co

Moderate alcohol intake is linked to lower risk of ischaemic stroke, study finds




co

Lying flat after stroke achieves similar outcomes to sitting up, trial finds




co

Development and validation of outcome prediction models for aneurysmal subarachnoid haemorrhage: the SAHIT multinational cohort study




co

Endovascular treatment for acute ischaemic stroke in routine clinical practice: prospective, observational cohort study (MR CLEAN Registry)




co

Thrombectomy can be considered up to 24 hours after onset of stroke, says NICE




co

NICE recommends implantable monitor to identify atrial fibrillation after stroke




co

NICE recommends hybrid closed loop systems for poorly controlled type 1 diabetes




co

FDA approves first over-the-counter blood glucose monitor for diabetes




co

GLP-1 shortages will not resolve this year, EMA warns, amid concern over off-label use




co

Covid-19: Progression to clinical type 1 diabetes accelerated after infection, study suggests




co

People with type 1 diabetes and disordered eating need joined-up care, says coroner after woman’s death




co

Helen Salisbury: Failings at the Care Quality Commission




co

Helen Salisbury: GP collective action to end unfunded work




co

Patient related outcome measures (PROMs) in long term conditions—is it time to bring them into routine clinical practice?




co

Diabetes: Once weekly insulin could be as effective as daily injections, studies indicate




co

The Commonwealth reimagined

The Commonwealth reimagined 8 November 2022 — 6:00PM TO 7:00PM Anonymous (not verified) 18 October 2022 Chatham House and Online

Ghana’s minister of foreign Affairs, the Hon. Shirley Ayorkor Botchwey, discusses her vision for a modern Commonwealth and how it can evolve and match demands from its members.

The death of HM Queen Elizabeth II has focused attention on the future of the Commonwealth. The Commonwealth is an expanding voluntary organization of 56 independent countries in Africa, Asia, the Americas, Europe, and the Pacific.

Its appeal is increasingly beyond the circle of former British colonies – ex-French colonies Togo and Gabon officially joined in October 2022 and the ex-Portuguese colony, Angola, has applied. The Commonwealth Secretariat, established in 1965, is its main intergovernmental agency, which coordinates and carries out much of the Commonwealth’s work, supported by a network of more than 80 organizations.

King Charles III now heads the Commonwealth, which is focused on shared goals of prosperity, democracy and peace. However, the future of the Commonwealth and its purpose are unclear, and the organization needs to develop a sharper agenda on what its international contribution can be across its 56 state members and their peoples.

The minister discusses key questions including:

  • What should a modern Commonwealth look like and how can it best operate?

  • How can the organization impact policies and actions at a country level?

  • What role will young people play in the future of the Commonwealth?

  • How can the organization harness collective resources and technology to tackle major global issues such as climate change?

  • Can the issue of mobility and immigration among member states be managed?




co

The road to COP27: In conversation with US Special Presidential Envoy for Climate John Kerry

The road to COP27: In conversation with US Special Presidential Envoy for Climate John Kerry 27 October 2022 — 3:00PM TO 4:00PM Anonymous (not verified) 20 October 2022 Chatham House and Online

What will progress on climate change look like at COP27?

With global attention zeroing in on COP27, policymakers and world leaders will meet in Egypt to take the next step in the fight against the climate crisis. The planet is on course to warm well beyond 1.5°C and climate hazards are increasing our exposure to climate risk. Violent and unpredictable weather events increasingly leave devastation among communities, particularly in vulnerable countries.

At the same time, the ripple effects of the conflict in Ukraine will have wide-ranging economic, social and geopolitical consequences for years to come. Whilst some finance is being made available, more is needed to properly address the damage caused by climate change and fund the transition to net zero worldwide. These challenges have become more acute as the world grapples with a growing energy crisis, the war in Ukraine and a troubling economic outlook.

Joined by US Special Presidential Envoy for Climate John Kerry, the following questions are considered:

  • Is ‘1.5 degrees’ still on track?

  • How can countries better collaborate to move to net zero faster?

  • How can we achieve progress on adaptation, climate finance, and loss and damage?

As with all members events, questions from the audience drive the conversation.

Read the transcript. 




co

Middle East and great power competition

Middle East and great power competition 28 November 2022 — 12:00PM TO 1:00PM Anonymous (not verified) 25 October 2022 Chatham House and Online

Experts discuss how the Middle East is changing in a fast-moving geopolitical environment.

The war in Ukraine and great power competition define not only global politics but also regional ones. The Middle East is a microcosm for observing how the great power rivalry informs regional affairs.

OPEC+’s decision to reduce oil supply to international markets and many regional states’ balancing act between the West and Russia, for that matter China as well, are only a few recent policy choices that clearly illustrate how the global and regional levels interact with each other.

Plus this is now a region in which the US has downsized its security commitments, whereas Russia has increased its footprint in regional security and China in economy.

This event tries to unpack how the great power rivalry and the war in Ukraine affect regional politics and how the Middle East adjusts itself to this new phase in global politics.




co

Nigeria's 2023 elections: Security, economic and foreign policy imperatives

Nigeria's 2023 elections: Security, economic and foreign policy imperatives 5 December 2022 — 1:00PM TO 2:00PM Anonymous (not verified) 23 November 2022 Chatham House and Online

Bola Ahmed Tinubu, presidential candidate for the All-Progressives Congress, discusses his vision and recently-unveiled manifesto for ‘renewing hope’ in Nigeria.

Nigeria is scheduled to hold presidential and national assembly elections on 25 February 2023 as well as governorship and other subnational elections on 11 March 2023.

The elections will end President Muhammadu Buhari’s two terms in office since his election in 2015 and will mark the first time that he is not engaging in a presidential poll since Nigeria’s transition to civilian rule in 1999 – an important marker in Nigeria’s trajectory of democratic consolidation.

Nigeria’s recently enacted Electoral Act has contributed to improved hope around the election process, reflected in the addition of 12.29 million new voters in Nigeria’s voter registration exercise across the federation’s 36 states and 1,491 constituencies.

Yet Nigeria stands at a critical juncture, having suffered from two recessions in the past six years, unprecedented levels of food insecurity, persistent fuel scarcity and high levels of crude oil theft.

Civic fatigue also remains an important challenge and President Muhammadu Buhari’s three main policy pillars of security, economy and corruption continue to be defining issues for citizens.

At this event, Bola Ahmed Tinubu, presidential candidate for the All-Progressives Congress, discusses his vision and recently unveiled manifesto for ‘renewing hope’ in Nigeria including his policy proposals for economic reform and revival and how to deliver secure and inclusive job opportunities for Nigerian citizens.

Download a transcript

This event is a members and Africa programme event and is part of a series of events and outputs examining Nigeria’s 2023 elections and political developments.

As with all Chatham House member events, questions from members drive the conversation.




co

Ten conflicts to watch in 2023

Ten conflicts to watch in 2023 11 January 2023 — 6:00PM TO 7:00PM Anonymous (not verified) 8 December 2022 Chatham House and Online

This event examines the most dangerous wars and crises through the lens of the International Crisis Group’s flagship annual report ‘10 Conflicts to watch in 2023’.

Each year, International Crisis Group compiles a list of the ten conflicts to watch that examines key conflicts across the globe. Please join us for this event at which Dr Comfort Ero, International Crisis Group president and CEO, discusses today’s and tomorrow’s most impactful wars and crises.

Key questions to consider include:

  • What far-reaching repercussions and knock-on effects of Russia’s war on Ukraine will have for Europe and the rest of the world?

  • Which crises beyond Ukraine warrant collective attention in the year ahead?

  • How do rising tensions among major powers impact multilateral efforts to resolve these conflicts, impede progress on global challenges and impact institutions working on crisis prevention?

As with all members events, questions from the audience drive the conversation.

Read the transcript. 




co

The state of the union? US foreign policy and a new US Congress

The state of the union? US foreign policy and a new US Congress 30 January 2023 — 5:30PM TO 6:30PM Anonymous (not verified) 11 January 2023 Chatham House and Online

As a new Congress takes shape, what is the impact for US foreign policy?  

The recent US 2022 midterm elections have led to a split with Republicans in command of the US House of Representatives and Democrats retaining a slim majority in the Senate.

Following a gruelling selection process for the new Speaker of the House, the new Congress took its seats in January 2023, but President Joe Biden no longer enjoys single-party control of Congress.

  • What will be the implications of this for US leadership and US foreign policy?
  • How will domestic politics constrain foreign policy objectives?
  • Can policymakers across government set aside political differences to tackle global challenges?

This panel also unpacks insights into the following questions:

  • What will this Congress view as foreign policy priorities?
  • Will policies that are tough on China ramp up?
  • Can the US continue its support for Ukraine with a split Congress?
  • Will the next two years lead to any considerable foreign policy pivots with a general election on the horizon?

As with all members events, questions from the audience drive the conversation.

Read the transcript.




co

In conversation with Rahul Gandhi

In conversation with Rahul Gandhi 6 March 2023 — 6:00PM TO 7:00PM Anonymous (not verified) 27 February 2023 Chatham House and Online

The former president of the Indian National Congress discusses how today’s world will set the path for the world’s biggest democracy.

Soon to be the world’s largest population, and with a rapidly growing economy and an increasing presence in global affairs, India’s place in the world is changing.

Hosting the G20 this year, the New Delhi summit in September 2023 is a symbol of India’s growing might, moving from emerging to prominent player on the world stage.

However, challenges faced by the country are substantial. Frosty relations with China, ongoing tension with Pakistan, climate catastrophe, and food insecurity all represent significant global concerns to India.

Internally, the hurdles are imposing. Millions still live below the poverty line and demographic instability poses risks to the country. The state of democracy across the country is consistently questioned.

At this event, Rahul Gandhi explores key questions including:

  • How does India see the impact of the war in Ukraine?
  • Will New Delhi be able to balance relations between the West and Russia?
  • Can India offer an alternative vision for Asia that challenges China?
  • Internally, to what extent is democracy in India under strain?
  • Can India’s economy evolve to create a wide-reaching, prosperous nation in the coming years?

As with all member events, questions from the audience drive the conversation.




co

Is China's economy on the rebound?

Is China's economy on the rebound? 5 April 2023 — 6:00PM TO 7:00PM Anonymous (not verified) 28 February 2023 Chatham House and Online

Exploring the domestic and international signals from the first annual session of the 14th National People’s Congress.

