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The issue of the terminal patient is an ever-present topic in the approaches focused on the real and efficient control on the end of life, while it entails both in theoretical analysis and practical illustrations a wide category of terms, which have not yet reach consensus despite almost five decades of academic debate. Thus, terms such as assisted dying, end of life, terminal illness, terminal care highlight the manners in which technologic and scientific advances allow for the artificial preservation of vital functions in correlation with a series of medical consequences regarding the increase of life expectancy, effects on health and criteria for establishing the death of an individual. The concerns and deep medical, social, economic and legal implications of the patient diagnosed with a terminal illness define through palliative care the objectives and basic tenets emerging from the ethical aim to preserve the dignity of the patient. Control of symptoms, spiritual state and care for the family of the affected individual are involved in life care or life support therapies and appeal to the principle of benefaction. From the point of view of preserving human dignity, benefaction becomes the basis for the elaboration of bioethical criteria intended for the evaluation of the decisions implicated in the management of the terminally ill patient. Since the importance of the dignity of the patient at the end of his or her life cannot be denied, in this paper we aim to identify the ethical attributes which define the concept of dignity, to outline its multidimensional character and the complex nature of this concept.

Ageism involves all aspects of life and it manifests through the manner in which people interact, as well as through our self-perception. Impact of age on social interactions and especially on mental and physical health remains for the most part unknown or underestimated, with a tendency towards homogenized characterization from which derives a risk of damage, exaggeration and even distortion. Covid-19 pandemic generated a complex context in the medical field, with a significant reverberation in the social space, allowing for the assessment of the impact and reaction to a series of ethical values, as well as gathering evidence which, in the area of preconceptions, reflect how COVID-19 pandemic altered the manner to approach ageism. Attitudes towards elders occurring in a series of areas in general, and particularly during COVID-19 pandemic, turn the reality of age into a great challenge. Towards this end, multidisciplinary approaches are necessary, with diverse representations and involvement of all the interested factors, so that we may outline a truthful and accurate portrait of age, for various domains and trials of life.

Although oral drug delivery is the preferred administration route and has been used for centuries, modern drug discovery and development pipelines challenge conventional formulation approaches and highlight the insufficient mechanistic understanding of processes critical to oral drug absorption. This review presents the opinion of UNGAP scientists on four key themes across the oral absorption landscape: (1) specific patient populations, (2) regional differences in the gastrointestinal tract, (3) advanced formulations and (4) food-drug interactions. The differences of oral absorption in pediatric and geriatric populations, the specific issues in colonic absorption, the formulation approaches for poorly water-soluble (small molecules) and poorly permeable (peptides, RNA etc.) drugs, as well as the vast realm of food effects, are some of the topics discussed in detail. The identified controversies and gaps in the current understanding of gastrointestinal absorption-related processes are used to create a roadmap for the future of oral drug absorption research.(c) 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Background: Non-alcoholic fatty liver disease (NAFLD) has increased exponentially in recent years in Western European countries, where the number of hepatitis of viral etiology has been declining, and it is thought to be the most common cause of chronic liver disease in the near future (1). Currently, NAFLD is both the second most common cause of hepatocellular carcinoma (HCC) and the second most common indication for liver transplantation (2-4). This problem is very serious, as cases of NAFLDs are increasingly in children, a population with a long life ahead, and in whom the disease has all the time to progress to cirrhosis and HCC (5, 6). Objectives: The goal of this prospective study is to determine the effect of an original formula consisting in silymarin, organic selenium and alpha lipoic acid, in reducing liver damage in patients with chronic liver disease. Material and methods: The study started in March 2018, initially with a group of patients from Bucharest, integrated in the study at St. Mary’s Hospital. In October 2018 it was expanded at the national level to 1 718 patients, monitored by 145 investigating physicians from 134 centers, with an average of 11.8 patients per investigating physician. Outcomes: Taking each stage of fatty liver disease (FLD) at T0 moment (the beginning of the study), we observed that 25% of patients with grade I FLD had no sign of disease at the end of the study, 74% of those with grade II FLD recovered or improved their health, and 83% of patients with grade III FLD recovered or improved their health. There were 149 patients with no FLD detected at the end of the study (recovered). Conclusion: Based on triple antioxidant therapy, the original formula improved the evolution and prognosis of patients with chronic liver disease.

