In: Kong , D Z , Liang , N , Yang , G L , Zhang , Z , Liu , Y , Yang , Y , Liu , Y X , Wang , Q G , Zhang , F , Zhang , H Y , Nikolova , D , Jakobsen , J C , Gluud , C & Liu , J P 2019 , ' Acupuncture for chronic hepatitis b ' , Cochrane Database of Systematic Reviews , vol. 2019 , no. 8 , CD013107 . https://doi.org/10.1002/14651858.CD013107.pub2
Background Chronic hepatitis B is a liver disease associated with high morbidity and mortality. Chronic hepatitis B requires long-term management aiming to reduce the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, as well as to improve health-related quality of life. Acupuncture is being used to decrease discomfort and improve immune function in people with chronic hepatitis B. However, the benefits and harms of acupuncture still need to be established in a rigorous way. Objectives To assess the benefits and harms of acupuncture versus no intervention or sham acupuncture in people with chronic hepatitis B. Search methods We undertook electronic searches of the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, China National Knowledge Infrastructure (CNKI), Chongqing VIP ( CQVIP), Wanfang Data, and SinoMed to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp), ClinicalTrials.gov ( www.clinicaltrials.gov/), and the Chinese Clinical Trial Registry (ChiCTR) for ongoing or unpublished trials until 1 March 2019. Selection criteria We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing acupuncture versus no intervention or sham acupuncture in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B as defined by the trialists or according to guidelines. We allowed co-interventions when the co-interventions were administered equally to all intervention groups. Data collection and analysis Review authors in pairs individually retrieved data from reports and through correspondence with investigators. Primary outcomes were all-cause mortality, proportion of participants with one or more serious adverse events, and health-related quality of life. Secondary outcomes were hepatitis B-related mortality, hepatitis B-related morbidity, and adverse events considered not to be serious. We presented the pooled results as risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the risks of bias using risk of bias domains with predefined definitions. We put more weight on the estimate closest to zero effect when results with fixed-effect and random-effects models differed. We evaluated the certainty of evidence using GRADE. Main results We included eight randomised clinical trials with 555 randomised participants. All included trials compared acupuncture versus no intervention. These trials assessed heterogeneous acupuncture interventions. All trials used heterogeneous co-interventions applied equally in the compared groups. Seven trials included participants with chronic hepatitis B, and one trial included participants with chronic hepatitis B with comorbid tuberculosis. All trials were assessed at overall high risk of bias, and the certainty of evidence for all outcomes was very low due to high risk of bias for each outcome, imprecision of results (the confidence intervals were wide), and publication bias (small sample size of the trials, and all trials were conducted in China). Additionally, 79 trials lacked the necessary methodological information to ensure their inclusion in our review. None of the included trials aim to assess all-cause mortality, serious adverse events, health-related quality of life, hepatitis B-related mortality, and hepatitis B-related morbidity. We are uncertain whether acupuncture, compared with no intervention, has an effect regarding adverse events considered not to be serious (RR 0.67, 95% CI 0.43 to 1.06; I² = 0%; 3 trials; 203 participants; very low-certainty evidence) or detectable hepatitis B e-antigen (HBeAg) (RR 0.64, 95% CI 0.11 to 3.68; I² = 98%; 2 trials; 158 participants; very low-certainty evidence). Acupuncture showed a reduction in detectable hepatitis B virus (HBV) DNA (a non-validated surrogate outcome; RR 0.45, 95% CI 0.27 to 0.74; 1 trial, 58 participants; very low-certainty evidence). We are uncertain whether acupuncture has an effect regarding the remaining separately reported adverse events considered not to be serious. Three of the eight included trials received academic funding from government or hospital. None of the remaining five trials reported information on funding. Authors' conclusions The clinical effects of acupuncture for chronic hepatitis B remain unknown. The included trials lacked data on all-cause mortality, health-related quality of life, serious adverse events, hepatitis-B related mortality, and hepatitis-B related morbidity. The vast number of excluded trials lacked clear descriptions of their design and conduct. Whether acupuncture influences adverse events considered not to be serious is uncertain. It remains unclear if acupuncture affects HBeAg, and if it is associated with reduction in detectable HBV DNA. Based on available data from only one or two small trials on adverse events considered not to be serious and on the surrogate outcomes HBeAg and HBV DNA, the certainty of evidence is very low. In view of the wide usage of acupuncture, any conclusion that one might try to draw in the future should be based on data on patient and clinically relevant outcomes, assessed in large, high-quality randomised sham-controlled trials with homogeneous groups of participants and transparent funding.