2022 proved to be a difficult year for China. War, COVID-19 and economic turbulence presented a cocktail of significant challenges for the ruling CCP in China. Having dispensed of the infamous zero-COVID-19 policy, China is apparently back open for business.

On the international front, continued tensions with the West, war in Europe and climate change are just some of the obstacles standing in the way of Chinese economic recovery. 

Domestically, China must find ways to reinvigorate demand and move on from a low of 3 per cent GDP growth in 2022. With a frustrated population, people are also keen to be freed from the shackles of a stream of lockdowns and quarantining.

The in-tray for the 14th National People’s Congress, as it begins its first session, is substantial. The implications, at home and abroad, from its recent summit in Beijing reverberate around the world.

The experts on the panel discuss:

  • What has been the true extent of COVID-related damage to China’s economy and wider society?
  • What economic scars are visible post-recovery?
  • Will there be longer-term implications for China’s economic and diplomatic footprint globally post-COVID? 

As with all member events, questions from the audience drive the conversation.




co

In conversation with Ehud Barak

In conversation with Ehud Barak 27 March 2023 — 12:00PM TO 1:00PM Anonymous (not verified) 21 March 2023 Chatham House and Online

The former prime minister of Israel discusses his country’s political outlook and foreign policy priorities.

On the eve of its 75th independence anniversary, Israel is at a critical crossroads. Weeks of long, intense protests surrounding judicial reforms pursued by the current government have widened the debate over the role played by the, so far independent, judiciary, notably the Supreme Court.

Supporters on both sides of the argument are fighting over different visions of Israel – a true liberal-democracy, or a much-reduced version of a democratic system. Whichever side of the argument people fall, the debate symbolizes tension in Israel’s society and decline in trust of its political and constitutional institutions.

Abroad, the situation remains intricate. Israel-Iran relations remain on a knife edge while the Abraham Accords normalized relations with parts of the Gulf. Then there are the continual issues surrounding relations with the Palestinians and their right to self-determination and statehood.

Old international challenges are now rubbing up against the new. Israel is part of a changing power dynamic in the Middle East, the result of a much-reduced US footprint. Furthermore, it must now contend with the other global superpower in China and continue to work on its response to the war in Ukraine.

Amid its domestic struggle to maintain its democratic character, fast-moving regional and international developments are in need of addressing. Friends and allies are deeply concerned with the country’s constitutional crisis, potentially re-evaluating their relations with the Jewish state.

Former prime minister of Israel Ehud Barak lays out his views on the complexities of domestic and international challenges facing Israel today.

Questions covered include:

  • What are the main root causes of the current constitutional crisis, and how could it be best resolved?
  • Could the current situation lead to a breakdown of the political system, even widespread violence?
  • How could the current circumstances in Israel and Palestine affect relations between the two and any prospect for peace negotiations?
  • How will US-Israel relations stand up against China’s influence in the region?
  • What is Israel’s interpretation of the war in Ukraine and how is the country affected?

As with all member events, questions from the audience drive the conversation.




co

Chatham House exhibition - In conversation with the future

Chatham House exhibition - In conversation with the future 19 April 2023 — 6:00PM TO 8:00PM Anonymous (not verified) 31 March 2023 Chatham House

Hear from the innovative leaders and companies driving change towards a more sustainable future.

This event is an opportunity to hear from the innovative leaders and companies driving change towards a more sustainable future.

The evening begins with a panel discussion then, over sustainably sourced drinks and canapés, you are invited to walk through Chatham House and explore the innovative and experimental ideas enabling radical shifts to allow us to prosper without exhausting our planet’s resources.

Our exhibiting partners include Earthshot Prize winner NotPla, Hawkins Brown, Polymateria, and BEEN London. 

Bronwen Maddox, director of Chatham House, opens the evening at 6pm and introduces our panel of experts, chaired by Ana Yang, head of Chatham House’s Sustainability Accelerator. 

Please note that this event is operating a ballot for in-person attendance. Your place will be confirmed by Wednesday 12 April if you are successful.




co

GP leaders in Wales reject contract offer

General practice leaders in Wales have voted unanimously to reject the Welsh government’s GP contract offer for 2024-25.The BMA’s ​General Practitioners Committee Wales said the government’s general medical services contract offer for the current financial year “fails to provide a credible and sustainable future” for general practice.GPs in Wales will now vote on whether to accept or reject the contract in a referendum that will open later this month.Gareth Oelmann, chair of the committee, said, “The decision to disregard the serious concerns and valuable contribution of general practice in Wales is beyond insulting, it is dangerous, leaving more surgeries and their patients in peril. We are concerned that this offer will leave more practices with no option but to close. GPs are being denied the resources they need to deliver vital services to the population.”The BMA said it was not yet able to disclose any details on the offer, and...




co

Former chair of BMA GP Committee wins right to tribunal for unfair dismissal

An employment judge has cleared the way for Farah Jameel, a former chair of the BMA’s General Practitioners Committee for England (GPCE), to go ahead with claims of discrimination and unfair dismissal against the association over her removal from the post during maternity leave.Jameel, who was elected the first female chair in November 2021, was put on temporary suspension in 2022 after complaints by BMA staff. The BMA told her in August 2023 that her contract was being terminated.The contract described her as a contractor providing consultancy services rather than an employee. But in a preliminary ruling the employment judge Natasha Joffe has held that Jameel was in reality an office holder and an employee, opening the way for her claims to proceed to a full hearing by an employment tribunal.The GPCE passed a vote of no confidence in Jameel in July 2023, as a means of electing a new...




co

The World in Brief: European Court of Justice

The World in Brief: European Court of Justice The World Today Anonymous (not verified) 29 July 2021

EU brings members into line over fundamental rights

The European Union has had a challenging start to the summer trying to uphold the rule of law and avoid democratic regression in its member states.

On July 14, the Polish constitutional court ruled that the country did not have to comply with the measures imposed by the European Court of Justice against its controversial judicial reforms, citing that these measures were not in line with the Polish constitution.

The ruling Law and Justice Party, known as PiS, has introduced extensive changes to the judiciary since coming to power six years ago. In 2018, the government appointed new judges and set up a disciplinary chamber for the Supreme Court, which was given a temporary suspension by the European Court of Justice in an interim decision last year.

PiS reasoned that the changes were necessary to eliminate corruption stemming from the communist era, but critics say it merely allows the government to punish judges it regards as disloyal. Under the disciplinary system, Polish judges can have sanctions imposed on them for their judgments in the lower courts or if they refer cases to EU courts for preliminary rulings.

In the day following the Polish top court’s decision, the stand-off worsened when the European Court of Justice ruled that the disciplinary chamber undermines judicial independence and violates EU law. It ordered its immediate suspension and reiterated that the EU has primacy over national law – a vital condition countries agree to when joining the EU.

Didier Reynders, the European justice commissioner, sent a letter to Warsaw with an August 16 deadline for an answer on whether Poland would comply with the ruling. If the EU does not receive a satisfactory answer, it will impose financial sanctions on the state.

The former communist country, which joined the EU in 2004, is one of the bloc’s success stories. Its economy has boomed, and most people hold favourable views about the union – less than a handful of other member states have greater support for EU membership.

The EU has had to step up its efforts as members express anger over the gradual dismantling of fundamental rights under populist governments, not only in Poland. 

A recent survey by the Bertelsmann Stiftung showed that ‘although only 35 per cent of Poles are satisfied with the democracy in their own country, a full 70 per cent express positive views on the state of democracy in the EU’. These figures feed into a larger picture of many Europeans welcoming the EU as a supervisory agent that is capable of intervening when individual states falter.

Recently, however, the EU has had to step up its efforts as members express anger over the gradual dismantling of fundamental rights under populist governments, not only in Poland.

The persistent backsliding in Viktor Orbán’s Hungary has led to concerns in the EU parliament, which is putting pressure on the European Commission to do more to protect the EU’s values and legal order.

In a simultaneous battle in July, the commission launched legal action against Poland and Hungary, challenging anti-LGBTQ laws in those countries. It was triggered by a decision of more than 100 Polish regions to pass resolutions declaring themselves free of ‘LGBTQ ideology’, and a recently adopted law in Hungary banning any depiction of LGBTQ people on television or in books for under-18s.

An annual report on the rule of law in the union, released by the commission in July, singled out the two countries for their non-compliance. The report, the second of its kind, is a new tool to address concerns that the union was not scrutinizing democratic backsliding within its own bloc. Critics were quick to point out, however, that there is no mention of enforcement actions.

At the start of the year the EU vowed to be tougher in upholding democracy with a new regulation that lets it withhold money from member states that breach the rule of law. The EU has already delayed approving spending plans for Hungary and Poland as part of the €800 billion pandemic recovery fund.

As the European Parliament calls for the commission to reduce budget allocations to those that undermine democratic rights, Poland and Hungary could see the new mechanism put to the test this autumn.




co

Memory politics: the challenge of commemoration in post-Soviet Eastern Europe and the Caucasus

Memory politics: the challenge of commemoration in post-Soviet Eastern Europe and the Caucasus 5 October 2021 — 1:00PM TO 2:30PM Anonymous (not verified) 21 September 2021 Online

This event explores how to address memory and commemoration in the former Soviet states, considering their role in political processes and violent conflict. 

How the past is remembered and commemorated plays a large role – perhaps too large – in contemporary political debates and in how conflicts are negotiated.

Perceptions of history influence people’s actions and are used to judge or dismiss the actions of others. Nowhere is this more so than in the political, territorial and social debates and disputes across the former Soviet Union.
 
This event examines how to address the problems caused by entrenched memory debates – and proposes a framework for ‘ethical political commemoration’ for use across historical enquiry, political processes, and conflict transformation initiatives.

The speakers explore the topic through the context of Turkey and the Armenian genocide, as well as more broadly through their own experiences in conflict transformation and peace processes.




co

The law as a tool for EU integration could be ending

The law as a tool for EU integration could be ending Expert comment NCapeling 15 October 2021

Poland is not the only EU member state challenging the supremacy of European law, as historic change is happening in how European integration functions.

The Polish Constitutional Tribunal’s ruling that several articles of the European treaties are incompatible with the Polish constitution is prompting much debate, especially in terms of both the similarities and differences between it and rulings by the German constitutional court which have also challenged the European Court of Justice (ECJ).

Pro-Europeans are keen to draw a sharp distinction between the reasoning deployed by the two courts. They see the Polish court’s challenge as an exceptional case which the European Union (EU) cannot ‘tolerate’ because it would lead to the ‘demolition of the EU’s legal order from within’ and argue the EU must take a tough approach to Poland by re-asserting the supremacy of EU law.