Introduction: Henoch-Schonlein purpura (HSP), is a self-limiting vasculitis involving the small vessels of the skin, gastrointestinal tract, kidneys, joints, and rarely the lungs and central nervous system (CNS). The severe acute respiratory syndrome coronavirus-2 (Sars-CoV-2) infection may be a condition associated with the development of vasculitis sustained by an exacerbated IgA-mediated immune response. Case Description/Methods: In the context of the current pandemic, we report the case of a 32-yearold patient who showed clinical features of HSP that appeared in a few days after the diagnosis of Coronavirus Disease 2019 (COVID-19) mild form, confirmed by PCR test. He presented an acute onset with marked asthenia, edema and painful bilateral swelling of the knee, associated with difficulty walking. Small flat lesions distributed on the upper and lower extremity and on the posteriorchest have been identified, one day later. He needed hospitalization in a medical center where he received corticosteroid therapy, anticoagulant, antiviral with regression of skin lesions and joint swelling. After five days the skin lesions expand and after 48 hours there is intense abdominal pain accompanied by accelerated intestinal transit with blood. The objective examination reveals a rash on both lower extremity, which extends from the soles to the ankles (Figure 1). Examination of the knee joints shows no local erythema, but a painful limitation of passive movements is noted. Laboratory data indicate a biological inflammatory syndrome, proteinuria and hematuria. The immunological profile does not indicate the presence of non-COVID-19 reactive arthritis. Upper gastrointestinal examination performed at 4 days reveals gastric vascular spots. There are no evidence of suggestive lesions for inflammatory bowel disease (IBD) observed both on colonoscopy and abdominal CT based on 7 mm parietal thickening of the descending colon and sigmoid. Clinical, laboratory, imaging and endoscopic data establish the diagnosis of HSP with nephritic syndrome and reactive arthritis in the context of Sars-CoV-2 infection. Under cortisone treatment, purpura disappears completely after 10 days. Discussion: In our patient the presence of purpura in the absence of thrombocytopenia, as a mandatory criterion, in association with other criteria, namely arthritis reactive at onset, renal and digestive impairment, support according to EULAR / PRINTO / PRES criteria, the diagnosis of Henoch-Schonlein purpura..

The primary aim of this study is to assess the actual impact of healthcare public financing on population health status, while controlling for other non-financial health determinants. There are plenty of heterogeneous studies dealing with the negative or positive effects of different products consumption (e.g. sugar, alcohol, tobacco, fruits, vegetables, etc.) on people’s health. Starting from the relevant ones, we kept for our models those non-financial variables with public available data, used as control variables. After performing variable selection, we ranked the actual impact of different public expenditures categories on health status change, using simple and multiple regression fixed-effects techniques on a panel dataset regarding the European members of OECD (ranging from 1970 to 2014). Our results show that financing preventive care has the strongest positive impact on the health status, followed by auxiliary (ancillary) services. Administrative expenditures for the healthcare system do not have a significant influence, suggesting there is available room to enhance the effectiveness and performance of sanitary institutions management. Our results also show that life expectancy is negatively affected by the consumption of alcohol and sugar, in a decreasing order. These results were then connected with Romanian realities regarding health care financing and people’s consumption habits. In strong connection with our findings and these realities, this study provides, as a final part, a set of policy recommendations useful for Romanian public authorities in designing their policies, as well as for other interested non-governmental actors.

Sunitinib, a multi-targeted receptor tyrosine kinase inhibitor, has demonstrated survival benefit in patients with metastatic renal cell carcinoma (mRCC) and is generally well tolerated with most adverse events, manifesting as mild to moderate in severity. The most frequent related adverse events include hand-foot syndrome (HFS), hypertension, proteinuria, cardiac toxicities, myelosuppression, fatigue/asthenia, hypothyroidism, diarrhea and hepatotoxicity. The study aims to determine incidence of adverse events among patients with metastatic renal cell carcinoma (mRCC) treated Sunitinib within five years from 2010 to 2015 and comparing the results with data from literature. The study included a total of 56 patients treated with Sunitinib, with a dose of 50 mg (Schedule 4/2). Due to adverse events and individual safety and tolerability, at the indication of the personal clinician, 11 patients needed dose reduction, with a continuous dose of 37.5 mg, daily and 28 patients continued the dose of 50 mg taken daily, on a different schedule (2/1 schedule). The most important toxicities were anemia, leukopenia, thrombocytopenia, gastrointestinal effects (diarrhea), fatigue and hypertension. After dose reduction or modified schedule the incidence of the most frequent toxicities (HFS, leukopenia, thrombocytopenia and fatigue) decreased, but hypertension was still observed in 30% of patients. The results are similar with data from literature. Early identification of individuals at risk and monitoring patients during Sunitinib treatment is very important and it can facilitate early intervention with prophylactic measures or supportive treatment, thus increasing quality of life and adherence to treatment. Further studies need to establish which targeted population can benefit the most from adjusted regimens and to correlate them with prognostic factors for survival.

