Preventive predictive-and-personalized-medicine

Preventive,
predictive and personalized
medicine
National Representative:
Prof. Luiza Spiru, MD, PhD
President of Ana Aslan International Foundation
Ana Aslan International Academy of Aging
Head of the Geriatric Department & Day Hospital of Memory
Diseases of “Elias” University Hospital
Professor of Geriatric Dept. of ”Carol Davila” University of
Medicine and Pharmacy Bucharest, ROMANIA
Chronic Disease and
Health Management
2nd Edition
22-23th September 2010
Bucharest, Romania
ANA ASLAN
INTERNATIONAL
ACADEMY
ANA ASLAN
INTERNATIONAL
FOUNDATION

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http://www.euromonitor.com
Chronic diseases management
Chronic diseases can only be controlled, not cured.
Living with a chronic disease impacts the quality of life of the patients and their
families
The incidence of chronic pathology increases with age.
The care of people with chronic conditions also requires a important health and
social care resources.
People with chronic conditions are accounting for about 80% of GP consultations,
and use more inpatient days.
The World Health Organization:
• chronic conditions will be the leading cause of disability by 2020
• if not successfully managed, will become the most expensive problem for
health care systems.
Preventive, predictive and personalized medicine, Prof. Luiza Spiru, MD, PHD
All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the
approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©.

1
The long-term condition
pyramid (LTC pyramid) is
suggested as an important
framework for designing
services.
The Quality and Outcomes
Framework of the General
Medical Services contract
aims to improve primary
care standards.
Investment in Expert
Patient programs and
health literacy support self-
care at lower levels of the
pyramid.
S.Hamilton et al., 2008. Mind the gap between policy imperatives and service provision: a
qualitative study of the process of respiratory service development in England and Wales. BMC
Health Services Research 2008, 8:248.
Pyramid of care for long-term conditions.
(adapted from Improving Chronic Disease Management by Hamilton et al. 2008

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Semi-structured qualitative telephone interviews with the person(s) responsible
for driving respiratory service reconfiguration in a purposive sample of 30 Primary
Care Organizations (PCOs).
Outcomes:
• “There is a large gap between central policy rhetoric driving workforce change,
and the practical reality of implementing change within PCOs when faced with:
• limited resources,
• diverse professional attitudes
• an uncertain organizational context”.
• “Research should concentrate on understanding these complex dynamics in
order to inform the policymakers, commissioners, health service managers and
professionals”.
S.Hamilton et al., 2008. Mind the gap between policy imperatives and service provision: a
qualitative study of the process of respiratory service development in England and Wales. BMC
Health Services Research 2008, 8:248.
S.Hamilton et al. Study [UK], 2008

WHO STRATEGIC AGENDA
WHO will work with the Government of Romania to narrow the gap between policy
objectives and policy implementation
• Stewardship, health financing, service delivery and resource development
• Communicable disease surveillance and control
• Public health system reform
© World Health Organization 2007 – All rights reserved.

The need of 3P-Medicine approach
The result:
despite high care costs, long-term prognosis usually
remains poor due to:
• inadequate control of disease manifestations,
• treatment failure,
• disease-recurrence
• appearance of severe secondary
complications,
• relatively low life-quality of the treated
persons,
• high morbidity and mortality.
The facts:
current healthcare practices
essentially rely on emergence
of signs and symptoms of human
pathologies prior to initiation of
interventional modalities.
A major limitation:
often the disease process has already
taken its toll through manifestation of
its complications
(http://www.epmanet.eu)

