The intervention of local public authorities and the impact of the COVID-19 pandemic in Romania: a subnational analysis.

The COVID-19 pandemic had a strong territorial dimension, with a highly asymmetric impact among Romanian counties, depending on pre-existing vulnerabilities, regions' economic structure, exposure to global value chains, specialization, and overall ability to shift a large share of employees to remote working. The aim of this paper is to assess the role of Romanian local authorities during this unprecedented global medical emergency by capturing the changes of public spending at the local level between 2010 and 2021 and amid the COVID-19 pandemic, and to identify clusters of Romanian counties that shared similar characteristics in this period, using a panel data quantitative model and hierarchical cluster analysis. Our empirical analysis shows that between 2010-2021, the impact of social assistance expenditures was higher than public investment (capital spending and EU funds) on the GDP per capita at county level. Additionally, based on various macroeconomic and structural indicators (health, labour market performance, economic development, entrepreneurship, and both local public revenues and several types of expenditures), we determined seven clusters of counties. The research contributes to the discussion regarding the increase of economic resilience but also to the evidence-based public policies implementation at local level.

Assessment of the prevalence and risk factors for dry eye symptoms among Romanian medical students using the ocular surface disease index - a cross-sectional study.

BACKGROUND: This study aims to assess how Romanian medical students suffer from dry eye disease symptoms, establish the prevalence and severity of dry eye (DE) symptoms and identify potential risk factors. METHODS: An analytical, cross-sectional study was conducted on students from "Carol Davila" University of Medicine, Romania, after the final examination period of July 2022. The OSDI score (Ocular Surface Disease Index©) was applied in an online survey. The study adopted the standards used by other authors, who defined symptomatic DED as an OSDI score greater than 12. The chi-square test was used to establish statistical significance at a cutoff value of p < 0.05. The predictive model was created using linear logistic regression analysis. The goodness of fit of the logistic regression model was assessed using the Hosmer-Lemeshow test. When the severity outcome had a nominal categorical form, multinomial regression analysis with normal subjects as a reference was performed. The distribution of the severe type of symptomatology across sex categories and years of study was analyzed using a nonparametric test (Independent-Samples Kruskal-Wallis Test). RESULTS: A total of 274 answers were received from 81.4% females and 18.6% males with a response rate of 35.58%. The mean age was 22.7 years ± 1.66 with an age range between 20 and 25 years old. Using the OSDI score, we established that the overall prevalence of DE symptoms was 83.6% (95%CI: 79.6%, 88%), with an 85.2% (95%CI: 80.5%, 89.8%) prevalence in females and 76.5% (95%CI: 65%,88%) in males. The severe form of DE was the most prevalent, regardless of the study year or sex. Increased screen time (p-value < 0.05) and non-smokers (p-value < 0.05) were proven risk factors. The predictive model which includes the explanatory variables (sex, contact lens wearers, smoking, oral contraceptives, screen time) proved an 84.7% predictability for symptomatic DE and was able to better predict the dependent variable than the intercept model only (p-value < 0.05). Smoking (p = 0.002) and screen time (p = 0.009) preserved their significance in the multinominal regression as well. CONCLUSIONS: This is the first study to report the epidemiology of DE symptoms among Romanian medical students. OSDI revealed a high prevalence of symptomatic DE in medical students. Screen time, although not the only factor, likely plays a role in exacerbating the disease. This information can be used to inform healthcare policies, establish occupational health guidelines, and implement preventive measures for individuals in similar high-stress academic or professional environments.

Assessment of the Particularities of Thrombophilia in the Management of Pregnant Women in the Western Part of Romania.

Background and objectives: Thrombophilia in pregnant women is a condition whose incidence is constantly increasing worldwide, and, under these conditions, the development of preventive procedures is becoming essential. In this study, we aimed to evaluate thrombophilia in pregnant women in the western part of Romania and to establish anthropometric characteristics, socioeconomic features, and genetic and risk factors. Material and Methods: 178 pregnant women were divided into three study groups, according to the type of thrombophilia, aiming to carry out the genetic profile and the acquired one. Anthropometric measures and biological tests were performed. Results: The mixed type of thrombophilia predominates. The particularities of pregnant women diagnosed with thrombophilia are higher age, living in an urban environment, with normal BMI, approximately 36 weeks of gestational period, and having at least one miscarriage. Regarding the most frequent thrombophilic genetic markers, we obtained the MTFHR gene mutation C677T and A1298C, followed by the PAI-1 4G/5G gene mutation. Smoking represents an aggravating factor in the evolution of this pathology, manifested through the increase of D-dimers and the decrease in antithrombin values, simultaneously with the increase in therapeutic need. Conclusions: The predominance of MTHFR and PAI-1 4G/5G gene polymorphism is a particularity of pregnant women with thrombophilia from the western part of Romania. Smoking is confirmed as an important risk factor in spontaneous abortion.

