At a recent clinical meeting, I heard that GPs local to me are about to lose the ability to request magnetic resonance imaging (MRI) scans for patients presenting with musculoskeletal symptoms. We’re instead advised to refer our patients to a musculoskeletal clinical assessment and triage service (CATS)—staffed largely by musculoskeletal advanced practitioners, who will assess our patients and determine whether imaging is warranted.The hope is that fewer patients will have unnecessary imaging and that this will reduce the potential harms of overdiagnosis. Radiologists rarely report musculoskeletal MRI scans as entirely normal, and it can be hard to know what to do with abnormal findings on an MRI. More often than not, patients with abnormal scans are referred to orthopaedic teams, even though there may not necessarily be a surgical target.At a population level, this is problematic on two fronts. Firstly, MRI scans are expensive and need to be used judiciously....

Q&A: Maria Kolesnikova The World Today rescobales.drupal 29 September 2021

The jailed Belarusian opposition activist says: ‘It’s worth it’

Earlier this month, the Belarusian opposition activists, Maria Kolesnikova and Maxim Znak, were sentenced to long prison terms on charges of conspiring to seize power and crimes against national security. Both Kolesnikova, a prominent musician, and Znak, a lawyer, are supporters of Sviatlana Tsikhanouskaya, who ran against President Alexander Lukashenka in last year’s election and is now in exile in Lithuania. European Union countries have called for all political detainees, including Kolesnikova, to be released, but so far these calls have fallen on deaf ears. Alistair Burnett interviewed Maria Kolesnikova.

What is your response to the verdict and the 11-year sentence handed down to you?

My conscience is clear. We didn’t break the law. We followed the law at all the stages of the electoral campaign.

After the verdict, we applauded when the judges left the courtroom. They fulfilled their despicable role in this historical process – now this decision is on their conscience.

It is impossible to take the court and the verdict in any way seriously. This is not a verdict on Maxim and me but on the authorities themselves, on the system itself.

It is evidence not only of a legal default, but of a system-wide default. I feel sorry for those who did not understand what happened and did not learn history’s lessons.

Your trial was held behind closed doors and you were charged with conspiring to seize power and crimes against national security. What can you tell us about the prosecution’s case against you?

If there had been any evidence against us, the trial would have been open.

The very existence of accusations like this denies people the potential to participate in election campaigning and in political activity generally. It also prohibits public criticism of the authorities.

Such a judgment and verdict is a Pandora’s box with far-reaching negative consequences.

After the crackdown over last year’s protests and now your sentencing, what is the state of the opposition within Belarus?

I am in prison, so it is hard for me to judge objectively people’s attempts to fight for their freedom and basic human rights. According to what I see on TV, as well as the mood of those few people I have had a chance to talk to, I can say that the authorities are scared by the people’s activism.

They understand that though they can put down protests, they can’t change people’s mindsets. I see the fear in their eyes. I also believe that even those outside of Belarus can do a lot, and it’s important to continue opposition activity both inside and outside the country.

Sviatlana Tsikhanouskaya has been visiting European countries and the United States to maintain their support. Has international pressure, including from human rights groups, had any effect on the Lukashenka government?

I will use this opportunity to say hi to Sviatlana: ‘You are amazing. Keep it up.’

I’m sure Lukashenka is scared. He turned from a person who meets presidents to talk about Ukraine into an outcast no one wants to shake hands with.

It is traumatic for him, but the fear will pass. He will get used to it.

That is why it’s important to think about the next step, to understand what American and European partners are ready to offer Lukashenka in return for him to change course. If they aren’t ready to offer him anything – it’s important to know how long they are ready to maintain the pressure.

It concerns Russia as well. Maybe they simply don’t understand that Lukashenka and his government are in a bad way.

To what extent do you believe the futures of the Lukashenka and Russian President Vladimir Putin are now intertwined?

Lukashenka is a famous manipulator. Almost 30 years in power has made his self-preservation instincts automatic. It’s a tactical choice. There’s nothing behind it besides the willingness to stay in power till he dies.

But a trapped person is a dangerous and unreliable partner. It won’t remain like this for a long time. His partners will sooner or later face unpleasant surprises.

What can the international community do?

Hundreds of political prisoners, thousands in exile, tens of thousands arrested, fined, subjected to violence, and the media and businesses are being destroyed. The authorities are at war with their own people and leading the country into an abyss.

The support of the international community is very important for Belarusians. We need to look for an opportunity to start a dialogue, both within the country and with international partners.

Why did last year’s protests last as long as they did? Was it the relative youth of the protesters; the use of social media; the prominence of women; and did COVID restrictions play any part?

For me, the protests aren’t the main thing. The transformation of Belarusian society is the most important thing.

Most Belarusians decided what they want to see in their county: Belarus as a free, democratic, sovereign country. And the current authorities aren’t able to provide that.

Regarding new technology, of course, it gives more opportunities for people to organize, however, social media users are still the minority in Belarus. Everything happened on a deeper level after being built up over time through people’s real-life experience.

Throughout the campaign, I have been surprised by the fact that most of the activists are middle-aged people from different professions. There were plenty of women who expressed their objection first.

Through the situation with COVID, we gained a new experience of solidarity and mutual assistance, so when the government turned against the people, we realized then how many we were.

Looking back now at the protests, would you do anything differently and have you learned lessons for the future?