1
• Initially chronic pathologies are generally triggered at the molecular level,
followed by pathology-specific molecular events predisposing to certain pathologies
long before organ damage and symptomatic manifestation of the disease.
•Genetic and environmental factors are interacting:
F Borrell-Carrió et al., 2004. The Biopsychosocial Model 25 Years Later:
Principles, Practice, and Scientific Inquiry. Annals of Family Medicine 2:576-582
inner, individual
predisposing factors
(old age, certain genetic polymorphisms,
oxidative stress, vitamin deficiencies,
inflammation, immune, endocrine, vascular
And metabolic conditions, depression,
tumors, gender, level of education)
susceptibility to disease development
environmental risk factors
(head trauma, certain infections,
smoking and chemical exposure,
bad stress management)
subtle, cumulative alterations
The Bio-Psycho-Social model
3P-Medicine - a golden premise for improved strategies

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Innovative biotechnologies are golden tools for:
• prediction of human pathologies,
• design of appropriate and timely preventive strategies,
• personalized treatment planning.
[Costigliola V et al., Predictive Medicine as the new philosophy in health care. In: Predictive Diagnostics
& Personalized Treatment: Dream or Reality?, Golubnitschaja O. Ed., Nova Science Publishers, New
York, USA, 2009]
Therefore:
Early detection of pathology-
specific molecular patterns can
create a well-founded basis for
the predictive approaches.

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Therefore:
3P Medicine offers great promise for the future practice of chronic disease
management.
Essential components of 3P Medicine approach are:
• well-organized population screening protocols
• novel diagnostic biomarkers
• targeted prevention of common human pathologies
• personalized, optimal treatment planning.
Resulting main outcomes:
• substantial improvement of the quality of life
• care delivery at potentially reduced costs to the population at large
• addressing social and ethical issues related to access
• affordability of healthcare
[Costigliola V et al., Predictive Medicine as the new philosophy in health care. In: Predictive Diagnostics
& Personalized Treatment: Dream or Reality?, Golubnitschaja O. Ed., Nova Science Publishers, New
York, USA, 2009; www.epmanet.eu]

EPMA has the coordinating MISSION of the European-Network
in Predictive, Preventive & Personalised Medicine.
The EPMA-Network is open for issue-related cooperation
worldwide.
(http://www.epmanet.eu)
EPMA Mission
• Raising awareness and recognition of 3P Medicine throughout all EU Member and
Associated countries;
• Providing up-to-date information and educational materials on Predictive & Personalised
Medicine and targeted preventive measures;
Promoting:
• the adequate allocation of resources for 3P Medicine;
• advanced programs for personalized patient treatment;
• high-quality research focused on predictive diagnostics and personalised patient treatment;
• standardisation of bio-analytical technologies for predictive pre-clinical and clinical
applications;
• multidisciplinary efforts in 3P Medicine;
• creation of Guidelines in European health care with the accentuated role of prediction,
prevention and personalised patient treatment

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http://www.epmanet.eu/index.php/education/professionals
EPMA 3P-Medicine concept

1
Actors called to contribute
Students and professionals in:
• conventional and molecular diagnostics,
• biomedicine,
• biotechnologies,
• ethics, and economics
Universities, research units, hospitals (private and public)
Patients and/or their care givers (family members) organizations
Scientific media
International associations with healthcare-oriented scientific, research
and public health-related activities/responsibilities
Political organisations and authorities active in the healthcare sector
Civil society representatives
Healthcare industry including policy-makers.

is open for issue-related cooperation worldwide.
The EPMA Network
More accurate research is needed to
enlighten and validate individual
“clusters” of inner and outer
interacting risk factors responsible
for the onset of degenerative
processes.
Until the elaboration of cutting-edge,
highly efficient disease-modifying
drugs and other interventions, the
most important way to be pursued is
the most obvious one: prevention.
The ongoing development of
Predictive, Preventive and
Personalized Medicine (3P Medicine)
is a step forward dealing with the
elaboration of good answers to
demographic aging and its outcomes.

