Onion (Allium cepa L.) Skin Waste Valorization: Unveiling the Phenolic Profile and Biological Potential for the Creation of Bioactive Agents through Subcritical Water Extraction.

Onion skin waste (OSW), the primary non-edible byproduct from onion processing, offers a renewable source of bioactive compounds. This study aims to valorize OSW through subcritical water extraction (SWE), aligning with a circular economy and biorefinery principles. SWE was carried out at 145 °C and 50 bar for 50 min in a discontinuous reactor, producing a phenolic-rich extract (32.3 ± 2.6 mg/g) dominated by protocatechuic acid (20.3 ± 2.5 mg/g), quercetin-4'-O-glucoside (7.5 ± 0.2 mg/g), and quercetin (3.2 ± 0.6 mg/g). Additionally, the extract contains sugars (207.1 ± 20.3 mg sucrose-Eq/g), proteins (22.8 ± 1.6 mg BSA-Eq/g), and free amino acids (20.4 ± 1.2 mg arginine-Eq/g). Its phenolic richness determines its scavenging activity against ●NO and O2●- radicals and its α-glucosidase and aldose-reductase inhibition without affecting α-amylase. Notably, the extract demonstrates significant α-glucosidase inhibition (IC50 = 75.6 ± 43.5 µg/mL), surpassing acarbose (IC50 = 129.5 ± 1.0 µg/mL) in both pure enzyme and cell culture tests without showing cytotoxicity to AGS, HepG2, and Caco-2 human cell lines. The extract's bioactivity and nutritional content make it suitable for developing antioxidant and antidiabetic nutraceutical/food components, highlighting SWE's potential for OSW valorization without using organic solvents.

Impact of a teaching strategy to promote evidence-based practice on nursing students' knowledge and confidence in simulated clinical intervention choices.

BACKGROUND: Nurses self-efficacy, confidence and their competency for evidence-based practice have a relevant impact in the quality of care provided to patients. However, the implementation of evidence-based practice continues to be limited to date and the relationship between these elements has not been thoroughly understood. Thus, the aim of this study was to analyze the impact on confidence levels of a teaching strategy to promote evidence incorporation into clinical decisions made by student nurses in hypothetical scenarios. Besides, students' satisfaction with the new teaching strategy was assessed. METHODS: The teaching strategy was asynchronous, on-line and based on multiple-choice questionnaires related to decision making on an intensive care unit patient. Confidence levels were assessed by introducing the scoring tool confidence-based marking. Changes between pre- and post-tests in correct answers, confidence levels and expected-observed ranges of accuracy at each level of certainty were analyzed through non-parametric McNemar's sign tests for paired-samples differences. To assess students' satisfaction with the teaching strategy, a mixed-methods approach was followed. Descriptive statistical methods and Qualitative Content Analysis were followed respectively in order to analyze students' satisfaction. RESULTS: A total of 165 students completed the assignment, 101 answered the satisfaction survey and 7 participated in the interviews. Statistically significant better scoring and higher confidence levels were found in the post-intervention. Statistically significant differences in expected-observed ranges of accuracy were found for the three levels of certainty. Students were highly satisfied with the proposed task. In the qualitative analysis one category was elaborated which illustrated the students' perceived added value of this new assignment. CONCLUSIONS: On-line teaching strategies based on clinical scenarios that focus on evidence-based decision-making have the potential to increase the confidence of nursing students. Additionally, interventions designed by teams incorporating clinical nurses, university librarians and academic nurses have the potential to bridge the evidence-practice gap in nursing education.

Achievements and challenges in baccalaureate student nurses' preparation for evidence-based nursing practice: A mixed methods study.

BACKGROUND: Evidence-based nursing (EBN) implementation is still limited. The effect of the incorporation of this competence into the whole nursing curricula as a cross-cutting topic has not yet been assessed. OBJECTIVE: This study aimed to explore the perceptions of final year student nurses of their preparation for EBN practice and its current implementation in the local healthcare system. DESIGN: This study followed a mixed-methods approach. The data collection methods were a self-administered online questionnaire followed by individual in-depth interviews. RESULTS: The majority of participants (93.4%) chose asking a colleague as the main source of information for decision making during their last year of clinical training. However, scientific evidence was considered the most accurate and credible source instead of colleagues. The main barriers impeding EBN practice were revealed to be: not being able to find the required information, lack of time to search, and not feeling able to interpret information found. In the qualitative analysis of the interviews, three categories were identified: 'Towards EBN at a snail's pace'; 'A huge gap between theory and practice'; and 'Where is nursing?' CONCLUSIONS: Although participants in this study consistently attributed more credibility to clinical guidelines, protocols, and scientific publications over colleagues, asking a colleague continues to be the main resource to address clinical doubts. Lack of institutional support, the unresolved theory-practice gap in nursing, and the status of nurses in relation to other healthcare providers were identified as barriers for further EBN implementation.