In: Liang , N , Kong , D Z , Ma , S S , Lu , C L , Yang , M , Feng , L D , Shen , C , Diao , R H , Cui , L J , Lu , X Y , Nikolova , D , Jakobsen , J C , Gluud , C & Liu , J P 2019 , ' Radix Sophorae flavescentis versus no intervention or placebo for chronic hepatitis B ' , Cochrane Database of Systematic Reviews , vol. 4 , no. 4 , CD013089 . https://doi.org/10.1002/14651858.CD013089.pub2
BACKGROUND: Hepatitis B virus (HBV) infection, a liver disease caused by hepatitis B virus, may lead to serious complications such as cirrhosis and hepatocellular carcinoma. People with HBV infection may have co-infections including HIV and other hepatitis viruses (hepatitis C or D), and co-infection may increase the risk of all-cause mortality. Chronic HBV infection increases morbidity and psychological stress and is an economic burden on people with chronic hepatitis B and their families. Radix Sophorae flavescentis, an herbal medicine, is administered most often in combination with other drugs or herbs. It is believed that it decreases discomfort and prevents replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Radix Sophorae flavescentis for patient-centred outcomes are not known, and its wide usage has never been established with rigorous review methodology. OBJECTIVES: To assess the benefits and harms of Radix Sophorae flavescentis versus placebo or no intervention in people with chronic hepatitis B. SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), Wanfang Data, and SinoMed. We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp), ClinicalTrials.gov (www.clinicaltrials.gov/), and the Chinese Clinical Trial Registry for ongoing or unpublished trials. We conducted the last search in December 2018. SELECTION CRITERIA: We included randomised clinical trials, irrespective of publication status, language, or blinding, comparing Radix Sophorae flavescentis versus no intervention or placebo in people with chronic hepatitis B. We excluded polyherbal blends containing Radix Sophorae flavescentis. We allowed co-interventions when the co-interventions were administered equally to all intervention groups. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. Review authors in pairs retrieved data from individual published reports and after correspondence with investigators. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. Our secondary outcomes were hepatitis B-related mortality, hepatitis B-related morbidity, and adverse events considered 'not to be serious'. We presented meta-analysed results as risk ratios (RRs) with 95% confidence intervals (CIs). We assessed risk of bias using domains with pre-defined definitions. We conducted Trial Sequential Analyses to control the risk of random errors. We used GRADE methodology to evaluate our certainty in the evidence (i.e. "the extent of our confidence that the estimates of the effect are correct or are adequate to support a particular decision or recommendation"). MAIN RESULTS: We included 35 randomised clinical trials with 3556 participants. One trial compared Radix Sophorae flavescentis with placebo; the remaining 34 trials compared effects of Radix Sophorae flavescentis in addition to a co-intervention versus the same co-intervention. The included trials assessed heterogenous forms and ways of administering Radix Sophorae flavescentis (e.g. oral capsules, oral tablets, intravenous infusion, intramuscular injection, acupoint (a specifically chosen site of acupuncture) injection) with treatment duration of 1 to 24 months. Two of the trials included children up to 14 years old. Participants in two trials had cirrhosis in addition to chronic hepatitis B. All trials were assessed at high risk of bias, and certainty of the evidence for all outcomes was very low.Only one of the 35 trials assessed mortality; no deaths occurred. Ten trials assessed serious adverse events; no serious adverse events occurred. None of the trials reported health-related quality of life, hepatitis B-related mortality, or morbidity. Adverse events considered 'not to be serious' was an outcome in 19 trials; nine of these trials had zero events in both groups. Radix Sophorae flavescentis versus placebo or no intervention showed no difference in effects on adverse events considered 'not to be serious' (RR 1.10, 95% CI 0.76 to 1.59; I² = 49%; 10 trials, 1050 participants). Radix Sophorae flavescentis showed a reduction in the proportion of participants with detectable HBV-DNA (RR 0.61, 95% CI 0.55 to 0.68; I² = 56%; 29 trials, 2914 participants) and in the proportion of participants with detectable HBeAg (hepatitis B e-antigen) (RR 0.71, 95% CI 0.66 to 0.76; I² = 19%; 20 trials, 2129 participants).Seven of the 35 randomised clinical trials received academic funding from government or hospital. Four trials received no funding. The remaining 24 trials provided no information on funding.Additionally, 432 trials lacked the methodological information needed to ensure inclusion of these trials in our review. AUTHORS' CONCLUSIONS: The included trials lacked data on health-related quality of life, hepatitis B-related mortality, and hepatitis B-related morbidity. The effects of Radix Sophorae flavescentis on all-cause mortality and on the proportion of participants with serious adverse events and adverse events considered 'not to be serious' remain unclear. We advise caution in interpreting results showing that Radix Sophorae flavescentis reduced the proportion of people with detectable HBV-DNA and detectable HBeAg because the trials reporting on these outcomes are at high risk of bias and both outcomes are non-validated surrogate outcomes. We were unable to obtain information on the design and conduct of a large number of trials; therefore, we were deterred from including them in our review. Undisclosed funding may influence trial results and may lead to poor trial design. Given the wide usage of Radix Sophorae flavescentis, we need large, unbiased, high-quality placebo-controlled randomised trials in which patient-centred outcomes are assessed.
Eine dauerhafte Verfügbarkeit ist nicht garantiert und liegt vollumfänglich in den Händen der Herausgeber:innen. Bitte erstellen Sie sich selbständig eine Kopie falls Sie diese Quelle zitieren möchten.
A week ago, German Chancellor Scholz wrapped up his second visit to China since taking office. The German government published its first 'China strategy' last year, siding with the European Commission's hardline policy toward China. But is Chancellor Olaf Scholz's heart really in it? For both economic and historical reasons, Germany cannot let go of China in the same way the U.S. and some other European countries have. In fact, Scholz is caught in an unenviable cage of Germany's own making: its continuing economic dependence on China. Scholz is therefore pursuing a rather cautious course toward China. This approach is in line with recent German politics, not least the legacy of Détente and Ostpolitik, and the needs of the German economy.Scholz's visit to ChinaTo make up for his very short initial one-day visit to China as Chancellor in November 2023, Scholz spent a full three days in China, visiting a German factory in Chongqing, giving a talk at Tongji University in Shanghai, and meeting with President Xi and other officials. Scholz brought three other cabinet members along as well as the CEOs of twelve leading German companies, including the leaders of BMW, Mercedes, BASF, Merck, Thyssenkrupp, and many others.Not surprisingly, the Chancellor's visit to China was dominated by economic and business concerns, such as market access reciprocity, intellectual property issues, and the looming danger of Chinese overcapacity and dumping of products on the German and EU markets. Yet, climate change and several geopolitical concerns – notably the war in Ukraine, the increasingly close cooperation between China and Russia, and the threat of a widening regional conflict in the Middle East – were also on Scholz's agenda. The first outcomes of Scholz's trip have already emerged and have given us some idea about the Chancellor's policy on China. The visit underlined Scholz's tendency to prioritize German-Chinese economic cooperation rather than focusing on issues of disagreement.Regarding the economy, and especially the automotive industry, "Germany and China have signed a joint declaration to cooperate on autonomous and connected driving which Germany hopes will enable carmakers to transfer data from China to Germany." With regard to the envisaged Swiss plan to organize an international peace conference to resolve the Ukraine war, both Scholz and Xi have agreed to promote the holding of such a summit.To 'de-risk' or not to 'de-risk'?After having bitterly learned from its energy dependencies on Russia, Scholz is wants to avoid making the same mistake again. Germany adopted its first Strategy on China in 2023 focusing on de-risking and diversifying. Berlin now views China as a "partner, competitor, and systemic rival." However, initial studies show that while Chinese imports to Germany have decreased, there remains a high dependency on Chinese products, particularly in critical industries. Economic interests – both German and European ones – remain on Scholz's mind even after his Beijing trip. Germany, as one of the world's top car producers, has started becoming deeply concerned about the possibility of widespread imports of Chinese EVs. This is a concern echoed by the EU, which started a probe late last year to investigate EV imports and Chinese subsidies into