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Background. Hip fractures are a major issue of public health as they are responsible for high morbidity, excess mortality and costs. There are differences in Europe and worldwide in the incidence rates of hip fractures and time trends, in the context of the population aging. Ten years ago, we characterized the incidence of hip fracture in Romania using data from the national hospital discharge register. Objective. This is the first Romanian study to assess the hip fracture incidence rates over a period of 11 years, between 2008 and 2018. Subjects and Methods. This analysis is a nationwide retrospective study on hospitals reporting primary DRG data on hip fracture, using a rigorous definition with both diagnostic and surgical procedure codes. The population aged 40+ was stratified in 5-year intervals and both the crude incidence rates and the adjusted incidence rates of hip fracture using standardization on age for the 2018 reference population were calculated in women and men. Results. From 2008 to 2018, the number of hip fractures rose by 53 % in women (from 7513 to 11512) and 22.4 % in men (from 4266 to 5220). Meanwhile, the Romanian population over 40 years increased by 12.5% in women and 14.2% in men. The crude incidence rate rose by 36.2% in women and 7.2% in men and the age-standardized incidence rates by 27.4% in women and 6% in men. These increases are mostly based on 85+ age populations' changes. Conclusions. In Romania, the hip fractures incidence continues to grow throughout an 11-year-period, especially in women, representing an increasing burden for our society. [ABSTRACT FROM AUTHOR]

This article provides a snapshot of primary prevention activities in hospitals in 20 European high-income countries, based on inputs from experts of the Observatory's Health Systems and Policies Monitor (HSPM) network using a structured questionnaire. We found that in the vast majority of countries (15), there are no systematic national policies on primary prevention in hospitals. Five countries (Cyprus, Finland, Ireland, Romania and the United Kingdom) reported systematic primary prevention activities in hospitals, although in one of them (Cyprus) this was due to the fact that small hospitals in rural areas or less populated districts host providers of primary care. In two of the five countries with systematic national policies on primary prevention, there are no incentives (financial or otherwise) to provide these interventions. The remaining three countries (Finland, Romania and the United Kingdom) report the existence of incentives, but only two of them (Romania and the United Kingdom) provide financial incentives in the form of additional funding. Only two of the 20 countries (Ireland and the United Kingdom) make explicit use of the Making Every Contact Count (MECC) approach. Overall, it can be concluded that there is little focus on primary prevention in hospitals in Europe, which may be seen as a missed opportunity., Competing Interests: Declaration of competing interest The authors have no financial interests and no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier B.V.)

Background: Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement., Methods: Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates., Results: Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms., Conclusions: Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Background: Mental health service providers are increasingly interested in patient perspectives. We examined rates and predictors of patient-reported satisfaction and perceived helpfulness in a cross-national general population survey of adults with 12-month DSM-IV disorders who saw a provider for help with their mental health., Methods: Data were obtained from epidemiological surveys in the World Mental Health Survey Initiative. Respondents were asked about satisfaction with treatments received from up to 11 different types of providers (very satisfied, satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied) and helpfulness of the provider (a lot, some, a little, not at all). We modelled predictors of satisfaction and helpfulness using a dataset of patient-provider observations (n = 5,248)., Results: Most treatment was provided by general medical providers (37.4%), psychiatrists (18.4%) and psychologists (12.7%). Most patients were satisfied or very satisfied (65.9-87.5%, across provider) and helped a lot or some (64.4-90.3%). Spiritual advisors and healers were most often rated satisfactory and helpful. Social workers in human services settings were rated lowest on both dimensions. Patients also reported comparatively low satisfaction with general medical doctors and psychiatrists/psychologists and found general medical doctors less helpful than other providers. Men and students reported lower levels of satisfaction than women and nonstudents. Respondents with high education reported higher satisfaction and helpfulness than those with lower education. Type of mental disorder was unrelated to satisfaction but in some cases (depression, bipolar spectrum disorder, social phobia) was associated with low perceived helpfulness. Insurance was unrelated to either satisfaction or perceived helpfulness but in some cases was associated with elevated perceived helpfulness for a given level of satisfaction., Conclusions: Satisfaction with and perceived helpfulness of treatment varied as a function of type of provider, service setting, mental status, and socio-demographic variables. Invariably, caution is needed in combining data from multiple countries where there are cultural and service delivery variations. Even so, our findings underscore the utility of patient perspectives in treatment evaluation and may also be relevant in efforts to match patients to treatments., (© 2024. The Author(s).)