Subcritical Water Extraction of Phenolic Compounds from Onion Skin Wastes (Allium cepa cv. Horcal): Effect of Temperature and Solvent Properties.

The valorization of onion skin wastes (OSW) through the extraction, identification, and quantification of phenolic compounds was studied in this work, using subcritical water in a semicontinuous extractor (2.5 mL/min; 105-180 °C; 5 MPa). The extraction of flavonoids resulted to be fast (<30 min) and temperature sensitive (maximum at 145 °C; total flavonoids, 27.4 ± 0.9 mg/g dry OSW (DOSW)). The experimental results were fitted to the Weibull model. The influence of the solvent properties on the flavonoids quantification was found to be critical. A precipitate was formed once the extracts cooled down. If removed, a significant fraction of the high temperature extracted flavonoids (as much as 71%, at 180 °C) was lost. Such a condition affected especially those compounds that show extremely low solubility in water at room temperature, whereas quercetin glycosylated derivatives were less affected by the polarity change of the medium induced by the temperature change. It was demonstrated that it is necessary to re-dissolve the subcritical water extracts by the addition of ethanol, which led to a medium with a polarity equivalent to that obtained with water at high temperature. At 145 °C, quercetin (15.4 ± 0.4 mg/g DOSW) and quercetin-4'-glucoside (8.4 ± 0.1 mg/g DOSW) accounted for the 90% of the total flavonoids identified. By recovering high added value bioactive compounds from OSW the principles of circular economy were fulfilled, providing a new use for this agricultural waste.

Caracterización clínico-epidemiológica de pacientes con tuberculosis en el Departamento de Caaguazú, Paraguay. 2014 a 2017

Resumen Introducción: La tuberculosis (TBC) es una de las diez principales causas de muerte en todo el mundo. Objetivo: Caracterizar clínica y epidemiológicamente los casos de TBC del Departamento de Caaguazú-Paraguay, entre los años 2014 y 2017. Pacientes y Métodos: Se realizó un estudio observacional, retrospectivo, utilizando datos secundarios del Programa Nacional de Control de la Tuberculosis (PNCT). La población: 659 casos de TBC registrados en el PNCT. Las variables: edad, sexo, grupo poblacional, tipo de TBC, co-infección TBC/VIH, y categoría de egreso. Procesamos la base de datos en Excel 2016 © usando Stata 14.0®. Resultado: El 63,3% de los participantes fue del género masculino. La edad promedio fue de 35,8 años. El 39,6% eran indígenas y 14,5% fueron personas privadas de libertad (PPL) conocidos como reclusos. El 89,6% tuvo TBC pulmonar, 2,4% tuvo co-infección TBC/VIH. La tasa de incidencia fue superior a 21,6/100.000 habts en 2014. La incidencia en indígenas fue de 76,5/100.000 habts en 2017. La incidencia en PPL fue de 2.272,1/100.000 habitantes en 2017. Conclusión: La incidencia de TBC en el Departamento de Caaguazú es baja en la población general afectando principalmente a hombres, mientras que en la población indígena y PPL es alta.

Abstract Background: Tuberculosis (TB) is one of the ten leading causes of death worldwide. Aim: To characterize the clinical and epidemiological point of view of TB cases reported in the Department of Caaguazú-Paraguay, from 2014 to 2017. Methods: Observational, descriptive, retrospective study; Population: 659 cases of TB registered in the National Tuberculosis Control Program (NTCP); variables: age, sex, population group, type of TB, TB/HIV coinfection. We procesed database in Excel 2016 © using Stata 14.0®. Results: 63.3% were of male gender, average age: 35.8 years, 39.6% were indigenous and 85.4% were liberty deprived persons known as inmates (LDP), 89.6% had pulmonary TB and 2,4% had TB/HIV coinfection. Incidence rate exceed 21.6/100,000 inhabitants in 2014. Indigenous incidence was 76.5/100,000 inhabitants in 2017, LDP incidence was 2,272.1/ 100,000 inhabitants in 2017. Conclusion: The incidence of TB in the Department of Caaguazú is low, mainly affecting men, while TB incidence in indigenous people and LDP was high.

