Humanity has triggered the sixth mass extinction episode since the beginning of the Phanerozoic. The complexity of this extinction crisis is centred on the intersection of two complex adaptive systems: human culture and ecosystem functioning, although the significance of this intersection is not properly appreciated. Human beings are part of biodiversity and elements in a global ecosystem. Civilization, and perhaps even the fate of our species, is utterly dependent on that ecosystem's proper functioning, which society is increasingly degrading. The crisis seems rooted in three factors. First, relatively few people globally are aware of its existence. Second, most people who are, and even many scientists, assume incorrectly that the problem is primarily one of the disappearance of species, when it is the existential threat of myriad population extinctions. Third, while concerned scientists know there are many individual and collective steps that must be taken to slow population extinction rates, some are not willing to advocate the one fundamental, necessary, ‘simple’ cure, that is, reducing the scale of the human enterprise. We argue that compassionate shrinkage of the human population by further encouraging lower birth rates while reducing both inequity and aggregate wasteful consumption—that is, an end to growthmania—will be required.This article is part of the theme issue ‘Ecological complexity and the biosphere: the next 30 years’. Save for the ethically and ecologically unsound arguments of de-extinction advocates (see ), the lo. 2Most conservation research focuses on the impact of each of the drivers of global change on biodiversity. It is critical, however, to appreciate that the overall impact is the result of the drivers interacting in multiple and complex ways, including synergies, feedbacks and nonlinear direct and indirect effects . This meAppreciation of the complex interplay of drivers of biodiversity loss warrants future research, and it is encouraging that recent work has started to analyse the impact of combined drivers of biodiversity loss . Neverth. 3ca 50% ).The vast literature on the biodiversity–ecosystem function relationship and the significance thereof in terms of services to humanity has focused its attention on the consequences of changes in the diversity of (mostly) plant species or genetic variants on four major types of ecological processes: (i) provisioning, such as crop yield, fodder yield, wood production, medicines and medicine models; (ii) regulating, such as biocontrol, pollination and nutrient cycling; (iii) support services such as primary productivity; and (iv) cultural services, such as inspiration, and education . BiodivIn a different perspective, ecosystem services have been examined in economic terms (see a major review in ), and seHomo sapiens being present when the normal recovery times following a mass extinction occur is simply unrealistic. Finally, it is imperative to appreciate that all these aspects of human dependence on biodiversity—the intersection between human culture and ecosystem services—occur at the level of the populations of the myriad species and functional groups present where human populations are present. Therefore, it is crucial that we examine the impact of the human enterprise on the myriad populations of plants, animals, fungi and microorganisms.This short review makes it evident that humanity cannot survive in the absence of biodiversity and ecosystem functioning, which, as we have discussed above, we are increasingly degrading. Furthermore, the prospect of . 5We re-emphasize that the magnitude of the current extinction crisis is underestimated owing to three key factors. First, the lack of attention given to this existential threat . Second,Let us consider, first the global extinction of species—the total disappearance of different kinds of organisms from the face of the Earth; that is the facet of the sixth mass extinction event that captures most of the attention, among both the scientific community and the public. The strong emphasis placed on numbers of extinct species leads to the misinterpretation that biodiversity is not immediately threatened but is just part of a slow episode of extinction. For example, the number of vertebrate species recorded as extinct since year 1500 is 338, or 667 if we count species extinct in the wild and those regarded as threatened  Species Red List). These are seemingly low numbers, in contrast with estimates of many millions of species extant. However, they result from close to 60 and 70%, respectively, occurring over just the last 120 years ,12. Thisa). Depending on the environmental heterogeneity that occurs through the range, populations of the species can be phenotypically or genetically differentiated into locally adapted populations (represented by the different shades of colour in figure 1a). In their native range, the individuals that make up such populations are sufficiently abundant that the populations are demographically and genetically viable (stage 0 in figure 1b). It is these population mosaics that are being impacted by the different drivers of anthropogenic impact—individually and in complex synergies among all these. Under such stresses, the abundance of individuals begins to decline , with some populations reducing their densities to levels below population viability , in some cases with populations experiencing extreme declines, leading to local population extinctions and range contractions . As this process progresses and population extinctions continue, the range shrinks even further , to the point that only a few populations, comprising a few individuals , remain. At this stage, the species can still be counted as not extinct, even though it has experienced the collapse of its populations and humanity has lost the ecosystem services it once supplied. The extinction dynamics depicted here represent the prelude of the global extinction of species and are exemplified by numerous species of plants and animals. For example, from a sample of 177 species of mammals, just shy of 50% exhibited a range contraction of at least 80% in the period of 1990–2015 [Most species are constituted of a mosaic of populations distributed throughout their geographical range a. Depend990–2015 . Similar990–2015 . These eLoxodonta africana), common hippopotamus (Hippopotamus amphibius) and black rhino (Diceros bicornis), which have been exterminated in many areas of their original distribution ranges throughout Africa and South Asia [within-species biological extinction); that the ecology of the savannah  in those localities is now disrupted [Pongo spp.), Asian rhinos (Rhinoceros spp.) and the Oriental pied hornbill ; the koala (Phascolarctos cinereus) [Panthera onca), harpy eagle (Harpia harpyja) [Tapirus spp.) [Bison bison), wolf (Canis lupus) and grizzly bear (Ursus arctos) in North America [Furthermore, from the point of view of the species' ecological roles within their natural communities and ecosystems, it is their local populations that really matter. Consider, for example, the case of the elephant   in Austrharpyja)  and tapius spp.)  in Latin America ,51.. 6A number of proximate actions can be taken to prevent populations from circling the extinction drain, including the following. (a)Although the magnitude of the crisis is formidable, as we have outlined here, effective communication of what is at stake is central . Graspin (b)Although the damage to biodiversity is considerable, we still have a few relatively unscathed remnants in the natural protected areas of the world and, to some degree, in some human-dominated landscapes. Since a large portion of such remnants of biodiversity is present in Indigenous and rural territories, recognizing, supporting and materially compensating those populations is a matter of utmost importance. In addition, safeguarding those Indigenous territories is critical to retain the traditional ecological knowledge and languages that are being profoundly eroded from these communities across the world ,53. This (c)The dramatic deforestation resulting from land conversion for agriculture and meat production could be reduced via adopting a diet that reduces meat consumption. Less meat can translate not only into less heat, but also more space for biodiversity and betterment of human health . Althoug (d)To the extent that we engage in telling it like it is, and society becomes increasingly better informed of the risks of a ghastly future , we can . 7It is clear that only a giant change in human culture can significantly limit the extinction crisis. Humanity must face the need to reduce birth rates further, especially among the overconsuming wealthy and middle classes. In addition, a reduction of wasteful consumption will be necessary, accompanied by a transition away from environmentally malign technological choices such as private automobiles, plastic everything, and treating billionaires to space tourism. Otherwise growthmania will win; the human enterprise will not undergo the needed shrinkage, but will continue to expand, destroying most of biodiversity and further wrecking the life-support systems of humanity until global civilization collapses . AvoidinMAHB.Stanford.edu) must challenge us to pay attention to the biospheric complex adaptive systems as well. The price of not doing so will end the dizziness—we will go down the environmental and cultural drain.Circling the drain is dizzying even for scientists documenting it. All people well enough off to pay attention to issues beyond their immediate needs and those of their loved ones are faced with arrays of serious issues buried in the cultural complex adaptive systems. Health, finances, politics, status and such, demand our attention. However, from childhood, the formal education system and the communications of civil society (


N = 219) and Finnish (N = 775) school leaders’ responses to open-ended questions in an electronic survey. In the analysis we used five categories drawn from the data: Making decisions, Re-organizing schoolwork, Communication, Giving support, and Self. The findings show leaders stressing especially the themes of within school communication and giving support both at emotional-level and in the use of technology in teaching. The findings signal a leadership approach composed of care and empathy. Moreover, within the category Self, the leader’s ability to lead themselves and manage stress were extensively brought out. We provide four messages reflecting leadership during times of both turbulence and tranquility. For example, a leader’s knowledge about pedagogy prepares the ground for meaningful reorganization of teaching and learning. Also, attention should be paid to locally established structures for collaboration across schools as they support leaders’ work.We examined practices and experiences of leadership during the COVID-19 school closures in 2020 by analyzing Estonian ( During the early months of 2020, countries around Europe reacted with a range of measures to suppress the spread of COVID-19 . Most coIn the European context, the shift to remote learning can be considered as an acceleration and consolidation of the implementation and use of a variety of technologies in schools . NeverthFrom the perspective of school leaders’ work, the era of the COVID-19 pandemic has brought up challenges culminating in experiences of uncertainty and ambiguity . LeadersAs the earlier studies published here have noted, national education systems differ regarding their experiences on crisis or unexpected events affecting the functionality of the society e.g. . A largeLeaders having a broad understanding of change and leadership are more likely