ESV studies. China, the United States, and several European countries play dominant roles in terms of both output and international collaboration. Research hotspots have shifted from conceptual frameworks and regional case studies to methodological innovations, such as spatial modeling, integration of remote sensing with ecosystem accounting frameworks, and applications in ecological security and sustainable development. This study highlights the increasing importance of remote sensing in advancing ecosystem service valuation and provides insights into future directions, including high-resolution monitoring, machine learning integration, and policy-oriented assessments.

Purpose This study examines the generation of fintech technology and market activities across European regions, drawing on the evolutionary economic geography literature. It aims to assess the role of path dependence and knowledge recombination in fostering regional development and fintech opportunities. Design/methodology/approach We compile a novel dataset approximating fintech-related technological and market activities, covering 21 European countries and 258 NUTS-2 regions over the period 1996–2020. Using these data, we analyze the relationships between related technologies and fintech development. Findings Consistent with prior literature, we find that related technologies promote the development of fintech technologies. In addition, the study reveals that regions with high intensity in fintech technologies are more likely to exhibit strong fintech market activities. Originality/value This research provides novel empirical evidence linking fintech technological intensity with fintech market activity across European regions, thereby advancing understanding of the regional drivers of fintech development and informing innovation policy. Further, it supports smart specialization strategies, highlighting the importance of leveraging existing endowments for generating fintech comparative advantages. Finally, it underscores the need for policy interventions that build on existing technological advantages in the regions to support the sustainable development of the fintech sectors through investment and cross-regional cooperation.

Introduction Climate governance is increasingly contested, with public acceptance of renewable energy projects such as wind farms often facing resistance. This study explores how different trust-building strategies, including science communication, co-creation, benefit sharing, and social media, affect public perceptions of wind energy across diverse socio-demographic groups in four European countries (Austria, Cyprus, Greece, and Spain). Methods Drawing on an experimental vignette-based survey developed within the EU-funded VERITY project, we assess the impact of these strategies on two contrasting demographic groups: Group 1 (young, urban, university-educated) and Group 2 (older, rural, without a university degree). Results Our findings reveal significant variations in trust and engagement, with Group 1 generally exhibiting more positive attitudes toward wind energy (mean score: 0.49), while Group 2 was neutral or slightly negative (−0.01). Benefit sharing emerged as the most universally effective strategy, improving perceptions across all groups, particularly among sceptical male respondents. Science communication was most effective among women, especially in Group 1, while social media showed minimal or negative impact. Discussion The study highlights the importance of tailoring trust-building strategies to different demographic contexts, emphasizing that a one-size-fits-all approach is inadequate for inclusive climate governance. These findings offer actionable insights for policymakers seeking to enhance public trust in renewable energy transitions, aligning local engagement strategies with broader climate diplomacy.

The genus Roeslerstammia Zeller, 1839, the type genus of the family Roeslerstammiidae, comprises a total of four species on a global scale. The type species, Roeslerstammia erxlebella (Fabricius, 1787) is distributed across the Palaearctic Region, from Europe to Japan. However, the presence of this species has only been confirmed in European countries, Russia and Japan. The present study reports the first record of Roeslerstammia erxlebella in Korea, specifically from Odae-san National Park. This paper constitutes a review of the taxonomic history of the family Roeslerstammiidae and the genus Roeslerstammia . A thorough taxonomic account of the recently documented species, R. erxlebella , is presented, accompanied by a taxonomic key and an illustrated map delineating the geographical distribution of the genus Roeslerstammia . Furthemore, the DNA Barcode data of a Korean individual was made available, alongside public data from BOLD systems. The DNA Barcoding analysis further indicates that the Korean individual is R. erxlebella .