The present study evaluates the use of methadone in patients with advanced cancer and moderately-severe pain under palliative care at home over a period of 5 years, from 1996 to 2000. We calculated the index for methadone dosage increase (as a percentage and value in milligrams). Of the 1,079 patients cared for, 247 (22.89%) received methadone treatment: 126 from the very beginning, average dose of 15 mg / day (5- 50), and in 121 patients treatment with methadone was initiated at a later moment during the period they were cared for (5- 40). The median period of time of methadone administration was 27 days (1-416), the median dose of methadone at the moment of treatment discontinuation being 20 mg (5-60). The main reason for methadone treatment discontinuation was impossibility of oral administration (49.8% in terminal stages, 7.3% presenting nausea, vomiting), and 62.3% showed no side effects. Dosage increase index was 0.33 mg, 2.33% respectively. Methadone has been used mainly as a potent first line opioid, and has been shown to be effective and safe.

Introduction of contrast agents as microbubbles and to improve ultrasound examination techniques has increased the rate of detection and characterization of liver lesions. Contrast-enhanced ultrasonography (CEUS) is a relatively new method of exploring the liver and diagnosing focal liver lesions (FLL). The aim of this study is to determine the efficiency of microbubbles used for CEUS in managing patients detected in conventional ultrasonography with FLL. We examined 84 patients with FLL, detected on conventional ultrasonography (US), during October 2012-September 2015. We performed contrast-enhanced ultrasonography, using sulphur hexafluoride as a contrast agent, and contrast-enhanced MRI to set the diagnosis. For 37 patients (44.1%) CEUS showed a malignity pattern of enhancement (according to the EFSUMB - European Federation of Societies for Ultrasound in Medicine and Biology- Guidelines 2012), while for 54 (64.3%) patients MRI set the diagnosis of malignity. CEUS detected fewer malignant lesions than MRI, in 20.1% of the cases MRI set de diagnosis. We need further studies in order to improve the quality of CEUS images and technique.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths worldwide, while at the same time having a constant growth in incidence. A commonly used biomarker in managing liver cancer cases, alpha-fetoprotein (AFP) is losing clinical ground in favor of imaging studies and emerging biomarkers. The study aims to reassess potential prognosis indicators and risk factors for an elevated level of this glycoprotein by analyzing its relationship with macroscopic morphology tumor-related features.One hundred and thirty-one newly diagnosed HCC patients had their clinical, tumor and liver disease features investigated in contrast to elevated AFP levels with 200 IU∕mL being used as preferred cut-off.Tumor size =5 cm [odds ratio (OR) 3.36, 95% confidence interval (CI): 1.29-8.74, p=0.013] is an independent tumor-related predictor of markedly elevated AFP values. Noteworthy connections with the type of tumor, multinodular appearance and portal vein thrombosis were also found through univariate analysis.AFP could still be a reliable tool in diagnosis and prognosis of HCC patients especially in developing countries due to its relevant association with aspects of advanced tumor and liver disease, gender and a poor functional status.

This paper examines the link between the transport infrastructure and the economic performance in the EU-28 countries, over the period of time 2000&ndash, 2014, using panel data methods. Firstly, we aim to provide the theoretical background of the transport infrastructure development, public sector performance and economic growth. The paper's key point is the detailed look at the components of transport infrastructure, analyzing the implications of the policy-makers based on a production function and in order to test the policy implication, factor analysis is also employed. The results show significant effects from transport infrastructure components even after institutional and other factors are controlled for. From the path analysis results, the study confirm the alternative hypothesis, outlining the unidirectional long-run causality relationship between growth, transport infrastructure and Public Sector Performance. Transport infrastructure status (measured thought index of transport) has significant impact on economic development with coefficient estimate. The public performance indicators influence the way to economic growth. On the one hand, the corruption, the regulatory environment, size shadow economy, infant mortality, income inequality, inflation and unemployment rate negatively affect the economic growth, and on the other hand there is a strong positive relationship between the quality of the judiciary, education achievement, life expectancy and economic growth.

The accelerated development of information and communication technology (ICT) over the past two decades has encouraged an increasing number of researchers to examine and measure the impact of this technology on economic growth. Our study aims to identify and evaluate the effect of using ICT infrastructure on economic growth in European Union (EU) countries for a period of 18 years (2000&ndash, 2017). Using panel-data estimation techniques, we investigate empirically how various indicators of ICT infrastructure affect economic growth, proxied in our study by GDP per capita. Within the estimates, we have included some macroeconomic control variables. Our results indicate a positive and strongly effect of using ICT infrastructure on economic growth in the EU member states, but the magnitude of the effect differs depending on the type of technology examined. Regarding the impact of macroeconomic factors, our estimates indicate that inflation rate, unemployment rate, the degree of trade openness, government expenditures, and foreign direct investments would significantly affect GDP per capita at EU level. The findings are broadly similar to the theoretical predictions, but also to the findings of some relevant empirical studies. Our research reveals that ICT infrastructure, along with other macroeconomic factors, is an important driver of economic growth in EU countries.