Water Ultrasound-Assisted Extraction of Polyphenol Compounds from Brewer's Spent Grain: Kinetic Study, Extract Characterization, and Concentration.

Brewer's spent grain (BSG) was chemically characterized obtaining 52.1% of carbohydrates, 17.8% protein, 5.9% lipids, 13.5% insoluble lignin and 24.3% of water-soluble extractives. This work has been focused on the study of polyphenol extraction of the extractive fraction by water ultrasound-assisted extraction. Selected extraction conditions were 47 °C and 21.7 mL water/gdry-BSG. The effect of solvent polarity on polyphenol extraction was studied by using ethanol aqueous mixtures, from 20% to 100% ethanol. The kinetics of polyphenol extraction have been fitted to the power law and the Weibull models yielding mean values of the root mean square deviation lower than 7.5%. Extracts have been characterized in terms of quantification of individual phenolic compounds by HPLC-DAD and protein and sugar soluble fractions (glucose, xylose, and arabinose). Polyphenol profile has been compared with other hydrolytic techniques, such as acid, basic and enzymatic hydrolysis, showing that ultrasound was not as effective as basic hydrolysis to release the phenolic acids esterified to the cell wall. A further centrifuge ultrafiltration concentration step was able to yield a retentate enriched in the protein fraction while individual phenolic compounds where mainly transferred to the permeate.

[Clinical-epidemiological characterization of patients with tuberculosis in the Department of Caaguazú, Paraguay. 2014-2017]. / Caracterización clínico-epidemiológica de pacientes con tuberculosis en el Departamento de Caaguazú, Paraguay. 2014 a 2017.

BACKGROUND: Tuberculosis (TB) is one of the ten leading causes of death worldwide. AIM: To characterize the clinical and epidemiological point of view of TB cases reported in the Department of Caaguazú-Paraguay, from 2014 to 2017. METHODS: Observational, descriptive, retrospective study; Population: 659 cases of TB registered in the National Tuberculosis Control Program (NTCP); variables: age, sex, population group, type of TB, TB/HIV coinfection. We procesed database in Excel 2016 © using Stata 14.0®. RESULTS: 63.3% were of male gender, average age: 35.8 years, 39.6% were indigenous and 85.4% were liberty deprived persons known as inmates (LDP), 89.6% had pulmonary TB and 2,4% had TB/HIV coinfection. Incidence rate exceed 21.6/100,000 inhabitants in 2014. Indigenous incidence was 76.5/100,000 inhabitants in 2017, LDP incidence was 2,272.1/ 100,000 inhabitants in 2017. CONCLUSION: The incidence of TB in the Department of Caaguazú is low, mainly affecting men, while TB incidence in indigenous people and LDP was high.

Early virtual reality adopters in Spain: sociodemographic profile and interest in the use of virtual reality as a learning tool.

This study describes the social and demographic profile of the first generation of users of marketed virtual reality (VR) viewers in Spain and, subsequently, it assesses the interest in its use as a learning tool. For that purpose, an online questionnaire created ad hoc was administered to a sample of 117 participants. The relationship between twelve variables was analysed comparing means through the Snedecor's F distribution and the contingency tables through the Chi-squared test and Somers' D. Among other issues, it was concluded that the virtual reality user profile at present corresponds to a person older than 36, mainly men, with higher education and having acquired their viewer no longer than one year ago. Concerning the interests of virtual reality users as a learning tool, only a few of them currently use virtual reality for this aim, but they mainly show an interest in using the virtual reality as a learning method and they feel optimism regarding the future use of this technology as a learning tool. However, this is not the case among users of video game consoles (PSVR), who are mainly men not interested in their use as a learning tool at present. Finally, it can be stated that current use as a learning tool among teachers and students is occasional and preferably via smartphones.

Green determination of brominated flame retardants and organochloride pollutants in fish oils by vortex assisted liquid-liquid microextraction and gas chromatography-tandem mass spectrometry.