to be successful in navigating their school communities through turbulent times . LeadersThe COVID-19 pandemic led to challenges characterized by uncertainty and complexity, to which we cannot automatically apply the currently known methods . In a scIn uncertain times, communication becomes a central means for sense-making , giving Conflicting information concerning the COVID-19 and the methods and means of protection have added to the complexity of the situation in which school leaders work . PracticCollective responsibilities and practices can foster a collaborative culture and encourage teachers to participate in school-based decision making, taking initiative  and engaA sudden transition to a new way of schooling changed the nature of leaders’ work and called for more emphasis on supporting the school community . It has Empathy as the ability to understand the perspectives of others  is one oLeaders are increasingly managing emotional responses to the crisis including anxiety, frustration, loss, and anger that can become emotionally exhausting . ConsequIn this article we report on a study the aim of which was to explore how school leaders experienced their work during the COVID-19 school closure period in Estonia and Finland. The research was guided by the following question: Which aspects of leadership became vital in Estonian and Finnish school leaders’ work during the first remote learning period in 2020?In April-May 2020, during the simultaneous remote learning periods in Estonia and Finland, researchers in both countries were separately preparing a nationwide data collection to gather information on how the unexpected changes had affected the daily practices of school leaders, personnel, students, and guardians. To gain a wider perspective of leadership, Estonian and Finnish researchers decided on a joint set of open-ended questions for school leaders to be integrated into their national surveys. In the context of this study, the concept of a school leader has been defined as a member of the school community who is involved in a formal leadership team. The data have been composed of school leaders’ responses to two open-ended questions: What was the most challenging for you as a leader in this situation [school closures]? What are the qualities required of a leader in a change like this? These questions were to complement each other and to trigger the thinking of the leaders and to reflect more broadly on the leadership in critical situations.N = 166), representing all Estonian regions (N = 15), which is 31% of schools in Estonia. Altogether 219 school leaders from 138 schools responded to the survey. Most respondents (91%) worked at schools where the language of instruction is Estonian, whilst 9% reported Russian as the language of instruction. A third of the respondents (34%) worked at schools in the capital area, which demographically corresponds with the distribution of the Estonian population. The data were representative of the Estonian school leader population in terms of age (see In Estonia an electronic survey was sent to a sample of comprehensive schools ( age see  and the N = 2231) in all Finnish municipalities (N = 309). The response rate was good (38%). The data are representative in the Finnish context covering 74% of the local education organizers . Altogether 775 Finnish school leaders answered at least one of the open-ended questions and their responses were included in the study. Data collection was carried out in Finland’s two official languages, Finnish and Swedish, and 10% of school leaders answered in Swedish. The Finnish data are representative of the Finnish school leader population in terms of age  and resulted in identifying 13 sub-themes and 5 main themes.Two researchers in Finland and two in Estonia engaged in independent initial coding of the responses of the open questions to encounter issue-relevant meaning units, that is, small sections of text of one or several phrases long . The meap < 0.001), 95% CI , which is considered as “good” (p < 0.001), 95% CI .The credibility was increased by constant peer-checking and comparison, reliability of the main themes and sub-themes was decided by consensus . One of s “good” . Also, tResearch participants in Estonia and Finland were provided with information about the key elements of the national studies, their rights as respondents, and the storage, analysis, and the use of the data. In Estonia the study went through the ethics committee of the Tallinn University to get approval for data collection. The researchers of the University of Helsinki are committed to following the Ethical Principles of Research in the Humanities and Social and Behavioural Sciences . A stateThe overview of the emphasis in responses to the open-ended question shows  that manStructured leadership was related to authoritarian style of organizing the schoolwork entailing giving clear and strict instructions to personnel. Second, Sharing in leadership practices concerned distribution of responsibilities and opportunities for joint discussions. In addition, some responses contained mentions of Risk management referring to situations in which leaders felt how they led the school through the crisis by making hasty decisions without enough knowledge or experience. Of the three subthemes, school leaders reported more structured than shared leadership or risk management, yet the emphasis varied in the responses per country.Under this main theme we looked at the ways school leaders made decisions, the pace of making them, and the aspect of sharing in these processes . The firThe Estonian school leaders placed strong emphasis on structured leadership in their responses. They reported that the most important thing for the teaching community was to receive clear and strict instructions about what to do and how to act. Therefore, the decisions had to be contemplated, tangible, and clearly formulated. Sometimes the only thing “What is needed is the courage to decide, a bad decision is better than no decision at all” as one leader (EST48) stated. In the crisis, an authoritarian (or even autocratic) way of leading was sometimes perceived as necessary, especially if there was no time for a shared discussion with others. Some leaders considered essential to form a crisis management team having competence and power to make decisions and implement them. As a sub-theme, sharing in leadership was related to leaders’ feelings of not being able or willing to make all decisions by themselves, having trust in teachers, and encouraging teachers to solve problems on the spot.The mentions of decision-making were relatively scarce in the Finnish school leaders’ responses if compared to the other main themes . The leaImplementing new technology-related practices focused on the (new) technologies and platforms leaders introduced and implemented in their schools for teaching, learning, and other daily practices (e.g. meetings). The other sub-theme, Re-organizing teaching concerned leading the pedagogy needed with the new technologies and re-thinking the ways to organize a school day and re-allocating timetables. Overall, our observations indicate that the Estonian school leaders reflected on both the implementation of new practices in their schools and reorganization of teaching practices, whereas their Finnish colleagues focused on the reorganization of teaching practices  could easily follow. They found it challenging to come by and implement new digital platforms and technological solutions, but also to share and store digital teaching materials to make them accessible to students. The introduction of platforms for meetings, finding ways for teachers to communicate with students, give them feedback and assess them were regarded as a hurdle. Moreover, several daily issues kept leaders busy, such as offering digital devices to underprivileged students, managing licenses and accounts, and organizing the admission of future students. In their responses the leaders considered the future and pointed out the need for clearly specified channels of communication and platforms for digital learning materials organized at the national level. In addition, the challenges they perceived that leading school life in an unknown situation included dealing with students who had lost their motivation, and practices enhancing students’ well-being . They also pointed out that teachers who earlier worked autonomously in their classrooms, found it difficult to work individually and to give up old work habits. Further, leaders had to work closely with teachers in developing common principles for online assessment, student workload, and enriching teaching methods.The Finnish leaders noted that to lead remote learning, a clear pedagogical vision, and an ability to apply it to the new situation were necessary. The concept of “pedagogical leadership” emerged often in the responses and referred to leaders’ response to teachers’ need for guidance regarding the structure of a school day and the requirements for student learning. One leader (FIN600) wrote that “In the beginning, the role of pedagogical leadership became more obvious as some teachers tended to demand too little from the students while others demanded too much.” Some leaders mentioned the importance of deciding on joint practices and the assessment of them, which enabled them to adjust the schoolwork according to the received feedback. In addition, some stated how it was essential that they were knowledgeable in the use of technology in schoolwork. They implemented new technologies for communication with teachers, among teachers, and between teachers and students. Some schools provided laptops or computers to students who did not have them at home.Internal and External Communication, was an oft-repeated topic in both countries  space for teacher collaboration. Although the organization of regular online meetings became a routine, finding ways to prevent teacher burnout caused by extensive online work was considered difficult. One leader (EST98) put this in words as follows:When describing communication with parents during the early phases of the pandemic, leaders emphasized launching of information channels and mutual communication. In addition, the formulation of guidelines for the members of the school community felt demanding while being surrounded by contradicting information coming from various sources.In the Finnish context school leaders used expressions such as precision, transparency, and regularity when they described giving instructions and guidelines to teachers, students, and homes. In many responses the leaders underlined the requirement of clarity in the internal communication, and it was vital to possess “the ability to communicate in a clear and reassuring manner” (FIN585). It was the leader’s responsibility to filter out pieces of information that were not relevant for their school as there were various channels (including media) producing information and instructions. Although the aspect of providing guidelines was emphasized, internal communication was also about interaction and informal communication within the school community. Most challenges were related to the demand to keep contact with all members of the school personnel. External communication was often described as burdensome. The Finnish leaders reported struggling with the rapidly changing instructions coming from the authorities at state and local/municipal levels. These instructions were sometimes contradictory, and it was difficult to work out the best way to instruct the school community. Leaders expressed a need for centrally given instructions for all schools in the same local area. Some even wished