But this view misses a bigger long-term shift in the EU. Both the German and Polish cases illustrate some of the basic conflicts within the EU’s legal system for decades. What is being challenged increasingly openly – even since the UK left the EU – is the idea of the EU as a de facto federation in which non-majoritarian institutions such as the ECJ have final say about the quality of democracy in member states.

ECJ’s quiet revolution

Historically ‘integration through law’ was central to the European project and the ECJ was a key institution driving forward integration – usually benefiting from what Erik Stein called ‘benign neglect by the powers that be and the mass media’. Even when European integration in the form of treaties stalled in the 1960s and 1970s, ‘judicial integration’ through the ECJ continued, including its notable 1964 decision that EU law was supreme.

According to the German court’s theory of ‘constitutional pluralism’, there is in effect a constant dialogue and accommodation between the national and EU level rather than a simple primacy of EU law over national law

This self-empowerment of the ECJ – what another scholar of European constitutionalism Joseph Weiler calls ‘a quiet revolution’ – was possible because there was a ‘permissive consensus’ in member states which allowed judicial integration to continue largely unchallenged. But this has now changed as both politicians and national courts are more willing to challenge what they see as judicial overreach.

There are important differences between the approach of the German and the Polish constitutional courts. The Law and Justice Party has politicized the Polish court, packing it with judges sympathetic to that party, whereas the German court is more independent.

In addition, whereas the German court made qualified and subdued objections to measures taken in response to the euro crisis during the past decade and, in particular, the steps towards the mutualization of eurozone debt – but often backed down with ‘all bark and no bite’ as Christoph Schmid put it – the Polish court is driven by political considerations and has challenged the supremacy of EU law in a more direct and general way.

However, the German court has made it clear it is the guardian of the German constitution and seeks to impose limits on the ECJ’s self-empowerment by arguing Europe is not a federation. According to the German court’s theory of ‘constitutional pluralism’, there is in effect a constant dialogue and accommodation between the national and EU level rather than a simple primacy of EU law over national law.

The court sees itself as the ultimate arbiter of whether steps in European integration are consistent with the German constitution, and is likely to challenge any further steps in fiscal integration even if the ECJ deems them in accordance with the treaties – as it did with the European Central Bank’s quantitative easing programme.

Supremacy of EU law is under pressure

Right across Europe, courts and politicians are increasingly challenging the ECJ and questioning the supremacy of EU law. Michel Barnier called for France to regain ‘legal sovereignty’ and should no longer be subject to the judgments of the ECJ – an extraordinary demand from the EU Brexit negotiator who regularly lectured the UK about the sanctity of the EU’s legal order.

The Polish challenge is part of a historic change in how European integration functions – or does not function

Other possible French presidential candidates such as Valérie Pécresse and Eric Zemmour are also openly challenging the primacy of EU law. The UK, of course, is fighting its own battle with the EU about the ECJ’s role in the Northern Ireland Protocol.

It was not the current Polish government but the people of France and the Netherlands who blocked the attempt at explicit constitutionalisation of the EU in a referendum just one year after the 2004 enlargement. Whereas the Constitutional Treaty ‘would have codified the doctrine of EU legal supremacy’, that provision was dropped from its successor the Lisbon Treaty, again indicating consensus on EU legal supremacy is not as strong as is often claimed.




co

Limited expectations as Scholz heads to Kyiv and Moscow

Limited expectations as Scholz heads to Kyiv and Moscow Expert comment NCapeling 14 February 2022

After heavy criticism for an initially timid response, the approach of Germany’s new government to the Ukraine crisis is improving as its position on Russia evolves.

Olaf Scholz is a famously quiet and cautious communicator and, as concerns mounted in Washington and London about the possibility of a Russian invasion of Ukraine, the new German chancellor remained silent.

This time his silence reflected the fact that his government was unprepared for its first major foreign policy test, with marked divisions between the SPD and the Greens on how to manage a rapidly deteriorating relationship with Russia.

When he did speak, Scholz caused dismay in several NATO capitals by defending the controversial Nord Stream 2 pipeline. He called it ‘a purely private economic project’ even though the company building the pipeline is a subsidiary of Russia’s state-owned Gazprom.

Scholz has prepared the ground carefully for his visits to Kyiv and Moscow, extensively coordinating with NATO allies, such as France and Poland – as part of the Weimar Triangle – and the three Baltic states

The absence of crisis management from Berlin was a stark reminder of the gap left by Angela Merkel. Her knowledge of Russia and Ukraine, and her personal experience of dealing with Vladimir Putin, were key assets in 2014 in developing a unified western response to Russia’s annexation of Crimea and its destabilization of south-eastern Ukraine.

Germany has coordinated with its allies

Scholz has prepared the ground carefully for his visits to Kyiv and Moscow, extensively coordinating with NATO allies, such as France and Poland – as part of the Weimar Triangle – and the three Baltic states. His inaugural visit to Washington helped align positions on US-EU efforts to develop an economic deterrent against further Russian intervention in Ukraine.

Scholz has also repeated Merkel’s language from 2014 to signal to Moscow that Germany and its partners are ‘united and determined’ to stand their ground. And he has spoken of Germany’s continuing double strategy of ‘clear announcements’ to Moscow of the price it would pay for further aggression accompanied by a readiness to use all possible channels of dialogue to preserve peace.

The continuation of Germany’s established policy will not surprise Moscow. But under the surface Germany’s discourse on Russia is evolving as the political class internalizes the fact that the current Russian leadership is openly threatening to use military force to impose its will on Ukraine and re-configure Europe’s security arrangements.

Despite deep concerns about Germany’s dependence on Russian gas – more than half of the gas it consumes comes from Russia – there is broad acceptance that Nord Stream 2 cannot go ahead if Russia invades Ukraine. But typically, Scholz has not yet said as much publicly, limiting himself to stating ‘all options are on the table.’

Despite its mantra that there is no alternative to the Minsk Agreements, Berlin now admits these currently offer no prospect of resolving the war in Donbas

Robert Habeck, Germany’s vice-chancellor as well as economic affairs and climate action minister, says the ‘geopolitical situation’ requires Germany to diversify its gas supplies and infrastructure for importing gas. For years, a strong pro-Russian gas lobby has dominated the thinking of the Economics Ministry and one consequence is the complete absence of facilities to import liquefied natural gas.

The German debate on Russia is shifting

A public debate has also started about weapons deliveries to Ukraine, even though this runs counter to deeply embedded pacifist tendencies in German society. Some MPs, former diplomats, and experts have begun to make the case for Germany to supply weapons to Ukraine so it can exercise its right to self-defence and deter military attack.

Christoph Heusgen, a former long-standing foreign policy adviser in the Federal Chancellery, says Berlin’s decision not to deliver arms to Ukraine to avoid endangering the Minsk peace process requires revision now Moscow has abandoned the path of negotiation.

Despite its mantra that there is no alternative to the Minsk Agreements, Berlin now admits these currently offer no prospect of resolving the war in Donbas because Russia is not prepared to implement them properly.

Other taboos are also being broken inside Germany. Heavyweight left-of-centre Die Zeit published the first results of its investigation into the SPD’s links with Russia and their place in Russia’s channels of influence in Germany. And even the SPD’s Sigmar Gabriel, an outspoken champion of Nord Stream 2 during his time as a government minister, has raised the question of Germany terminating energy imports from Russia if there is a drastic deterioration of the security situation.




co

Why a no-fly zone risks escalating the Ukraine conflict

Why a no-fly zone risks escalating the Ukraine conflict Expert comment NCapeling 13 March 2022

The US rejection of Poland’s offer to send fighter jets as a boost to Ukraine’s air defence shows just how uneasy nations are about direct combat with Russia.

The Pentagon’s decision to turn down the proposal by its fellow NATO member Poland to put Russian-made MiG-29 jets at its disposal demonstrates again how keen the US and allies are to avoid risking major confrontation with Russian forces.

The US Department of Defense says the offer to locate jets at bases in Germany was ‘not tenable’ as this risks flying into contested airspace over Ukraine – a non-NATO member – raising ‘serious concerns for the entire NATO alliance’ and echoing the continuing rejection of calls to implement no-fly zones (NFZs) as a way of easing the devastation being faced by trapped Ukraine civilians.

NFZs restrict any aircraft, including drones, from flying over a pre-defined region and can be used for both military and civilian purposes. But the implementation of NFZs is difficult to enforce and – most significantly – is unlikely to achieve the intended effect on the ground.

In the long-term, under the terms of a ceasefire agreement, it may be possible to include a NFZ under a UN or joint OSCE-UN peace terms

In conflict situations, they are usually implemented under the remit of United Nations (UN) peace support operations, requiring authorization under Article 42 of the UN Charter. This details that if all possible methods have proven ineffective in responding to a threat, countries ‘may take such action by air, or land forces as may be necessary to maintain or restore international peace and security’.

Protection but with limitations

NFZs provide both protection from attack and surveillance but do have limitations. They must be monitored and enforced which requires committing to fighter jet patrols with the explicit task of defending the area from the air by whatever means necessary.

This could mean jets firing upon Russian planes and drones so, if NATO allies and partners were to enforce a NFZ, it would represent an escalation of measures which is a step that would most likely provoke an unpredictable Vladimir Putin into further escalation – in short, it is highly likely to be seen as an act of war.

UK defence secretary Ben Wallace – among others – has repeatedly dispelled the idea, saying that enforcing NFZs would mean deploying ‘British fighter jets directly against Russian fighter jets’. In relation to moves such as the Polish jets, the Kremlin has warned that any countries offering airfields to Ukraine for attacks on Russia may be viewed as having entered the conflict.

There have only been three past instances of military NFZs. In Bosnia, as part of Operation Deny Flight from 1993-1995, a NFZ was enforced as part of a strategy which also including the provision of close air support and approved air strikes.

In Iraq, an NFZ endured for 12 years from 1991 and was succcesful in preventing Saddam Hussein from attacking Kurdish and Shia Muslim civilians. And in Libya in 2011, a NFZ was deployed to prevent the destruction of military infrastructure and the Libyan regime – although this quickly morphed into the provision of close air support.

So it is unclear just how successful NFZs are at providing protection. In Iraq and Libya, NFZ cover protection was provided but neither Saddam Hussein or Colonel Gaddafi were able to effectively target victims through their ground forces whereas, in Bosnia, Slobodan Milosevic infamously used ground troops to slaughter 8,000 Bosnian men and boys at Srebrenica.