We definitely have more appreciation for what we already have. We appreciate our amazing journalists, our civil society, and private businesses. And, of course, our upcoming victory.

What could we have done differently? We could have been more consistent in terms of our willingness to resolve the crisis quickly and painlessly for the country. We were calling for dialogue in August, and then we had this unfortunate period of ultimatums that damaged both sides.

The situation is different now, and everything is more complicated. The moment has gone, and I don’t think that negotiation or national dialogue in the form we expected a year ago is possible anymore.

We had to make very hard choices many times, but the most important thing is that we never deviated from our principles and values - the fairness of the law, kindness, respect and love. I believe it is the only right way.

How can you now achieve your goal of removing President Lukashenka from power?

To be a politician in Belarus nowadays means to be in prison. In this way, I can contribute to the common endeavor. It’s not our objective, though.

Our objective is a country free of current and future forms of authoritarianism.

How to free the country? On the one hand, we all have to maintain our effort, cohesion and solidarity. We should try not to lose that. On the other hand, we should focus on limiting the political space for the government. We should show that the system will have to deal with us, the Belarusians.

Thirdly, we have to think about the future of Belarus. We have to dream about it, believe in it and stay active. Everything is up to us.

You were a musician before becoming active in politics. Has music shaped your approach to political activism and have you had the chance to continue playing in detention?

The artistic path shapes the personality. Of course, teamwork, looking for unusual solutions, and the ability to stay concentrated and work for a long time in critical situations, as well as performing in public, is what I’ve been learning my whole life as a musician.

Management of contemporary art projects and partnerships with businesses, like with Viktar Babaryka, the former presidential candidate, for example, gave me even more experience.

I miss music a lot, but in Belarusian prisons, even books aren’t really allowed. I don’t have an opportunity to play.

Do you have any regrets about your decision to become involved in opposition politics?

I consider my decision to participate in the campaign the most important and responsible one of my life. I knew it would be hard, but the future of the nation is at stake. So it’s worth it. My love for Belarus and Belarusian people didn’t allow me to stay aloof.

Here we go again: Russia’s energy ‘diplomacy’ in Moldova Expert comment LJefferson 6 December 2021

The gas crisis shows that while the new Moldovan government may wish for geopolitics to go away, they are a weapon Russia will deploy at will.

In October, Moldova came under the spotlight when Russia, its primary provider of gas, slashed supplies by a third and refused to extend the existing contract.

The crisis was resolved at the end of October when Russia and Moldova signed a new contract, in which Moscow has used Moldova’s gas dependence to extract geopolitical concessions, weaken the new pro-western Chisinau government and drive a wedge between the EU and Moldova.

A chronic failure to reform

Moldova became a classic case of state capture when political elites – including nominally pro-European political elites – engaged in massive rent-extraction.

Up until 2020, when pro-reform forces came to power, Moldovan politics offered rapid route to riches for both the nominally pro-European parties and the pro-Russian Socialist Party; each was responsible for playing up ethnic and geopolitical cleavages in the country to mobilize votes and shore up legitimacy.

These predatory elites hollowed out Moldova economically and politically by a chronic failure to reform, in particular the energy sector which became a major source of rent.

However, this started to change when the pro-reform forces came to power as a result of the 2020 presidential and then 2021 parliament elections. The pro-reformist Maia Sandu defeated the incumbent president Igor Dodon (58 per cent to 42 per cent) in November of that year. And then her party got 58 per cent of the vote in the parliamentary elections which followed in July 2021.

Her Party of Action’s (PAS) winning formula was to focus on corruption and domestic reforms – rather than playing the ‘geopolitical’ card, a favourite strategy of their predecessors. As Sandu put it, the elections marked ‘the end of the reign of thieves in Moldova’.

A gas crisis is initiated  

Russia’s response to these results was to initiate a gas crisis. Up until the victory of the pro-reform forces, Russia had annually renewed a gas contract signed in 2007. However, in September 2021, Russia refused to renew the contract as it had done many times before and instead insisted on a new contract, which allowed Russia to create linkages between energy prices, debt settlement, a halt on energy market reforms and, it can be logically inferred, further integration with the EU.

Moldova’s national energy company, Moldovgaz, is 63.5 per cent de facto owned by Gazprom with the Moldovan government owning the remaining 35.5 per cent. (Moldova was forced to give Gazprom a controlling stake when faced with a cut in supplies in January 2006). It is therefore hardly surprising that no efforts were made to de-monopolise the sector and diversify energy supplies.

This lack of modernization can be explained by the somewhat surreal fact that in any negotiations and planning, Moldovagaz – majority owned by Gazprom – represents the Moldovan side in negotiations with Gazprom. So, when it came to signing of the new five-year contract in October 2021, Russia, through Gazprom, was able to institute a contract which made gas prices conditional on various geopolitical conditions.

It is noteworthy that Moldova’s original 2007 gas contract had been renewed annually despite the supposed accrual of debt. However, the very nature of this debt is suspect. While Moldova’s debt is said to be approximately $700 million, the debt of the much smaller breakaway Transnistria was around $7.3 billion.

The exact level and source of the debt remain murky. Russia appears to be making Moldova liable to repay at least some of Transnistria’s debt while only demanding the debt settlement with Moldova, but not with Transnistria.

High stakes for Moscow

Moreover, the contract is used to derail liberalisation of the energy market in line with EU’s energy market rules (through the so-called unbundling of supplies and distribution) which Moldova had committed itself to since the country joined the Energy Community in 2010.