Central and Eastern European (CEE) countries have recently implemented reforms to health care provider payment systems, which include changing payment methods and related systems such as contracting, management information systems, and accountability mechanisms. This study examines factors influencing provider payment reforms implemented since 2010 in Bulgaria, Croatia, Czechia, Estonia, Latvia, Lithuania, Hungary, Poland, and Romania. A four-stage mixed methods approach was used: developing a theoretical framework and data collection form using existing literature, mapping payment reforms, consulting with national health policy experts, and conducting a comparative analysis. Qualitative analysis included inductive thematic analysis and deductive approaches based on an existing health policy model, distinguishing context, content, process, and actors. We analyzed 27 payment reforms that focus mainly on hospitals and primary health care. We identified 14 major factor themes influencing those reforms. These factors primarily related to the policy process (pilot study, coordination of implementation systems, availability of funds, IT systems, training for providers, reform management) and content (availability of performance indicators, use of clinical guidelines, favorability of the payment system for providers, tariff valuation). Two factors concerned the reform context (political willingness or support, regulatory framework, and bureaucracy) and two were in the actors' dimension (engagement of stakeholders, capacity of stakeholders). This study highlights that the content and manner of implementation (process) of a reform are crucial. Stakeholder involvement and their capacities could influence every dimension of the reform cycle. The nine countries analyzed share similarities in barriers and facilitators, suggesting the potential for cross-country learning., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Multiple studies have reported immune thrombocytopenia (ITP) relapse following SARS-CoV-2 vaccination, however baseline ITP relapse rate and antibody response to vaccination are not known. Patients with ITP who received at least one of the first three SARS-CoV-2 vaccination doses were included in the study. One hundred and twenty-four patients met the inclusion criteria. Relapse rate was 4.2% following a first vaccine dose, 9.1% after a second and 2.9% after a third; baseline relapse rate was 7.6%. Ninety-four per cent of patients who received three vaccine doses developed a clinical antibody response. SARS-CoV-2 vaccination appears to be safe and effective in patients with ITP., (© 2023 The Authors. British Journal of Haematology published by British Society for Haematology and John Wiley & Sons Ltd.)

Background: Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation., Methods: Face-to-face interviews with community samples from 13 countries ( n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months., Results: 10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation., Conclusion: Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