A five-year (2017-2021) time series evaluation of patient-reported informal healthcare payments in Romania.

Low wages of health professionals are widely recognized as one of the drivers of informal payments in Romania's healthcare system. In January 2018, the government increased wages by an average of 70% to 172% in the public healthcare sector. This study examined the trends in patient-reported informal healthcare payments, discussing the effect of a one-time wage increase in 2018 and the impact of the COVID-19 pandemic in 2020 and 2021. It draws on monthly survey data of patient-reported informal payments collected between January 2017 and December 2021. We analyzed three periods: before the wage rise ("low pay"), between the wage rise and the COVID-19 pandemic ("high pay"), and during the COVID-19 pandemic. We found that patient-reported informal payments decreased between the "low pay" and "high pay" period but with a sharper decline during the COVID-19 pandemic. The share of respondents willing to report informal payments increased during the "high pay" period, indicating a stronger willingness to voice dissatisfaction with health services and informal payments, but slowed down during the first lockdown in 2020. Informal payments were more frequently reported in larger hospitals and the poorest geographical areas. While the 2018 wage increase may have contributed to less prevalent informal payments, survey coverage and design must be improved to draw robust, system-level conclusions to inform tailored policy actions.

Women's assessment of the quality of hospital-based perinatal care by mode of birth in Romania during the COVID-19 pandemic: Results from the IMAgiNE EURO study.

OBJECTIVE: To assess women's perceptions of the quality of maternal and newborn care (QMNC) received in hospitals in Romania during the COVID-19 pandemic by mode of birth. METHODS: A validated anonymous online questionnaire based on WHO quality measures. Subgroup analysis of spontaneous vaginal birth (SVB), emergency cesarean, and elective cesarean and multivariate analyses were performed, and QMNC indexes were calculated. Maternal age, educational level, year of birth, mother born in Romania, parity, type of hospital, and type of professionals assisting the birth were used for multivariate analysis. RESULTS: A total of 620 women completed the survey. Overall, several quality measures suggested gaps in QMNC in Romania, with the lowest QMNC indexes reported for provision of care and availability of resources. Women who had either elective or emergency cesarean compared with those who had SVB more frequently lacked early breastfeeding (OR 2.04 and 2.13, respectively), skin-to-skin contact (OR 1.73 and 1.75, respectively), rooming-in (OR 2.07 and 1.96, respectively), and exclusive breastfeeding at discharge (OR 2.27 and 1.64, respectively). Compared with elective cesarean, emergency cesarean had higher odds of ineffective communication by healthcare providers (OR 1.65), lack of involvement in choices (OR 1.58), insufficient emotional support (OR 2.07), and no privacy (OR 2.06). Compared with other modes of birth, a trend for lower QMNC indexes for emergency cesarean was observed for all domains, while for elective cesarean the QMNC index for provision of care was significantly lower. CONCLUSION: Quality indicators of perinatal care remain behind targets in Romania, with births by cesarean the most affected. GOV IDENTIFIER: NCT04847336.

Lost productivity due to head and neck cancer mortality in Hungary, Poland, and Romania.