A "green", simple, and low-cost sample extraction procedure involving the use of a deep eutectic solvent (DES) in a vortex assisted liquid-liquid microextraction (VALLME) technique followed by gas chromatography-tandem mass spectrometry (GC-MS/MS) analysis was developed for the simultaneous determination of different PBDEs congeners and OCPs residues in fish oils. After evaluation of different eutectic mixtures, the extraction parameters (volume of DES, amount of oil sample and extraction time) were optimized by means of experimental design in order to maximise extraction efficiency. The developed method was validated in terms of linearity, accuracy and precision, presenting limits of detection in the low ng g-1 level. Its application in the analysis of five fish oil samples, allowed the detection of all the target analytes at levels up 21.5 ng g-1. Fish oils used in animal feed showed to be more contaminated than fish oils for human consumption.

Omega-3 encapsulation by PGSS-drying and conventional drying methods. Particle characterization and oxidative stability.

Particles from Gas-Saturated Solutions (PGSS)-drying has been used as a green alternative to encapsulate omega-3 polyunsaturated fatty acids (n-3 PUFAs) at mild, non-oxidative conditions. PGSS-dried particles have been compared to those obtained by conventional drying methods such as spray-drying and freeze-drying, finding encapsulation efficiencies (EE) up to 98% and spherical morphology for PGSS- and spray-dried particles. Freeze-dried powders showed irregular morphology and EE from 95.8 to 98.6%, depending on the freezing method. Differential scanning calorimetry (DSC) analysis revealed glass-transition and melting peaks of OSA-starch and a cold-crystallization peak corresponding to the encapsulated n-3 PUFA concentrate. Compared to conventionally dried powders, PGSS-dried microparticles showed lower primary and secondary oxidation after 28 days of storage at 4 °C. Ascorbic acid addition combined with the mild processing conditions of PGSS-drying yielded particles with a maximum peroxide value of 2.5 meq O2/kg oil after 28 days of storage at 4 °C.

Demographic data, habits of use and personal impression of the first generation of users of virtual reality viewers in Spain.

Taking into account that the first virtual reality viewers started to be marketed in Spain at the end of 2016 (Gadelha, 2018; Parong and Mayer, 2018; Rizzo and Koenig, 2017) [1], [2], [3], a questionnaire was designed in order to show the social and demographic profile of this first generation of users of virtual reality experiences, itemising their ages, genders, educational level, professional field and present work status. Furthermore, the participants' habits of use, interests, attitudes, assessments about the future potential of virtual reality in a range of areas and their preferences in this area are shown through the other items of the questionnaire. A wide sample of 117 participants, who were early adopters of virtual reality viewers, was obtained posting a new thread in the virtual reality forum of the Internet website 'Elotrolado.net'. The data were collected by means of an online questionnaire hosted at the private servers of 'Encuestafacil.com'. The sample did not undergo any pre-treatment and the obtained data were not altered.

El médico en una nueva encrucijada

El médico actual se ha visto enfrentado a una serie de cambios en su accionar profesional. Destacan las enferme-dades emergentes, el aumento de la sobrevida, la frecuencia mantenida y a veces en aumento, de las enfermedades crónicas no trasmisibles y sus factores de riesgo, y los cambios socioculturales y de autonomía de los pacientes y de su entorno familiar. Estas nuevas realidades contrastan en su enfrentamiento y manejo con las orientaciones clásicas referidas únicamente al diagnóstico y tratamiento de las enfermedades. Ésta última rutina no ha sido capaz de reducir la mortalidad general de la población en forma significativa y se plantea que es el momento de intensificar las accio-nes de promoción y prevención de las enfermedades como una acertada forma de hacerlo. El nuevo médico que se debe formar tiene que ser capaz de enfrentar este desafío con conductas y manejo psico-social y apoyado en sólidos principios éticos que refuercen y mejoren la relación médico-paciente.(AU)

Laparoscopic resection of a gastric schwannoma: A case report.