Background: Information on the frequency and timing of mental disorder onsets across the lifespan is of fundamental importance for public health planning. Broad, cross-national estimates of this information from coordinated general population surveys were last updated in 2007. We aimed to provide updated and improved estimates of age-of-onset distributions, lifetime prevalence, and morbid risk., Methods: In this cross-national analysis, we analysed data from respondents aged 18 years or older to the World Mental Health surveys, a coordinated series of cross-sectional, face-to-face community epidemiological surveys administered between 2001 and 2022. In the surveys, the WHO Composite International Diagnostic Interview, a fully structured psychiatric diagnostic interview, was used to assess age of onset, lifetime prevalence, and morbid risk of 13 DSM-IV mental disorders until age 75 years across surveys by sex. We did not assess ethnicity. The surveys were geographically clustered and weighted to adjust for selection probability, and standard errors of incidence rates and cumulative incidence curves were calculated using the jackknife repeated replications simulation method, taking weighting and geographical clustering of data into account., Findings: We included 156 331 respondents from 32 surveys in 29 countries, including 12 low-income and middle-income countries and 17 high-income countries, and including 85 308 (54·5%) female respondents and 71 023 (45·4%) male respondents. The lifetime prevalence of any mental disorder was 28·6% (95% CI 27·9-29·2) for male respondents and 29·8% (29·2-30·3) for female respondents. Morbid risk of any mental disorder by age 75 years was 46·4% (44·9-47·8) for male respondents and 53·1% (51·9-54·3) for female respondents. Conditional probabilities of first onset peaked at approximately age 15 years, with a median age of onset of 19 years (IQR 14-32) for male respondents and 20 years (12-36) for female respondents. The two most prevalent disorders were alcohol use disorder and major depressive disorder for male respondents and major depressive disorder and specific phobia for female respondents., Interpretation: By age 75 years, approximately half the population can expect to develop one or more of the 13 mental disorders considered in this Article. These disorders typically first emerge in childhood, adolescence, or young adulthood. Services should have the capacity to detect and treat common mental disorders promptly and to optimise care that suits people at these crucial parts of the life course., Funding: None., Competing Interests: Declaration of interests LD receives educational grants from Indivior and Seqirus. OVD receives funding from Kowa Research Institute and has been an advisor in the PROMINENT trial. SMK and PWW receive grant funding from Hamad Medical Corporation through the Cambridgeshire and Peterborough National Health Service Foundation trust and from Qatar University. PWW has received financial support from the Qatar National Research Fund and an honorarium from Gresham College. RCK has been a consultant for Cambridge Health Alliance, Canandaigua Veterans Affairs Medical Center, Holmusk, Partners Healthcare, RallyPoint Networks, and Sage Therapeutics. He holds stock options in Cerebral, Mirah, Prepare Your Mind, Roga Sciences, and Verisense Health. DN receives honoraria from AIG General Insurance and Takeda Pharmaceutical and financial support from Startia, En-power, and MD.net. DJS receives royalties from American Psychiatric Press, Cambridge University Press, and Elsevier–Academic Press. He has received honoraria from Discovery Vitality, Johnson & Johnson, Kanna, L'Oreal, Lundbeck, Orion, Sanofi, Servier, Takeda, and Vistagen. He was the president of the African College of Neuropsychopharmacology and is financially supported by the Medical Research Council of South Africa. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The cost-effectiveness of Cerebrolysin as an add-on therapy for moderate-severe acute ischemic stroke is a topic that remains understudied. This study aims to address this gap by performing a comprehensive cost-utility analysis using both deterministic and probabilistic methods from a payer perspective and within the Romanian inpatient care setting. Quality-adjusted life years (QALYs) were calculated using partial individual patient data from the 2016 Cerebrolysin and Recovery After Stroke (CARS) trial, utilizing three different health state valuation models. Cost data was extracted from actual acute care costs reported by Romanian public hospitals for reimbursement purposes for patients included in the CARS study. Incremental cost-effectiveness ratios were calculated for each treatment arm for the duration of the clinical trial. Deterministic analysis based on sample mean values indicates Cerebrolysin would be cost-effective at a threshold between roughly 18.8 and 29.9 thousand EUR, depending on valuation techniques. Probabilistic sensitivity analysis results indicate an 80% chance probability of cost-effectiveness of Cerebrolysin as an add-on therapy for acute ischemic stroke, considering a willingness-to-pay threshold of 50,000 EUR in a 90-day timeframe after stroke. Further economic evaluations of Cerebrolysin are needed to strengthen these findings, covering a timeframe of at least 12 months after the acute incident, which would account for treatment effects spanning beyond the first 90 days after ischemic stroke. These should be conducted to determine its cost-effectiveness under various care settings and patient pathways. Most importantly, modelling techniques are needed to answer important questions such as the estimates of population gain in QALYs after acute administration of Cerebrolysin and the potential offsetting of direct medical costs as a result of administering the intervention.