Putin would still be able to continue to use both ground forces and artillery to assault Ukrainian cities with or without a NFZ – in fact, his sparse use of his Russian Aerospace Forces (VKS) has been one of the surprising features of the war so far. Under a NFZ, missile attacks could also continue, there is nothing in the record of no-fly zones to suggest the provision of safe areas for non-combatants would work.

And NFZs have only been successful against vastly inferior forces such as in Iraq, Bosnia, and Libya. But Russia has an air force second only in size to the US and has a vast range of defences including the potent S-400 Triumf at its disposal. Not only would an NFZ be ineffective, it might also not be possible to enforce without risking significant losses to the peace operations force.

It is due to a combination of these reasons that NFZs have not been used more in previous conflicts. The most recent consideration for a NFZ was in Syria but President Bashar al-Assad’s Syrian forces, protected by Russian air cover, could still have targeted their intended victims despite air policing so a NFZ was not used.

If NATO allies and partners were to enforce a NFZ, it would represent an escalation of measures which is a step that would most likely provoke an unpredictable Vladimir Putin into further escalation

In the long-term, under the terms of a ceasefire agreement, it may be possible to include a NFZ under a UN or joint OSCE-UN peace terms. However, the forces involved should exclude NATO allies and partners or any states with Russian alliances to avoid further conflict.

This leaves few suitable countries with the capacity, willingness, and political stance to be called on. Two of the world’s most militarily capable states – China and India – abstained in the Uniting for Peace vote in the UN General Assembly (UNGA). Whether another willing state with the military capability – such as a Gulf state – could be considered acceptable to all sides remains to be tested.

Notable successes with SAMs

Many military commentators also note that currently Ukrainian forces are having notable success without jets, downing Russian aircraft using sophisticated surface-to-air missiles (SAMs) such as Stinger and Javelin, and NATO countries continue to supply those in their thousands.




co

Ukraine crisis could trigger cascading risks globally

Ukraine crisis could trigger cascading risks globally Expert comment NCapeling 16 March 2022

The effects on the wider world from the Ukraine invasion go far beyond the waves of shock and horror being felt from this escalating conflict.

Russia and Ukraine rank 11th and 55th respectively in terms of their national economies but, for the global supply of critical resources such as energy, food, and minerals, these two countries together are far bigger hitters – and both the threat and reality of resource flows from them being reduced have already driven up global prices.

The world is already facing a cost-of-living squeeze coming out of the COVID-19 pandemic, so further price spikes or supply constraints have the potential to seriously undermine food and energy security, equitable access to basic goods and services, and social stability around the world – which can then potentially create systemic risks for economies and societies.

The global implications of the Ukraine conflict are only just beginning to be explored fully but the immediate impacts of the crisis on global markets are already well-documented. In the first few days after Russia’s invasion, energy prices spiked, triggering further fertilizer price rises – as fertilizer production is highly energy intensive – which in turn is contributing to food price rises because fertilizer costs are an important factor in food production.

Further price spikes or supply constraints have the potential to seriously undermine food and energy security, equitable access to basic goods and services, and social stability around the world

Interruptions to shipping in the region around Ukraine – as well as globally – have impeded the flow of goods which pushed prices up even further, while economic sanctions on cross-border flows of goods and finance are further adding to market pressures. But this is just the start – these impacts will bring ripple effects which propagate far beyond their point of origin, known as ‘cascading risks’.

Risk is a combination of hazard, exposure, and vulnerability – in terms of the Ukraine invasion, the hazard is the conflict and its immediate impacts on the societies and economies of Ukraine and Russia, while exposure relates to the degree to which other countries are likely to be affected depending on how much they are integrated into the global economy or the ‘just in time’ nature of their supply chains.

Vulnerability relates to a society’s capacity to mitigate the harmful impacts of the conflict, such as controlling borders, sourcing alternative goods from suppliers, or protecting against price or supply shocks.

Risk cascades – the second- and third-order impacts of the original hazard and of responses to that hazard – can interact across sectoral boundaries – as with energy and food, for example – and their compound effect can lead to overall systemic risks for society.

Anticipating this potential is essential to understanding the nature and scale of the global ramifications being felt from the Ukraine conflict. Recent work in the UK to assess levels of cascading risks resulting from a changing climate – the UK Climate Change Risk Assessment – provides a valuable framework for thinking about this area.

It examines key pathways for risk to cascade through global systems – when applied to the situation in Ukraine, these pathways and their interactions offer an indication of the scale of crisis that citizens face far beyond Ukraine’s and Russia’s borders.

Interruptions to the flows of goods and energy

In globalized trade networks, localized disruption to supply chains rapidly yields widespread international impacts – of particular concern is the immediate supply of food because most countries rely on lean supply chains and some may only have a few days food within their own borders.

Experience from previous food price crises indicate even small interruptions to trade can result in runs on the market and rapid price inflation. In the case of this conflict, the trade interruption will be far from small because, between them, Russia and Ukraine export around one-quarter of all traded wheat, more than three-quarters of traded sunflower oil, and one-sixth of traded maize.

Given many people are understandably fleeing this conflict, other countries may struggle to cope as the cost-of-living crisis and urgent efforts to bolster national security infrastructure may squeeze available public funds

Energy markets are also a concern because many countries use more energy than they produce and therefore rely on imports of energy or fuel for domestic use. Russia produces around ten per cent of the world’s commercial energy with a concentration of sales in major regions such as the European Union (EU) and China.

As with food, a shortfall in energy provision leads to market runs and rapid inflation as actors compete in a tightening space, while poorly designed policy interventions by nations trying to ensure their own security add further pressure to global supply and worsen price rises. In addition, the closely interconnected nature of energy markets means disruption to one fuel – such as gas in this case – affects global prices for other forms of energy.

The impact of moving people and money

As the last decade richly illustrates, the cross-border flows of people impact those societies absorbing them – for example, contributing to a rise in nationalism – as well as increase the costs of supplying essential resources. Given many people are understandably fleeing this conflict, other countries may struggle to cope as the cost-of-living crisis and urgent efforts to bolster national security infrastructure may squeeze available public funds.

Financial flows are crucial to the functioning of global economies, whether for inward investment or insurance and – as Russian citizens may be about to discover – restricting the global flow of money has a serious impact on households. Beyond Russia, the outflow of money from major financial centres such as London to meet insurance claims or to enable infrastructure reinvestment post-conflict may also have severe knock-on economic impacts.

The impact on governance and health

The global spikes in energy and food prices resulting from these supply chain disruptions will see many countries struggle with rising food and energy insecurity as well as increased inequality. Taken together these conditions create many issues beyond immigration pressures and the associated politics, including increased inequality and civil unrest.

This potentially destabilizes governments which has consequences for the stability of an entire region such as interrupted supply chains, the need to deploy peacekeeping forces, or significant flows of aid – all with global consequences far beyond the countries in question.

Populations may suffer mental health impacts arising from the Ukraine invasion, whether from the trauma of being forced to leave home to escape conflict, anxiety for the wellbeing and safety of families and friends caught up in it, or a more general anxiety arising from the perception of living in an unstable world.




co

War on Ukraine: Exploring the humanitarian response to the conflict

War on Ukraine: Exploring the humanitarian response to the conflict 12 April 2022 — 12:00PM TO 1:00PM Anonymous (not verified) 6 April 2022 Online

This event explores the implications of the humanitarian realities from Russia’s invasion of Ukraine, the largest ground campaign in Europe since World War Two.

Reports from humanitarian organizations working in Ukraine are dire and reveal that a humanitarian disaster on an epic scale is unfolding.

The United Nations (UN) and other organizations estimate 12 million of Ukraine’s population are in need of assistance, 4.1 million have been displaced to neighbouring countries, and 6.4 million have become internally displaced.

Gillian Triggs, the assistant secretary-general and assistant high commissioner for protection at the UNHCR, joins other experts to discuss the humanitarian situation in Ukraine.

The panel considers:

  • What are the greatest needs in Ukraine now?
  • How can aid agencies meet those needs?
  • What are the short and long-term implications of the crisis for Ukraine and Europe?
  • How do international organizations work with local NGOs to provide food, medical aid and shelter?

This event is part of a regular series of events offering insight and analysis from experts and policymakers on how the war is affecting Ukraine, the region and the world.

This event is part of Chatham House’s ongoing work on the future of conflict.

Read the transcript




co

New research on 21st-century conflict

New research on 21st-century conflict 25 April 2022 — 5:00PM TO 6:00PM Anonymous (not verified) 11 April 2022 Online

This International Affairs webinar shares research on US special operations, urban warfare, and digital activism in recent conflicts.

Given the ongoing Russian invasion of Ukraine, and continuing conflicts in Myanmar, Yemen, and other countries, it is important to understand the changing nature of conflict in the 21st century.

In this webinar, authors from the March 2022 issue of International Affairs share research on the transformation of Western special forces, the impact of army size in urban warfare, and the use of social media and online activism in war.

The speakers in this event drew on the following research:

International Affairs was started at Chatham House in 1922 to communicate research to members who could not attend in person. Over the past 100 years, it has transformed into a journal that publishes academically rigorous and policy-relevant research. It is published for Chatham House by Oxford University Press. Read the latest issue here.




co

Putin’s Eurasian dream may soon become a nightmare

Putin’s Eurasian dream may soon become a nightmare Expert comment NCapeling 3 May 2022

The Ukraine invasion has detrimental consequences for the Russia-led Eurasian Economic Union, a project which has been stumbling since its inception.

The Eurasian Economic Union (EAEU) – consisting of Russia with Armenia, Belarus, Kazakhstan, and Kyrgyzstan – represents the culmination of Russia’s pursuit of regional integration with its post-Soviet neighbours.

Officially, the Union has an ambitious economic goal – the creation of a market based on common rules for its five member states and their 180 million citizens – and Russia likes to portray the EAEU as an Eurasian replica of the European Union (EU).

But although a common market was placed at the heart of the EAEU as a way to appeal to member states, it is of marginal importance for the Russian economy. For Moscow, the EAEU is primarily a geopolitical tool to help re-assert its regional and global role.

In a world of evermore powerful trading blocs, Moscow wants to use the EAEU to establish its own economic power base in the new polycentric world order. But Russia’s limited interest in the technocratic intricacies needed for the economic union to live up to its lofty proclamations exposes the real geopolitical ambitions.