Respiratory diseases are globally a major challenge in today's pig production. Despite the efforts to manage the disease, the number of pigs affected is still increasing, indicating gaps in the current knowledge. In 2016, a novel pneumovirus, swine orthopneumovirus, was detected in the USA. Since then, the virus has been detected in a few European countries and in South Korea. However, the wider distribution of the virus is still greatly unknown, as well as its clinical relevance. This report describes the first detection of swine orthopneumovirus in a Swedish pig herd. The virus was detected as the result of an investigation conducted between September 2023 to June 2024, where all clinical samples (n = 682) sent to the Swedish Veterinary Agency for diagnostic purposes from 112 Swedish pig farms exhibiting clinical signs of respiratory disease were screened for the presence of swine orthopneumovirus. The virus was detected in one piglet producing farm that had a respiratory disease outbreak in autumn 2023, which presented with cough and nasal discharge. In November 2023, 11 nasal swabs were collected, of which 9 were PCR-positive for swine orthopneumovirus. In addition, each sample was also PCR-positive for Mesomycoplasma hyorhinis and Pasteurella multocida, and 2 samples were PCR-positive for Actinobacillus pleuropneumoniae, indicating a polymicrobial respiratory infection. This report emphasises the importance of ongoing efforts to identify emerging pathogens and determine their clinical significance. Therefore, further research is needed to assess the distribution and potential clinical relevance of swine orthopneumovirus.

Lichen - mite interactions have generally been acknowledged for a long time and yet, despite their ubiquity they are rarely studied in detail. Oribatid mites occur on and in various lichens and prior research has shown that mites use them as shelter and food source. To gain deeper insights into specific mite-lichen relationships, we investigated the oribatid mite fauna of three lichens from the genus Cladonia, C. coniocraea, C. norvegica and C. rubrotincta, from four European countries. In total, we found 61 oribatid mite species in all samples, from which 28 are common in all investigated lichen species. Most abundant were Carabodes areolatus, C. labyrinthicus, C. marginatus, C. subarcticus, Melanozetes mollicomus and Neobrachychthonius marginatus magnus. The species richness and the overall abundance of the oribatid mite fauna were similar between the investigated lichens and independent of geographic origin. The lichen Cladonia rubrotincta is characterized by red spots on its vegetative structures, and these spots have been suggested to be the result of mite feeding activity. Our investigations of these red spots revealed signs of endophagous mite activity in approx. 75% of the cases; immature mite stages were found tunneling, feeding and living inside the lichens. Molecular genetic identification of these juveniles showed that Carabodes areolatus, C. labyrinthicus, C. marginatus and Mycobates carli use Cladonia rubrotincta as kindergarten. Additionally, we characterize the morphology of Carabodes ssp. and Mycobates carli juveniles in detail and show their adaptations to an endophagous lifestyle, e.g. stocky body, short legs, reduced trichobothria and a subterminally positioned anal orifice. We conclude that lichen-mite interactions are versatile and diverse. Adult mites lay their eggs on the lichen, hatched juveniles complete their development inside the lichen and after their final molt, adults leave the lichen. Based on our results, we suggest that Cladonia rubrotincta reacts with color changes to the feeding activity of immature mites. Mite feeding on lichens is generally common, although it remains to be tested whether all life stages can trigger phenotypic responses in their lichen food sources.

Although various studies have been conducted on satisfaction with healthcare service, few have explored universal factors that work in multiple countries. Therefore, this study focused on resident satisfaction with public health service and affecting factors in the UK, Germany, France, Sweden, and Norway. Considering significant heterogeneity among influencing factors, we constructed a stepwise multiple logistic regression model to investigate relationships between resident satisfaction with public health service and residents’ health status, service expectation, service effectiveness and other individual characteristics. The data was derived from the 7th European Social Survey data in 2014. The study empirically established that 63.45% of surveyed residents across five European countries reported moderate-to-high satisfaction with public health service. Crucially, self-assessed health status (βʹ = 0.0012, p < 0.001), mental health status (βʹ = 0.002, p < 0.01), service expectation (βʹ = 0.0011, p < 0.001), and service availability (βʹ = 0.016, p < 0.001) positively affected public health service satisfaction, whereas international migration negatively affected satisfaction (βʹ = −0.033, p < 0.001). Policymakers in Western welfare countries need to take advantage of these universal influencing factors affecting public health service satisfaction and align the service provision with residents’ reasonable expectation. The satisfaction-driven healthcare system also provides references for the public healthcare reformation in other countries and regions.