Background and Objectives : Groin hernia repair surgery (GHRS) is among the most common elective interventions. The aim of this three-year nationwide study on GHRS is to provide a thorough analysis of the impact that the COVID-19 pandemic had on the Romanian Health System in regard to elective procedures. Materials and Methods : 46,795 groin hernia cases obtained between 2019 and 2021 from the DRG database using ICD-10 diagnostic codes. The data were collected from all 261 GHRS performing hospitals nationwide, including 227 public hospitals (PbH) and 34 private hospitals (PvH). The 42 variables taken into account were processed using Microsoft Excel 2021, applying Chi square, F-Test Two-Sample for variances, and Two Sample t -Test. The significance threshold considered was p < 0.001. Results : Of the grand total of cases, 96.2% were inguinal hernias, 86.8% were performed on men, 15.2% were laparoscopic procedures, and 6.88% were in PvH. Overall, due to the pandemic, the total number of GHRS decreased with 44.45% in 2020 and with 29.72% in 2021 compared to pre-pandemic year 2019. April 2020 shows the steepest decrease in GHRS (91 procedures nationwide). In the private sector, there was an opposite trend with increases in the number of cases by 12.21% and a 70.22% in both pandemic years. The mean admission period (MAP) for all procedures was 5.5 days. There was a significant difference between PbH and PvH (5.75 vs. 2.8 days, p < 0.0001). During the pandemic, the MAP in PbH decreased (6.02 in 2019, 5.82 in 2020 and 5.3 in 2021), remaining stable for PvH (2.9 days in 2019, 2.85 days in 2020 and 2.74 days in 2021). Conclusions : The COVID-19 pandemic significantly reduced the overall number of GHRS performed in Romania in 2020 and 2021, compared to 2019. However, the private sector thrived with an actual increase in the number of cases. There was a significant lower MAP in the PvH compared to PbH throughout the three-year period.

Introduction: The COVID-19 pandemic context led to a relevant burden on essential sectors of society; hospital sector capacity is tested in this period., Methods: A cross-sectional study of admissions in hospitals reporting DRG data for 2018-2020. Trend analysis of admissions and deaths in hospitals was carried out for identifying annual patterns and deviations from the 2010-2020 trend. Data aggregated by year, month, diagnosis, death in hospital. Graph analysis for time and diagnosis comparisons and correlation identifying associations., Results: There is an annual change in admission and death patterns recorded in Romanian hospitals. An important contraction in number of acute hospital admissions was recording during the COVID-19 pandemic; patients' hesitancy to seek healthcare and limited capacity to treat patients other than COVID-19 patients due to legal regulations limiting the admissions number could explain this pattern of admission only for serious condition or emergency surgery. In Romania excess deaths in second half 2020 was generally greater than COVID-19 deaths. Overall, excess mortality between March and December 2020 was more than double than reported COVID-19 deaths. The same mortality pattern persists, but with significant decreases for some diagnoses., Conclusions: The Romanian healthcare system has been challenged due to COVID-19 pandemic, leading to temporary reorganization of hospitals with consequences on all acute care diagnostics and therapeutic pathways. It is a challenge to identify causes of reduced inpatient treatment rates and to provide evidence on hospital activity for understanding future optimal management of patients with COVID-19, but also with other acute and chronic conditions., Competing Interests: Conflicts of interest: All authors – none to declare., (GERMS.)

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths., (Copyright © 2022. Published by Elsevier B.V.)

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care., (Copyright © 2021. Published by Elsevier B.V.)

Background: N-Pep-12 is a dietary supplement with neuroprotective and pro-cognitive effects, as shown in experimental models and clinical studies on patients after ischemic stroke. We tested the hypothesis that N-Pep-12 influences quantitative electroencephalography (QEEG) parameters in patients with subacute to chronic supratentorial ischemic lesions., Methods: We performed secondary data analysis on an exploratory clinical trial (ISRCTN10702895), assessing the efficacy and safety of 90 days of once-daily treatment with 90 mg N-Pep-12 on neurocognitive function and neurorecovery outcome in patients with post-stroke cognitive impairment against a control group. All participants performed two 32-channel QEEG in resting and active states at baseline (30-120 days after stroke) and 90 days later. Power spectral density on the alpha, beta, theta, delta frequency bands, delta/alpha power ratio (DAR), and (delta+theta)/(alpha+beta) ratio (DTABR) were computed and compared across study groups using means comparison and descriptive methods. Secondarily, associations between QEEG parameters and available neuropsychological tests were explored., Results: Our analysis showed a statistically significant main effect of EEG segments (p<0.001) in alpha, beta, delta, theta, DA, and DTAB power spectral density. An interaction effect between EEG segments and time was noticed in the alpha power. There was a significant difference in theta spectral power between patients with N-Pep-12 supplementation versus placebo at 0.05 alpha level (p=0.023), independent of time points., Conclusion: A 90-day, 90 mg daily administration of N-Pep-12 had significant impact on some QEEG indicators in patients after supratentorial ischemic stroke, confirming possible enhancement of post-stroke neurorecovery. Further research is needed to consolidate our findings., (© 2021. Fondazione Società Italiana di Neurologia.)