for stronger leadership from the Ministry of Education. Furthermore, respondents suggested that local authorities should facilitate networking and collaboration between schools, which could help school leaders formulate shared guidelines and create local level coherency in school leadership.Technological encouragement and the other Emotional support. Technological encouragement covered students and the teachers, and it was about organizing short training sessions for the use of new technologies , encouraging and providing informal guidance for using them. The emotional part of support involved listening to teachers, students, and guardians. The leaders felt a strong urge for being available, and to act in a sensitive manner and provide safety. Emotional support covered leaders’ practices aimed at creating a feeling of security among teachers and students. In general, emotional support was included in the responses more often than technological encouragement. Leaders experienced giving emotional support both as a challenge and as something that was expected from them at that moment, and it was reflected often, especially by the Finnish school leaders whereas the Estonian leaders focused more on technological encouragement.The aspect of giving support emerged in the responses relatively often . We notiAccording to the Estonian leaders, teachers needed technological encouragement in finding digital solutions and suitable platforms. The leaders noted that teachers afraid of online teaching needed guidance and support, and early career teachers seemed to require special attention. Regarding emotional support, the leaders reported how through offering constant attention, support, and by addressing teachers’ problems they tried to foster the feeling of community and the school spirit. One leader (EST12) wrote: “I tried to be supportive and mediate success stories and good experiences. I was there just to listen to teachers’ worries and comfort them. I told them to take care of themselves.” Leaders also considered it essential to support students’ sense of belonging to the school and had offered informal meeting spaces for students. Sometimes stressful situations at home arose, and the guardians needed reassurance. In some cases, the leaders sought professional help: “Through many interactions we tried to solve upcoming problems in a peaceful way. We involved a social worker and a psychologist to help these families” (EST62).In the Finnish data, emotional support was one of the two themes emerging in the responses most often . LeadersSelf-management skills when they described the practice of prioritizing and organizing tasks into controllable units. They also wrote about being flexible and creative in regulating one’s work and time. Regarding the subtheme Managing stress leaders emphasized facing increasing workloads, lack of time, feelings of uncertainty, a sense of loneliness and continual changes caused by the constantly evolving situation. Envisioning has been composed of descriptions about predicting the near future, understanding the big picture, and acting proactively accordingly. Trusting others emerged in leaders’ expressions of the importance of being able to rely on their teaching community and teachers’ performance. Descriptions of Self-management and Managing stress were included in leaders’ answers relatively often, whereas Envisioning and Trusting others were seldom reported.This theme was formed from four sub-themes reflecting leaders’ individual strategies for confronting and coping in the new situation . School Self-management to be an important aspect in coping with an unknown situation. They mentioned prioritizing tasks, drafting a clear plan for daily activities, and finding time for themselves and for their families. One respondent (EST101) described this as follows: “Combining my personal and professional life was hard. I had to implement a certain routine to be able to work and to spend some time with my children. I used to work in the evenings.” Regarding Stress management, the Estonian leaders reflected on the need to take care of their own health. Some leaders brought up parent encounters with negative overtones, which seemed to be psychologically difficult. Although they were supporting their school’s teaching community, leaders missed discussions with peers and often lacked support from municipal education administration: “When alone, you feel a growing need to discuss matters with an outsider, preferably with municipal administrators” (EST125).In the Estonian context the leaders considered Self-management as an essential quality required of a leader. The participants considered the ability to distinguish the crucial duties from the ones that could be postponed being important. Typical themes emerging in the responses included flexibility regarding working hours and tasks, adaptation to demands, agility to react, re-organizing own duties, and directing one’s own workload and wellbeing. Leaders working in small schools (less than 150 students) and having double roles as principals and teachers, reported the need to prioritize duties, as their workload had increased tremendously. One respondent described the situation as follows: “having a school with 100 students, over 10 teachers to supervise, my own class to teach, and duties of a principal—it required a lot of planning and preparation” (FIN234). Under this sub-theme, the challenges included features similar to the ones described as essential for pulling through the situation as a leader. Regarding Stress management, the leaders expressed their worries about their own wellbeing and that of teachers and students. This challenged the leaders in several ways, and many of them reported that they could not be certain “how teachers were doing their work, how they communicated with the students, how the students were coping with distance learning, and what had happened to the dropouts” (FIN150). Consequently, the Finnish leaders experienced feelings of inadequacy and sometimes loneliness. Trusting others and envisioning were scarce subthemes, yet we observed them more often in the Finnish responses than in the Estonian. Some leaders reflected on the importance of being able to understand the big picture and having wide knowledge of the educational field.Half of the responses in the Finnish data had a stance on The Estonian and Finnish school leaders’ self-reported experiences stressed the themes of communication, giving support to the school community, and the leader’s ability to lead themselves and manage stress. These aspects signaled the leaders’ approaches as being composed of caring and empathy. We draw together and discuss the findings through four themes. We also bring out practical implications that would be helpful in developing leadership practices for leaders and teachers alike, in school communities in times of both turbulence and tranquility.The process of making decisions is one of the foundations of leadership whether we focus on school leaders’ individual or collective leadership (e.g. leadership team) actions or leaders’ methods for ensuring and supporting teacher teams in their joint decision-making . LiteratClear guidance coming from the leaders can be of utmost importance in critical situations creating the feeling of safety in an organization . HoweverCrises can provide schools with the potential to develop, yet it requires leaders to redirect their focus from minimizing damage and restoring order to innovating, giving up old habits and redirecting their practices . Our finTurbulent times and crises are characterized by sudden turns in situations. They make future requirements for teaching and learning increasingly unpredictable, providing numerous options for the next steps, but often without a certainty of their correctness . A rapidSchool leaders participating in this study reported how they tried to tackle the challenges of distance learning by introducing new devices and technology-based practices. They were guiding teachers about new working methods. Both these channels require understanding of pedagogy and classroom work in re-organizing schooling in a meaningful way. The leaders’ descriptions of guidance for enrichment of online teaching, assessment methods, and requirements for student learning reflected a pedagogy-oriented approach to leading. This observation adds to the discourse around training and qualification requirements for school leaders and principals, and specifically focuses on the question of the meaning of studies in pedagogy or teacher qualification for the position of a leader in the context of education .Leaders in Estonia and Finland often describe teachers as autonomous actors at the classroom-level . The schIn the processes of creating the feeling of safety or encouraging stronger involvement of teachers in decision-making, the emotional component is an integral part of leadership , and timIn a school community, the leader’s task is to focus on ensuring that stress is reduced for all members along with managing their own emotions and wellbeing . In the School leaders are public figures in their local communities and their actions are explicit to all school community members. They are often expected to take full responsibility for solving conflicts and to fulfill all their duties with considerable urgency, which can be emotionally exhausting . The perNetworks and other structures enabling encounters with leaders from other schools are important in general. These professional channels can become essential in times of crisis, and enable a space for sharing worries, and getting support from peers facing similar challenges . Our stuAs the lack of local level collaboration and support appeared to be a factor challenging the leaders, more focus could be put on facilitating the interaction between the schools. If planned carefully, the structures for horizontal collaboration can function as places for distributing crucial information and provide peer support. Environments like these that may not only offer resources for coping with the critical situations but also create coherence in practices across schools locally and through that enhance educational equality. Moreover, lessons from the COVID-19 pandemic period regarding support to teachers, pedagogical innovations, and novel ways for teaching could be spread through collaboration between school leaders. Being proactive in preparing for future challenges entails intentionally looking for and discussing the ways others have reacted during the times of crisis and its aftermath.There are at least two directions for further research. First, we need follow-up studies to understand how the continuation of the pandemic has developed leadership practices, which of the developments had emerged at the beginning, and which are more entrenched in school culture. Secondly, the teachers’ perspective would deepen the understanding of leadership practices regarding leaders’ coping, support, and organizational climate.Although the researchers were careful in the formulation of the two open-ended questions in their national languages, the questions were placed in a different order in the national surveys. The Estonian researchers asked first about challenges  and the Finnish about the leadership qualities . After noticing this slip-up, this was considered when interpreting the results, yet it may have led to a certain emphasis in the responses. Nonetheless, the questions were adjacent in both surveys, aiming to complement each other and helping leaders to reflect more broadly their work.Click here for additional data file.Supplemental material, sj-docx-1-eer-10.1177_14749041221138989 for Leading schools during the COVID-19 school closures in Estonia and Finland by Raisa Ahtiainen, Eve Eisenschmidt, Lauri Heikonen and Merilyn Meristo in European Educational Research Journal