Referring to ‘the non-application of forced reorganization and sanctions against Moldovagaz’, the new gas contract forces Moldova to postpone implementing the unbundling of supplies and distribution by making it conditional on resolving the energy debt.

Furthermore, Moldova ominously agreed to create an ‘intergovernmental commission on economic cooperation’ with Russia, which effectively blocks Moldova’s economic integration with the EU. (This demand is hardly new as Russia previously requested, and was granted, a seat at the negotiating table on a bilateral trade agreement between the EU and Ukraine. The trilateral EU-Ukraine-Russia negotiations have made it clear that Russia is seeking a veto over European integration of all neighbouring countries.)  

Targeting Moldova’s new reformist government reflects high personal stakes for Moscow. Moldova’s caretaker (kurator) in the Kremlin is Dimitrii Kozak, who in 2003 masterminded the so-called ‘Kozak Memorandum’. This sought to reintegrate breakaway Transnistria into a Moldova-Transnistria federation.

It was thwarted at the last minute but the Russian leadership has not given up on its plan. Now using his position as the deputy head of Presidential Administration, Kozak is masterminding Russia’s rehashed policy towards Moldova and has attempted to bring back his Memorandum as a political blueprint for a ‘settlement’.

Russia’s heavy-handed energy ‘diplomacy’

The new Moldovan government is caught in a crossfire of domestic expectations and Russian geopolitical demands. The gas crisis shows that while the new government may wish for geopolitics to go away, they are a weapon Russia will deploy at will.

The Moldovan government is brand new so it has relatively little experience of dealing with Russia’s heavy-handed ‘energy diplomacy’. But the EU has been on the receiving end of this before – this is a direct replica of Russia’s strategy toward Armenia and Ukraine – and neither ended well for the target countries or for the EU.

So, Russia’s plans for Moldova are likely to have similar consequences for the EU’s latest attempts to be a convincing foreign policy actor. 

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

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.

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.

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.

Review: One-man bandwagons The World Today rsoppelsa.drupal 25 May 2022

The ills of strongman politics are diagnosed sharply in this accessible overview – but a cure is nowhere to be found, says Natasha Lindstaedt

The Age of the Strongman: How the Cult of the Leader Threatens Democracy around the World
Gideon Rachman, Bodley Head, £20.00

For anyone reading the headlines, it should come as no surprise that democracy has regressed to where it was in 1989. The profound geopolitical and technological changes in the post-Cold World era have led to chaos, polarization, nationalist backlash and nostalgia for strong leadership in democracies. 

Countries such as Russia and China have provided a new model for leadership that has become frighteningly infectious – the strongman. 

Gideon Rachman charts this new era, offering an accessible overview of 14 examples, including Britain’s Boris Johnson, Donald Trump of the United States, Narendra Modi of India, Jair Bolsonaro of Brazil, Viktor Orbán of Hungary, Xi Jinping of China and – the archetype – Vladmir Putin of Russia.

The idea that we are living in the age of strongman politics is not particularly novel. Scholars of authoritarian politics have noted for years that there has been a steady rise in ‘personalist’ dictatorship and personalism in democracy in general. Nearly 40 per cent of all dictatorships are personalist, meaning domination by a single person, compared with 23 per cent in 1988. Autocracies have become increasingly aggressive, using sharp power to undermine democracy, which signals a shift. 

Autocracies used to focus on their own stability and didn’t interfere with democracies.

Rachman focuses on this threat that the strongman poses to democracy while macho one-man rule spreads across the globe. He provides a well-written, clear overview of why each leader fits the strongman label, what explains their appeal and what informs their worldview. 

Where Rachman is effective is in weaving together the commonalities of these strongmen – and they are all men – and their relationship to each other. Despite their ultra-nationalism, they have created an unofficial, multilateral network of mutual support. This includes leaders whose religious convictions may appear to be in conflict – such as Benjamin Netanyahu of Israel and Muhammed bin Salman of Saudi Arabia. 

This is not just a network of dictators – autocratic-style leaders of democratic countries have been welcomed to the club. In this system, strongmen openly admire each other, revel in their disdain for liberalism and human rights, and share advice and inspiration. 

This contrasts with western European leaders who fail to build such iron-clad bonds.

Each chapter is peppered with anecdotes about Rachman’s first-hand impressions of some of these leaders and other notables in positions of power gained from his decades as a foreign correspondent and analyst. His colourful commentary complements his understanding of how they operate. 

A common theme throughout is that the strongman’s appeal appears as a breath of fresh air for democracy, liberalism or peace. They are often labelled as anti-elitist and men of the people. This honeymoon period ends when each leader shows their true colours: attacking political opponents, sometimes in ruthless purges, disregarding the rule of law, weakening the courts and vilifying or controlling the media. 

A well-placed quote from Recep Erdogan sums this up: ‘Democracy is like a tram you ride until you arrive at your destination.’

Genuine public support exists for these manoeuvres. Dislocation from unmanaged globalization and economic crises has created an audience for political entrepreneurs. Strongman leaders have earned the distinction of being relatable and telling it like it is, despite many being considered to be liars and often filthy rich. 

Their ability to tap into people’s fears of the West, crime, immigrants or other ethnic and religious groups has helped gain them a fiercely loyal following. According to Rachman, strongman politics is linked to fear that a majority group that was once dominant is being threatened – something leaders such as Donald Trump have astutely tapped into.