car production. The number of EU probes into Chinese imports has multiplied since then, ranging from wind turbines to medical devices. Still, Scholz is aware that he needs to delicately balance his de-risking strategy. While diversifying away from China to some extent, the German Chancellor also needs to ensure the continued access of German companies and products to the tightly-ruled Chinese market. This explains why Scholz was accompanied by a large delegation of German CEOs in Beijing. In the case of Volkswagen for example, China has remained its biggest market. Overall, Scholz's approach to China remains one of caution and continuation, rather than any abrupt change of course. Historical and domestic context of German China policyScholz's China policy reflects the conciliatory strategies most of his predecessors pursued. In 1994, Helmut Kohl was the first Western leader to visit China following the 1989 disruption of ties between China and the Western world. Kohl brought German business leaders from top companies – such as Lufthansa – with him, which resulted in dozens of agreements being signed. Approximately $7 billion dollars worth of business deals were concluded during his trip. Kohl saw the potential of Chinese economic growth for the German economy. In fact, Kohl, the leader of the German conservative party (the Christian Democrats), continued the policy of 'change through' trade with China, which had first flourished under the social democratic chancellor Helmut Schmidt. Chancellors Gerhard Schroeder and Angela Merkel followed in Kohl's footsteps and maintained a close partnership with China. While Angela Merkel pursued intensive trade relations with China–which eventually became Germany's top trading partner in 2016–she also pursued a variety of initiatives, such as a dialogue on human rights in the later years of her chancellorship. Merkel was also one of the rare Western leaders who truly took the time to visit China and learn about the country, traveling not only to the capital and industrial hotspots, but also to Xi'an, Chengdu, Guangzhou, Tianjin, Nanjing, and Hefei, among othersIs Scholz carefully balancing or is he falling behind EU policy?Since Scholz became German Chancellor in December 2021 he has carefully sought to re-define Germany's China policy. As head of a three-party coalition government, this has proven rather difficult. While the geopolitical climate has drastically changed, Germany's dependence on trade and investment relations with China is still as large as before, if not even more. Yet, as the term 'systemic rivalry' indicates, Germany, like the EU and the U.S., has woken up to the challenges China's increasingly assertive economic and geopolitical policies present. Still, Scholz's recent China visit did not reflect this. His visit was very much in the tradition of Angela Merkel's regular polite visits to China. While this may boost the German economy in the short-term, it does little for Germany's reputation as Europe's foremost country.
Eine dauerhafte Verfügbarkeit ist nicht garantiert und liegt vollumfänglich in den Händen der Herausgeber:innen. Bitte erstellen Sie sich selbständig eine Kopie falls Sie diese Quelle zitieren möchten.
A week ago, German Chancellor Scholz wrapped up his second visit to China since taking office. The German government published its first 'China strategy' last year, siding with the European Commission's hardline policy toward China. But is Chancellor Olaf Scholz's heart really in it? For both economic and historical reasons, Germany cannot let go of China in the same way the U.S. and some other European countries have. In fact, Scholz is caught in an unenviable cage of Germany's own making: its continuing economic dependence on China. Scholz is therefore pursuing a rather cautious course toward China. This approach is in line with recent German politics, not least the legacy of Détente and Ostpolitik, and the needs of the German economy.Scholz's visit to ChinaTo make up for his very short initial one-day visit to China as Chancellor in November 2023, Scholz spent a full three days in China, visiting a German factory in Chongqing, giving a talk at Tongji University in Shanghai, and meeting with President Xi and other officials. Scholz brought three other cabinet members along as well as the CEOs of twelve leading German companies, including the leaders of BMW, Mercedes, BASF, Merck, Thyssenkrupp, and many others.Not surprisingly, the Chancellor's visit to China was dominated by economic and business concerns, such as market access reciprocity, intellectual property issues, and the looming danger of Chinese overcapacity and dumping of products on the German and EU markets. Yet, climate change and several geopolitical concerns – notably the war in Ukraine, the increasingly close cooperation between China and Russia, and the threat of a widening regional conflict in the Middle East – were also on Scholz's agenda. The first outcomes of Scholz's trip have already emerged and have given us some idea about the Chancellor's policy on China. The visit underlined Scholz's tendency to prioritize German-Chinese economic cooperation rather than focusing on issues of disagreement.Regarding the economy, and especially the automotive industry, "Germany and China have signed a joint declaration to cooperate on autonomous and connected driving which Germany hopes will enable carmakers to transfer data from China to Germany." With regard to the envisaged Swiss plan to organize an international peace conference to resolve the Ukraine war, both Scholz and Xi have agreed to promote the holding of such a summit.To 'de-risk' or not to 'de-risk'?After having bitterly learned from its energy dependencies on Russia, Scholz is wants to avoid making the same mistake again. Germany adopted its first Strategy on China in 2023 focusing on de-risking and diversifying. Berlin now views China as a "partner, competitor, and systemic rival." However, initial studies show that while Chinese imports to Germany have decreased, there remains a high dependency on Chinese products, particularly in critical industries. Economic interests – both German and European ones – remain on Scholz's mind even after his Beijing trip. Germany, as one of the world's top car producers, has started becoming deeply concerned about the possibility of widespread imports of Chinese EVs. This is a concern echoed by the EU, which started a probe late last year to investigate EV imports and Chinese subsidies into car production. The number of EU probes into Chinese imports has multiplied since then, ranging from wind turbines to medical devices. Still, Scholz is aware that he needs to delicately balance his de-risking strategy. While diversifying away from China to some extent, the German Chancellor also needs to ensure the continued access of German companies and products to the tightly-ruled Chinese market. This explains why Scholz was accompanied by a large delegation of German CEOs in Beijing. In the case of Volkswagen for example, China has remained its biggest market. Overall, Scholz's approach to China remains one of caution and continuation, rather than any abrupt change of course. Historical and domestic context of German China policyScholz's China policy reflects the conciliatory strategies most of his predecessors pursued. In 1994, Helmut Kohl was the first Western leader to visit China following the 1989 disruption of ties between China and the Western world. Kohl brought German business leaders from top companies – such as Lufthansa – with him, which resulted in dozens of agreements being signed. Approximately $7 billion dollars worth of business deals were concluded during his trip. Kohl saw the potential of Chinese economic growth for the German economy. In fact, Kohl, the leader of the German conservative party (the Christian Democrats), continued the policy of 'change through' trade with China, which had first flourished under the social democratic chancellor Helmut Schmidt. Chancellors Gerhard Schroeder and Angela Merkel followed in Kohl's footsteps and maintained a close partnership with China. While Angela Merkel pursued intensive trade relations with China–which eventually became Germany's top trading partner in 2016–she also pursued a variety of initiatives, such as a dialogue on human rights in the later years of her chancellorship. Merkel was also one of the rare Western leaders who truly took the time to visit China and learn about the country, traveling not only to the capital and industrial hotspots, but also to Xi'an, Chengdu, Guangzhou, Tianjin, Nanjing, and Hefei, among othersIs Scholz carefully balancing or is he falling behind EU policy?Since Scholz became German Chancellor in December 2021 he has carefully sought to re-define Germany's China policy. As head of a three-party coalition government, this has proven rather difficult. While the geopolitical climate has drastically changed, Germany's dependence on trade and investment relations with China is still as large as before, if not even more. Yet, as the term 'systemic rivalry' indicates, Germany, like the EU and the U.S., has woken up to the challenges China's increasingly assertive economic and geopolitical policies present. Still, Scholz's recent China visit did not reflect this. His visit was very much in the tradition of Angela Merkel's regular polite visits to China. While this may boost the German economy in the short-term, it does little for Germany's reputation as Europe's foremost country.