BACKGROUND/AIMS: Head and neck cancer (HNC) describes a range of malignant tumours that arise from the epithelium of the mucous membranes in the head and neck region, including the oral cavity, pharynx, larynx, nasal cavity, and paranasal sinuses. In Hungary, oral cancer is among the top ten causes of cancer-related death (Diz et al., 2017 [1]). In Romania, HNC mortality has increased by more than 50 % in the last decade, and in Poland, HNC is the seventh most common type of cancer (Diz et al., 2017, Pinkas et al., 2022 [1,2]). To inform priorities for cancer control, this analysis estimated the mortality burden and cost of lost productivity due to premature HNC-deaths in Hungary, Poland, and Romania. The model used years of life lost (YLL), years of productive life lost (YPLL) and present value of future lost productivity (PVFLP). METHODS: We modelled patients who died from HNC in Hungary, Poland, and Romania in a single year and utilised epidemiological inputs and economic inputs to estimate YLL, YPLL, PVFLP and PVFLP/death. RESULTS: HNC resulted in 9729 annual deaths and 157,328 YLL in Hungary, Poland, and Romania. PVFLP was estimated to be €449 million, (€87 million, €193 million, €169 million, in Hungary, Poland and Romania respectively) with a total PVFLP/HNC-death of €46,158. CONCLUSION: HNC leads to substantial societal costs in Hungary, Poland, and Romania. Given the number of premature deaths and associated productivity loss, reducing HNC burden should be a priority for policymakers. POLICY SUMMARY: Given the severe clinical and economic burden of HNC, a multidisciplinary approach is required to reduce this burden, including prevention policies and improved diagnostic techniques to promote early diagnosis. Improvements in preventative measures will not only decrease productivity losses relating to HNC but would also have a huge impact across other cancer indications (e.g., lung and cervical cancers) and other illnesses linked to these policy areas (e.g., heart disease and diabetes).

Approaches related to the effects of Covid-19 pandemics on financing of the healthcare system in Romania.

Background: The healthcare financial system faced a significant disturbance of the budget balance after the outbreak of the pandemic, amid government measures to combat the disease. These measures have led to shifts in funding weights within the income and expenditure budget structure, with a focus on prevention and treatment of patients infected with SARS-COV 2. The purpose of this research is to analyse the financial balance of the healthcare system and the related modelling to support decision-makers in adopting and implementing appropriate financing measures for the pandemic. Methods: The working hypotheses of this study were tested using an econometric linear regression model based on the financing budgetary function, which matches funding to the specific need for each expenditure heading. SPSS 25 statistical software was used to define the model and to test the homogeneity of the data and their statistical relevance to the phenomenon under analysis. Results: The proposed model showed that there is a significant correlation of the dependent variable, Dynamics of budget revenues in the healthcare sector (TIM), with the regressors. We believe that a problem-solving rebalancing of allocations could help to eliminate the synergy in health. This redistribution should take into account the impact that economic and budgetary factors have on healthcare factors and vice versa, so that at some point after successive adjustments the minimum distance between forecast and realisation or between need and financing of need can be reached. The used data were analysed dynamically to assess changes in trend as absolute data do not allow the construction of an overall picture. Relative data captures changes in financing from year to year and can be linked to events such as pandemics, financial crises or inflation. Conclusions: In relation to the objectives of the research, it emerges that, under the impact of pandemic stress, measures to improve healthcare management, increase performance and streamline financial allocation are vulnerable and cannot counteract the effects that the pandemic has on the healthcare of the population as reflected in the morbidity and mortality indicators collected during the pandemic. In this regard, it is necessary a rethinking of the strategic healthcare management, a better planning of the procurement of medicines and healthcare supplies, a rethinking of the partnerships with the European Commission and other global entities. This approach can effectively improve the impact of the pandemic on the healthcare status of the population, a rebalancing of the demand-supply balance in healthcare and a maintenance of the strategic programmes, according to the objectives assumed in the planning, given that these programmes protect categories of people already medically affected.

Predictive value of a novel sub-item mortality risk score derived from the Norfolk Quality of Life in Diabetic Neuropathy questionnaire in Romanian participants with diabetes mellitus.

AIMS: To evaluate whether the Norfolk Quality of Life in Diabetic Neuropathy (QOL-DN) questionnaire and the novel Norfolk Mortality Risk Score (NMRS), comprising Norfolk QOL-DN items, can identify 4-year mortality risk in individuals with diabetes. METHODS: Of 21,756 adults completing Norfolk QOL-DN in 2012, two groups of surviving and deceased patients were identified in 2016: Group 1, from a county capital and Group 2, from six small cities. NMRS was calculated in Group 1 using the 2012 scores of Norfolk QOL-DN items that discriminate between deceased and surviving participants (p < 0.05) and was subsequently applied to Group 2. RESULTS: 763 participants were included (Group 1: 481 [450 surviving, 31 deceased]; Group 2: 282 [218 surviving, 64 deceased]). Total Norfolk QOL-DN score was significantly higher (worse) in deceased participants than in survivors in both groups (p ≤ 0.008). Optimal cut-off for the 25-item NMRS was 11.5 in Group 1. Individuals in Groups 1 and 2 with NMRS≥ 11.5 in 2012 had a 4-year mortality risk ratio of 4.24 (95 % confidence interval [CI]: 1.65-10.84) and 2.33 (95 % CI: 1.33-4.07), respectively, corresponding to 8 and 16 additional deaths/100 persons/4 years (p = 0.001). CONCLUSION: Norfolk QOL-DN and NMRS can identify individuals with diabetes at risk of 4-year mortality.