Unlike some of the kleptocratic regimes of the 1970s and 1980s that were the embodiment of venal opportunists – think of Ferdinand Marcos of the Philippines, Mobutu of the Democratic Republic of the Congo and Jean-Claude Duvalier of Haiti – the strongmen of today have been inspired by the ideology of hyper-nationalism and anti-liberalism. 

Rachman links strongmen to the work of Carl Schmitt, a Nazi Party member, who was a vociferous critic of parliamentary democracy and cosmopolitanism, while touting the importance of illiberal norms to exercise power. Rachman argues that we are in a war of ideas, with liberalism under attack. He hones in on the perennial target George Soros, and how his support for liberal democracy has garnered the unwanted attention from the world’s right-wing ideologues and strongmen.

Social media has been usurped by these leaders and their regimes to forge closer, direct relationships with their supporters, to churn out fake news and create dangerous echo chambers. They are snake oil salesmen, making huge promises but offering very little in practice. They are never as they initially appear, and their images are carefully crafted.

Another theme emerges on the career pathway. Many served as a mayor of a cosmopolitan city. An interesting chapter on Johnson explains how he comes across like a relatable ‘good chap’, being able to handle embarrassing photo-ops. He was also a devoted Europhile, attended Eton and Oxford, and championed multi-culturalism as Mayor of London. Always the opportunist, Johnson had few qualms about campaigning for Brexit, and then later breaking the law to make it happen.

Yet there are some gaps in Rachman’s analysis.

It is never made clear why leaders such as Abdel Fattah el-Sisi of Egypt, Nicolás Maduro of Venezuela and Kim Jong-un of North Korea are largely missing, or a number of other strongman dictators in sub-Saharan Africa. 

Though there is a chapter devoted to Abiy Ahmed of Ethiopia, along with a few paragraphs devoted to Paul Kagame of Rwanda, Meles Zenawi also of Ethiopia, Emmerson Mnangagwa of Zimbabwe and Jacob Zuma of South Africa, the chapter on African strongmen does not acknowledge that this is the only continent where the regional trend is not as depressing. 

Rachman only occasionally engages with data on dictatorships to verify some of the patterns that he explores in the book. And his work would benefit from an examination of the institutional factors that may explain the rise of strongman politics, such as the pre-existing weakness of parties, parliaments and courts. 

Nor does he go in depth into how strongmen interact with their institutions and what the implications of this brand of politics are for conflict and development. The failures of strongmen to address Covid-19 are mentioned, but it is never explained why they may be so poorly equipped to govern. 

So, is democracy dead? Though Rachman is largely pessimistic, he acknowledges that politics tends to go in waves. There is little advice about how the West can expedite the end of this particular wave. 

The one positive Rachman offers is that strongman rule cannot deal with succession. This is largely true, though handovers have taken place, such as with the Kim dynasty. 

But there are definitely more questions raised than answers provided. What is left after strongmen are no longer in power? What must democracies do to undermine strongmen or prevent their rise? Where will the next strongman appear? 

Rachman’s book doesn’t provide these answers, but he does offer an interesting overview of the leaders dominating the headlines.
 

President Maia Sandu on democracy and politics in Moldova Video jon.wallace 4 July 2022

The president covers Moldova’s challenges as it seeks closer integration with the European Union.

President Maia Sandu discusses challenges to Moldovan democracy and society during an interview at Chatham House’s 2022 London Conference.

She covers issues including corruption, the presence of Russian troops in the Transnistria region, neutrality in Moldova’s constitution, popular support for EU membership and refugees from Russian aggression in Ukraine.

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.

Africa and Europe: Climate security for the future 20 April 2023 TO 21 April 2023 — 7:30AM TO 12:00PM Anonymous (not verified) 31 March 2023 Slovenia and Online

The 12th Africa Day International Conference hosted in Slovenia offers a platform for interregional exchange and policy cooperation between African and European countries on climate security.

The 12th Africa Day International Conference offers a platform for inter-regional exchange and cooperation to further contribute to progress on climate security.

The 12th Africa Day International Conference is hosted by the Ministry of Foreign and European Affairs of the Republic of Slovenia, in collaboration with the European Commission and the Chatham House Africa Programme. This high-level annual event seeks to improve policy outcomes for citizens in Europe and Africa on the basis of mutual understanding and cooperation between the two regions, while strengthening bilateral relations between Slovenia and African countries.

Climate change poses one of the most serious threats to global security. No individual country or region can face it alone; strong regional and international partnerships are crucial. Analysing risk and taking action can help towards achieving a number of SDGs and a more secure and sustainable future. Addressing climate security is essential for the well-being and future stability of nations and societies around the world, and for the global community as a whole.

This conference will offer a platform for interregional exchange and cooperation on the topic of climate security policy. It will bring together decision-makers and experts from Europe, Africa and across the globe to identify the key challenges and policy priorities in addressing climate security.

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

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 (K_i) (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 K_i (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 K_i 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.