Summer is up beating for everybody and for CHPAMS as well. To promote the potential collaborations among our members and make the professional network stronger, CHPAMS initiated a series of activities in summer 2015. Dr. Lizheng Shi from Tulane University opened the scene of summer 2015 by organizing a CHPAMS reception at International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual International Meeting in Philadelphia on May 19, 2015. This event was well attended by over more than 40 scholars from industry, academia, and government agencies across the world. After the event, a special wechat group with more than 150 members was developed almost overnight, which shows a strong momentum of this excellent social network event. June is definitely a busy month for CHPAMS. Our members were actively participating in events in China and U.S. The Chinese Economists Society (CES) 2015 Conference in Chongqing, China was definitely a highlight for CHPAMS members. Dr. Lizheng Shi, the incumbent CES President and myself both served on the CES board to organize this significant event on June 13-14. We fortunately invited two Nobel Laureates, Kenneth Arrow, and Sir James Mirrlees, as keynote speakers. CHPAMS hosted a forum for junior scholars at the meeting and I chaired a round table which focused on Aging Population and Health Reform in China. Dr. Gordon Liu, Dr. Shuanglin Lin from Peking University, Dr. Yinyao Chen from Fudan University, and Dr. Hengjin Dong from Zhejiang University delivered excellent speeches at this roundtable and received warm responses from the audience. CHPAMS members also received several prestigious awards: Mr. HUANG Wei for Best CES Economics Student Award, Dr. HE Guojun for Gregory Chow Best Paper Award, and I'm so humble to receive the Best Service Award. All these activities and awards demonstrate the excellence CHPAMS and its members are pursuing. Right after the CES conference, CHPAMS members joined the 2nd Westlake Youth Forum on June 15-18, 2015 in Hangzhou, China. The Westlake Youth Forum is a significant event organized by China Medical Board (CMB), Zhejiang University School of Medicine, and CHPAMS. The forum attracted over 50 attendees and CHPAMS members actively participated in the forums as presenters, moderators, and discussants. CHPAMS also held its reception on June 16, which had an unforgettable night for all attendees. Thanks to CMB's generous support, the Westlake Youth Forum provides excellent educational and networking opportunities to junior public health and health policy scholars in China and overseas. Almost at the same time, a group of health services researchers attended CHPAMS' reception at the 2015 AcademyHealth Annual Research Meeting (ARM) on June 15, 2015 in Minneapolis, MN. Approximately 20 current and new CHPAMS members participated and enjoyed the reception. This social event provided a delightful opportunity for Chinese researchers from all around the world to exchange ideas and collaborate in the future. The China Health Policy and Management Society (CHPAMS) and its members actively participated in the International Health Economics Association (iHEA) 11th World Congress in Milan, Italy on July 13-15, 2015. CHPAMS was highlighted as one of the premier Chinese organizations in the Congress' program. CHPAMS members contributed to the biennial conference as scientific committee members, session chairs, and presenters. CHPAMS also hosted a reception for attending members with a memorable reunion in the summer of Milan. Except for attending a variety of conferences in the summer, CHPAMS successfully hosted the 2nd Jump-Start Your Career (JSYC) Webinar on June 30, 2015. The Jump-Start Your Career is a series of webinars hosted by CHPAMS to facilitate the members' career development in their own fields by introducing career opportunities in and out of China. CHPAMS hosted the 1st Jump-Start Your Career in May 2015 and we invited two premier speakers for this inaugural event from Peking University and Shandong University. The 2nd JSYC highlighted senior speakers from Zhejiang University and Fudan University, who introduced their institutions, job opportunities, benefits to recruit talented scholars. Several junior faculty members from each institution described their experience and lives as the returnees in China. The speakers interacted with CHPAMS members and answered questions from the participants during the live event. CHPAMS appreciated the following speakers who support the Jump-Start Your Career webinars. Peking University, School of Public Health Qingyue Meng, Dean, School of Public Health and Executive Director, PKU China Center for Health Development Studies Xiaoyun Liu, Associate Professor, PKU China Center for Health Development Studies Shandong University, School of Medicine and Health Management Qiang Sun, Deputy Dean, School of Medicine and Health Management and Executive Director, Center for Health Management and Policy Xiaojie Sun, Associate Professor, Center for Health Management and Policy Zhejiang University, School of Public Health & School of Medicine Shankuan ZHU, Associate Dean and Professor, Founding Director of Chronic Disease Institute, School of Public Health Hai YU, Professor, Center for Health Policy Studies, School of Medicine Hengjin DONG, Professor, Associate Director of Department of Social Medicine , School of Public Health; Director of Center for Health Policy, School of Medicine Xiaoguang MA, Associate Professor, Secretary of Human Resource Committee, School of Public Health Fudan University, School of Public Health Wen CHEN, Dean, Professor of Health Economics Yingyao CHEN, Associate Dean, Professor of Health Services Zhuohui ZHAO, Associate Professor of Environmental Health Yubin ZHANG, Associate Research Fellow of Occupational Health Min HU, Lecturer of Health Economics CHPAMS welcomes other institutions to conduct recruitment talks at the future Jump-Start Your Career webinar series. All these activities significantly enhanced the bondage of our members and the organization and received positive responses from all stakeholders. CHPAMS is determined to continue these efforts to provide more opportunities to our members. We thank the China Medical Board (CMB) and Beijing Office colleagues' strong support to CHPAMS and the diverse activities in this summer. We will continue to roll out our activities into the Fall!