The epidemiology of neglected tropical diseases (NTD) is persistently underprioritized, despite NTD being widespread among the poorest populations and in the least developed countries on earth. This situation necessitates thorough and efficient public health intervention. Romania is at the brink of becoming a developed country. However, this South-Eastern European country appears to be a region that is susceptible to an underestimated burden of parasitic diseases despite recent public health reforms. Moreover, there is an evident lack of new epidemiologic data on NTD after Romania's accession to the European Union (EU) in 2007. Using the national ICD-10 dataset for hospitalized patients in Romania, we generated time series datasets for 2008-2018. The objective was to gain deep understanding of the epidemiological distribution of three selected and highly endemic parasitic diseases, namely, ascariasis, enterobiasis and cystic echinococcosis (CE), during this period and forecast their courses for the ensuing two years. Through descriptive and inferential analysis, we observed a decline in case numbers for all three NTD. Several distributional particularities at regional level emerged. Furthermore, we performed predictions using a novel automated time series (AutoTS) machine learning tool and could interestingly show a stable course for these parasitic NTD. Such predictions can help public health officials and medical organizations to implement targeted disease prevention and control. To our knowledge, this is the first study involving a retrospective analysis of ascariasis, enterobiasis and CE on a nationwide scale in Romania. It is also the first to use AutoTS technology for parasitic NTD., Competing Interests: The authors have declared that no competing interests exist.

The mental health of the elderly is a matter of increased concern in the context of an aging population since currently only a small fraction of this population is receiving adequate care. The provision of treatment in primary care by the General Practitioners (GPs) has been proposed for over a decade as a potential solution, as services offered by GPs are more accessible, less susceptible to stigma, and have a more comprehensive view of the other health care problems that the elderly might suffer from. In this study, we explored the perception of Romanian GPs regarding their practice and roles in caring for the mental health of the elderly as well as the willingness to increase their future involvement in the management of dementia and other mental health problems. Data was collected via an online questionnaire structured on four dimensions: (1) GPs' sociodemographic profile and practice characteristics, (2) GPs assessment of the services available for elderly with mental health problems, (3) GPs current involvement in mental health care for different categories of problems, and (4) factors that might influence the future involvement of GPs in providing care for elderly with mental health problems. The survey was sent via the member mailing lists of the National Society for Family Medicine. Results show that GPs are currently limited by prescribing possibilities, available resources and knowledge in the area, but they are willing to expand their role in the areas of early recognition and prevention of mental health problems as well as providing disease management and collaborative care. An improved communication with mental health care professionals, a better access to resources and having more financial incentives are the three most important categories for GPs to increase their involvement. In conclusion, increasing the access to personal and professional resources and setting up functional communication channels with specialized mental health care could motivate GPs to provide timely mental health support to elderly patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sfetcu, Toma, Tudose and Vladescu.)

Background: Health policies in transitioning health systems are rarely informed by the economic burden of disease due to scanty access to data. This study aimed to estimate direct and indirect costs for first-ever acute ischemic stroke (AIS) during the first year for patients residing in Cluj, Romania, and hospitalized in 2019 at the County Emergency Hospital (CEH)., Methods: The study was conducted using a mixed, retrospective costing methodology from a societal perspective to measure the cost of first-ever AIS in the first year after onset. Patient pathways for AIS were reconstructed to aid in mapping inpatient and outpatient cost items. We used anonymized administrative and clinical data at the hospital level and publicly available databases., Results: The average cost per patient in the first year after stroke onset was RON 25,297.83 (EUR 5226.82), out of which 80.87% were direct costs. The total cost in Cluj, Romania in 2019 was RON 17,455,502.7 (EUR 3,606,505.8)., Conclusions: Our costing exercise uncovered shortcomings of stroke management in Romania, particularly related to acute care and neurorehabilitation service provision. Romania spends significantly less on healthcare than other countries (5.5% of GDP vs. 9.8% European Union average), exposing stroke survivors to a disproportionately high risk for preventable and treatable post-stroke disability.