Quantification of ¹⁸F-FDG PET images is useful for accurate diagnosis and evaluation of various brain diseases, including brain tumors, epilepsy, dementia, and Parkinson disease. However, accurate quantification of ¹⁸F-FDG PET images requires matched 3-dimensional T₁ MRI scans of the same individuals to provide detailed information on brain anatomy. In this paper, we propose a transfer learning approach to adapt a pretrained deep neural network model from amyloid PET to spatially normalize ¹⁸F-FDG PET images without the need for 3-dimensional MRI. Methods: The proposed method is based on a deep learning model for automatic spatial normalization of ¹⁸F-FDG brain PET images, which was developed by fine-tuning a pretrained model for amyloid PET using only 103 ¹⁸F-FDG PET and MR images. After training, the algorithm was tested on 65 internal and 78 external test sets. All T₁ MR images with a 1-mm isotropic voxel size were processed with FreeSurfer software to provide cortical segmentation maps used to extract a ground-truth regional SUV ratio using cerebellar gray matter as a reference region. These values were compared with those from spatial normalization-based quantification methods using the proposed method and statistical parametric mapping software. Results: The proposed method showed superior spatial normalization compared with statistical parametric mapping, as evidenced by increased normalized mutual information and better size and shape matching in PET images. Quantitative evaluation revealed a consistently higher SUV ratio correlation and intraclass correlation coefficients for the proposed method across various brain regions in both internal and external datasets. The remarkably good correlation and intraclass correlation coefficient values of the proposed method for the external dataset are noteworthy, considering the dataset’s different ethnic distribution and the use of different PET scanners and image reconstruction algorithms. Conclusion: This study successfully applied transfer learning to a deep neural network for ¹⁸F-FDG PET spatial normalization, demonstrating its resource efficiency and improved performance. This highlights the efficacy of transfer learning, which requires a smaller number of datasets than does the original network training, thus increasing the potential for broader use of deep learning–based brain PET spatial normalization techniques for various clinical and research radiotracers.

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.

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 p53^R175H 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 p53^R172H 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.

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).

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.

To date, the imaging and diagnosis of hepatocellular carcinoma (HCC) rely on CT/MRI, which have well-known limitations. Glypican-3 (GPC3) is a cell surface receptor highly expressed by HCC but not by normal or cirrhotic liver tissue. Here we report initial clinical results of GPC3-targeted PET imaging with [⁶⁸Ga]Ga-DOTA-RYZ-GPC3 (RAYZ-8009), a peptide-based GPC3 ligand in patients with known or suspected HCC. Methods: [⁶⁸Ga]Ga-RAYZ-8009 was obtained after labeling the peptide precursor with ⁶⁸Ga from a ⁶⁸Ge/⁶⁸Ga generator and heating at 90°C for 10 min followed by sterile filtration. After administration of [⁶⁸Ga]Ga-RAYZ-8009, a dynamic or static PET/CT scan was acquired between 45 min and 4 h after administration. Radiotracer uptake was measured by SUVs for the following tissues: suspected or actual HCC or hepatoblastoma lesions, non–tumor-bearing liver, renal cortex, blood pool in the left ventricle, and gastric fundus. Additionally, tumor–to–healthy-liver ratios (TLRs) were calculated. Results: Twenty-four patients (5 patients in the dynamic protocol; 19 patients in the static protocol) were scanned. No adverse events occurred. Two patients had no lesion detected and did not have HCC during follow-up. In total, 50 lesions were detected and analyzed. The mean SUV_max of these lesions was 19.6 (range, 2.7–95.3), and the mean SUV_mean was 10.1 (range, 1.0–49.2) at approximately 60 min after administration. Uptake in non–tumor-bearing liver and blood pool rapidly decreased over time and became negligible 45 min after administration (mean SUV_mean, <1.6), with a continuous decline to 4 h after administration (mean SUV_mean, 1.0). The opposite was observed for HCC lesions, for which SUVs and TLRs continuously increased for up to 4 h after administration. In individual lesion analysis, TLR was the highest between 60 and 120 min after administration. Uptake in the gastric fundus gradually increased for up to 45 min (to an SUV_max of 31.3) and decreased gradually afterward. Conclusion: [⁶⁸Ga]Ga-RAYZ-8009 is safe and allows for high-contrast imaging of GPC3-positive HCC, with rapid clearance from most normal organs. Thereby, [⁶⁸Ga]Ga-RAYZ-8009 is promising for HCC diagnosis and staging. Further research is warranted.

Our purpose was to prospectively assess the distribution of NETPET scores in well-differentiated (WD) grade 2 and 3 gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) and to determine the impact of the NETPET score on clinical management. Methods: This single-arm, institutional ethics review board–approved prospective study included 40 patients with histologically proven WD GEP NETs. ⁶⁸Ga-DOTATATE PET and ¹⁸F-FDG PET were performed within 21 d of each other. NETPET scores were evaluated qualitatively by 2 reviewers, with up to 10 marker lesions selected for each patient. The quantitative parameters that were evaluated included marker lesion SUV_max for each tracer; ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios; functional tumor volume (FTV) and metabolic tumor volume (MTV) on ⁶⁸Ga-DOTATATE and ¹⁸F-FDG PET, respectively; and FTV/MTV ratios. The treatment plan before and after ¹⁸F-FDG PET was recorded. Results: There were 22 men and 18 women (mean age, 60.8 y) with grade 2 (n = 24) or grade 3 (n = 16) tumors and a mean Ki-67 index of 16.1%. NETPET scores of P0, P1, P2A, P2B, P3B, P4B, and P5 were documented in 2 (5%), 5 (12.5%), 5 (12.5%) 20 (50%), 2 (5%), 4 (10%), and 2 (5%) patients, respectively. No association was found between the SUV_max of target lesions on ⁶⁸Ga-DOTATATE and the SUV_max of target lesions on ¹⁸F-FDG PET (P = 0.505). ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios were significantly lower for patients with low (P1–P2) primary NETPET scores than for those with high (P3–P5) primary NETPET scores (mean ± SD, 0.20 ± 0.13 and 1.68 ± 1.44, respectively; P < 0.001). MTV on ¹⁸F-FDG PET was significantly lower for low primary NETPET scores than for high ones (mean ± SD, 464 ± 601 cm³ and 66 ± 114 cm³, respectively; P = 0.005). A change in the type of management was observed in 42.5% of patients after ¹⁸F-FDG PET, with the most common being a change from systemic therapy to peptide receptor radionuclide therapy and from debulking surgery to systemic therapy. Conclusion: There was a heterogeneous distribution of NETPET scores in patients with WD grade 2 and 3 GEP NETs, with more than 1 in 5 patients having a high NETPET score and a frequent change in management after ¹⁸F-FDG PET. Quantitative parameters including ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios in target lesions and FTV/MTV ratios can discriminate between patients with high and low NETPET scores.