Contemporary medicine is experiencing a high volume of information, which often exceeds the normal capacity of reception and processing. Time management is important in selection and retention of the volume and diversity of information, which raise the challenge to identify and experiment with new ways to learn. In this paper we aim to evaluate the effectiveness of the jigsaw puzzle method for teams applied in the clinical simulation module (human patient simulator and digestive endoscopy simulators). The target group consisted of medical students (IIIrd, IVth, and Vth) organized in mixed groups of six students coming from different years of study. Clinical scenarios selected from the library of the simulators were divided into sub-themes (puzzle pieces) distributed to students according to the type of professional and transversal skills characteristic to the year of study. Working groups have retraced the selected clinical scenarios by independent reports. We used the self-evaluation forms in the software of the equipment for checking the specific indicators of learning objectives. Processing and interpretation of information obtained from the results revealed how the documentation and presentation of independent research results to others, the communication and cooperation tasks and the transfer of knowledge between group members have contributed to cooperative learning. In conclusion, students thought that the essential element for the puzzle method is the interdependence between group members, which stimulates them to cooperate in order to achieve the goals.

Conscientious objection is one of the most frequent conflict situations between professional obligations of the doctor and the rights of the patient, based on the contradiction between the request of the patient for certain health-care services and the principles (religious or moral) of the medical staff. The ethical challenge of conscientious objection draw the attention to by the medical procedures performed in specific domains such as: reproductive medicine, terminal stages, reparatory and esthetic facial surgery etc. The phenomenon, although recognized, accepted and regulated by law in many states remains an extremely controversial issue in the medical field due to the ethical dilemmas derived from the right to freedom of conscience in correlation with preservation of the right to health-care. In this paper we aim to highlight the main ethical aspects involved by the conscientious objection in the medical field, with statements on the complexity and diversity of the conscientious objection identified in the space of multicultural societies specific for medical migration.

The substantial increase of the medical needs in society triggered the development of various medical domains which generated a wide field for the applicability of biomedical technologies, and thus facilitated new perspectives in the worldwide management of important health issues. Biomedical technologies are a useful segment of contemporary medicine and an omnipresent component of modern society, while they also provide enough reasons in support of the assertion that their implementation in current health care should not be an exception. However, scientific progress maintained by application of biomedical technologies in research, treatment and prevention is challenged by several ethical and moral issues. Therefore, within the framework of ethical discussions regarding the impact of biomedical technologies, the emphasis placed on the moral qualities of technological interventions is equivalent with the interest to evaluate quantifiable medical consequencest.

Chronic diseases are a major issue for healthcare both by the alarming increase of the number of new cases but also from the point of view of the negative consequences of prognosis and quality of life. Available treatments, although effective for most chronic diseases cannot guarantee the decrease of complications, as long as the best healthcare will be provided only by specialized centers. In the last decades, the integration of IT instruments at every level of healthcare reconfigured significantly the manner in which the care is offered and can ensure valuable and profitable remote healthcare far from the hospital. Successfully explored in several states, the interventions mobile-health confirmed through various software and applications that the integration of mobile technology in healthcare may be a viable manner to complete and improve the current strategies for the efficient management of chronic diseases. This paper aims to review the current state of art in a common field for the evolution of medicine, namely healthcare systems and mobile-health. For the presentation of the most important aspects that mobile-health entails in the management of chronic diseases we selected liver cirrhosis.

This paper aims to approach from the ethical perspective the relationship between medical education of healthcare services providers and globalization. Starting from the argument that the approach from the ethical perspective of medical education within the context of globalization allows for a better understanding of the requirements of contemporary medical act, the main issues refer to the ethical needs of medical profession worldwide, the ethical aspects of medical education and to the extent to which medical education corresponds to the contemporary level of globalization.

Endoscopic retrograde cholangiopancreatography is one of the most difficult and complications-prone procedures in the field of digestive endoscopy. Numerous studies assessed possible quality indicators that could lead towards a better procedural outcome and that in the same time would trigger red flags regarding possible complications' incidence. As telemedicine techniques are nowadays more and more popular among medical professionals, our paper aims at reviewing the literature about the possible use of these techniques as quality indicators for ERCP. Telemedicine may help in assuring procedural safety and therefore may narrow the incidence of risks and complications post-ERCP.