An orthopedic bone bank's creation and management is a challenging procedure where medical organization and legal requirements interact. There are no formal regulations for the management and organization of an orthopedic bone bank in the Netherlands or any other nation in Europe. The recently revised "law of security and quality for utilizing human materials in the Netherlands establishes guidelines for the technical and administrative elements of using human tissue and cells. The bone bank's processes involve a rigorous questionnaire for choosing donors, a complete bacteriological, histological, and serological examination, as well as industry-standard, practices for registering, processing, preserving, distributing, and storing bone allografts. This article explains how an approved bone bank is run, and it may be used as a suggestion for formal regulation or as a model for additional orthopedic bone banks in Europe. Osseous graft manufacture, testing, packing, storage, and transportation are all handled by bone banks. Their primary responsibility is to guarantee the transplants' biological characteristics and microbial cleanliness by legal and quality criteria. All orthopedic surgeons face the challenge of reconstructing bone defects; to address this issue, there are several methods, including the use of autografts, allografts, and bone substitutes to enhance and speed bone recovery. Although autografts have superior biological qualities, their volume is constrained and they are linked to donor site morbidity. Allografts are readily accessible, however, there are still worries about the possibility of infections, and they lack osteosarcoma qualities. In today’s world of bone grafting, it is necessary to have bone stored so that we could look for bone grafts easily. Donor bone from the orthopedic bank is frequently required for the reconstruction of bone defects . The cliAlthough autologous bone can start new development and can grow on the surface of the bone, it is typically not available at the desired spot . Only alThe VU University Medical Center (VUmc) in Amsterdam, which houses femoral heads for appropriate patients who had undergone hip replacement surgery, is one example of a hospital operating its bone bank. When a patient needs bone surgery, bone grafting surgery, or bone replacement surgery, it has the advantage that they sometimes do not have to hunt for bone donors. Additionally, it is advantageous financially for the associated hospitals. In India, bone banks may be found in institutions like Parvathy Ortho Hospital GST Road, Chrompet, Chennai, M/s Ganga Medical Centre & Hospitals Private Limited, Mettupalayam Road, Coimbatore 641043, Rajiv Gandhi Government General Hospital, and Cancer Institute, WIA .Dutch Bone Bank Foundation (NBF) was established in the city of Leiden, Netherlands, in 1988 . The bonThere are currently no nationally recognized standards for the upkeep and administration of bone banks in the Netherlands. The VUmc bone bank technique which uses received official permission, and recognition and may serve as a model for many other institutions is described in this study .Bank proceduresThe orthopedic bone bank of VU University has been recognized officially by the Ministry of Health, Sport, and Welfare as of October 2008. Bank policies are altered to comply with the laws of quality and security for employing materials of the human body . The NetIn the past, the Association of Musculoskeletal Transplantation of Europe's recommendations were followed. The present organization has ceased to exist as a European umbrella organization due to divergent European laws; at this time, only national associations are in use. Since there is currently no such organization in the Netherlands, there is no national standard for the upkeep and administration of an orthopedic bone bank .The Association of Tissue Bank of America rules is now used in the Netherlands for orthopedic bone banks, and the Council for the Blood Transfusion of the Netherland Red Cross provides requirements for the banks , in addiGerman musculoskeletal tissue banks are now in a radically different condition as a result of the new tissue legislation of 2007. The new rules in the most current German tissue legislation are intended to increase safety by lowering the danger of spreading viral and nonviral illnesses . In IndiBone bank protocolsAn elaborate protocol with the following five sections should be used to properly outline the bone bank procedure: organization, donor selection, documentation, storage place, processing, and allocation implementation. This protocol was created by the administrator of the bone bank and the Head of Department (HOD), of the Orthopedics Division Figure  20]..20].OrganizationsAn organizational chart lists the tasks of many stakeholders, including the head of the department of orthopedics, the bone bank administrator, the theatre nurse, the medical microbiology, an anatomic pathologist, the clinical chemical analyst, the hematological laboratory technician, and the trainer. The administrator is in charge of daily operations, with the HOD serving as the bone bank's chief management. The knowledge and abilities of surgical techniques and clinical cleanliness must be upheld, and this responsibility falls on the orthopedic surgeon and theatre nurse. The administrators of the bone bank are responsible for administration, donor bone storage, and allocation. Additionally, the administrator makes sure that the storage areas are kept clean and well-maintained. The administrator also verifies that the registration papers for femoral heads submitted meet the requirements. The administrator is also responsible for ensuring that the registration documentation for femoral heads that meet the requirements for storage in the bone bank is accurate, as well as maintaining and cleaning the storage facilities . Both the trainer and the bone bank administrator are in charge of employee training .Donor SelectionThe attending orthopedic surgeon asks the patient for his consent to keep any extracted tissue for donation before performing the hip replacement surgery. It concerns patients whose femoral head grafts will be removed so that a complete hip prosthesis can take their place. Patients having knee or shoulder arthroplasty cannot be considered for bone tissue donation because corticospongious bone tissue cannot be collected in significant quantities.DocumentationsA well-operating bone bank must have accurate paperwork and coding. Each femoral head is given a special registration code. Based on this code, only the administrator of the bone bank may identify the donor. A file is maintained for each registered femoral head that includes the consent documents as well as the outcomes of the bacteriological, histological, and erythrocyte sedimentation rate (ESR) tests. This file also records and stores additional pertinent information, such as the allocation date and the size of the head of the femur. Both the bone bank administrator and the appropriate orthopedic surgeon sign the paperwork after the file is finished, which takes at least six months before the serological examination and there aren’t any problems to be noted. It is now possible to transplant the head of the femur. The head of the femur shall be destroyed in the accordance with hospital practice in the event that a file cannot be completed completely or any aberrant data are reported.Storage Place and ProcessingSurgery is performed to remove the head of the femur under sterile circumstances. Aerobic and anaerobic microorganisms are used to cultivate the ligament and synovial tissue. A biopsy of corticospongious ligaments and bones is taken for histological analysis in order to rule out infections, auto-immune conditions, and cancers. The head of the femur is measured, wrapped in a sterile plastic bag, packaged in three layers with sterile packing material, labeled, and put in the freezer within 30 minutes. A continuous temperature registration device is put in the freezer, which is set at -80°C. A 24-hour guarantee against temperature-related tissue damage is provided by an alarm system that sends a warning signal to the Technical Service if the temperature veers outside the permitted range of -90℃ and -70°C. In the event that the freezer's mechanical components fail, a nitrogen tank is mounted to it as a backup cooling system. When it is extremely frozen, the allogenic bone tissue can only be stored for a maximum of five years. The temperature data is managed and kept for a minimum of five years by bone bank management.Allocation and ImplementationFemoral heads are removed from the freezer and given to the orthopedic surgeon and surgical team if a surgeon wishes to utilize one as an allograft during surgery. The head of the femur file and expiry date are checked by the orthopedic surgeon and the operating room nurse. The theatre nurse collects a bacterial culture swab after the head of the femur has been defrosted and thawed in physiological saline. The hospital or care institution guarantees that the identifiable criteria are met, which includes preserving the femoral head file and receiving patient information for 30 years after implantation.DiscussionIn 1881, Macewen wrote the first description of the utilization of allogeneic human bone tissue . AllogenBone allografts facilitate bone reconstruction in orthopedic surgery. Appropriate donor selection and processing of grafts minimize the risk of disease transfer . A comprBefore surgery, a laboratory evaluation that includes ESR measurement is carried out. Elevated levels are often observed with no clinical repercussions . The excIn addition to currently existing national and international rules and processes of the American Association of Tissue Bank (AATB) and earlier European Association of Musculo-Skeletal Transplantation (EAMST), histopathological examination is added to the current bone bank approach. It is advised that a histological evaluation of this frequently utilized source of bone allograft be included as part of the screening strategy for bone bank collection given our results that concealed pathological diseases are frequent . FollowiControl of the Local Bone Bank When Japan Declared a State of Emergency Due to COVID-19Biological allografts for a variety of orthopedic surgeries must be provided by bone banks. Health-care practitioners, institutions, and patients are particularly concerned about how the COVID-19 disease pandemic could affect organ donation and transplantation as countries deal with new realities brought on by the epidemic. Now let us discuss how the Kitasato University Bone Bank was running while a state of emergency was imposed as a result of COVID-19. Allograft bone from donors that tested COVID-19-negative underwent pre-operative polymerase chain reaction (PCR) screening for living donors, and these tissues were then cryopreserved for transplantation.From February 2-9 to April 5-11, the weekly infection rate steadily climbed in the area where the bank harvests deceased donor-derived allograft bone. It is now known that asymptomatic individuals may transfer the virus, and that this method may have aided in the spread of COVID-19. As a result, the bank stopped accepting donations from deceased donors in order to protect medical personnel. Following bone allograft, none of the patients had any symptoms . The samMoroccan Authorities Have Established a Bone Bank in the Vicinity of Rabat and CasablancaBone grafting has long been used