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 SUV_max, SUV_mean, PSMA tumor volume, and total lesion PSMA. The same volume of interest was applied to CT images to calculate the mean Hounsfield units (HU_mean) 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 SUV_max (P < 0.001) and HU_mean (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 HU_mean (AUC, 0.62) and remained high among lesions with HU_mean 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.

This analysis aimed to identify clinical factors associated with positivity on repeat ⁶⁸Ga-PSMA-11 PET/CT after a negative scan in patients with recurrent prostate cancer (PCa) under observation. Methods: This single-center, retrospective analysis included patients who underwent at least 2 ⁶⁸Ga-PSMA-11 PET/CT scans (PET1 and PET2) at UCLA between October 2016 and June 2021 for recurrent PCa with negative PET1 and no PCa-related treatments between the 2 scans. Using Prostate Cancer Molecular Imaging Standardized Evaluation criteria to define negative and positive scans, the final cohort was divided into PET2-negative (PET2-Neg) and PET2-positive (PET2-Pos). The same PET1 was used twice in the more than 2 PET cases with inclusion criteria fulfilled. Patient characteristics and clinical parameters were compared between the 2 cohorts using Mann–Whitney U test and Fisher exact test. Areas under the curve (AUCs) of the receiver operating characteristic and the Youden index were computed to determine the discrimination ability of statistically significant factors and specific cut points that maximized sensitivity and specificity, respectively. Results: The final analysis included 83 sets of 2 PET/CT scans from 70 patients. Thirty-nine of 83 (47%) sets were PET2-Neg, and 44 of 83 (53%) sets were PET2-Pos. Prostate-specific antigen (PSA) increased from PET1 to PET2 for all 83 (100%) sets of scans. Median PSA at PET1 was 0.4 ng/mL (interquartile range, 0.2–1.0) and at PET2 was 1.6 ng/mL (interquartile range, 0.9–3.8). We found higher serum PSA at PET2 (median, 1.8 vs. 1.1 ng/mL; P = 0.015), absolute PSA difference (median, 1.4 vs. 0.7 ng/mL; P = 0.006), percentage of PSA change (median, +270.4% vs. +150.0%: P = 0.031), and median PSA velocity (0.044 vs. 0.017 ng/mL/wk, P = 0.002) and shorter PSA doubling time (DT; median, 5.1 vs. 8.3 mo; P = 0.006) in the PET2-Pos cohort than in the PET2-Neg cohort. Receiver operating characteristic curves showed cutoffs for PSA at PET2 of 4.80 ng/mL (sensitivity, 34%; specificity, 92%; AUC, 0.66), absolute PSA difference of 0.95 ng/mL (sensitivity, 62%; specificity, 71%; AUC, 0.68), percentage of PSA change of a positive 289.50% (sensitivity, 48%; specificity, 82%; AUC, 0.64), PSA velocity of 0.033 ng/mL/wk (sensitivity, 57%; specificity, 80%; AUC, 0.70), and PSA DT of 7.91 mo (sensitivity, 71%; specificity, 62%; AUC, 0.67). Conclusion: Patients with recurrent PCa under observation after a negative ⁶⁸Ga-PSMA-11 PET/CT scan with markedly elevated serum PSA levels and shorter PSA DT are more likely to have positive findings on repeat ⁶⁸Ga-PSMA-11 PET/CT.