Management of symptoms and prevention of life-threatening hemorrhage in immune thrombocytopenia (ITP) must be balanced against adverse effects of therapies. Because current treatment guidelines based on platelet count are confounded by variable bleeding phenotypes, there is a need to identify new objective markers of disease severity for treatment stratification. In this cross-sectional prospective study of 49 patients with ITP and nadir platelet counts <30 × 109/L and 18 aged-matched healthy controls, we used susceptibility-weighted magnetic resonance imaging to detect cerebral microbleeds (CMBs) as a marker of occult hemorrhage. CMBs were detected using a semiautomated method and correlated with clinical metadata using multivariate regression analysis. No CMBs were detected in health controls. In contrast, lobar CMBs were identified in 43% (21 of 49) of patients with ITP; prevalence increased with decreasing nadir platelet count (0/4, ≥15 × 109/L; 2/9, 10-14 × 109/L; 4/11, 5-9 × 109/L; 15/25 <5 × 109/L) and was associated with longer disease duration (P = 7 × 10-6), lower nadir platelet count (P = .005), lower platelet count at time of neuroimaging (P = .029), and higher organ bleeding scores (P = .028). Mucosal and skin bleeding scores, number of previous treatments, age, and sex were not associated with CMBs. Occult cerebral microhemorrhage is common in patients with moderate to severe ITP. Strong associations with ITP duration may reflect CMB accrual over time or more refractory disease. Further longitudinal studies in children and adults will allow greater understanding of the natural history and clinical and prognostic significance of CMBs., (© 2020 by The American Society of Hematology.)

The application of machine learning (ML) for use in generating insights and making predictions on new records continues to expand within the medical community. Despite this progress to date, the application of time series analysis has remained underexplored due to complexity of the underlying techniques. In this study, we have deployed a novel ML, called automated time series (AutoTS) machine learning, to automate data processing and the application of a multitude of models to assess which best forecasts future values. This rapid experimentation allows for and enables the selection of the most accurate model in order to perform time series predictions. By using the nation-wide ICD-10 (International Classification of Diseases, Tenth Revision) dataset of hospitalized patients of Romania, we have generated time series datasets over the period of 2008-2018 and performed highly accurate AutoTS predictions for the ten deadliest diseases. Forecast results for the years 2019 and 2020 were generated on a NUTS 2 (Nomenclature of Territorial Units for Statistics) regional level. This is the first study to our knowledge to perform time series forecasting of multiple diseases at a regional level using automated time series machine learning on a national ICD-10 dataset. The deployment of AutoTS technology can help decision makers in implementing targeted national health policies more efficiently.

The aim of this paper is to examine aggressive behaviors among Romanian high school students between 15 and 16 years old, to compare data in two national representative samples and to identify factors associated with physical fighting. This study investigates the association of selected factors (social, school performance and substance use) with physical fighting. A total of 2289 Romanian students were included in the 2007 database and 2770 in the 2011 database. This study revealed that 35.87% of the teenagers have taken part in a physical fight during the previous 12 months, as compared with the European average of 31.5%. Romania has the highest prevalence of violent behavior by participating in a group bruising of an individual in both surveys, 2007 and 2011. A logistic regression analysis performed for the 2011 study revealed the following factors associated with physical fighting: binge drinking during the previous 30 days, male gender, serious problems with friends, parent(s) who do not know where and with whom the adolescents spend their evenings, poor parental caring, low school grades, and high truancy. A decrease in almost all aggressive behaviors was noticed in 2011, compared to 2007. These findings may be useful to support and guide policy makers regarding improvement and implementation of strategies to further prevent aggressive behaviors in teenagers., Competing Interests: The authors declare no conflict of interest.