Geological CO₂ storage is one of the key solutions for reducing greenhouse gas emissions, but its successful implementation depends on developing effective monitoring strategies and compliance assessment frameworks. This paper presents a risk-based monitoring methodology for CO₂ storage, based on the experience gained from the feasibility study of the Getica CCS project, which aims to store CO₂ in saline aquifers. The monitoring plan developed within Getica CCS ensures compliance with European and international regulations while demonstrating the safety and efficiency of the storage process. It integrates a comprehensive set of monitoring technologies, including geophysical, geochemical, and reservoir engineering methods. Geophysical monitoring is a core component of the plan, utilizing advanced technologies such as 4D seismic based on distributed acoustic sensing (DAS) and seismic nodes. These methods allow for detecting any changes in the geological structure of the saline aquifer and identifying potential risks associated with CO₂ migration. Additionally, gravimetric and ground deformation measurements are employed to assess the behavior of the geological formation and detect any variations in pressure and mechanical stresses. Geochemical monitoring plays a crucial role in verifying CO₂ storage safety and identifying possible chemical interactions between CO₂ and the host formation. The monitoring plan includes isotopic analyses and CO₂ concentration sensors in groundwater to detect potential leaks and assess the system’s chemical stability. These methods are complemented by analyses of dissolved gas composition and measurements of pH and alkalinity, providing essential data on the geochemical balance of the site. Furthermore, the monitoring plan incorporates an advanced pressure and temperature monitoring system within the reservoirs, using dedicated probes and numerical modeling to predict the long-term evolution of the CO₂ storage site. This approach enables the adjustment of operational strategies to ensure long-term storage security. Another important aspect analyzed in this study is the integration of risk perspectives and monitoring strategies from different European countries. The Getica CCS project serves as a concrete example of how these methods can be applied in the specific context of saline aquifers, contributing to the development of best practices for future CO₂ storage projects. This paper highlights the importance of integrated and risk-based monitoring for ensuring compliance and operational safety in CO₂ storage projects. The lessons learned from Getica CCS demonstrate the necessity of using advanced technologies and a multidisciplinary approach to guarantee efficient and sustainable CO₂ storage, offering a replicable model for future carbon capture and storage initiatives.

Background Managing patients with fatigue is a clinical challenge. Because fatigue is often reported in hypothyroidism, thyroid hormone (TH) therapy may sometimes be incorrectly considered for biochemically euthyroid individuals. This study aimed to evaluate the prevalence and determinants of this practice in different European countries. Methods We analyzed aggregate data from the THESIS (Treatment of Hypothyroidism in Europe by Specialists: an International Survey) online survey. We analyzed responses from 5,695 members of 28 national endocrine/thyroid societies’ specialists to the statement: “Thyroid hormones may be indicated in biochemically euthyroid patients with unexplained fatigue”. Results Overall, 7.5% (426/5695) of respondents indicated that TH therapy might be considered for euthyroid patients with unexplained fatigue. The proportion of positive responses varied widely across different countries (between 1.1% in Switzerland and 29.3% in Serbia; p=2 ×10 -16 ) and regions (between 4.7% in Western Europe and 8.7% in Western Asia or 8.8% in Eastern Europe; p=0.004). TH were more frequently prescribed for unexplained fatigue by male respondents (Odds Ratio, OR 1.45, 95% CI 1.18-1.78) and physicians practicing in private practice (OR 1.27, 95% CI 1.02-1.58), and less frequently by endocrinologists (OR 0.62, 95% CI 0.46-0.83). Conclusion A small, yet not negligible percentage of European thyroid-focused physicians consider using TH for euthyroid patients with unexplained fatigue, with significant variations based on geographic, demographic, and practice-related factors. Using levothyroxine and/or liothyronine in such cases lacks evidence and may partially contribute to the concerning overuse of TH therapy.