Single-domain antibodies (sdAbs) demonstrate favorable pharmacokinetic profiles for molecular imaging applications. However, their renal excretion and retention are obstacles for applications in targeted radionuclide therapy (TRT). Methods: Using a click-chemistry–based pretargeting approach, we aimed to reduce kidney retention of a fibroblast activation protein α (FAP)–targeted sdAb, 4AH29, for ¹⁷⁷Lu-TRT. Key pretargeting parameters (sdAb-injected mass and lag time) were optimized in healthy mice and U87MG (FAP⁺) xenografts. A TRT study in a pancreatic ductal adenocarcinoma (PDAC) patient-derived xenograft (PDX) model was performed as a pilot study for sdAb-based pretargeting applications. Results: Modification of 4AH29 with trans-cyclooctene (TCO) moieties did not modify the sdAb pharmacokinetic profile. A 200-µg injected mass of 4AH29-TCO and an 8-h lag time for the injection of [¹⁷⁷Lu]Lu-DOTA-PEG₇-tetrazine resulted in the highest kidney therapeutic index (2.0 ± 0.4), which was 5-fold higher than that of [¹⁷⁷Lu]Lu-DOTA-4AH29 (0.4 ± 0.1). FAP expression in the tumor microenvironment was validated in a PDAC PDX model with both immunohistochemistry and PET/CT imaging. Mice treated with the pretargeting high-activity approach (4AH29-TCO + [¹⁷⁷Lu]Lu-DOTA-PEG₇-tetrazine; 3 x 88 MBq, 1 injection per week for 3 wk) demonstrated prolonged survival compared with the vehicle control and conventionally treated ([¹⁷⁷Lu]Lu-DOTA-4AH29; 3 x 37 MBq, 1 injection per week for 3 wk) mice. Mesangial expansion was reported in 7 of 10 mice in the conventional cohort, suggesting treatment-related kidney morphologic changes, but was not observed in the pretargeting cohort. Conclusion: This study validates pretargeting to mitigate sdAbs’ kidney retention with no observation of morphologic changes on therapy regimen at early time points. Clinical translation of click-chemistry–based pre-TRT is warranted on the basis of its ability to alleviate toxicities related to biovectors’ intrinsic pharmacokinetic profiles. The absence of representative animal models with extensive stroma and high FAP expression on cancer-associated fibroblasts led to a low mean tumor-absorbed dose even with high injected activity and consequently to modest survival benefit in this PDAC PDX.

Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumors for which standardized diagnostic work-up fails to identify the primary site. We aimed to describe the Peter MacCallum Cancer Centre experience with ¹⁸F-FDG PET/CT in extracervical CUP with respect to detection of a primary site and its impact on management. A secondary aim was to compare overall survival (OS) in patients with and without a detected primary site. Methods: CUP patients treated between 2014 and 2020 were identified from medical oncology clinics and ¹⁸F-FDG PET/CT records. Information collated from electronic medical records included the suspected primary site and treatment details before and after ¹⁸F-FDG PET/CT. Clinicopathologic details and genomic analysis were used to determine the clinically suspected primary site and compared against 2 independent masked reads of ¹⁸F-FDG PET/CT images by nuclear medicine specialists to determine sensitivity, specificity, accuracy, and the rate of detection of the primary site. Results: We identified 147 patients, 65% of whom had undergone molecular profiling. The median age at diagnosis was 61 y (range, 20–84 y), and the median follow-up time was 74 mo (range, 26–83 mo). Eighty-two percent were classified as having an unfavorable CUP subtype as per international guidelines.¹⁸F-FDG PET/CT demonstrated a primary site detection rate of 41%, resulted in a change in management in 22%, and identified previously occult disease sites in 37%. Median OS was 16.8 mo for all patients and 104.7 and 12.1 mo for favorable and unfavorable CUP subtypes, respectively (P < 0.0001). Median OS in CUP patients when using ¹⁸F-FDG PET/CT, clinicopathologic, and genomic information was 19.8 and 8.5 mo when a primary site was detected and not detected, respectively (P = 0.016). Multivariable analysis of survival adjusted for age and sex remained significant for identification of a potential primary site (P < 0.001), a favorable CUP (P < 0.001), and an Eastern Cooperative Oncology Group status of 1 or less (P < 0.001). Conclusion: ¹⁸F-FDG PET/CT plays a complementary role in CUP diagnostic work-up and was able to determine the likely primary site in 41% of cases. OS is improved with primary site identification, demonstrating the value of access to diagnostic ¹⁸F-FDG PET/CT for CUP patients.

This study evaluates the diagnostic utility of PET/MRI for primary, locoregional, and nodal head and neck squamous cell carcinoma (HNSCC) through systematic review and metaanalysis. Methods: A systematic search was conducted using PubMed and Scopus to identify studies on the diagnostic accuracy of PET/MRI for HNSCC. The search included specific terms and excluded nonhybrid PET/MRI studies, and those with a sample size of fewer than 10 patients were excluded. Results: In total, 15 studies encompassing 638 patients were found addressing the diagnostic test accuracy for PET/MRI within the chosen subject domain. Squamous cell carcinoma of the nasopharynx was the most observed HNSCC subtype (n = 198). The metaanalysis included 12 studies, with pooled sensitivity and specificity values of 93% and 95% per patient for primary disease evaluation, 93% and 96% for locoregional evaluation, and 89% and 98% per lesion for nodal disease detection, respectively. An examination of a subset of studies comparing PET/MRI against PET/CT or MRI alone for evaluating nodal and locoregional HNSCC found that PET/MRI may offer slightly higher accuracy than other modalities. However, this difference was not statistically significant. Conclusion: PET/MRI has excellent potential for identifying primary, locoregional, and nodal HNSCC.