1
Like the conventional, but also the new branches of biomedicine, 3P
Medicine is facing a lot of challenges:
• Should molecular diagnostic approaches to complement or substitute
measures to conventional approaches? *
• How reliable are biomarkers for any given pathology? *
• What about ethical aspects in genetic approach?
• How to distinguish between the highly predictive power of innovation and
quackery in diagnostics? *
• How to overcome currently well-recognizable (inter)national barriers in
knowledge transfer? *
• How to correctly educate the new generation of experts in 3P Medicine? *
(*http://www.epmanet.eu)

1
PREDICTIVE Medicine tasks/means
Expanding research in genomic/proteomic testing
• Innovative approach
• sustained funding needed
• genomic testing more accessible
Expanding research in sophisticated imaging tools
• to confirm lab tests
• to develop powerful predictive markers
To assure easier, direct consumer access to lab testing
Expanding research regarding the predictive value of
environmental and life style predisposing risk factors

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Challenges of predictive biomarkers
The biomarkers have different temporal relationships with the
manifestation of disease.
• Abnormal concentrations of the two liver enzymes indicate
existing liver damage, not just an increased risk.
• Abnormal insulinemia indicate that pathological changes and
clinically manifest disease may occur.
• There is now clear evidence that the pathological processes
that lead to manifest cardiovascular disease may be underway in
children under 10 years of age.
[Markers of chronic disease. NSW Schools Physical Activity and
Nutrition Survey – SPANS Report 2004, NSW Health, pp.206-212]

1
NSW Schools Physical Activity and Nutrition Survey – SPANS Report
2004:
Conclusions:
Adolescence is a time when risk behaviors and biological conditions
become established. An overweight adolescent with cardiovascular
and other risk factors is likely to become an overweight adult with
heart disease.
The earlier in life these behaviors and conditions become established,
the earlier the natural course of the disease process begins.
Chronic diseases manifest earlier in life.
Risk factors for serious chronic diseases proved highly prevalent
among young people.

1
Development of screening guidelines to confront
“Alzheimer’s crisis”

1

• The patterns of transmission and biological mechanisms through which a family
history of LOAD confers risk to the offspring – still not known.
• Brain imaging with 18 F-FDG PET:
normal individuals with a maternal history of LOAD, but not with a paternal one,
express a phenotype characterised by a pattern of progressive reductions of brain
glucose metabolism, similar to that in AD patients.
• genetic mutations implicated in EOFAD and their effects on brain chemistry,
structure and function may induce selective patterns of hypometabolism in
maternally inherited AD
Prodromal metabolic phenotype
and the search for genes in AD
L Mosconi et al, 2010. Maternal transmission of Alzheimer's disease: Prodromal
metabolic phenotype and the search for genes. Human Genomics, 4(3): 170 - 193
L Mosconi et al, 2010

1
PREVENTION of chronic conditions
Older people are not the only ones affected by chronic diseases. Rising
numbers of young and middle-aged people have some form of chronic health
problem (Pomerleau, Knai and Nolte 2008 1).
The WHO’s project The Global Burden of Disease 2:
• 72% of all deaths before the age of 60 years in 2002 were due to chronic or
noncommunicable conditions in developed countries.
• 68% of DALYs (disability-adjusted life years) lost to chronic diseases in
developed countries occurred among those of working age.
•These findings suggest that chronic disease can no longer be considered just a
problem of the elderly (Suhrcke et al. 2006; Mathers et al. 2003 3).

1
The important outcomes of Nature and Nurture concept
The knowledge of gene-environment interaction may provide valuable
insights for the scientific, evidence based design of preventive strategies
Epigenetics - changes in gene expression under the influence of well
targeted drug and non-drug interventions

1
Preventive evaluation and interventions must be performed during:
• Prenatal and neonatal period
• In infancy and childhood
• In adolescence and early adult life
• In middle and later adult life
The continuum of Prevention

Prenatal and neonatal interventions
•Immunisation against maternal rubella and influenza
•Voluntary screening for HIV and syphilis infection
•Dietary supplementation during pregnancy, including
folates
•prenatal prevention of teratogenic toxicity, foetal
alchohol syndrome and neonatal narcotic dependency
Brian COOPER, Nature, nurture and mental disorder: old concepts in
the new millennium, The British Journal of Psychiatry (2001) 178: s91-s101
Preventive actions aiming to reduce mental health damage caused by
environmental exposures or their consequences:
Nature, Nurture and Prevention