Length of Hospital Stay, Hospitalization Costs, and Their Drivers in Adults with Diabetes in the Romanian Public Hospital System.

The aim of this analysis was to assess the costs associated with the hospitalizations of persons with diabetes in a Romanian public hospital. We performed a retrospective "top-down" cost analysis of all adult patients discharged from a tertiary care hospital with an ICD-10 primary or secondary code of diabetes mellitus (type 1, type 2, or specific forms) between 1 January 2015 and 31 December 2018. All costs were adjusted with the annual inflation rates and converted to EUR. We included 16,868 patients with diabetes and 28,055 episodes of hospitalization. The total adjusted hospitalization cost in the analyzed period was EUR 26,418,126.8 and the adjusted median cost/episode of hospitalization was EUR 596.5. The mean length of a hospital stay/episode was 7.3 days. In the multivariate regression analysis, higher adjusted average costs/episodes of hospitalization and longer lengths of hospital stays were associated with increasing age, the presence of cardiovascular diseases, chronic kidney disease, and foot ulcerations. Moreover, a significant association between the average cost/episode of hospitalization and the length of hospital stay was observed (ß = 0.704, p < 0.001). This study shows the burden on Romanian public hospitals of inpatient diabetes care and the main drivers of the costs.

The Prevalence of Ureaplasma Urealyticum and Mycoplasma Hominis Infections in Infertile Patients in the Northeast Region of Romania.

Background and objectives: Ureaplasma urealyticum (UU) and Mycoplasma hominis (MH) are two commensal microorganisms that form the urogenital microbiota. Under a state of dysbiosis, both bacteria cause intrauterine infection. Material and methods: Therefore, the purpose of the present study was to analyze the prevalence of UU and MH among four hundred and eleven infertile women. Results: Women between thirty and thirty-five years old were the most affected group, followed by those that were 25 and 30 years old, respectively. Cumulatively, the prevalence of single UU and MH, and coinfection, was 28.46% (n = 117), (n = 2) 0.48%, and 2.91% (n = 12), respectively, with an overall detection rate of 31.87% (n = 131). To assess the associated drug susceptibility, endocervical samples were unequally sent to Regina Maria (n = 281) and Synevo (n = 130) laboratories for further analyses. Pristinamycin (100% vs. 100%) and Josamycin (100% vs. 98.00%) were the most efficient antibiotics in eradicating UU and MH, several others also displaying a high efficiency, among which can be mentioned Doxycycline (98.23%), Minocycline (96.00%), Tetracycline (96.48% vs. 68.00%), and Erythromycin (70.17% vs. 92.00%). Based on antibiograms, Clarithromycin (88.00%), Roxithromycin (88.00%), Levofloxacin (82.00%), and Azithromycin (78.94%) can be further used in treating such infections. On the other hand, Clindamycin (4.00%) and Ciprofloxacin (12.27% vs. 2.00%) are no longer viable because both UU and MH display an intermediate response towards gained resistance. Interestingly, the efficiency of Ofloxacin (22.79% vs. 60.00%) was conflicting, this possibly suggesting a transient stage to a gradual adaptability of these microorganisms to Ofloxacin. Conclusions: The most susceptible age groups in each case were women that were between twenty and forty years old. It can be concluded that four antibiotics can be safely used for treating UU, MH, or dual infections whose efficiency was over 95%.

Hospitalization Costs of Lower Limb Ulcerations and Amputations in Patients with Diabetes in Romania.