Tumor hypoxia, an integral biomarker to guide radiotherapy, can be imaged with ¹⁸F-fluoromisonidazole (¹⁸F-FMISO) hypoxia PET. One major obstacle to its broader application is the lack of standardized interpretation criteria. We sought to develop and validate practical interpretation criteria and a dedicated training protocol for nuclear medicine physicians to interpret ¹⁸F-FMISO hypoxia PET. Methods: We randomly selected 123 patients with human papillomavirus–positive oropharyngeal cancer enrolled in a phase II trial who underwent 123 ¹⁸F-FDG PET/CT and 134 ¹⁸F-FMISO PET/CT scans. Four independent nuclear medicine physicians with no ¹⁸F-FMISO experience read the scans. Interpretation by a fifth nuclear medicine physician with over 2 decades of ¹⁸F-FMISO experience was the reference standard. Performance was evaluated after initial instruction and subsequent dedicated training. Scans were considered positive for hypoxia by visual assessment if ¹⁸F-FMISO uptake was greater than floor-of-mouth uptake. Additionally, SUV_max was determined to evaluate whether quantitative assessment using tumor-to-background ratios could be helpful to define hypoxia positivity. Results: Visual assessment produced a mean sensitivity and specificity of 77.3% and 80.9%, with fair interreader agreement ( = 0.34), after initial instruction. After dedicated training, mean sensitivity and specificity improved to 97.6% and 86.9%, with almost perfect agreement ( = 0.86). Quantitative assessment with an estimated best SUV_max ratio threshold of more than 1.2 to define hypoxia positivity produced a mean sensitivity and specificity of 56.8% and 95.9%, respectively, with substantial interreader agreement ( = 0.66), after initial instruction. After dedicated training, mean sensitivity improved to 89.6% whereas mean specificity remained high at 95.3%, with near-perfect interreader agreement ( = 0.86). Conclusion: Nuclear medicine physicians without ¹⁸F-FMISO hypoxia PET reading experience demonstrate much improved interreader agreement with dedicated training using specific interpretation criteria.

Bispecific antibodies (bsAbs) are engineered to target 2 different epitopes simultaneously. About 75% of the 16 clinically approved bsAbs have entered the clinic internationally since 2022. Hence, research on biomedical imaging of various radiolabeled bsAb scaffolds may serve to improve patient selection for bsAb therapy. Here, we provide a comprehensive overview of recent advances in radiolabeled bsAbs for imaging via PET or SPECT. We compare direct targeting and pretargeting approaches in preclinical and clinical studies in oncologic research. Furthermore, we show preclinical applications of imaging bsAbs in neurodegenerative diseases. Finally, we offer perspectives on the future directions of imaging bsAbs based on their challenges and opportunities.

Following early acceptance by urologists, the use of surgical robotic platforms is rapidly spreading to other surgical fields. This empowerment of surgical perception via robotic advances occurs in parallel to developments in intraoperative molecular imaging. Convergence of these efforts creates a logical incentive to advance the decades-old image-guided robotics paradigm. This yields new radioguided surgery strategies set to optimally exploit the symbiosis between the growing clinical translation of robotics and molecular imaging. These strategies intend to advance surgical precision by increasing dexterity and optimizing surgical decision-making. In this state-of-the-art review, topic-related developments in chemistry (tracer development) and engineering (medical device development) are discussed, and future scientific robotic growth markets for molecular imaging are presented.

Turkey's Foreign Policy: The Perspective of the Main Opposition Party 5 November 2020 — 12:00PM TO 1:00PM Anonymous (not verified) 14 October 2020 Online

The Republican People’s Party (CHP), the main Turkish opposition party, is becoming a serious contender for a leading role in the country’s politics.

This is an online only event.

CHP’s mayoral candidates defeated the Justice and Development Party (AKP) incumbents in the 2019 local elections in Ankara and Istanbul, which held both cities for a quarter of a century. Its ascendency in Turkish politics is improving prospects for a CHP-led government after the next general election in 2023.

In this webinar, the speaker will share CHP’s stance on the country’s foreign policy towards key regional allies in Europe, as well as its take on relations with Russia, the US and Turkey’s position and role in the Middle East. Finally, the speaker will share how CHP’s external policy might differ from the ruling AKP. 

Turkey-Russia Relations: A Marriage of Convenience? 26 November 2020 — 12:00PM TO 1:30PM Anonymous (not verified) 17 November 2020 Chatham House

Speakers discuss the complex but, so far, durable ties between Putin and Erdogan and the perspectives of each leader. Other issues will include the impact of the Biden presidency and the unfolding situation in Nagorny Karabakh.

This is an online only event

Russia-Turkey relations are governed by a unique dynamic between presidents Vladimir Putin and Recep Tayyip Erdogan. They pursue contrasting objectives in Libya, the Eastern Mediterranean, Caucasus and Ukraine; yet they have managed to compartmentalize their differences to avoid any spill-over into diplomatic, military and economic cooperation.

Erdogan purchased the Russian S400 missile defence system at the cost of ejection from the US-led fourth generation F35 stealth fighter programme; and at the risk of sanctions by Washington. Russia is also proceeding with the construction of the Akkuyu Nuclear Power Plant near Turkey’s Mediterranean coast.

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CHANDLER, Ariz., Oct. 23, 2024 — The global edge computing market is expected to grow by more than 30 percent in the next five years, serving mission-critical applications in the […]

The post Microchip Expands 64-Bit Portfolio with High-Performance PIC64HX Microprocessors for Edge Computing appeared first on HPCwire.

TEL AVIV, Israel and MINNEAPOLIS, Oct. 30, 2024 — NextSilicon, a pioneer in high-performance computing (HPC) innovation, today announced its emergence from stealth with the launch of Maverick-2, the industry’s first […]

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An American woman who was traveling in Hungary was killed in Budapest last week allegedly by a man she met on vacation.

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Oil giant Shell emerged victorious Tuesday from a Dutch court where it was appealing a ruling ordering it to slash its global carbon emissions by 45% by the end of the decade in line with the Paris climate agreement.

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