INTRODUCTION: Mesenchymal tumors of the gastrointestinal tract are a group spindle cell tumors which include gastrointestinal stromal tumors, leiomyomas, leiomyosarcomas and schwannomas (Nishida and Hirota, 2000). Schwannomas generally present as a slow and asymptomatic growing mass in the gastrointestinal tract typically arising in the gastric submucosa accounting for up to 0.2% of gastric tumors (Melvin and Wilkinson, 1993; Sarlomo-Rikala M, Miettinen, 1995). TREATMENT: with negative surgical margin resection (as approached in this case) is considered the standard treatment. PRESENTATION OF CASE: A 60-year-old woman was referred to our general surgery service for dyspepsia. During her evaluation a gastric mass was incidentally found on upper GI endoscopy which showed a submucosal exophytic neoplasm at the gastric antrum. The patient was discharged following an uneventful recovery from a successful surgical laparoscopic tumor resection. DISCUSSION: Schwannomas are benign neurogenic tumors that originate from Schwann cells. They commonly occur in the head and neck but are rare in the GI tract (Menno et al., 2010). The differential diagnosis between gastric schwannomas and GISTs can be difficult in the preoperative assessment. With the advent of immunohistochemical staining techniques it is now possible to make a differential diagnosis based on their distinctive immunophenotypes. Gastric schwannomas are consistently positive for S-100 protein and negative for c-kit; conversely, 95% of GISTs are positive for c-kit and negative for S-100 protein in up to 98 to 99% of the cases. CONCLUSION: Gastric schwannomas should be included in the differential diagnosis of any gastric submucosal mass. Negative margin resection as seen with this patient is the standard surgical treatment as there is low malignant transformation potential.

Pressurized aqueous ethanol extraction of ß-glucans and phenolic compounds from waxy barley.

Beta-glucans and phenolics were extracted from waxy barley using pressurized aqueous ethanol in a stirred batch reactor at 25bar and 500rpm. The effect of temperature (135-175°C), extraction time (15-55min) and ethanol content (5-20%) was evaluated. Temperature had an opposite effect on the extraction of both compounds. The higher the temperature, the lower the ß-glucan extraction yield due to fragmentation, but a significant increase on the phenolic recovery was observed. Long extraction times favored the extraction of ß-glucans at low temperatures and phenolics at any temperature. The ethanol content was not statistically significant on the ß-glucan extraction, but helped to maintain the molecular weight of the extracted ß-glucan. To obtain liquid extracts rich in high molecular weight ß-glucans and phenolics, mild conditions of 151°C, 21min and 16% ethanol are needed, leading to 51% ß-glucan extraction yield with a molecular weight of 500-600kDa and 5mgGAE/g barley.

Pesquisa de marcadores precoces de arterioesclerosis en sujetos pre-hipertensos e hipertensos / Detection of early markers for atherosclerosis in pre-hypertensive and hypertensive subjects

Introducción: Se han descrito varias alteraciones del sistema circulatorio y corazón que aparecen en forma precoz en el curso evolutivo de la hipertensión arterial, particularmente en niveles de pre-hipertensión y en hipertensión etapa 1. Objetivo: Estudiar algunos marcadores de daño en pacientes hipertensos no tratados. Métodos: Se incluyeron 2 grupos de hipertensos no tratados, uno con cifras consideradas pre-hipertensión (120-139/80-89 mmHg) en 17 casos y otro con hipertensión Etapa 1 (Consenso 7), cifras de 140160/90-100 mmHg en 47 pacientes. Se les estudiaron marcadores de daño, tales como alteraciones iniciales de fondo de ojo, ausencia de Dip nocturno en el monitoreo ambulatorio de presión arterial (PA) de 24 hrs., hipertrofia ventricular izquierda y micro albuminuria elevada en 24 hrs. Se exigió rangos estrictos en 3 registros clínicos clásicos de medición de la PA. Resultados: En ambos grupos se observó la presencia de uno o más marcadores analizados: en el 59 por ciento del grupo de pre- hipertensos y en el 68 por ciento de los pacientes hipertensos etapa 1. Entre ambos grupos, sólo la presencia de hipertrofia ventricular fue significativamente más frecuente en los pacientes en Etapa 1 (p<0.05). Los factores de riesgo se distribuyeron con igual frecuencia en ambos grupos Conclusión: Se concluye que en etapas precoces del curso evolutivo de la PA aparecen marcadores de alteración ateroesclerótica inicial del sistema circulatorio en más de la mitad de los pacientes, antes de la aparición de daño severo de órganos blancos.