in orthopedic surgery and traumatology, demonstrating its value in these fields. Autografts, which are still used rather regularly, have many issues. Finding the right quality and enough amount of bone is important on the one hand. However, removing the graft adds time to the procedure and is often uncomfortable thereafter. Bone allografts have emerged as a result of the drawbacks of autografts. It is feasible to overcome the different issues presented by bone autografts due to the low immunogenic power of the bone, the graft's good integration, and the simplicity of bone preservation procedures. The necessity for a framework that allows for the administration of graft stocks has arisen as a result of the growing usage of bone allografts. The goal of this paper is to show how a bone bank operates, specifically how it conserves femoral heads without using a further sterilizing procedure or freezing them. The bank first works with all orthopedic physicians in Rabat and Casablanca before expanding to all Moroccan orthopedic surgeons. It offers allografts that are high-quality and secure . This siUpbringing of banksThe bone bank unit that is the focus of this article was created in a teaching hospital for tertiary care in north India in January 2018. This article's goal is to describe where allografts were obtained, how often they were discarded, and how often patients were infected after receiving them.From extraction and storage through utilization, we outline the Bone and Soft Tissue Bank's methods. Cortical and spongy bone grafts can be utilized in replacement surgery, big post-traumatic reconstructions, and surgeries to rescue cancer patients with significant bone deficiencies when structural support is needed. The former is typically employed in these situations. Due to their many applications, spongy grafts are the most popular. They are particularly helpful in filling holes that need a substantial amount of graft when the autograft is insufficient or as a compliment. Additionally, they are especially beneficial in healing fractures caused by bone loss, delays in fusion, and pseudo-arthrosis in zones with limited blood supply and necrotic tissue. Additionally, they are employed in prosthetic surgery to combat abnormalities of the cavity kind. Soft tissue allografts are particularly recognized in numerous ligament injuries that need repair. Although they may be used to fill any ligament or tendon deficiency, the ones most frequently utilized now are those used in the surgery of the patella. Given that these patients are immunosuppressed from the treatment, the main challenges of cortical allografts are the combination of the ends with the bone itself and in tumor surgery, where the incidence of infection is increased in comparison to spongy grafts and soft tissues, which is irrelevant .Material and method of banksIn musculoskeletal surgery, bone transplants are frequently used to restore mechanical integrity where there is a deficiency and to enable skeletal reconstruction. Auto and allografts have traditionally been utilized. For vast, intricate flaws, the latter is the preferred option. They are available from both live and dead donors. They are kept in facilities known as bone banks using lyophilization and cryopreservation. Before receiving the grafts, donors had their information thoroughly reviewed for common specific criteria, and all relevant data was retained on file. Before storage and immediately before usage, aerobic culture was conducted. Samples with incomplete donor screening, inadequate paperwork, or positive cultures were thrown out .The processes underlying this phenomenon as well as the many aspects affecting osteoinductivity by biomaterials are also described, demonstrating that it is fairly restricted in comparison to osteoinductivity demonstrated by bone morphogenetic proteins (BMPs). As a result, a new word is suggested to define osteoinductivity by biomaterials. Also mentioned are several methods for incorporating osteoinductivity  into artificial bone replacements .ResultsOver two years, the bone bank received allografts from 196 different donors. The head of the femur from complete or partial hip replacements was the main supply of bone. It was necessary to reject 44 (22.4%) grafts. Eighty-eight patients received 95 allografts throughout this period. Bone tumor surgery (40%) was the most frequent reason for usage, followed by difficult initial or revision arthroplasty (30.5%). Following surgery, three patients (3.4%) had a profound infection.An orthopedic bone bank's establishment and maintenance as an organ bank is a very complicated procedure where elements of legal structure and medical organization interact. In this paper, the outline of the bone bank technique, that had been authorized and acknowledged by the Ministry of Welfare, Sport and Health of the Dutch Government. The construction and upkeep of other orthopedic bone banks might be accomplished using this technique as a preliminary Dutch standard. In India, we have four bone banks to be precise but this is not enough looking at future needs. Getting a graft from one's own body could be an alternative to the bone bank but it is difficult to have two incisions at a time and go through that pain. In India, we should make protocols taking references from different countries to increase the number of bone banks.


This article explores the patents of solar energy technologies in the organic Rankine cycle (ORC) applications. The conversion of low-quality thermal energy into electricity is one of the main characteristics of an ORC, making efficient and viable technologies available today. However, only a few and outdated articles that analyze patents that use solar energy technologies in ORC applications exist. This leads to a lack of updated information regarding the number of published patents, International Patent Classification (IPC) codes associated with them, technology life cycle status, and the most relevant patented developments. Thus, this article conducts a current investigation of patents published between January 2010 and May 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and keywords. One thousand two hundred ninety-nine patents were obtained as part of the study and classified in F and Y groups of the IPC. The time-lapse analyzed was between January 2010 and May 2022. In 2014 and 2015, a peak of published patents was observed. China (CN) was the country that published the most significant number of patents worldwide. However, the European Patent Office (EP), the World Intellectual Property Organization (WO), and the United States (US) publish the patents with the highest number of patent citations. Furthermore, the possible trend regarding the development of patents for each technology is presented. A high-performance theoretical ORC plant based on the patent information analyzed by this article is introduced. Finally, exploration of IPC revealed 17 codes related to solar energy technologies in ORC applications not indexed in the main search. Competitor analysis;Testing and monitoring technology;Mastery of crucial technology;Identification of trends and conditions for the development of patents in different markets.For business policy making groups, legal and business departments, and industries, it is essential to have a database of articles that provide information about existing patents in their branches of operation . Four fuThe constant search for trends in technological developments enables managers and decision-makers to identify innovations in the different branches of interest. This is important for research and development (R&D) in the government and business sectors, since it establishes strategies for identifying and monitoring trends in developing new technologies from a technical perspective .On a global level, companies are in the process of constant improvement to be sustainable in the long term. Business competition is fierce, and introducing innovations or promoting R&D activities can make a difference on the road to success. Patent development can be considered a rectangular stone to gain a competitive advantage .The annual number of patent applications worldwide has been increasing. This has made the ability to process all applications a cumbersome process for the patent examiners . The in-A review of the status of published patents on using the solar resource for implementation in an ORC is vital for developing current and future research. Moreover, it helps to determine the trends of scientific research lines and the status of the different technologies worldwide. It will also enable researchers to understand if the product they are working on has been developed elsewhere .The objective of this article is to explore the status of patents on the application of solar energy in an ORC. In the last decade, technological advances increased solar collection efficiency. Due to these factors, new techniques have been implemented to supply energy to an ORC . TherefoThe article is structured as follows: An ORC is a thermodynamic system that allows to produce power or work and behaves in the same way as a conventional Rankine steam cycle. The main difference is in the working fluid and the operating temperature of the cycle .Isentropic compression in the pump;Isobaric evaporation in the boiler;Isentropic expansion in the turbine;Isobaric condensation in the condenser.ORC-based systems are a viable option for power generation as it is easier to obtain the necessary components for their operation on the market . The ORCAs for the working fluids, the ORC uses organic refrigerants with low condensation and boiling points. This withstands the use of low-grade heat, low temperature, and pressure .An ORC plant can use heat sources of up to 400 °C and generate electrical power in a range of 1 kW and 10 MW . The impDeveloping and implementing ORC-based and solar collection systems is a way to generate electricity in an environmentally friendly way. This strategy reduces greenhouse gases in the atmosphere, and sustainable technology to produce electricity is standardized .The sun is the natural regulator of temperature in the terrestrial atmosphere. Daily, it radiates to our planet the energy consumed by society in one year. Electricity production from this type of renewable energy has increased due to its potential and the technological advances made in capturing solar radiation, as shown in Different technologies can convert solar energy into electricity or heat by using a solar tower, a photovoltaic cell, a parabolic dish, p and a linear Fresnel reflector . Solar rORC plants are not designed to use solar energy. Due to the development of organic fluids and the increasing efficiency in solar collection, it has been possible to incorporate them into its operation . TraditiThus, Keywords are useful for indexing large volumes of information from the web. However, refining the search methodology is vital to obtaining accurate results . Today tTechnology research and development strategies can be established by consulting the existing patents for technology such as educational institutions, legal entities, and industries. Additionally, the respective economic incentive that entails the commercialization of a patented product or technology .The patent status, date of publication, country, and name of the inventor or assignee is found on the internet. However, to obtain accurate information, search criteria and reliable query should be established .The information is disaggregated in the search for published patents referring to the use of solar energy in an ORC. Likewise, obtaining the IPC code where a patent is classified is complex. In some