Measures in infancy and childhood
•Immunisation against measles, pertussis and herpes simplex encephalitis
meningococcal meningitis and congenital syphilis
•Iodine supplementation in deficiency-endemic areas
•Detection and dietary treatment of phenylketonuria and other metabolic
errors
•Detection of non-accidental injury, physical and sexual abuse
•Monitoring of prolonged medication (e.g. anti-epileptic drugs)
•Reduction of neurotoxic exposures (e.g. lead pollution from petrol additives)

Measures in adolescence and early adult life
•Prevention of brain trauma
•Programmes targeting risk-taking behavior (use of alcohol and ‘designer’
drugs, AIDS infection, etc.)
•Anxiety/Depression treatment
•Occupational health and safety programmes (reducing exposure to organic
solvents, organophosphates, heavy metal compounds)

Measures in middle and later adult life
• Reduction of cerebrovascular disease risk, hypertension and stroke (control
of diet, alcohol consumption, etc.)
• Detection of conditions with neuropsychiatric complications (e.g. vitamin B12
deficiency and megaloblastic anaemia, hypothyroidism, Borrelia infection)
• Avoidance of iatrogenic neuropsychiatric syndromes
• Medico-social support in high-risk situations (e.g. admission to long-term
care)

The WHO report 2002 - Reducing Risks, Promoting Healthy Life
http://www.who.int/whr/2002/en/
The objectives of Integrated Chronic Disease Prevention and Control
Programme:
• to strengthen prevention and control of chronic no communicable
diseases by tackling the major risk factors
• to reduce premature mortality and morbidity
• to improve quality of life, with particular focus on developing countries,
working through the Global Forum and the regional networks, in accordance
with the global strategy approved by the 53rd World Health Assembly.

http://www.who.int/whr/2002/en/
The areas of work of the WHO Integrated Chronic Disease Prevention and Control
Programme (ICP) include:
•To raise awareness for chronic diseases;
•to ensure that chronic disease prevention is placed on top of the
agenda of health care policies;
•to promote development and implementation of national policy & strategy, programmes,
community-based demonstration projects for prevention and control of chronic diseases
(with a special focus on developing countries);
•to promote the development of regional networks of national chronic disease prevention
programmes;

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To providing the Right Treatment for the Right Person at the Right Time
Personalized Medicine (PM) = tailoring of medical treatment to the individual
characteristics of each patient.
To use the information about individuals’ personal traits:
genomes,
health states,
behavioral,
environmental,
socioeconomic,
cultural
and other personal determinants
in order to manage the response to health care interventions.
PM provides the ability to classify individuals into subpopulations that differ in their
susceptibility to a particular disease, or their response to a specific treatment.
PERSONALIZED Medicine
Chronic Diseases and Personalized Medicine Needs. Ignite Institute for Individualized Health .
http://www.ctisinc.com/Chronic_Diseases_and_Personalized_Medicine.aspx

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Health Information Technology Accelerates Personalized Medicine and Chronic Disease
Management.
Solutions:
• Uses sophisticated molecular scanning technologies to identify at-risk individuals
prior to disease symptoms.
• Develop and test therapies.
• Focuses on molecular analysis and translational research on chronic disease
detection, management, and treatment.
• Applies a chronic disease-centric approach to public health burdens.
• Integrates Health Information Technology to enable clinical decision support for
personalized medicine.
Chronic Diseases and Personalized Medicine Needs. Ignite Institute for Individualized Health .
http://www.ctisinc.com/Chronic_Diseases_and_Personalized_Medicine.aspx

42
Through personalized medicine, medical professionals are
developing sub populations for complex diseases and physical
conditions such as:
Diabetes
Dementia
Cancer
Heart Disease.
Personalized medicine may help medical community to make the
most effective clinical decisions for each patient (individual
approach).
http://www.personalizedmedicine.com/contact.php

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EPMA – ROMANIA - National Report 2009, Prof. Luiza Spiru, MD, PHD
When coupled with personal pharmacogenetics, Personalized
medicine is a unique approach that may be well suited for the health
challenges of population grow up.
approach).
Personalized medicine may help to determine the right dose for a
patient, to avoid hazards based on familial history, environmental
influences, and genetic variation.