The Kremlin has no qualms about disregarding the common rules when they clash with Russia’s own foreign policy, and it soon became evident the EAEU was a means to an end rather than an equitable institution within which Russia would accept constraints on its unilateral behaviour.

A crisis in the making

Although the EAEU has enabled some internal trade liberalization as well as the movement of people and labour to the benefit of its members reliant on labour migrant remittances, it has failed to tackle institutional barriers or promote growth and development policies.

Russia’s limited interest in the technocratic intricacies needed for the economic union to live up to its lofty proclamations exposes the real geopolitical ambitions

It has been hampered by weak common institutions and a lack of institutional capacity of its member states, while Russia’s dubious commitment is also problematic. The EAEU lacks the institutional features of a genuine common market and any attempts to address these shortcomings have been essentially empty promises.

EAEU membership does benefit the political elites of its member states, because its hub-and-spoke model relies on bilateral high-level political deals between Russia and each member state individually. And by using the enticement of security guarantees and both political and financial support, Moscow has succeeded in attracting new members to join.

But a member’s political survival – or defence against political and economic reform – is dependent on military, economic, financial, and political support from Russia. This has been evidenced by the Armenian-Azerbaijan conflict, and by Russia’s backing of the Lukashenka regime in Belarus and the Tokayev government in Kazakhstan.

The design of the EAEU ties it to Russia’s own fate, and so the impact of harsh sanctions imposed on Russia for invading Ukraine are in stark evidence across its member states. Both Kazakhstan and Kyrgyzstan are reeling from the adverse effects on their domestic currencies and remittances, and the trade bans of key commodities.

And although the ban Russia imposed on grain export to EAEU members has softened, it shows the extent to which Russia was prepared to disregard the rules and sacrifice the EAEU to rescue its own economy. Members are incurring direct economic losses from Putin’s war against Ukraine and the fluctuation of the rouble has created a major impediment to trade with Russia.

Russia seems to increasingly view the Union as a convenient tool to bypass sanctions, with massive implications for its partner countries. And the supposed advantages of EAEU membership – enhanced trade, growth, and modernization – have simply not materialized.

Due to the rapid economic decline of Russia – a fall of 10-15 per cent is anticipated for 2022 – the EAEU is even less likely to deliver the promised economic benefits, while also putting members at risk of secondary sanctions.

The Ukraine invasion has also reignited domestic sensitivities and regional tensions. In Kazakhstan, Tokayev has failed to endorse Russia’s justification for the invasion and refuses to recognize the ‘independence’ of the separatist LNR and DNR.

Russia’s invasion of Ukraine clearly reduces the benefits of Eurasian integration even further than before and imposes higher cost on the partner countries than were envisaged when they joined

Meanwhile Azerbaijan has pursued territorial gains in Nagorno-Karabakh while Russia is distracted by its invasion of Ukraine, and has requested the withdrawal of Russian peacekeeping from the disputed territory.

Russia is keen for partner countries to help mitigate the economic impact of sanctions by providing alternative transit routes for imports to Russia. But the EAEU faces challenges even at its most basic level because the sharing of custom duties among member states was denominated in dollars, which Russia now wants to move away from.

No easy escape

Russia’s invasion of Ukraine clearly reduces the benefits of Eurasian integration even further than before and imposes higher cost on the partner countries than were envisaged when they joined. They have been dragged into a geopolitical calamity over which they have no control – the inability of EAEU institutions to mediate or constrain Russia’s behaviour is stark.




co

Africa and Europe: Cooperation on digital transitions and new technologies

Africa and Europe: Cooperation on digital transitions and new technologies 26 May 2022 — 8:00AM TO 12:30PM Anonymous (not verified) 12 May 2022 Online

The 11th Africa Day International Conference takes place under the auspices of the president of the Republic of Slovenia, HE Mr Borut Pahor, and within the framework of the Bled Strategic Forum.

Slovenia’s annual high-level Africa event seeks to improve policy outcomes for citizens in Europe and Africa as a result of a mutual understanding and strengthened cooperation between the two regions.

The event is co-hosted by the Ministry of Foreign Affairs of the Republic of Slovenia, the Chatham House Africa Programme and the European Commission.

Expert discussions at this year’s edition will examine collaborative links between Africa and Europe in promoting responsible innovation and governance of emerging technologies, as well as the role of technology in shaping creative and cultural economies.

The conference will be broadcast live on this website, on the Slovenian Ministry of Foreign Affairs website and on the Africa Programme Facebook page.




co

Gorbachev's complex legacy is beyond the popular belief

Gorbachev's complex legacy is beyond the popular belief Expert comment NCapeling 3 September 2022

The last major figure with a decisive Cold War role, Mikhail Gorbachev was not as bad as Putin’s Russia portrays him, but also not as heroic as the West thinks.

Arguably the worst year of the Cold War since the Cuban Missile Crisis was 1983, with three major incidents which escalated East-West tensions – and any one of them could have led to a full-scale war.

The first was the Korean Airline KAL007 being shot down by an SU15 fighter aircraft for straying into Soviet airspace, killing all 269 passengers and crew. Then came the identification of signals from Soviet satellites as being incoming US intercontinental ballistic missiles – Colonel Stanislav Petrov, going against all protocols, thankfully decided to report them as a false alarm before he could be sure.

The third was perhaps the most dangerous, being the misinterpretation of a live-fire NATO exercise which was believed by some in both East Germany and Russia to be a front for an imminent attack.

The greatest disappointment in Gorbachev’s legacy was he completely believed the USSR could be reformed and still survive as an entity while others, such as Boris Yeltsin and Ronald Reagan, understood it had to be dismantled

All three incidents occurred in the few months following the infamous March 1983 ‘Star Wars’ speech by US president Ronald Reagan, in which he talked about nuclear arms control and laid out the US case for a ballistic missile defence programme.

At that time Mikhail Sergeyevich Gorbachev was the youngest serving member of the USSR Politburo, known to be a favourite of Soviet leader Yuri Andropov, and it is highly likely he had been aware of these close calls and was part of discussions within Kremlin decision-making circles.

A changemaker both inside and outside the USSR

Following the deaths of Andropov in 1984 and his replacement Konstantin Chernenko in 1985, Gorbachev’s appointment as general secretary of the Communist Party saw him immediately begin to change the Soviet Union from within – and also change relationships with the major Western powers, especially the US, Germany, and the UK.

His policies of glasnost (openness) and perestroika (restructuring) were primarily aimed at internal reforms but translated into a major reset of international relations and international security. During his six years as leader, Gorbachev initiated many arms control negotiations which resulted in treaties and increased both the transparency and the confidence between the USSR and the US.

These included the 1986 Stockholm Accord which emanated from the Helsinki Process and allowed for the observation and inspection of large-scale military exercises, the 1985 resumption of the Strategic Arms Reduction Talks which lead to START I, and the 1987 INF Treaty in which the USSR ‘out-yessed’ the US – the most open and transparent disarmament treaty in terms of notification and verification measures ever agreed.

There was also a reciprocal moratorium on nuclear weapons tests starting from 1985 – which laid the groundwork for the 1996 CTBT – the 1991 Chemical Weapons Convention, and the 1990 Conventional Forces in Europe (CFE) Treaty.

The most dramatic moment of all was when Gorbachev and Reagan met at a summit in Reykjavik and came close to deciding to eliminate nuclear weapons – but the initiative failed to reach agreement, mainly because Reagan could not drop his commitment to ballistic missile defences and Gorbachev could not accept the offer of joint development.

Nonetheless, all these nuclear arms control treaties led the way for their descendants which have kept nuclear weapons in check ever since and are still in place in the form of the New START agreement.

During his six years as leader, Gorbachev initiated many arms control negotiations which resulted in treaties and increased both the transparency and the confidence between the USSR and the US

But despite these outstanding achievements, Gorbachev had blind spots – such as enabling rather than destroying the USSR bioweapons programme, unlike the US which had dismantled its own bioweapons offensive capability by 1973.

And it is now known that, despite negotiating the Chemical Weapons Convention, Russia withheld information on new chemical weapons agents – Novichoks – which have since been used to lethal effect by Russia in Salisbury and against figures opposing the current regime.

His misguided faith in a Soviet future

Gorbachev was markedly different to his predecessors as secretary general. He was neither as decrepit nor as hardline, and he understood from the outset that the Soviet Union was, by the 1980s, finally dying.

Using the intellectual abilities of Aleksandr Yakovlev, he forced through the reforms which simultaneously captured the imagination of the free world and liberated his countrymen and women.

But although he built solid relationships – even friendships – with the world’s major heads of state and improved the USSR’s human rights, releasing dissidents such as Andrei Sakharov, but many – especially Ukrainian dissidents – continued to languish in camps.

The greatest disappointment in Gorbachev’s legacy was he completely believed the USSR could be reformed and still survive as an entity while others, such as Boris Yeltsin and Ronald Reagan, understood it had to be dismantled.

This shortcoming is especially uncomfortable as today’s Russia continues to insist it has a given right to control other former Soviet states, to the extent it is willing to destroy them if they do not concede.




co

Central and Eastern Europe become hawkish on China

Central and Eastern Europe become hawkish on China Expert comment LJefferson 16 September 2022

The recent withdrawal of the Baltic countries from the ‘17+1’ format displays changing perceptions of China due to its ambiguity towards the war in Ukraine.

While the Russian invasion of Ukraine only confirmed Central and Eastern Europe’s views of Russia, it is also affecting their relations with China. Although the relationship was already complicated due to unfulfilled Chinese economic promises to CEE countries and growing indications of efforts to influence their domestic politics, China’s support for Russia is pushing Central and Eastern Europeans even further away.

This shift was highlighted, and formalized, recently by several countries in the region leaving the ‘17+1’ format, through which China cooperates with a group of countries from the region. The shifting attitudes towards China will also influence the relationship between the European Union as a whole and China.

A Trojan Horse that never was

When the format was launched in 2012 between 16 CEE countries at the time and China, the countries jumping on board expected a wave of Chinese investment and an opportunity to diversify mostly west-bound trade.

These hopes never fully materialized as Chinese foreign direct investment (FDI) in CEE has been generally lower compared to the rest of Europe and China never became an important export destination for any of the countries. The growing disillusionment and concern about Chinese security threats has led to some of the countries speaking up about the perceived perils of closer cooperation.