cases, patents are shown that are not related to the search that has been defined. A study that organizes the information of the number of patents by technology, year of publication, relevant developments, IPC codes where they are indexed, and countries or assignees that are at the forefront in the publication of patents, is necessary to establish the degree of penetration of power generation systems that use an ORC in different countries. Establishing cooperative alliances to promote its use where conditions encourage the development of sustainable technologies ,29.The indexed results are compared using the exact keywords in Google Patents and Scopus Patent. However, when analyzing the data obtained using Excel tools based on the names of the patents, IPC code, country/assignee, patent date publication, and inventor name, it is noted that the indexing carried out by Google Patents contains all results returned by Scopus Patent. Therefore, Google Patent was chosen as the default search engine.The latest version of the patent must be published no earlier than 1 January 2010, and no later than 1 May 2022;The name of the patent cannot be registered in more than one country or assignee the name of a patent;Patents should be related to parabolic dish, parabolic through, photovoltaic cell, solar tower, and linear Fresnel reflector technologies in an ORC.Patents to encounter the eligibility criteria meet specific requirements:As part of the eligibility process established in the Prisma methodology, there is no duplication in the name of the patents so that the total number of patents to be shown always refers to innovations that are different from each other.Search settings include indexing in all languages, although the results are displayed in English.Of the initial sample of 3510 patents, 743 were removed due to duplicate names. One thousand two hundred sixty-eight patents were eliminated because they were not directly related to an ORC. Additionally, 200 were terminated for filing active claims. Thus, 1299 patents met the eligibility criteria and are part of the article.In this section, the analysis results are discussed.The number of patents published on PVC and STP could be given by the cost of the equipment used to put this type of technology into operation, energy efficiency, and the durability of the devices .A considerable increase in the number of patents occurred during 2013. The maximum peak was reached in 2014 with 219 published patents. The growing disclosure of the benefits and facilities offered by an ORC allows for an increase in the number of published patents .The number of publications decreased moderately in 2015. However, in 2016 there was a considerable rise in the number of published patents, and between 2017 and 2019, there was a similar average in patented developments. In 2020 and 2021, there was a downward trend, with only 81 and 44 patents being published yearly, respectively. Until 1 May 2022, six patents had been published.These figures are alarming for developing plants with ORC and incorporating PVC, STP, LFR, PDC, and PTC systems into their operation. The COVID-19 pandemic, which has paralyzed R&D activities, and the loss of interest in generating energy with solar technology in ORC applications, could be fundamental factors for the decrease of published patents .Annual average of patents published from 2010 to 2022 was 108. Therefore, monitoring number of patents issued in the period 2022–2030 will give insight into the technological progress in an ORC through solar collection systems.Of the countries in the Americas, excluding the English-speaking countries, only Brazil and Mexico have patent publications; 31 and 6, respectively. Central America and part of South America have good solar radiation values to implement ORC plants that incorporate solar collection systems .CN has promoted international scientific collaboration, which has favored the development of its researchers and science and technology. Implementing government programs to develop technology and construction of large factories for firms from other countries have provided the opportunity to perform the latest scientific advances first-hand .US, WO, and EP have similar numbers of published patents for solar energy technologies in ORC applications. Although CN has most significant number of publications, the US has the largest number of citations per capita, setting the trend in development lines .Data analysis obtained in the tables demonstrates how CN dramatically impacts the number of patent publications. As long as solar energy technologies in ORC applications are considered necessary, the percentage of publications worldwide will remain stable. However, the US has the most relevant patents published between 2010 and 2022, which is synonymous with the quality of the research they generate. Other offices, such as WO and EP, also have patents of interest that seem helpful in improving the performance of ORC applications. The almost non-existent number of patents developed in Central and South America depicts how far the region is from being part of the select group of inventors and developers of solar energy technologies. The short distance from a a world power, such as the US, should enable the search for cooperation mechanisms, in order to promote and massify the use of the ORC application for power generation.The information in Based on the strategy defined by the assignee, a patent can be filed in one or several countries. The first patent application is considered the main application. A patent family is generally defined as a group of patents usually filed in several countries/offices to protect the innovation from possible plagiarism. However, there are some issues regarding the meaning of patent family.To prevent double counting of one invention;To suffer from a home bias and overestimate the patent propensity of residents because applicants are more likely to apply in their home country first;To forecast the number of patent applications to plan future resource requirements at patent offices;To analyze the internationalization of technology markets;To study the economic value of patents, as well as the strategies employed by applicants.Data on patent families are most useful for the topics described below :To preveTwo of the most widely used definitions of patent family are detailed below. First, there are the equivalent patents, which identify patents that protect the same invention. According to the EP statutes , they arThe second definition refers to the extended patent families, and according to The International Patent Documentation Center (INPADOC): “All the documents directly or indirectly linked via a priority document belonging to one patent family” . This arOn 28 September 1979, the IPC was established by signing the Strasbourg Agreement. According to the different areas of existing technology, there is a hierarchy system through symbols without the use of language .The IPC classifies technologies into eight groups and divides them into more than 70,000 subgroups. Each subgroup consists of a symbol that consists of Arabic numerals and letters of the Latin alphabet. This system is essential for the organization and searches for patents, as well as for knowing the state of the art of these possible similar developments, which is useful for people or companies interested in developing a specific technology. A new version of the IPC comes into force every 1 January .The remaining 23% is concentrated in group Y. As mentioned by EP , group YHaving the IPC code at hand may not be feasible, and it is well-known that it is difficult to memorize the codes. In fact, the discussion derived from The most important result of the article is the non-appearance of the IPC codes related to solar energies technologies in ORC applications in the keyword search is shown in Advanced knowledge of the groups and subsections where patents can be found in a particular technology permits the inventor/assignee to know if his development can be patented. Complementing the patent search through keywords with the help of IPC codes becomes a valuable tool to obtain accurate results immediately .Some current relevant patents on solar energy technologies in ORC applications are presented in this section. Technology upgrades in each category are clarified below.The innovation in  presentsThe patent  presentsThe thermetic longitudinal greenhouse box is installed at a designated reflecting point and from where both direct and upper radiation is captured. The already high temperature provided by the lower reflection is concentrated by the compensated paraboloid gutter (temperature up to 70 times more than standard surfaces). The design facilitates rapid reheating of large volumes of thermal fluid.The innovation in  featuresThe patent  presentsThe technology  describeThe cited patents represent the most outstanding technological advances published between 2010 and 2022. During these years, solar energy has grown due to the increase in the efficiency of solar capture . First, Aristodemou and Tietze  posit thThe authors , argue tThis section proposes an ideal theoretical configuration from patents to achieve a high-performance ORC plant using solar energy technologies. In ORC applications, some factors can alter its performance; working organic fluid, solar collection system, and turbine. For each factor, a theoretical solution is proposed below.The invention is related to a working fluid designed to obtain a greater cycle and general efficiency of the ORC system and reduce the impact of gases on climate change. The novel working fluid has a chemical composition of 4-hexafluoro-2-butene (HFO-1336mzz-E) or a mixture thereof. IPC codes for this patent are F01K25/08 . The invThis article has analyzed published patents referring to the use of solar energy technologies in ORC applications. The search engine used to obtain patent data was Google Patents. The analysis of the patents was obtained after applying the PRISMA methodology to obtain the quantity to be analyzed. The findings obtained from this study are listed below.The number of published patents grew gradually from 2010 to 2014 when the maximum number of publications was reached. However, as of 2015, there is a slight downward trend. Starting in 2020, this phenomenon has been accentuated, and so far, in 2022, the number of published patents is lower than the previous annual averages;Two groups of the IPC contain patents related to solar energy technologies in ORC applications. Group F owns 77% and group Y 23% of the total number of patents, respectively;Although groups F and G contain the patents related to the topic of the article, when performing the search, only part of the IPC codes was indexed. Seventeen IPC codes that belong to patents related to solar energy technologies in ORC applications were collected;TheUS, WO, and EP were the countries/assignees with the most significant impact due to the number of citations of their patents. Although a predominant number of publications come from CN, this indicates that there is a prevailing number of studies and potential for future development;Patents related to Photovoltaic cell technology present the most stable number of patent publications per year as data;Patents that will possibly implement a high-performance theoretical ORC plant are filed.Studies to be carried out in the future should focus on the evolution of PVC and STP technologies, expecting new developments to be improved. These would enable the identification of new horizons for the development of patents and also the evaluation of R&D trends to identify in which areas innovations are expected to develop.