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Warnung zur Verfügbarkeit
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Loet Leydesdorff on the Triple Helix: How Synergies in University-Industry-Government Relations can Shape Innovation Systems
This is the sixth and last in a series of Talks dedicated to the technopolitics of International Relations, linked to the forthcoming double volume 'The Global Politics of Science and Technology' edited by Maximilian Mayer, Mariana Carpes, and Ruth Knoblich
The relationship between technological innovation processes and the nation state remains a challenge for the discipline of International Relations. Non-linear and multi-directional characteristics of knowledge production, and the diffusive nature of knowledge itself, limit the general ability of governments to influence and steer innovation processes. Loet Leydesdorff advances the framework of the "Triple Helix" that disaggregates national innovation systems into evolving university-industry-government eco-systems. In this Talk, amongst others, he shows that these eco-systems can be expected to generate niches with synergy at all scales, and emphasizes that, though politics are always involved, synergies develop unintentionally.
Print version of this Talk (pdf)
What is the most relevant aspect of the dynamics of innovation for the discipline of International Relations?
The main challenge is to endogenize the notions of technological progress and technological development into theorizing about political economies and nation states. The endogenization of technological innovation and technological development was first placed on the research agenda of economics by evolutionary economists like Nelson and Winter in the late 1970s and early 1980s. In this context, the question was how to endogenize the dynamics of knowledge, organized knowledge, science and technology into economic theorizing. However, one can equally well formulate the problem of how to reflect on the global (sub)dynamics of organized knowledge production in political theory and International Relations.
From a longer-term perspective, one can consider that the nation states – the national or political economies in Europe – were shaped in the 19th century, somewhat later for Germany (after 1871), but for most countries it was during the first half of the 19th century. This was after the French and American Revolutions and in relation to industrialization. These nation states were able to develop an institutional framework for organizing the market as a wealth-generating mechanism, while the institutional framework permitted them to retain wealth, to regulate market forces, and also to steer them to a certain extent. However, the market is not only a local dynamics; it is also a global phenomenon.
Nowadays, another global dynamics is involved: science and technology add a dynamics different from that of the market. The market is an equilibrium-seeking mechanism at each moment of time. The evolutionary dynamics of science and technology nowadays adds a non-equilibrium-seeking dynamics over time on top of that, and this puts the nation state in a very different position. Combining an equilibrium-seeking dynamics at each moment of time with a non-equilibrium seeking one over time results in a complex adaptive dynamics, or an eco-dynamics, or however you want to call it – these are different words for approximately the same thing.
For the nation state, the question arises of how it relates to the global market dynamics on the one side, and the global dynamics of knowledge and innovation on the other. Thus, the nation state has to combine two tasks. I illustrated this model of three subdynamics with a figure in my 2006 book entitled The Knowledge-Based Economy: Modeled, measured, simulated (see image). The figure shows that first-order interactions generate a knowledge-based economy as a next-order or global regime on top of the localized trajectories of nation states and innovative firms. These complex dynamics have first to be specified and then to be analyzed empirically.
For example, the knowledge-based dynamics change the relation between government and the economy; and they consequently change the position of the state in relation to wealth-retaining mechanisms. How can the nation state be organized in such a way as to retain wealth from knowledge locally, while knowledge (like capital) tends to travel beyond boundaries? One can envisage the complex system dynamics as a kind of cloud – a cloud that touches the ground at certain places, as Harald Bathelt, for example, formulated.
How can national governments shape conditions for the cloud to touch and to remain on the ground? The Triple Helix of University-Industry-Government Relations can be considered as an eco-system of bi- and tri-lateral relations. The three institutions and their interrelations can be expected to form a system carrying the three functions of (i) novelty production, (ii) wealth generation, and (iii) normative control. One tends to think of university-industry-government relations first as neo-corporatist arrangements between these institutional partners. However, I am interested in the ecosystem shaped through the tri- and bilateral relationships.
This ecosystem can be shaped at different levels. It can be a regional ecosystem or a national ecosystem, for instance. One can ask whether there is a surplus of synergy between the three (sub-)dynamics of university-industry-government relations and where that synergy can generate wealth, knowledge, and control; in which places, and along trajectories for which periods of time – that is, the same synergy as meant by "a cloud touching the ground".
For example, when studying Piedmont as a region in Northern Italy, it is questionable whether the synergy in university-industry-government relations is optimal at this regional level or should better be examined from a larger perspective that includes Lombardy. On the one hand, the administrative borders of nations and regions result from the construction of political economies in the 19th century; but on the other hand, the niches of synergy that can be expected in a knowledge-based economy are bordered also; for example, in terms of metropolitan regions (e.g., Milan–Turin–Genoa).
Since political dynamics are always involved, this has implications for International Relations as a field of study. But the dynamic analysis is different from comparative statics (that is, measurement at different moments of time). The knowledge dynamics can travel and be "footloose" to use the words of Raymond Vernon, although it leaves footprints behind. Grasping "wealth from knowledge" (locally or regionally) requires taking a systems perspective. However, the system is not "given"; the system remains under reconstruction and can thus be articulated only as a theoretically informed hypothesis.
In the social sciences, one can use the concept of a hypothesized system heuristically. For example, when analyzing the knowledge-based economy in Germany, one can ask whether more synergy can be explained when looking at the level of the whole country (e.g., in terms of the East-West or North-South divide) or at the level of Germany's Federal States? What is the surplus of the nation or at the European level? How can one provide political decision-making with the required variety to operate as a control mechanism on the complex dynamics of these eco-systems?