This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure., (World Health Organization 2016 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

Aim: To evaluate the effects of the change in the diagnosis-related group (DRG) system on patient morbidity and hospital financial performance in the Romanian public health care system., Methods: Three variables were assessed before and after the classification switch in July 2007: clinical outcomes, the case mix index, and hospital budgets, using the database of the National School of Public Health and Health Services Management, which contains data regularly received from hospitals reimbursed through the Romanian DRG scheme (291 in 2009)., Results: The lack of a Romanian system for the calculation of cost-weights imposed the necessity to use an imported system, which was criticized by some clinicians for not accurately reflecting resource consumption in Romanian hospitals. The new DRG classification system allowed a more accurate clinical classification. However, it also exposed a lack of physicians' knowledge on diagnosing and coding procedures, which led to incorrect coding. Consequently, the reported hospital morbidity changed after the DRG switch, reflecting an increase in the national case-mix index of 25% in 2009 (compared with 2007). Since hospitals received the same reimbursement over the first two years after the classification switch, the new DRG system led them sometimes to change patients' diagnoses in order to receive more funding., Conclusion: Lack of oversight of hospital coding and reporting to the national reimbursement scheme allowed the increase in the case-mix index. The complexity of the new classification system requires more resources (human and financial), better monitoring and evaluation, and improved legislation in order to achieve better hospital resource allocation and more efficient patient care.

Aim: To examine high school students' suicidal behavior and to identify predictors of suicide attempt among adolescents in Timis County, Romania. We hypothesized that suicide attempt is associated with other health-risk behaviors., Methods: In this cross-sectional study we included 2908 high school students in grades 9 to 12. The students were asked to complete an anonymous structured questionnaire during a normal class. We examined the relationship between having attempted suicide and engaging in other health-risk or problem behaviors., Results: During the previous 12 months, 15.4% of the students had had suicidal ideation, 7.5% had made a suicide plan and 6.1% reported that they had attempted suicide. Based on logistic regression multivariate analysis, attempted suicide was associated with feeling sad or hopeless almost every day for two or more consecutive weeks (OR = 4.74; 95% CI: 3.07-7.31), being forced to have sexual intercourse (OR = 3.18; 95% CI: 1.83-5.50), being physically aggressed by his or her father (OR = 4.28; 95% CI: 1.96-9.34), performing poorly at school (OR = 4.22; 95% CI: 1.51-11.74), having an impaired relationship with parents (OR = 2.45; 95% CI: 1.17-5.12), not eating for 24 hours or more to lose weight or to avoid gaining weight during the past 30 days (OR = 2.23; 95% CI: 1.40-3.53), being female (OR = 1.91; 95% CI: 1.21-2.99) and carrying a weapon (OR = 2.44; 95% CI: 1.53-3.90)., Conclusion: This study suggests that suicide attempts are associated with other risk behaviors. These behaviors may help to evaluate suicide risk and should be considered when establishing preventive programs.

The authors studied the effect of ionising radiation on hepatic and overall collagen metabolism in rats. Doses of 100 and 250 rads produced a reduction in urinary hydroxyproline while doses of 500 and 700 rads produced an increase. These results may be interpreted in favour of an increase in reticulation in the first case and in the second case, destruction of inter-molecular bonds. The quantity of total and insoluble collagen increases proportionally to the dose 40 days after the radiation. This proportional relationship is not observed during the first few days after radiation. Prolonged radiation with 700 rads produces a marked reduction in all collagen fractions, compared with 4 days after acute radiation. Among the substances studied, "folcisteine" had the best radio-protective effect when administered before radiation with 700 rads.

Contrary to earlier findings in rats, cerebral lateral ventricular infusions of 1 X 10(-3) M or 2 X 10(-3) M solutions of phloridzin at a rate of 2.5 micronl/min for 90 min had no significant stimulating effects on food intake and weight gain in hens and cocks. These different responses to intraventricular phloridzin might reflect a difference of sensitivity to the inhibitory action of phloridzin on glucose transport in cerebral cells or certain peculiarities of mechanisms controlling food intake in chickens.

Unanaesthetized hens and cocks were infused into the cerebral lateral ventricle with 0.2 ml of a 6% glucose solution or equal volumes of isotonic saline following a 20-hr total food deprivation period. A more marked suppression of food intake occurred in the next 1-3 hr after glucose rather than after saline. The results provide new evidence that chickens possess central glucoreceptors involved in the regulation of their feeding behavior.