44
When coupled with personal pharmacogenetics, Personalized
Medicine is a unique approach that may be well suited for the health
challenges of aging population
approach).

45
Chronic and degenerative disease is a major health issue.
Its multifactorial etiology requires a multifactorial but integrative attempt.
3P Medicine and the holistic, integrative
approach of chronic conditions
inner, individual
predisposing factors
susceptibility to
disease development
environmental
risk factors
subtle, cumulative
alterations

46
The holistic, integrative research paradigm of 3P Medicine
Specific Epigenetic and
Metabolomic Alterations
• SAM-SAH / Folates cycles
•DNA merhylation patterns
• Relevant genes’ expression
•Detection
•Markers
Early Diagnosis tools
Improved Therapeutic
Interventions
Preventive
strategies
Final
Outcomes
• Healthy aging
•Social
benefits
(medical,
economical)
Bio-Medical
Outcomes
Environmental
• Nutrigenomic
•Sociomic
(Risk) factors
Organism
detection
• amendment

Established in 2009
Coordinator:
Prof. Luiza Spiru MD, PhD.
,
Head of the Geriatric and Old Age Psichiatry Clinic
Elias University Emergency Hospital
Carol Davila University of Medicine and Pharmacy,
Bucharest
President of the Ana Aslan International Foundation
By its activity, the Romanian EPMA Representative
•Promotes EPMA philosophy, principles and values
•Adapts them to the realities from Romania
•Advocate 3P Medicine in the benefit of patients, policy makers,
•And society as a whole
Romanian EPMA Representative

49
2005 2006 2007 2008 2009
Population aged
65+: January 1st
3,174.98 3,197.10 3,197.95 3,186.31 3,162.92
http://www.euromonitor.com/FactFile.aspx?country=RO
3rd age population segment (dynamics 2005-2009)
3,140.00
3,150.00
3,160.00
3,170.00
3,180.00
3,190.00
3,200.00
3,210.00
2005
2006
2007
2008
2009
Population
aged 65+:
January 1st
Romanian realities - Demography

50
Romania – Morbidity

51
Romania - Morbidity
Trends in incidence of occupational
morbidity, 1996–2006
European Working Conditions Observatory (EWCO), November, 2007
http://www.eurofound.europa.eu/ewco/2007/10/RO0710019I.htm

52
Cardiovascular diseases 31.80%
Neurodegenerative diseases 24.44%
Respiratory diseases 6.17%
Gastroenterologic disorders 4%
Endocrine disorders 2.94%
Otolaryngology problems 1.77%
Urinary tract disorders 1.42%
Other disorders 0.99%
Romania - Main morbidity data
for the geriatric population (2008)
THE CENTER FOR RESEARCH AND EVALUATION OF HEALTH
SERVICES, SNSPMS - Romania, 2009, http://www.drg.ro/

53
Romania – WHO cooperation
OPPORTUNITIES CHALLENGES
EU opportunities for increasing of quality
health services
Not equal access to health services
More efficient health systems Upgrading the public services, especially
into primary health care
Reforms of mental health care Health system funded – still at a low level
Mental Health Action Plan
An aging population – a need for
increased resources for the health
system dedicated to the elderly
Comprehensive approach of the health
policies
Geographically imbalanced human
resources
EU structural funds – developing the
infrastructure
The need of decentralized administration
and development of regional centres
© World Health Organization 2007 – All rights reserved.