A complex system can be expected to generate niches with synergy at all scales, but as unintended consequences. To what extent and for which time span can these effects be anticipated and then perhaps be facilitated? At this point, Luhmann's theory comes in because he has this notion of different codifications of communication, which then, at a next-order level, begin to self-organize when symbolically generalized.
Codes are constructed bottom-up, but what is constructed bottom-up may thereafter begin to control top-down. Thus, one should articulate reflexively the selection mechanisms that are constructed from the bottom-up variation by specifying the why as an hypothesis. What are the selection mechanisms? Observable relations (such as university-industry relations) are not neutral, but mean different things for the economy and for the state; and this meaning of the observable relations can be evaluated in terms of the codes of communication.
Against Niklas Luhmann's model, I would argue that codes of communication can be translated into one another since interhuman communications are not operationally closed, as in the biological model of autopoiesis. One also needs a social-scientific perspective on the fluidities ("overflows") and translations among functions, as emphasized, for example, by French scholars such as Michel Callon and Bruno Latour. In evolutionary economics, one distinguishes between market and non-market selection environments, but not among selection environments that are differently codified. Here, Luhmann's theory offers us a heuristic: The complex system of communications tends to differentiate in terms of the symbolic generalizations of codes of communication because this differentiation is functional in allowing the system to process more complexity and thus to be more innovative. The more orthogonal the codes, the more options for translations among them. The synergy indicator measures these options as redundancy. The selection environments, however, have to be specified historically because these redundancies—other possibilities—are not given but rather constructed over long periods of time.
How did you arrive where you currently work on?
I became interested in the relations between science, technology, and society as an undergraduate (in biochemistry) which coincided with the time of the student movement of the late 1960s. We began to study Jürgen Habermas in the framework of the "critical university," and I decided to continue with a second degree in philosophy. After the discussions between Luhmann and Habermas (1971), I recognized the advantages of Luhmann's more empirically oriented systems approach and I pursued my Ph.D. in the sociology of organization and labour.
In the meantime, we got the opportunity to organize an interfaculty department for Science and Technology Dynamics at the University of Amsterdam after a competition for a large government grant. In the context of this department, I became interested in methodology: how can one compare across case studies and make inferences? Actually, my 1995 book The Challenge of Scientometrics had a kind of Triple-Helix model on the cover: How do cognitions, texts, and authors exhibit different dynamics that influence one another?
For example, when an author publishes a paper in a scholarly journal, this may add to his reputation as an author, but the knowledge claimed in the text enters a process of validation which can be much more global and anonymous. These processes are mediated since they are based on communication. Thus, one can add to the context of discovery (of authors) and the context of justification (of knowledge contents) a context of mediation (in texts). The status of a journal, for example, matters for the communication of the knowledge content in the article. The contexts operate as selection environments upon one another.
In evolutionary economics, one is used to distinguishing between market and non-market selection environments, but not among more selection environments that are differently codified. At this point, Luhmann's theory offers a new perspective: The complex system of communications tends to differentiate in terms of the symbolic generalization of codes of communication because this differentiation among the codes of communication allows the system to process more complexity and to be more innovative in terms of possible translations. The different selection environments for communications, however, are not given but constructed historically over long periods of time. The modern (standardized) format of the citation, for example, was constructed at the end of the 19th century, but it took until the 1950s before the idea of a citation index was formulated (by Eugene Garfield). The use of citations in evaluative bibliometrics is even more recent.
In evolutionary economics, one distinguishes furthermore between (technological) trajectories and regimes. Trajectories can result from "mutual shaping" between two selection environments, for example, markets and technologies. Nations and firms follow trajectories in a landscape. Regimes are global and require the specification of three (or more) selection environments. When three (or more) dynamics interact, symmetry can be broken and one can expect feed-forward and feedback loops. Such a system can begin to flourish auto-catalytically when the configuration is optimal.
From such considerations, that is, a confluence of the neo-institutional program of Henry Etzkowitz and my neo-evolutionary view, our Triple Helix model emerged in 1994: how do institutions and functions interrelate and change one another or, in other words, provide options for innovation? Under what conditions can university-industry-government relations lead to wealth generation and organized knowledge production? The starting point was a workshop about Evolutionary Economics and Chaos Theory: New directions for technology studies held in Amsterdam in 1993. Henry suggested thereafter that we could collaborate further on university-industry relations. I answered that I needed at least three (sub)dynamics from the perspective of my research program, and then we agreed about "A Triple Helix of University-Industry-Government Relations". Years later, however, we took our two lines of research apart again, and in 2002 I began developing a Triple-Helix indicator of synergy in a series of studies of national systems of innovation.
What would you give as advice to students who would like to get into the field of innovation and global politics?
In general, I would advise them to be both a specialist and broader than that. Innovation involves crossing established borders. Learn at least two languages. If your background is political science, then take a minor in science & technology studies or in economics. One needs both the specialist profile and the potential to reach out to other audiences by being aware of the need to make translations between different frameworks. Learn to be reflexive about the status of what one can say in one or the other framework.
For example, I learned to avoid the formulation of grandiose statements such as "modern economies are knowledge-based economies," and to say instead: "modern economies can increasingly be considered as knowledge-based economies." The latter formulation provides room for asking "to what extent," and thus one can ask for further information, indicators, and results of the measurement.
In the sociology of science, specialisms and paradigms are sometimes considered as belief systems. It seems to me that by considering scholarly discourses as systems of rationalized expectations one can make the distinction between normative and cognitive learning. Normative learning (that is, in belief systems) is slower than cognitive learning (in terms of theorized expectations) because the cognitive mode provides us with more room for experimentation: One can afford to make mistakes, since one's communication and knowledge claims remain under discussion, and not one's status as a communicator. The cognitive mode has advantages; it can be considered as the surplus that is further developed during higher education. Normative learning is slower; it dominates in the political sphere.
What does the "Triple Helix" reveal about the fragmentation of "national innovation systems"?