In this retrospective case-control study conducted in Cluj-Napoca, Romania, we assessed the effect of ulcerations/amputations on hospitalization costs of patients with diabetes. Patients with (Group 1) or without (Group 2) ulcerations/amputations (case-control ratio 3:1) admitted to a single diabetes center between 2012-2017 were included. The effects of hospitalization days, age, duration of diabetes, body mass index and glycated hemoglobin (HbA1c) on total costs was explored using a multivariate linear regression analysis, enter model. Overall, 876 patients were included (Group 1: 682, 323 [47.4%] with amputations; Group 2: 194). Median (interquartile range) total expenses in Group 1 were 40% higher compared to Group 2 (€724 [504; 1186] vs €517 [362; 645], p < 0.001). Significant differences were observed between hospitalization costs (p < 0.001), cost of food (p < 0.001), medication (p = 0.044), drugs administered at the emergency room/intensive care unit (p < 0.001) and other expenses (p = 0.003). Hospitalization costs represented 80.5% of total expenses in Group 1 and 76.3% in Group 2. In multivariate analysis, hospitalization days influenced significantly the total costs in both groups (p < 0.001); in Group 2, the effect of HbA1c was also significant (p = 0.021). Diabetic foot ulcers and subsequent amputations most likely impose a significant economic burden on the Romanian public healthcare system.

The impact of direct acting antivirals on hepatitis C virus disease burden and associated costs in four european countries.

BACKGROUND AND AIMS: We assessed the clinical and economic impact of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) in England, Italy, Romania and Spain. METHODS: An HCV progression Markov model was developed considering DAA eligibility and population data during the years 2015-2019. The period of time to recover the investment in DAAs was calculated as the cost saved by avoiding estimated clinical events for 1000 standardized treated patients. A delayed treatment scenario because of coronavirus disease (COVID-19) was also developed. RESULTS: The estimated number of avoided hepatocellular carcinoma, decompensated cirrhosis and liver transplantations over a 20-year time horizon was: 1,057 in England; 1,221 in Italy; 1,211 in Romania; and 1,103 in Spain for patients treated during 2015-2016 and 640 in England; 626 in Italy; 739 in Romania; and 643 in Spain for patients treated during 2017-2019. The cost-savings ranged from € 45 to € 275 million. The investment needed to expand access to DAAs in 2015-2019 is estimated to be recovered in 6.5 years in England; 5.4 years in Italy; 6.7 years in Romania; and 4.5 years in Spain. A delay in treatment because of COVID-19 will increase liver mortality in all countries. CONCLUSION: Direct-acting antivirals have significant clinical benefits and can bring substantial cost-savings over the next 20 years, reaching a Break-even point in a short period of time. When pursuing an exit strategy from strict lockdown measures for COVID-19, providing DAAs should remain high on the list of priorities in order to maintain HCV elimination efforts.

Effects of the COVID-19 Pandemic on the Budgetary Mechanism Established to Cover Public Health Expenditure. A Case Study of Romania.

The COVID-19 pandemic stressed the importance of understanding the sources of vulnerabilities that can lead to a financial crisis and highlighted the predominant impact on health systems. Firstly, the paper aims to conduct a retrospective analysis of the Romanian health care system, over the period of time 1985-2019, based on our own computed sustainability index for public health. Secondly, using the Gregory-Hansen cointegration method, we provide new evidence on the causal relationship between health expenditure and GDP for Romania over the period of time 1985-2017. Based on the retrospective analysis of the long-run co-movement between health spending and GDP, the study allows one to prospectively examine not only the effects of the COVID-19 pandemic on health care spending, but also to reveal the government's fiscal position and vulnerabilities. Our results highlight the intergenerational costs related to the policy incoherence roadmap and regulatory fragmentation, stressing the importance of economic system resilience through fiscal diligence and the consolidation of the institutional context.

Cervical Cancer Mortality in Romania: Trends, Regional and Rural-Urban Inequalities, and Policy Implications.

Background and Objectives: Despite being largely preventable, cervical cancer mortality still remains an important public health problem globally, in Europe, and in Romania. The European Union member states are urged to implement systematic, population-based screenings for cervical cancer, but the programs developed by the countries remain very heterogeneous. This study aimed to investigate the differences in cervix cancer mortality between Romania and EU and within Romania over the last two decades and to reveal the major sources of inequalities and the policy implications. Materials and Methods: We analyzed the number of deaths and the mortality rates by cervical cancer, standardized using the direct method, over two decades (2001-2016 for the EU, and 2001-2019 for the national and sub-national analyses). Trends, mortality reduction over the years, and mortality differences at the beginning and end of the time interval have been calculated for the EU and Romania, at national and sub-national levels (rural-urban and regions). Results: Our results revealed differences in cervical cancer mortality between Romania and EU and within Romania (among regions and rural-urban areas). These differences used to be very high in the past and are still persisting. Conclusions: The country should revisit its national cervical cancer screening program, which has been implemented for many years, but with a very limited participation rate. Due to the similar problems existing in Central-Eastern Europe, targeted support from the EU for the members from this geographical area could contribute to the minimization of differences in cervical cancer mortality among the EU members.