This study establishes research priorities for medically not yet explained symptoms (MNYES), also known as persistent physical symptoms or medically unexplained symptoms, from the perspective of patients, caregivers and clinicians, in a priority setting partnership (PSP) following the James Lind Alliance (JLA) approach. Research into such symptoms in general has been poorly funded over the years and so far has been primarily researcher-led with minimal input from patients, caregivers and clinicians; and sometimes has been controversial.JLA PSP method. The PSP termed these symptoms MNYES.The study was conducted according to the JLA’s detailed methodology for conducting priority setting exercises. It involved five key stages: defining the appropriate term for the conditions under study by the PSP Steering Group; gathering questions on MNYES from patients, caregivers and clinicians in a publicly accessible survey; checking these research questions against existing evidence; interim prioritisation in a second survey; and a final multi-stakeholder consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology.Over 700 responses from UK patients, caregivers and clinicians were identified in the two surveys and charities contributed from a broad range of medical specialties and primary care. The final top 10 unanswered research questions cover, among others: treatment strategies, personalisation of treatment, collaborative care pathways, training for clinicians and outcomes that matter to patients.The top 10 unanswered research questions are expected to generate much needed, relevant and impactful research into MNYES. Establishing research priorities for medically not yet explained symptoms from the perspective of patients, caregivers and clinicians for the first time is a strength of the study.The use of the established and transparent James Lind Alliance methodology is a strength of the study.Over 700 responses were gathered from patients, caregivers and clinicians from a wide range of medical specialties including primary care, indicating that the priorities were widely supported.Contributions of people from ethnic and gender minority groups and from underserved areas within the Priority Setting Partnership Steering Group, surveys and final workshop supports the inclusive nature of this work and indicates these priorities are important to a diverse range of people.Self-descriptions of participant roles and symptoms did not always provide sufficient detail to clearly describe the variety of the participants in the sample.Medically not yet explained symptoms (MNYES), also known as medically unexplained symptoms (MUS) or persistent physical symptoms (PPS),The focus of research on MNYES is often on particular subsets of symptoms, such as chronic pain, chronic fatigue, irritable bowel syndrome and dizziness, but lacks a comprehensive view. This has ramifications for patients who visit different clinics for their various symptoms, without sustained improvement, and as such experience unmet needs.16The European Association of Psychosomatic Medicine has published a research agenda in this domain with one of the research priorities being patient preferences for research in this field.The aim of this PSP was therefore to develop a research agenda with the joint perspectives of patients, caregivers, clinicians and support organisations across the UK as the frame of reference, to identify the most important unanswered research questions in MNYES.This study was undertaken according to the JLA’s method for undertaking PSPs as delineated in the JLAs Guidebook.19In March 2020 the MNYES PSP Steering Group met for the first time. The remit of the Steering Group was to oversee, project manage and publicise the PSP, networking with charitable, patient and professional organisations to maximise the response to the surveys. The Steering Group ensured that the JLA’s methodology and principles were adhered to and had no influence on the choice and ranking of the research priorities which were solely determined by the survey responses and final priority setting workshop.Members of the Steering Group were selected by a snowballing method via clinics and supporting organisations, inviting clinicians providing diagnosis and treatment of the different conditions potentially covered by MNYES. Also, charities, patient networks and PPI networks were approached to recruit patients and caregivers. They were invited and selected based on the capability, motivation and consent to contribute to the JLA PSP working group standards of reference as described in the JLA website. Efforts were made to have a representation of patients with pain, fatigue, FND, IBS and dizziness, as they are the most common MNYES conditions as shown in the literature.10.1136/bmjopen-2022-061263.supp1Supplementary dataMany terms are used for these symptoms, including, but not limited to, persistent physical symptoms (PPS),A common concern appeared to be the distress caused to patients, caregivers and clinicians alike by the lack of adequate explanations, diagnostic methods and treatments for these symptoms-which are often poorly understood across these groups too. This was felt to have a negative impact on clinical work and research pertaining to these conditions and to stigmatise them at a societal level. After deliberation, the PSP Steering Group agreed to use the term medically not yet explained symptoms (MNYES) to describe the subject matter for the duration of the study. This was an operational definition not intended to add to or replace other definitions already in use, that was constructed to embrace the views of all stakeholders. MNYES was meant to indicate that although some insights might exist, our understanding is still incomplete. This could pertain to biological, psychological and social factors, as well as factors involving the trajectory of patients through various healthcare settings. In that sense, the choice of the term MNYES conveys a message of hope, which feeds into the effort to identify research priorities for the condition.The PSP’s Steering Group agreed that the remit should include the aetiology, diagnosis and treatment or medical care of patients with MNYES in the UK, as well as the organisation of services, social consequences and long-term outcomes including cost implications for patients. Confirmed topics included (but were not limited to): pain, fatigue, dizziness, FND, bowel symptoms, palpitations and syncope. Ages 16 and older were included. Although fatigue as a symptom was considered for inclusion, chronic fatigue syndrome was considered out of scope since there was another PSP addressing this.A core principle of JLA PSPs is collaboration between all stakeholders  to ensure their views are represented at each stage of the process. At the level of the steering group, patients, caregivers and clinicians were members of the MNYES Steering Group, represented at every meeting, and involved in the development of PSP surveys. They were involved in the organisation of uncertainties, the wording of summary questions, and the verification of evidence checking. At the level of the surveys, patients, public and supporting organisations participated in the surveys as shown in The process is shown in the project flow diagram presented in The initial survey (June 2020–January 2021) asked patients, caregivers and healthcare professionals to indicate their priorities for future research related to MNYES.The information specialists (DV and JSw) and PSP lead (CMvdF-C), grouped similar or duplicate questions into five domains, generating 96 draft summary questions on aetiology, diagnosis, healthcare services, treatment, outcomes, prognosis and other. Those 96 draft questions were reviewed by small groups of PSP Steering Group members that comprised clinicians, patients and caregivers. Further consolidations were made resulting in 46 summary questions which were reviewed again and signed off at a meeting of the whole PSP Steering Group. A document illustrating this is available on the JLA website.The 46 summary questions were checked against published systematic reviews and clinical guidelines. We found that none of the 46 summary questions had been fully answered by previous research; some questions had been answered for specific symptoms, but not comprehensively across all MNYES symptoms. At a subsequent meeting, the Steering Group reviewed the 46 summary questions in relation to the original questions and statements from which they derived. This resulted in minor changes to the wording of these 46 questions which were then included in the interim prioritisation survey.This online survey was completed by 270 participants from across the UK. Patients and caregivers made up 74% of the participants. Demographic information is shown in The final priority setting workshop was conducted remotely over 2 days. In total, 25 people participated in the workshop sessions; 4 JLA advisors facilitated the subgroups, 8 people observed and one person provided technical support. Participants included 11 people with MNYES or caregivers, and 14 healthcare professionals representing psychiatry, general practice, stroke, neurology, physiotherapy, psychology, occupational therapy and gastroenterology. The final top 10 research priorities were agreed by consensus between all the participants as listed in 30The research priorities which were ranked 11–17 are also listed on the JLA websiteIn this study, we used the JLA PSP processes to identify the top 10 unanswered research questions for MNYES. We used the collective perspectives of patients, caregivers and clinicians and focused on areas where up-to-date, reliable research evidence is lacking. This process was supported by charitable and professional organisations across the UK. The study highlighted the paucity of evidence-driven practice in MNYES care since none of the 46 research questions gathered from our survey have been previously answered by level I evidence. Based on the extensive discussions during the meetings, the following major themes emerged from the top 10 unanswered research questions.What