In 2003, colleagues from the Department of Economics and Management Studies at the Erasmus University in Rotterdam offered me firm data from the Netherlands containing these three dimensions: the economic, the geographical, and the technological dimensions in data of more than a million Dutch firms. I presented the results at the Schumpeter Society in Turin in 2004, and asked whether someone in the audience had similar data for other countries. I expected Swedish or Israeli colleagues to have this type of statistics, but someone from Germany stepped in, Michael Fritsch, and so we did the analysis for Germany. These studies were first published in Research Policy. Thereafter, we did studies on Hungary, Norway, Sweden, and recently also China and Russia.
Several conclusions arise from these studies. Using entropy statistics, the data can be decomposed along the three different dimensions. One can decompose national systems geographically into regions, but one can also decompose them in terms of the technologies involved (e.g., high-tech versus medium-tech). We were mainly relying on national data. And of course, there are limitations to the data collections. Actually, we now have international data, but this is commercial data and therefore more difficult to use reliably than governmental statistics.
For the Netherlands, we obtained the picture that would more or less be expected: Amsterdam, Rotterdam, and Eindhoven are the most knowledge-intensive and knowledge-based regions. This is not surprising, although there was one surprise: We know that in terms of knowledge bases, Amsterdam is connected to Utrecht and then the geography goes a bit to the east in the direction of Wageningen. What we did not know was that the niche also spreads to the north in the direction of Zwolle. The highways to Amsterdam Airport (Schiphol) are probably the most important.
In the case of Germany, when we first analyzed the data at the level of the "Laender" (Federal States), we could see the East-West divide still prevailing, but when we repeated the analysis at the lower level of the "Regierungsbezirke" we no longer found the East-West divide as dominant (using 2004 data). So, the environment of Dresden for example was more synergetic in Triple-Helix terms than that of Saarbruecken. And this was nice to see considering my idea that the knowledge-based economy increasingly prevails since the fall of the Berlin Wall and the demise of the Soviet Union. The discussion about two different models for organizing the political economy—communism or liberal democracy—had become obsolete after 1990.
After studying Germany, I worked with Balázs Lengyel on Hungarian data. Originally, we could not find any regularity in the Hungarian data, but then the idea arose to analyze the Hungarian data as three different innovation systems: one around Budapest, which is a metropolitan innovation system; one in the west of the country, which has been incorporated into Western Europe; and one in the east of the country, which has remained the old innovation system that is state-led and dependent on subsidies. For the western part, one could say that Hungary has been "europeanized" by Austria and Germany; it has become part of a European system.
When Hungary came into the position to create a national innovation system, free from Russia and the Comecon, it was too late, as Europeanization had already stepped in and national boundaries were no longer as dominant. Accordingly, and this was a very nice result, assessing this synergy indicator on Hungary as a nation, we did not find additional synergy at the national (that is, above-regional) level. While we clearly found synergy at the national level for the Netherlands and also found it in Germany, but at the level of the Federal States, we could not find synergy at a national level for Hungary. Hungary has probably developed too late to develop a nationally controlled system of innovations.
A similar phenomenon appeared when we studied Norway: my Norwegian colleague (Øivind Strand) did most of our analysis there. To our surprise, the knowledge-based economy was not generated where the universities are located (Oslo and Trondheim), but on the West Coast, where the off-shore, marine and maritime industries are most dominant. FDI (foreign direct investment) in the marine and maritime industries leads to knowledge-based synergy in the regions on the West Shore of Norway. Norway is still a national system, but the Norwegian universities like Trondheim or Oslo are not so much involved in entrepreneurial networks. These are traditional universities, which tend to keep their hands off the economy.
Actually, when we had discussions about these two cases, Norway and Hungary, which both show that internationalization had become a major factor, either in the form of Europeanization in the Hungarian case, or in the form of foreign-driven investments (off-shore industry and oil companies) in the Norwegian case, I became uncertain and asked myself whether we did not believe too much in our indicators? Therefore, I proposed to Øivind to study Sweden, given the availability of well-organized data of this national system.
We expected to find synergy concentrated in the three regional systems of Stockholm, Gothenburg, and Malmö/Lund. Indeed, 48.5 percent of the Swedish synergy is created in these three regions. This is more than one would expect on the basis of the literature. Some colleagues were upset, because they had already started trying to work on new developments of the Triple Helix, for example, in Linköping. But the Swedish economy is organized and centralized in this geographical dimension. Perhaps that is why one talks so much about "regionalization" in policy documents. Sweden is very much a national innovation system, with additional synergy between the regions.
Can governments alter historical trajectories of national, regional or local innovation systems?
Let me mention the empirical results for China in order to illustrate the implications of empirical conclusions for policy options. We had no Chinese data set, but we obtained access to the database Orbis of the Bureau van Dijk (an international company, which is Wall Street oriented, assembling data about companies) that contains industry indicators such as names, addresses, NACE-codes, types of technology, the sizes of each enterprise, etc. However, this data can be very incomplete. Using this incomplete data for China, we said that we were just going to show how one could do the analysis if one had full data. We guess that the National Bureau of Statistics of China has complete data. I did the analysis with Ping Zhou, Professor at Zhejiang University.
We analyzed China first at the provincial level, and as expected, the East Coast emerged as much more knowledge intense than the rest of the country. After that, we also looked at the next-lower level of the 339 prefectures of China. From this analysis, four of them popped up as far more synergetic than the others. These four municipalities were: Beijing, Shanghai, Tianjin, and Chongqing.
These four municipalities became clearly visible as an order of magnitude more synergetic than other regions. The special characteristic about them is that –as against the others – these four municipalities are administered by the central government. Actually, it came out of my data and I did not understand it; but my Chinese colleague said that this result was very nice and specified this relationship.
The Chinese case thus illustrates that government control can make a difference. It shows – and that is not surprising, as China runs on a different model – that the government is able to organize the four municipalities in such a way as to increase synergy. Of course, I do not know what is happening on the ground. We know that the Chinese system is more complex than these three dimensions suggest. I guess the government agencies may wish to consider the option of extending the success of this development model, to Guangdong for example or to other parts of China. Isn't it worrisome that all the other and less controlled districts have not been as successful in generating synergy?