The first to withdraw from what had become ‘17+1’ by 2021 was Lithuania, which also took an interest in strengthening ties with Taiwan and allowed it to open a Taiwanese representative office in Vilnius. This triggered a breakdown in the bilateral relations with China. As a retaliatory response, China blocked Lithuanian imports and imports from other EU states containing inputs from Lithuania, leading the EU to launch an official dispute at the WTO.

War in Ukraine

Since the invasion started, CEE countries have been dealing with large numbers of Ukrainian refugees, organizing shipments of military equipment to Ukraine, and at the same time worrying whether they could be next on Russia’s list.

However, the concerns and security environment that these countries face seems to be almost entirely disregarded by China. On the sidelines of the 2022 Winter Olympics in Beijing, Xi and Putin signed the joint communiqué in which China backed Moscow’s demands to reverse NATO borders to the pre-1997 situation, completely disregarding CEE’s security interests.

Since the invasion started, CEE countries have been dealing with large numbers of Ukrainian refugees, organizing shipments of military equipment to Ukraine, and at the same time worrying whether they could be next on Russia’s list.

China’s implicit support for Russia after the invasion has sowed deep mistrust of its respect for the sovereignty of other nations. The Chinese diplomatic apparatus clearly noticed this changing mood among CEE governments and sent a special envoy to eight capitals in April-May tasked with ‘eliminating misunderstandings regarding Russia-Ukraine conflict’.

However, the trip was not particularly successful. The delegation failed to secure high-level meetings, with the most prominent case being the Polish minister of foreign affairs declining to meet Huo Yuzhen, the Chinese Special Councilor for CEEC cooperation. Given that Andrzej Duda, President of Poland, was the only head of an EU state who attended the Beijing Olympics opening ceremony just before the Russian invasion in February, the change in attitudes is clear.

Following the envoy’s visit to the Czech Republic, the Czech parliament’s foreign affairs committee unanimously approved a resolution calling for the country to quit the ‘16+1’ format and the government is expected to act upon it in the near future. Meanwhile, Latvia and Estonia recently jointly announced that they would no longer be participating in the cooperation framework, turning it into ‘14+1’.




co

In conversation with Edi Rama, prime minister of Albania

In conversation with Edi Rama, prime minister of Albania 23 March 2023 — 5:30PM TO 6:30PM Anonymous (not verified) 13 March 2023 Chatham House and Online

From migration to Russia and China, how is Albania responding to the geopolitical challenges of today?

In late 2022, the UK government made a pointed remark that many of the illegal migrants attempting to get into the country were from Albania. In response, Albania prime minister Edi Rama replied that targeting Albanians as the cause of Britain’s crime and border problems ‘makes for easy rhetoric but ignores hard fact’. 

This nuanced response demonstrated the challenges and complexities that Albania faces, the same as many other countries. As well as being embroiled in the major challenge of international migration, Albania has suffered from a serious cyber-attack in July 2022 from Iran. Government networks were compromised for a month with Tirana removing the Iranian embassy in the capital.

Then there is the ongoing threat from Russia and China. Nestled in the already volatile Balkans, Albania has been at the heart of international affairs in recent months.

Prime Minister Rama speaks at Chatham House to discuss:

  • How is Albania responding to Russian aggression and what is its stance on Ukraine?
  • Where does Tirana believe China poses the most serious threat?
  • How can countries in Europe best respond to illegal migration and better control the flow of people?
  • How is the region of the Western Balkans effected by the war in Ukraine and how can it contribute to the security challenges posed by the war?

As with all member events, questions from the audience drive the conversation.




co

Review: Rediscovering Milan Kundera’s European tragedy

Review: Rediscovering Milan Kundera’s European tragedy The World Today mhiggins.drupal 28 March 2023

The Czech writer’s 40-year-old essay on the roots of Russia’s empire-building, ‘A Kidnapped West’, reads all too presciently, writes Stefan Auer.

A Kidnapped West: The Tragedy of Central Europe
Milan Kundera, Faber, £10

‘In November 1956, the director of the Hungarian News Agency, shortly before his office was flattened by artillery fire, sent a telex to the entire world with a desperate message announcing that the Russian attack against Budapest had begun. The dispatch ended with these words: “We are going to die for Hungary and for Europe.”’ Thus, Milan Kundera began his 1983 essay for the French journal Le Débat, reflecting on the 1956 Hungarian Uprising.

A seminal essay

The Czech author might well have written a near-identical passage about the fraught hours immediately after Russia’s invasion of Ukraine in 2022. In the event, Russian tanks failed to occupy Kyiv, unlike Budapest in 1956. Nevertheless, Faber has chosen this moment, 40 years later, to republish Kundera’s seminal essay on Europe and Russian aggression in its original translation for the New York Review of Books by Edmund White. How salient are its observations today?

Thanks to the Cold War, the countries of Central Europe were denied their true destiny, Kundera thought, in the democratic West

The essay’s original French title, ‘Un Occident kidnappé ou la tragédie de l’Europe centrale’ (The Kidnapped West, or the Tragedy of Central Europe), described the fate of Hungary, Czechoslovakia in 1968 and, to an extent, Poland in 1980-81 at the hands of the Soviet Union. Owing to the Cold War division of Europe, the countries of Central Europe were denied their true destiny, Kundera thought, to be an integral part of the liberal, democratic West. Kundera himself fled Czechoslovakia for France in 1975.

The author of The Unbearable Lightness of Being might no longer be as well-known as he was at the height of his fame in the 1980s, but his novels and essays still deserve attention. So, it is pleasing to see Kundera’s masterpiece republished, even as it is awful to witness the enduring relevance of the questions it raises.

What did the Hungarian journalist mean when he declared his willingness to die for Europe, Kundera asked? That ‘Russians, in attacking Hungary, were attacking Europe itself. He was ready to die so that Hungary might remain Hungary and European’. The journalist did indeed die in the uprising.

It is a line that President Volodymyr Zelenskyy and his supporters abroad have echoed time and again: that Ukrainian soldiers are not just dying for their country, they are dying for Europe at large.

Kundera’s suspicion of Russia has been validated. His frustration about the indifference of the West less so

The ‘tragedy’ in Kundera’s essay was that the West didn’t care. ‘Europe hasn’t noticed the disappearance of its cultural home,’ Kundera wrote, ‘because Europe no longer perceives its unity as a cultural unity.’

In other words, as the cultural sphere in Central Europe continued to defy the political restrictions imposed by the Soviet empire, it embodied the western values of freedom and democracy more than the West itself did. The extent to which this analysis remains relevant today will prove decisive for Europe’s future.

As timely as ever

Kundera’s essay is as timely as ever but in ways that both vindicate and challenge his key arguments. His suspicion of Russia has been validated. His frustration about the indifference of the West less so. But the true tragedy of Ukraine would be if the West has not changed sufficiently. So far, the West appears to be doing enough to enable Ukraine to defend itself, but not enough to defeat the aggressor.

[A small nation] is one whose very existence can be put in question at any moment; a small nation can disappear and it knows it

Milan Kundera

Faber has made an excellent decision in combining The Tragedy of Central Europe with a lesser-known text by Kundera: his 1967 speech to the Czech Writers’ Congress given the year before the ill-fated Prague Spring. In it, Kundera addressed what was to become a lifelong preoccupation: the fate of small nations. ‘For Czechs’, Kundera wrote, ‘nothing has ever constituted an indisputable possession – neither their language nor their belonging to Europe.’

Rather than reflecting the size of its territory or population, a small nation ‘is one whose very existence can be put in question at any moment; a small nation can disappear, and it knows it.’ In this way Ukraine, Europe’s largest country, apart from Russia, is fighting to avoid the fate of Kundera’s ‘small nation’.

Historically, the ‘small’ nations of Central Europe were threatened by both Germany and Russia. But after the Second World War, the threat was from the Soviet Union, which for Kundera was indistinguishable from Russia (tacitly including Ukraine). In its expansiveness, Russia was the opposite of Central Europe. While the latter was based on the principle of ‘the greatest variety within the smallest space’, the former represented ‘the smallest variety within the greatest space’.

Kundera was criticized for observations that smack of civilizational racism, yet his bleak view of Russia remains prescient

In this sense, authoritarian communism was the fulfilment of Russian history, Kundera argued, writing that ‘Russian communism vigorously reawakened Russia’s old anti-western obsessions and turned it brutally against Europe’. Vladimir Putin’s Russia appears to build on these same pernicious impulses.

Kundera was widely criticized for observations in his essay that smack of civilizational racism (including by me) describing Russians as fundamentally different from us: ‘Russia knows another (greater) dimension of disaster, another image of space (a space so immense that entire nations are swallowed up in it), another sense of time (slow and patient), another way of laughing, living, and dying’.




co

Ultrashort Oncologic Whole-Body [18F]FDG Patlak Imaging Using LAFOV PET

Methods to shorten [18F]FDG Patlak PET imaging procedures ranging from 65–90 to 20–30 min after injection, using a population-averaged input function (PIF) scaled to patient-specific image-derived input function (IDIF) values, were recently evaluated. The aim of the present study was to explore the feasibility of ultrashort 10-min [18F]FDG Patlak imaging at 55–65 min after injection using a PIF combined with direct Patlak reconstructions to provide reliable quantitative accuracy of lung tumor uptake, compared with a full-duration 65-min acquisition using an IDIF. Methods: Patients underwent a 65-min dynamic PET acquisition on a long-axial-field-of-view (LAFOV) Biograph Vision Quadra PET/CT scanner. Subsequently, direct Patlak reconstructions and image-based (with reconstructed dynamic images) Patlak analyses were performed using both the IDIF (time to relative kinetic equilibrium between blood and tissue concentration (t*) = 30 min) and a scaled PIF at 30–60 min after injection. Next, direct Patlak reconstructions were performed on the system console using only the last 10 min of the acquisition, that is, from 55 to 65 min after injection, and a scaled PIF using maximum crystal ring difference settings of both 85 and 322. Tumor lesion and healthy-tissue uptake was quantified and compared between the differently obtained parametric images to assess quantitative accuracy. Results: Good agreement was obtained between direct- and image-based Patlak analyses using the IDIF (t* = 30 min) and scaled PIF at 30–60 min after injection, performed using the different approaches, with no more than 8.8% deviation in tumor influx rate value (Ki) (mean difference ranging from –0.0022 to 0.0018 mL/[min x g]). When direct Patlak reconstruction was performed on the system console, excellent agreement was found between the use of a scaled PIF at 30–60 min after injection versus 55–65 min after injection, with 2.4% deviation in tumor Ki (median difference, –0.0018 mL/[min x g]; range, –0.0047 to 0.0036 mL/[min x g]). For different maximum crystal ring difference settings using the scan time interval of 55–65 min after injection, only a 0.5% difference (median difference, 0.0000 mL/[min x g]; range, –0.0004 to 0.0013 mL/[min x g]) in tumor Ki was found. Conclusion: Ultrashort whole-body [18F]FDG Patlak imaging is feasible on an LAFOV Biograph Vision Quadra PET/CT system without loss of quantitative accuracy to assess lung tumor uptake compared with a full-duration 65-min acquisition. The ultrashort 10-min direct Patlak reconstruction with PIF allows for its implementation in clinical practice.