are the most effective treatment strategies for different symptoms of MNYES?How can the most appropriate treatment be selected, dependent on different MNYES symptoms, that a person with MNYES is most likely to benefit from?This pertains to all potential treatment strategies  to help manage or alleviate any MNYES or combination of symptoms, such as pain, fatigue, dizziness, FND, bowel symptoms, palpitations and syncope. It also focuses on the best ways to match people who experience specific MNYES with the treatments that are most likely to benefit them, personalising treatment based on diagnostic factors such as a history of trauma, biomarkers or treatment needs.Given the high unmet clinical need and the heterogeneity of MNYES, it is no surprise that this is considered an important research priority. Interestingly, treatment and personalised treatment were also research priorities identified by the Delphi study conducted among experts in the field on behalf of the European Association of Psychosomatic Medicine;How can clinicians collaborate effectively to form the most appropriate care pathway and service model to offer assessment and treatment for patients with MNYES?What are the most effective methods for training clinicians to diagnose and treat their patients with MNYES with compassion, empathy and respect?What are the most effective ways to support patients with MNYES and their carers to live with their symptoms?What strategies are effective at promoting awareness and up to date clinical knowledge about MNYES amongst healthcare professionals?Four of the ten research priorities involve the role of the clinicians in the diagnostic and treatment process, an indicator of the high relevance of this theme. Many different clinicians provide diagnostic assessments to people with MNYES, or are sought to provide treatment to them. The focus here is on finding the best ways for clinicians to collaborate, forming an appropriate care pathway to support people with MNYES. These could be psychiatric consultation models, multi-disciplinary team models, collaborative care models or other integrated care pathways. There is a focus on communication which acknowledges the perspective and concerns of the person experiencing MNYES. Another priority focuses on identifying options for supporting people with MNYES and their caregivers, such as for example shared decision-making regarding treatment options; coping with symptoms; and rehabilitation approaches. Another priority emphasises strategies to consistently and effectively ensure that clinicians know the most up-to-date information about MNYES and let care reflect current evidence. Given the existing knowledge gaps, this is considered an important priority.What outcomes matter most to patients with MNYES?What symptoms are commonly reported by people with MNYES and what links them?What factors affect outcomes for MNYES?Some research priorities mention the patient perspective explicitly. Based on the survey answers, outcomes relevant for patients may include but are not limited to: symptom reduction, changes in biomarkers; improvements in abilities to undertake daily tasks; improvements in quality of life; individual goal achievements or improvements in functioning. The list of MNYES is extensive, and people who experience these symptoms often report living with multiple MNYES. One priority aims to identify the most commonly co-occurring symptoms and their underlying factors and mechanisms. Given the number of questions that pertained to aetiological factors and the fact that the related uncertainty plays a role in the choice of MNYES as a term, this can be considered an important research theme. Factors affecting outcome should include biomarkers, psychological factors, health services, how information is shared between clinicians and people experiencing MNYES, and social factors such as poverty, education, family dysfunction or domestic abuse, trauma and work environment.Which self-management techniques are effective in MNYES?This priority concerns the strategies that people experiencing MNYES can use separately from clinic visits. The focus is to identify the most effective self-administered therapies for managing or alleviating MNYES, used separately or in combination with formal treatment. Examples of self-management approaches include education, exercise and dietary changes. It should be noted that this research priority, in contrast to ones covered by the other themes, considers that recovery in MNYES can occur, either by recovery of symptoms or by personal recovery with ongoing symptomatology. Recovery of symptomatology is referred to as clinical recovery and is covered by the other themes. Recovery while symptoms are ongoing is called personal recovery,In mental health research and clinical practice, especially concerning psychotic conditions, personal recovery is a construct that has increasingly gained attention over the past 30 years; however, the term has not been used in MNYES. Generally, both in clinical practice and in research, the emphasis seems to have been to either attempt to attain clinical recovery or send the patient home with the message that MNYES cannot be cured and that one would have to live with the condition. This dichotomy has fed into the ongoing controversy about how to approach MNYES. This polarising stance is unhelpful. It could provide an essential contribution to further research development in this domain, alongside the research priorities summarised in the other themes. Developing this research priority would require embracing the concept that personal recovery refers to an individual process of adaptation and development where one does not simply return to but instead grows beyond the premorbid self,This is the first study establishing research priorities for MNYES from the perspective of patients, caregivers and clinicians. The study follows the JLA method which offers a unique, and internationally highly regarded, approach to setting research priorities through an equal partnership between patients, carers and healthcare professionals. The priorities represent a ‘snapshot in time’ of the areas which matter the most to patients, caregivers and clinicians. It is reproducible  and the method can be used to ’refresh’ priorities at a future date to reflect changes in the management of the condition and patient/carer experiences. The use of this established and transparent JLA methodology supports the generalisability of the results and is a strength of this study.This is a highly contentious area; however, the research priorities were widely supported by over 400 participants including clinicians from a variety of disciplines, patients with a range of symptoms, caregivers, charitible organisations and other supporting organisations. Over 700 responses were gathered from patients, caregivers and clinicians from an array of medical specialties including primary care, indicating that the priorities were widely supported. Contributions of people from ethnic and gender minority groups and from underserved areas within the PSP Steering Group, surveys and final workshop supports the inclusive nature of this work and indicates these priorities are important to a diverse range of people.The themes identified in this PSP cover a broad range of ideas, issues and uncertainties; these are outlined in the top 10 research priorities and also reflected in the 7 research priorities that did not make the top 10. Research priorities 11, 12 and 17 would link well with theme 3 in exploring associations of MNYES with mental health and somatic comorbidity, as well as the development of symptoms over time. Priorities 13 and 14 would fit in theme 2, the role of clinicians; 15 and 16 link with theme 1, treatment. This suggests that the themes covered by the top 10 priorities are consistent with the other research priorities which were proposed during this priority setting process.When comparing the participants of survey 1 with survey 2, there were 443 participants in survey 1, and 270 in survey 2. The final workshop was attended by 25 people. These are high numbers and certainly adequate for priority setting according to the JLA method. However, as the description of the roles is self-described, the variety of investigative participants remains unclear in some respects. For example, it should be pointed out that in The study provides a good overview of research priorities for MYNES in the UK; however, given the specific cultural aspects and healthcare organisation in the UK, the findings may not be generalisable to other countries. A similar PSP is currently being conducted in the Netherlands and may shed light on research priorities in a non-NHS healthcare setting. This will provide an opportunity to compare and evaluate the generalisability of these findings and the influence of different cultural and healthcare settings. Future research highlighting the situation in low-income and middle-income countries would be beneficial. The results of this PSP will enable funders to prioritise research in MNYES as outlined here and hopefully will provide new, much needed knowledge in this domain.MYNES are common and reflect a high level of unmet clinical need. Incorporating patient-driven research in MNYES research can allow researchers to better address the complex care needs of people with MNYES. The most important aspect of this priority setting exercise was strengthening the relationship between patients, caregivers, clinicians and support organisations and generating a list of priorities valued by these stakeholders, which we hope will guide future research.We have identified the top 10 research priorities in MNYES using the rigorous JLA priority setting method that may open the door to further research addressing the knowledge gaps and controversies in this area, and hopefully alleviate some of the stigma related to these conditions and the people suffering from MNYES. Identification of these top 10 research priorities is an important first step to generating relevant, impactful research that will ultimately improve the lives of people with MNYES.