Referring more generally to innovation policies, I would advise as a heuristics that political discourse is able to signal a problem, but policy questions do not enable us to analyze the issues. Regional development, for example, is an issue in Sweden because the system is very centralized, more than in Norway, for example. But there is nothing in our data that supports the claim that the Swedish government is successful in decentralizing the knowledge-based economy beyond the three metropolitan regions. We may be able to reach conclusions like these serving as policy advice. One develops policies on the basis of intuitive assumptions which a researcher is sometimes able to test.
As noted, one can expect a complex system continuously to produce unintended consequences, and thus it needs monitoring. The dynamics of the system are different from the sum of the sub-dynamics because of the interaction effects and feedback loops. Metaphors such as a Triple Helix, Mode-2, or the Risk Society can be stimulating for the discourse, but these metaphors tend to develop their own dynamics of proliferating discourses.
The Triple Helix, for example, can first be considered as a call for collaboration in networks of institutions. However, in an ecosystem of bi-lateral and tri-lateral relations, one has a trade-off between local integration (collaboration) and global differentiation (competition). The markets and the sciences develop at the global level, above the level of specific relations. A principal agent such as government may be locked into a suboptimum. Institutional reform that frees the other two dynamics (markets and sciences) requires translation of political legitimation into other codes of communication. Translations among codes of communication provide the innovation engine.
Is there a connection between infrastructures and the success of innovation processes?
One of the conclusions, which pervades throughout all advanced economies, is that knowledge intensive services (KIS) are not synergetic locally because they can be disconnected – uncoupled – from the location. For example, if one offers a knowledge-intensive service in Munich and receives a phone call from Hamburg, the next step is to take a plane to Hamburg, or to catch a train inside Germany perhaps. Thus, it does not matter whether one is located in Munich or Hamburg as knowledge-intensive services uncouple from the local economy. The main point is proximity to an airport or train station.
This is also the case for high-tech knowledge-based manufacturing. But it is different for medium-tech manufacturing, because in this case the dynamics are more embedded in the other parts of the economy. If one looks at Russia, the knowledge-intensive services operate differently from the Western European model, where the phenomenon of uncoupling takes place. In Russia, KIS contribute to coupling, as knowledge-intensive services are related to state apparatuses.
In the Russian case, the knowledge-based economy is heavily concentrated in Moscow and St. Petersburg. So, if one aims –as the Russian government proclaims – to create not "wealth from knowledge" but "knowledge from wealth" – that is, oil revenues –it might be wise to uncouple the knowledge-intensive services from the state apparatuses. Of course, this is not easy to do in the Russian model because traditionally, the center (Moscow) has never done this. Uncoupling knowledge-intensive services, however, might give them a degree of freedom to move around, from Tomsk to Minsk or vice versa, steered by economic forces more than they currently are (via institutions in Moscow).
Final question. What does path-dependency mean in the context of innovation dynamics?
In The Challenge of Scientometrics. The development, measurement, and self-organization of scientific communications (1995), I used Shannon-type information theory to study scientometric problems, as this methodology combines both static and dynamic analyses. Connected to this theory I developed a measurement method for path-dependency and critical transitions.
In the case of a radio transmission, for example, you have a sender and a receiver, and in between you may have an auxiliary station. For instance, the sender is in New York and the receiver is in Bonn and the auxiliary station is in Iceland. The signal emerges in New York and travels to Bonn, but it may be possible to improve the reception by assuming the signal is from Iceland instead of listening to New York. When Iceland provides a better signal, it is possible to forget the history of the signal before it arrived in Island. It no longer matters whether Iceland obtained the signal originally from New York or Boston. One takes the signal from Iceland and the pre-history of the signal does not matter anymore for a receiver.
Such a configuration provides a path-dependency (on Iceland) in information-theoretical terms, measurable in terms of bits of information. In a certain sense you get negative bits of information, since the shortest path in the normal triangle would be from New York to Bonn, and in this case the shortest path is from New York via Iceland to Bonn. I called this at the time a critical transition. In a scientific text for instance, a new terminology can come up and if it overwrites the old terminology to the extent that one does not have to listen to the old terminology anymore, one has a critical transition that frees one from the path-dependencies at a previous moment of time.
Thus, my example is about radical and knowledge-based changes. As long as one has to listen to the past, one does not make a critical transition. The knowledge-based approach is always about creative destruction and about moving ahead, incorporating possible new options in the future. The hypothesized future states become more important than the past. The challenge, in my opinion, is to make the notion of options operational and to bring these ideas into measurement. The Triple-Helix indicator measures the number of possible options as additional redundancy. This measurement has the additional advantage that one becomes sensitive to uncertainty in the prediction.
Loet Leydesdorff is Professor Emeritus at the Amsterdam School of Communications Research (ASCoR) of the University of Amsterdam. He is Honorary Professor of the Science and Technology Policy Research Unit (SPRU) of the University of Sussex, Visiting Professor at the School of Management, Birkbeck, University of London, Visiting Professor of the Institute of Scientific and Technical Information of China (ISTIC) in Beijing, and Guest Professor at Zhejiang University in Hangzhou. He has published extensively in systems theory, social network analysis, scientometrics, and the sociology of innovation (see at http://www.leydesdorff.net/list.htm). With Henry Etzkowitz, he initiated a series of workshops, conferences, and special issues about the Triple Helix of University-Industry-Government Relations. He received the Derek de Solla Price Award for Scientometrics and Informetrics in 2003 and held "The City of Lausanne" Honor Chair at the School of Economics, Université de Lausanne, in 2005. In 2007, he was Vice-President of the 8th International Conference on Computing Anticipatory Systems (CASYS'07, Liège). In 2014, he was listed as a highly-cited author by Thomson Reuters.
Literature and Related links:
Science & Technology Dynamics, University of Amsterdam / Amsterdam School of Communications Research (ASCoR)
Leydesdorff, L. (2006). The Knowledge-Based Economy: Modeled, Measured, Simulated. Universal Publishers, Boca Raton, FL.
Leydesdorff, L. (2001). A Sociological Theory of Communication: The Self-Organization of the Knowledge-Based Society. Universal Publishers, Boca Raton, FL.
Leydesdorff, L. (1995). The Challenge of Scientometrics . The development, measurement, and self-organization of scientific communications. Leiden, DSWO Press, Leiden University.
http://www.leydesdorff.net/
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