co

C-X-C Motif Chemokine Receptor 4-Directed Scintigraphy Using [99mTc]Tc-Pentixatec in Primary Aldosteronism: A Proof-of-Concept Study

C-X-C motif chemokine receptor 4 (CXCR4)–directed imaging has gained clinical interest in aiding clinical diagnostics in primary aldosteronism (PA). We retrospectively evaluated the feasibility of CXCR4-directed scintigraphy using the novel CXCR-4 ligand [99mTc]Tc-pentixatec in patients with PA. Methods: Six patients (mean age ± SD, 49 ± 15 y) underwent CXCR4-directed scintigraphy (including planar imaging and SPECT/CT) 30, 120, and 240 min after injection of 435 ± 50 MBq of [99mTc]Tc-pentixatec. Adrenal CXCR4 expression was analyzed by calculating lesion-to-contralateral ratios (LCRs). Imaging results were correlated to clinical information. Histopathology and clinical follow-up served as the standard of reference. Results: Three subjects showed lateralization of adrenal tracer accumulation, with a mean maximum lesion-to-contralateral ratio of 1.65 (range, 1.52–1.70), which correlated with morphologic findings on CT. One individual underwent adrenalectomy and presented with complete biochemical and clinical remission at follow-up. Histopathologic workup confirmed unilateral aldosterone-producing adenoma. Conclusion: [99mTc]Tc-pentixatec scintigraphy with SPECT in patients with PA is feasible and might offer a valuable alternative to CXCR4-directed imaging with [68Ga]Ga-pentixafor PET.




co

Molecular Imaging of p53 in Mouse Models of Cancer Using a Radiolabeled Antibody TAT Conjugate with SPECT

Mutations of p53 protein occur in over half of all cancers, with profound effects on tumor biology. We present the first—to our knowledge—method for noninvasive visualization of p53 in tumor tissue in vivo, using SPECT, in 3 different models of cancer. Methods: Anti-p53 monoclonal antibodies were conjugated to the cell-penetrating transactivator of transcription (TAT) peptide and a metal ion chelator and then radiolabeled with 111In to allow SPECT imaging. 111In-anti-p53-TAT conjugates were retained longer in cells overexpressing p53-specific than non–p53-specific 111In-mIgG (mouse IgG from murine plasma)-TAT controls, but not in null p53 cells. Results: In vivo SPECT imaging showed enhanced uptake of 111In-anti-p53-TAT, versus 111In-mIgG-TAT, in high-expression p53R175H and medium-expression wild-type p53 but not in null p53 tumor xenografts. The results were confirmed in mice bearing genetically engineered KPC mouse–derived pancreatic ductal adenocarcinoma tumors. Imaging with 111In-anti-p53-TAT was possible in KPC mice bearing spontaneous p53R172H pancreatic ductal adenocarcinoma tumors. Conclusion: We demonstrate the feasibility of noninvasive in vivo molecular imaging of p53 in tumor tissue using a radiolabeled TAT-modified monoclonal antibody.




co

The Emission of Internal Conversion Electrons Rather Than Auger Electrons Increased the Nucleus-Absorbed Dose for 161Tb Compared with 177Lu with a Higher Dose Response for [161Tb]Tb-DOTA-LM3 Than for [161Tb]Tb-DOTATATE

Preclinical data have shown that 161Tb-labeled peptides targeting the somatostatin receptor are therapeutically more effective for peptide receptor radionuclide therapy than are their 177Lu-labeled counterparts. To further substantiate this enhanced therapeutic effect, we performed cellular dosimetry to quantify the absorbed dose to the cell nucleus and compared dose–response curves to evaluate differences in relative biological effectiveness in vitro. Methods: CA20948 cell survival was assessed after treatment with [161Tb]Tb- and [177Lu]Lu-DOTATATE (agonist) and with [161Tb]Tb- and [177Lu]Lu-DOTA-LM3 (antagonist) via a clonogenic assay. Cell binding, internalization, and dissociation assays were performed up to 7 d to acquire time-integrated activity coefficients. Separate S values for each type of particle emission (Auger/internal conversion [IC] electrons and β particles) were computed via Monte Carlo simulations, while considering spheric cells. Once the absorbed dose to the cell nucleus was calculated, survival curves were fitted to the appropriate linear or linear-quadratic model and corresponding relative biological effectiveness was evaluated. Results: Although the radiopeptide uptake was independent of the radionuclide, [161Tb]Tb-DOTATATE and [161Tb]Tb-DOTA-LM3 delivered a 3.6 and 3.8 times higher dose to the nucleus, respectively, than their 177Lu-labeled counterparts on saturated receptor binding. This increased nucleus-absorbed dose was mainly due to the additional emission of IC and not Auger electrons by 161Tb. When activity concentrations were considered, both [161Tb]Tb-DOTATATE and [161Tb]Tb-DOTA-LM3 showed a lower survival fraction than did labeling with 177Lu. When the absorbed dose to the nucleus was considered, no significant difference could be observed between the dose–response curves for [161Tb]Tb- and [177Lu]Lu-DOTATATE. [161Tb]Tb-DOTA-LM3 showed a linear-quadratic dose response, whereas [161Tb]Tb-DOTATATE showed only a linear dose response within the observed dose range, suggesting additional cell membrane damage by Auger electrons. Conclusion: The IC, rather than Auger, electrons emitted by 161Tb resulted in a higher absorbed dose to the cell nucleus and lower clonogenic survival for [161Tb]Tb-DOTATATE and [161Tb]Tb-DOTA-LM3 than for the 177Lu-labeled analogs. In contrast, [161Tb]Tb-DOTATATE showed no higher dose response than [177Lu]Lu-DOTATATE, whereas for [161Tb]Tb-DOTA-LM3 an additional quadratic response was observed. Because of this quadratic response, potentially caused by cell membrane damage, [161Tb]Tb-DOTA-LM3 is a more effective radiopeptide than [161Tb]Tb-DOTATATE for labeling with 161Tb.




co

Theranostic GPA33-Pretargeted Radioimmunotherapy of Human Colorectal Carcinoma with a Bivalent 177Lu-Labeled Radiohapten

Radiolabeled small-molecule DOTA-haptens can be combined with antitumor/anti-DOTA bispecific antibodies (BsAbs) for pretargeted radioimmunotherapy (PRIT). For optimized delivery of the theranostic - and β-emitting isotope 177Lu with DOTA-based PRIT (DOTA-PRIT), bivalent Gemini (DOTA-Bn-thiourea-PEG4-thiourea-Bn-DOTA, aka (3,6,9,12-tetraoxatetradecane-1,14-diyl)bis(DOTA-benzyl thiourea)) was developed. Methods: Gemini was synthesized by linking 2 S-2-(4-isothiocyanatobenzyl)-DOTA molecules together via a 1,14-diamino-PEG4 linker. [177Lu]Lu-Gemini was prepared with no-carrier-added 177LuCl3 to a molar-specific activity of 123 GBq/μmol and radiochemical purity of more than 99%. The specificity of BsAb-177Lu-Gemini was verified in vitro. Subsequently, we evaluated biodistribution and whole-body clearance for [177Lu]Lu-Gemini and, for comparison, our gold-standard monovalent [177Lu]Lu-S-2-(4-aminobenzyl)-DOTA ([177Lu]Lu-DOTA-Bn) in naïve (tumor-free) athymic nude mice. For our proof-of-concept system, a 3-step pretargeting approach was performed with an established DOTA-PRIT regimen (anti-GPA33/anti-DOTA IgG-scFv BsAb, a clearing agent, and [177Lu]Lu-Gemini) in mouse models. Results: Initial in vivo studies showed that [177Lu]Lu-Gemini behaved similarly to [177Lu]Lu-DOTA-Bn, with almost identical blood and whole-body clearance kinetics, as well as biodistribution and mouse kidney dosimetry. Pretargeting [177Lu]Lu-Gemini to GPA33-expressing SW1222 human colorectal xenografts was highly effective, leading to absorbed doses of [177Lu]Lu-Gemini for blood, tumor, liver, spleen, and kidneys of 3.99, 455, 6.93, 5.36, and 14.0 cGy/MBq, respectively. Tumor–to–normal tissue absorbed-dose ratios (i.e., therapeutic indices [TIs]) for the blood and kidneys were 114 and 33, respectively. In addition, we demonstrate that the use of bivalent [177Lu]Lu-Gemini in DOTA-PRIT leads to improved TIs and augmented [177Lu]Lu-Gemini tumor uptake and retention in comparison to monovalent [177Lu]Lu-DOTA-Bn. Finally, we established efficacy in SW1222 tumor-bearing mice, demonstrating that a single injection of anti-GPA33 DOTA-PRIT with 44 MBq (1.2 mCi) of [177Lu]Lu-Gemini (estimated tumor-absorbed dose, 200 Gy) induced complete responses in 5 of 5 animals and a histologic cure in 2 of 5 (40%) animals. Moreover, a significant increase in survival compared with nontreated controls was noted (maximum tolerated dose not reached). Conclusion: We have developed a bivalent DOTA-radiohapten, [177Lu]Lu-Gemini, that showed improved radiopharmacology for DOTA-PRIT application. The use of bivalent [177Lu]Lu-Gemini in DOTA-PRIT, as opposed to monovalent [177Lu]Lu-DOTA-Bn, allows curative treatments with considerably less administered 177Lu activity while still achieving high TIs for both the blood (>100) and the kidneys (>30).




co

Preclinical Evaluation of 177Lu-OncoFAP-23, a Multivalent FAP-Targeted Radiopharmaceutical Therapeutic for Solid Tumors