Cost Assessment of Inpatient Care Episodes of Stroke in Romania.

Introduction: Stroke is the second leading cause of death worldwide and Romania is no exception. There is a high economic burden associated with the treatment of stroke patients, which puts pressure on the healthcare budget. This study aims to measure the inpatient treatment costs of stroke patients in Romania. Methods: Our retrospective analysis follows stroke patients in six Romanian hospitals at different progressivity level from different regions. Patients are identified from the official hospital databases, reported for reimbursement purposes. Mean inpatient costs incurred with the treatment of these stroke patient episodes are calculated using the gross costing method. The cost data are derived from the management control system of the study hospitals. Results: 3,155 patient episodes of stroke were identified in the study hospitals. The average cost per stroke inpatient care episode sums up to EUR 995.57 (95% CI: EUR 963.74-EUR 1 027.39) in 2017, while the overall yearly healthcare burden adds up to EUR 140 million, representing 2.18% of the total national health insurance budget and a cost of EUR 7.15 per capita. Conclusion: The hospital cost of stroke inpatient care episode in Romania is high and it represents a sizable part of the healthcare budget, but it is among the lowest in Europe, which can mainly be explained by the level of economic development of the country. As both the number of patients and the cost of acute care are expected to increase in the future, the economic burden of stroke is also expected to increase.

Genetics of Hearing Impairment in North-Eastern Romania-A Cost-Effective Improved Diagnosis and Literature Review.

BACKGROUND: We have investigated the main genetic causes for non-syndromic hearing impairment (NSHI) in the hearing impairment individuals from the North-Eastern Romania and proposed a cost-effective diagnosis protocol. METHODS: MLPA followed by Sanger Sequencing were used for all 291 patients included in this study. RESULTS: MLPA revealed abnormal results in 141 cases (48.45%): 57 (40.5%) were c.35delG homozygous, 26 (18.44%) were c.35delG heterozygous, 14 (9.93%) were compound heterozygous and 16 (11.35%) had other types of variants. The entire coding region of GJB2 was sequenced and out of 150 patients with normal results at MLPA, 29.33% had abnormal results: variants in heterozygous state: c.71G>A (28%), c.457G>A (20%), c.269T>C (12%), c.109G>A (12%), c.100A>T (12%), c.551G>C (8%). Out of 26 patients with c.35delG in heterozygous state, 38.46% were in fact compound heterozygous. CONCLUSIONS: We identified two variants: c.109G>A and c.100A>T that have not been reported in any study from Romania. MLPA is an inexpensive, rapid and reliable technique that could be a cost-effective diagnosis method, useful for patients with hearing impairment. It can be adaptable for the mutation spectrum in every population and followed by Sanger sequencing can provide a genetic diagnosis for patients with different degrees of hearing impairment.

Treatment of rhabdomyosarcoma in children and adolescent from four low health expenditures average rates countries.

Background Survival of children with cancer in Eastern and Central Europe is 10-20% lower than in high income European countries. We evaluated outcome of children and adolescents with rhabdomyosarcoma (RMS) in Slovenia, Croatia, Slovakia and in Romania. Patients and methods We retrospectively analysed event-free survival (EFS) and overall survival (OS) for all patients treated in Slovenia and Croatia. Slovakia included patients from two centers, representing half of expected cases. Romania included patients from single institution, representing only 10% of expected patients. Joint database for analysis was established. Results One hundred seventy-eight children and adolescent with RMS diagnosed from January 2000 to December 2015 were included. Mean patient age at diagnosis was 7.7 years, one third was older than 10 years. Twenty-five percent had alveolar histology and 72% unfavorable location. Higher than expected proportion of patients had nodal involvement (24%) or metastatic disease (27%). All patients received systemic chemotherapy, 57% had radiotherapy and 63% surgery as local control. Kaplan- Meier estimates for 5-year EFS and OS were 50.7% and 59.6%, respectively. Five-year OS for patients with localised disease was 72% compared to 24% for metastatic disease. Conclusions Children with RMS treated in Eastern and Central Europe have inferior outcome compared to their counterparts treated in high income European countries. Active participation of low health expenditures average rates (LHEAR) countries in international clinical trials may improve outcome of paediatric oncology patients.