Background: Several alterations of the heart and circulatory system may appear early on during the course of hypertension, both at pre-hypertension or at stage I levels. Aim: to determine the frequency of early markers of organ damage in hypertensive subjects , both treated and un-treated Methods: two groups of un-treated hypertensive subjects, pre-hypertensives (blood pressure 120-139 / 80-89 mmHg, n=17) or stage I hypertensives (140-160 / 90100 mmHg, n=47) were studied. Three concordant measurements of blood pressure were required for inclusion. Initial fundoscopic abnormalities, absence of nocturnal blood pressure dip on 24 hr Holter monitoring, presence of left ventricular hypertrophy and increased 24hr albuminuria, were determined. Results: Both groups exhibited one or more of the abnormalities being studied. Only left ventricular hypertrophy was more frequent in stage I hypertensives compared to pre hypertensives (p<0.05). Risk factors for coronary artery disease did not differ between groups. Conclusion: More than 50% of patients with pre-hypertension or stage I hypertension exhibit initial markers for atherosclerotic changes in the circulatory system, before the development of severe target organ damage.

[Training of specialists in the Chilean national health services]. / Formación de médicos especialistas en el Sistema de Servicios de Salud de Chile. Su evolución en el período 2007-2010.

Several institutions, such as the Ministry of Health, Universities, the Chilean Medical Association, Scientific societies and public opinion, recognize that there is a deficiency of specialized physicians in Chile. To overcome this shortage of specialists, the Ministry of Health, along with universities, is developing diverse initiatives to train specialists and cope with the requirements of the country. Seventy five percent of posts offered were filled by physicians. The number of positions increased from 173 in 2007 to 576 in 2010, with a cumulative total of 1582 physicians in four years. Fifty two percent are being trained in Basic Primary Specialties and 48% in primary specialties. Thirty three percent of graduates have the obligation to continue working in the public service during a certain lapse. This figure will increase to 50% in the following years. These specialists are mainly working in the more densely populated regions of the country. The universities that offer the higher number of training positions are the University of Chile, The Catholic University of Chile and the University of Santiago.

Diagnóstico precoz y prevención de la enfermedad ateroesclerótica sistémica / Early diagnosis and prevention of systemic atherosclerotic disease

Existe evidencia significativa en varias comunicaciones que los sujetos con presión arterial ligeramente sobre el nivel normal de 120/80 mmHg, pero bajo 140/90 mmHg, considerados pre-hipertensos en los últimos Consensos internacionales, presentan signos precoces de alteración cardiovascular propios de la enfermedad arterioesclerótica. Además, estos cambios iniciales se presentan asociados a algunos factores de riesgo C-V, en especial de diabetes, dislipidemia, obesidad y sedentarismo. Por tanto, se ha propuesto cambiar el paradigma basado en las cifras de PA por otro que involucre las alteraciones precoces y los factores de riesgo. En esta etapa inicial de la enfermedad arterial, es preciso evaluar su riesgo multifactorial a 5 o 10 años plazo, y de acuerdo a éste, planificar las medidas terapéuticas de manejo de los FR y del posible uso de drogas antihipertensivas. De este modo se podrá implementar una profilaxis primaria racional y muy posiblemente eficaz.

Importance of temperature and anodic medium composition on microbial fuel cell (MFC) performance.

The performance of a microbial fuel cell (MFC) was investigated at different temperatures and anodic media. A lag phase of 30 h occurred at 30 degrees C which was half that at room temperature (22 degrees C). The maximum power density at 30 degrees C was 70 mW/m(2) and at 22 degrees C was 43 mW/m(2). At 15 degrees C, no successful operation was observed even after several loadings for a long period of operation. Maximum power density of 320 mW/m(2) was obtained with wastewater medium containing phosphate buffer (conductivity: 11.8 mS/cm), which was approx. 4 times higher than the value without phosphate additions (2.89 mS/cm).

[A critical appraisal to "AUGE" health plan in Chile]. / Una mirada crítica en torno al plan AUGE. Algunos aspectos generales y valóricos.

The health reform in Chile established a health plan called AUGE that guarantees an access to diagnosis and treatment of certain specific diseases within a time frame that must be respected. This article reviews and analyzes the general provisions of this plan and its management of values. Aspects that were implemented by the reform are discussed, especially those that refer to direct care of the population. The positive and negative aspects of the reform are balance and are contrasted with eventual changes that should be made from an ethical point of view.