Fibroblast activation protein (FAP) is abundantly expressed in the stroma of most human solid tumors. Clinical-stage radiolabeled FAP ligands are increasingly used as tools for the detection of various cancer lesions. To unleash the full therapeutic potential of FAP-targeting agents, ligands need to remain at the tumor site for several days after administration. We recently described the discovery of OncoFAP, a high-affinity small organic ligand of FAP with a rapid accumulation in tumors and low uptake in healthy tissues in cancer patients. Trimerization of OncoFAP provided a derivative (named TriOncoFAP, or OncoFAP-23) with improved FAP affinity. In this work, we evaluated the tissue biodistribution profile and the therapeutic performance of OncoFAP-23 in tumor-bearing mice. Methods: OncoFAP-23 was radiolabeled with the theranostic radionuclide 177Lu. Preclinical experiments were conducted on mice bearing SK-RC-52.hFAP (BALB/c nude mice) or CT-26.hFAP (BALB/c mice) tumors. 177Lu-OncoFAP and 177Lu-FAP-2286 were included in the biodistribution study as controls. Toxicologic evaluation was performed on Wistar rats and CD1 mice by injecting high doses of OncoFAP-23 or its cold-labeled counterpart, respectively. Results: 177Lu-OncoFAP-23 emerged for its best-in-class biodistribution profile, high and prolonged tumor uptake (i.e., ~16 percentage injected dose/g at 96 h), and low accumulation in healthy organs, which correlates well with its potent single-agent anticancer activity at low levels of administered radioactivity. Combination treatment with the tumor-targeted interleukin 2 (L19-IL2, a clinical-stage immunocytokine) further expands the therapeutic window of 177Lu-OncoFAP-23 by potentiating its in vivo antitumor activity. Proteomics studies revealed a potent tumor-directed immune response on treatment with the combination. OncoFAP-23 and natLu-OncoFAP-23 exhibited a favorable toxicologic profile, without showing any side effects or signs of toxicity. Conclusion: OncoFAP-23 presents enhanced tumor uptake and tumor retention and low accumulation in healthy organs, findings that correspond to a strongly improved in vivo antitumor efficacy. The data presented in this work support the clinical development of 177Lu-OncoFAP-23 for the treatment of FAP-positive solid tumors.




co

Composite Prediction Score to Interpret Bone Focal Uptake in Hormone-Sensitive Prostate Cancer Patients Imaged with [18F]PSMA-1007 PET/CT

Unspecific bone uptake (UBU) related to [18F]PSMA-1007 PET/CT imaging represents a clinical challenge. We aimed to assess whether a combination of clinical, biochemical, and imaging parameters could predict skeletal metastases in patients with [18F]PSMA-1007 bone focal uptake, aiding in result interpretation. Methods: We retrospectively analyzed [18F]PSMA-1007 PET/CT performed in hormone-sensitive prostate cancer (PCa) patients at 3 tertiary-level cancer centers. A fourth center was involved in performing an external validation. For each, a volume of interest was drawn using a threshold method to extract SUVmax, SUVmean, PSMA tumor volume, and total lesion PSMA. The same volume of interest was applied to CT images to calculate the mean Hounsfield units (HUmean) and maximum Hounsfield units. Clinical and laboratory data were collected from electronic medical records. A composite reference standard, including follow-up histopathology, biochemistry, and imaging data, was used to distinguish between PCa bone metastases and UBU. PET readers with less (n = 2) or more (n = 2) experience, masked to the reference standard, were asked to visually rate a subset of focal bone uptake (n = 178) as PCa metastases or not. Results: In total, 448 bone [18F]PSMA-1007 focal uptake specimens were identified in 267 PCa patients. Of the 448 uptake samples, 188 (41.9%) corresponded to PCa metastases. Ongoing androgen deprivation therapy at PET/CT (P < 0.001) with determination of SUVmax (P < 0.001) and HUmean (P < 0.001) independently predicted bone metastases. A composite prediction score, the bone uptake metastatic probability (BUMP) score, achieving an area under the receiver-operating-characteristic curve (AUC) of 0.87, was validated through a 10-fold internal and external validation (n = 89 bone uptake, 51% metastatic; AUC, 0.92). The BUMP score’s AUC was significantly higher than that of HUmean (AUC, 0.62) and remained high among lesions with HUmean in the first tertile (AUC, 0.80). A decision-curve analysis showed a higher net benefit with the score. Compared with the visual assessment, the BUMP score provided added value in terms of specificity in less-experienced PET readers (88% vs. 54%, P < 0.001). Conclusion: The BUMP score accurately distinguished UBU from bone metastases in PCa patients with [18F]PSMA-1007 focal bone uptake at PET imaging, offering additional value compared with the simple assessment of the osteoblastic CT correlate. Its use could help clinicians interpret imaging results, particularly those with less experience, potentially reducing the risk of patient overstaging.




co

Predicting Pathologic Complete Response in Locally Advanced Rectal Cancer with [68Ga]Ga-FAPI-04 PET, [18F]FDG PET, and Contrast-Enhanced MRI: Lesion-to-Lesion Comparison with Pathology

Neoadjuvant therapy in patients with locally advanced rectal cancer (LARC) has achieved good pathologic complete response (pCR) rates, potentially eliminating the need for surgical intervention. This study investigated preoperative methods for predicting pCR after neoadjuvant short-course radiotherapy (SCRT) combined with immunochemotherapy. Methods: Treatment-naïve patients with histologically confirmed LARC were enrolled from February 2023 to July 2023. Before surgery, the patients received neoadjuvant SCRT followed by 2 cycles of capecitabine and oxaliplatin plus camrelizumab. 68Ga-labeled fibroblast activation protein inhibitor ([68Ga]Ga-FAPI-04) PET/MRI, [18F]FDG PET/CT, and contrast-enhanced MRI were performed before treatment initiation and before surgery in each patient. PET and MRI features and the size and number of lesions were also collected from each scan. Each parameter’s sensitivity, specificity, and diagnostic cutoff were derived via receiver-operating-characteristic curve analysis. Results: Twenty eligible patients (13 men, 7 women; mean age, 60.2 y) were enrolled and completed the entire trial, and all patients had proficient mismatch repair or microsatellite-stable LARC. A postoperative pCR was achieved in 9 patients (45.0%). In the visual evaluation, both [68Ga]Ga-FAPI-04 PET/MRI and [18F]FDG PET/CT were limited to forecasting pCR. Contrast-enhanced MRI had a low sensitivity of 55.56% to predict pCR. In the quantitative evaluation, [68Ga]Ga-FAPI-04 change in SULpeak percentage, where SULpeak is SUVpeak standardized by lean body mass, had the largest area under the curve (0.929) with high specificity (sensitivity, 77.78%; specificity, 100.0%; cutoff, 63.92%). Conclusion: [68Ga]Ga-FAPI-04 PET/MRI is a promising imaging modality for predicting pCR after SCRT combined with immunochemotherapy. The SULpeak decrease exceeding 63.92% may provide valuable guidance in selecting patients who can forgo surgery after neoadjuvant therapy.




co

Turkey Is on the Road to a Severe Economic Crisis

Turkey Is on the Road to a Severe Economic Crisis Expert comment sysadmin 12 July 2018

The deteriorating state of the economy is President Erdoğan’s Achilles’ heel and the biggest threat to his currently unrivalled leadership.

A special one lira coin minted for the presidential inauguration of Recep Tayyip Erdogan. Photo: Getty Images.

Fifteen days after Turkey’s parliamentary and presidential elections, Turkish President Recep Tayyip Erdoğan appointed a new government under radically enhanced executive powers granted by the constitution. He chose 16 loyalists and partisan figures to ensure that he remains front and centre in decision-making and policy formation.

Most notably, Erdoğan sacrificed the former deputy prime minister and ex-Merrill Lynch chief economist Mehmet Şimşek in favour of his inexperienced son-in-law Berat Albayrak as finance and treasury minister to manage the fragile economy. Whether he has the competence to placate jittery financial markets and foreign investors is debatable.

Erdoğan will prioritize short-term growth at all costs to the detriment of macroeconomic and financial stability. That entails foregoing interest rate hikes needed to contain runaway double-digit inflation and to support a plummeting lira that depreciated nearly 20 per cent this year. It also means loosening the purse strings, flooding the markets with cheap credit and sponsoring rampant construction and mega-infrastructure projects.

True to his promise, he has appropriated to himself, by presidential decree, the right to hire the central bank governor, deputies and monetary policy committee members for a four-year term. This completes the politicization of the once-respected and independent central bank and is in line with his unorthodox monetary views that higher interest rates equates with higher inflation.

Erdoğan associates progress with gleaming high-rise buildings, gargantuan infrastructure show-pieces and elevated growth rates. He is spiking the fuel to boost the speed of the sputtering mid-sized Audi-style Turkish economy to achieve superior Ferrari growth rates. As any mechanic knows, these tactics are unsustainable in the long term. Eventually, the engine will burn out.

He does not seem to appreciate that Turkey’s growth model requires an overhaul to join the league of rich economies. It is too reliant on consumer spending and government-sponsored infrastructure and construction projects funded by speculative financial flows rather than on sustained private investment and exports.

Net result: the corporate sector’s foreign-exchange liabilities have climbed to a record $328 billion as of the end of 2017. When netted against foreign-exchange assets, it is still a worrying $214 billion. Its US dollar and euro debt pile has more than doubled since 2008, 80 per cent of which is held by domestic banks. Given these acute balance-of-payments conditions, it is not farfetched that Turkey may impose capital controls in the short-to-medium term to restrict the outflow of foreign assets. At $50 billion, the current account deficit – defined as the sum of the trade balance and financial flows – is not even covered by the central bank’s net international reserves at nearly $45 billion.

Unsurprisingly, some major Turkish companies are negotiating with their bondholders to restructure their sizeable foreign loan obligations as lira devaluation increases the financial burden. Should a significant number of Turkish corporates default on their foreign obligations, this would reverberate across the Turkish economy, cause mass consumer panic, shake the confidence of international financial markets and potentially lead to a crisis within the Turkish financial system and to a deep and prolonged economic recession.

Revealingly, Erdoğan’s nationalist allies, the Nationalist Movement Party (MHP), refused to join his government. Perhaps Devlet Bahçeli, the MHP leader, learned the lessons of the 2001 financial crisis as a member of a three-party government. So he is opting to project influence from the outside, rather than risk being tainted with responsibility for an economic downturn.

Turkey’s president is doubling down on his singular approach to governance irrespective of the fallout. Notwithstanding his current political dominance, the deteriorating state of the economy is his Achilles’ heel and the biggest threat to his currently unrivalled leadership.