Assessment of COVID-19 Waste Flows During the Emergency State in Romania and Related Public Health and Environmental Concerns.

This paper provides a rapid assessment method of potentially infectious waste flow related to the coronavirus disease (COVID-19) pandemic in Romania focusing on the emergency state (from 16 March to 14 May 2020) where a national lockdown was in force with restrictive and social distancing measures concerning population mobility and economic activities. Medical and municipal waste management systems are critical services in combating the virus spread in the community. This assessment is useful due to poor available data of medical waste flow in environmental reports and it covers COVID-19 patients, quarantined, and self-isolated persons as the main potential infectious waste sources. The proposed model estimates that COVID-19 related waste flow is 4312 t at the national level from 25 February to 15 June of which 2633 t in the emergency state period. This assessment is correlated with deficiencies of medical and municipal waste management systems in Romania before the COVID-19 pandemic as stress factors of public health and environment. This study points out the main challenges of waste operators and reveals some best practices during this pandemic crisis. Based on the results and discussion section, several recommendations are proposed to COVID-19 waste-related issues and points out the crucial role of the reliable medical and municipal waste database in managing such biologic hazards at national and EU levels. Monitoring of COVID-19 waste flow through such models are important for decision-makers, particularly in low and middle-income countries which are facing waste management deficiencies and gaps in waste statistics, to reduce other contamination risks or related environmental threats.

Modeling the Puzzle of Hepatitis C Epidemiology in Romania: A Pathway to Control.

BACKGROUND AND AIMS: To combat hepatitis C virus (HCV) and achieve its elimination by 2030, the emphasis should be on public health policies. In this study, we investigated the dynamics of epidemiology of HCV in Romanian risk groups that are characterized by higher occurrence densities with the aid of The Let's End HepC (LEHC) project. METHODS: The LEHC project addressed the modelling of HCV epidemiology, being applied in several countries, one of which is Romania. The model comprised an integrated solution of public health policies focused on the disease, using Adaptive Conjoint Analysis and Markov chains systems. This tool allowed the quantitative evaluation of public health policies' impact, for every year until 2030, in five population groups: people who inject drugs (PWID), prisoners, individuals who have received blood products, children at risk for vertical transmission, and the remnant population. RESULTS: It appears that Romania was already making great efforts in the context of public policies, allowing the achievement of HCV elimination by 2028 if current policies were maintained. Through additional work and greater efforts in further implementing public policies, the LEHC model estimated the possibility of anticipating this outcome to 2026. CONCLUSION: The LEHC model estimated an anticipation of the HCV elimination year in Romania to be 2026 if the twenty-four health policies in the study are fully implemented and consistently maintained over the years.

Assessment of STI screening in Romania using a multiplex PCR technique.

INTRODUCTION: Most sexually transmitted infections (STIs) are curable, but inappropriate treatment can lead to serious complications. The importance of setting up STI screening programs has been highlighted in various studies, the absence of such national programs accounting for the lack of STI statistics in Romania. The purpose of our study was to evaluate multiplex PCR as a screening method for the most common 6 STIs and establish their frequency in a group of symptomatic and asymptomatic patients. We aimed to highlight STI associations and correlations between STI pathogens and symptomatology, demographic status, antecedents or sexual partners. METHODOLOGY: A total of 249 patients, both symptomatic and asymptomatic, were included in this study. Chlamydia trachomatis (CT), Neisseia gonorrhoeae (NG), Trichomonas vaginalis (TV), Ureaplasma urealyticum (UU), Mycoplasma hominis (MH) and Mycoplasma genitalium (MG) were all identified in urine samples via multiplex Polymerase Chain Reaction (PCR). The SPSS IBM program was employed for statistical analysis. RESULTS: 32.12% of the patients were found positive, some presenting multiple infections. The results are representative for the Romanian male population. 107 STI pathogens were identified, most frequent being CT, UU and NG. Several statistical correlations between patient characteristics and the presence of STIs have been demonstrated. CONCLUSIONS: The results suggest that multiplex PCR meets all the prerequisites for a screening method, allowing the use of multiple specimens and enabling simultaneous detection of multiple pathogens in a short period of time. STI identification via multiplex PCR proved to be an effective method for quantifying their frequency in Romania.