5555
Running area - national level
Running time – 2009-2011
Coordinator: Ana Aslan International Academy of Aging
Prof. Luiza Spiru MD, PhD
developing the competences of specialists in
• neurosurgery,
• anesthesiology,
• psychiatry,
• geriatrics,
• Immagery
• molecular medicine and genomics/ epigenetics
in the field of brain aging
BRAINAGING - A 3P Medicine based, educational Project

5656
A new unit for holistic, integrated 3P Geriatric
approach in Romania
In December 2008 Ana Aslan International Foundation launched
The Clinic for Longevity Medicine, Healthy Aging
and Brain Aging Prevention
Bucharest – Otopeni, Romania
Under the auspices of:
the Romanian Academy and Ana Aslan International Foundation
Partnership:
„Carol Davila” University of Medicine and Pharmacy,
“Elias” Universitary Emergency Hospital, Bucharest
Departments:
• Alzheimer Unit
• Geriatrics and Gerontology University
Department
• The Centre for Diagnosis and Treatment
for Longevity and Brain Aging Prevention
Initiator and Coordinator:
Prof. Luiza Spiru, MD, PhD

57
Romanian organizations informed
about the EPMA-related activities
Romanian Medical Association
http://www.ong.ro/ong/amr/societati.htm
Romanian Association for Hepatic Research
http://www.ficat.ro/
Romanian Urological Association
http://www.aru.ro/aru/ie/index.jsp
Romanian Association for the Prevention of Osteoporrhosis -
ASPOR http://www.aspor.ro/
Romanian Society of Clinical Allergology and Immunology
http://www.sraic.ro
Romanian Society of Anesthesia and Intensive Care
www.srati.ro/
Romanian Society of Cardiology
http://www.cardioportal.ro/
Romanian League of Cancer
http://www.romaniancancerleague.org/ro/index.php
Society for the Study of Neuroprotection and Neuroplasticity
http://www.ssnn.ro/
The Romanian organizations invited as potential
members of the National EPMA Network

58
Romanian Society of Endocrinology
http://www.sre.ro/asp/statut.asp
Romanian Society of Gastroenterology and Hepathology
http://www.gastrohep.ro/index.php
Romanian Society of Rheumatology
http://www.srreumatologie.ro/index1.html
Romanian Society of Dermatology
www.srd.ro
The Romanian Society of Medical Informatics
http://www.medinfo.umft.ro/rsmi/
Romanian Society of Ultrasound in Medicine and Biology
http://www.srumb.ro/

59
Romanian Governmental Institutions invited
to join EPMA national network
Romanian Government
http://www.guv.ro/
Ministry of Research and Education http://www.edu.ro/
Health Ministry http://www.ms.ro/
Ministry of Labour, Family and Social Protection http://www.mmuncii.ro/en/
National House of Health Assurances
http://www.cnas.ro
National Council of Elderly Persons
http://www.cnpv.ro/
National Council of Scientific Research in High Education Institutions
http://www.cncsis.ro/
Romanian Aacademy
http://www.acad.ro/
Academy of Medical Sciences
http://www.ms.ro/a_ms/asm/asm.htm
The MD’s Romanian National College
http://www.cmr.ro/
The Order of Nurses and Midwifes from Romania
http://www.oammrbuc.ro/index.php

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Potential University members of
Romanian EPMA Network
Universities
“Carol Davila” University of Medicine and Pharmacy,
Bucharest, Romania
"Alexandru Ioan Cuza“University,
Iasi, Romania
University of Bucharest, Epigenetic Lab
Polytechnic University of Bucharest, Bioanalysis Lab
“Ovidius” University,
Constanta, Romania
Dunarea de Jos University,
Galati, Romania
“Iuliu Hatieganu” University of Medicine and Pharmacy,
Cluj, Romania
“Victor Babes” University of Medicine and Pharmacy,
Timisoara, Romania
University "Transilvania" of Brasov, Romania

61
Other potential members of EPMA National Network
Patient groups
• Association of Communitary Social Assistance – AGAPE
Oradea, Romania
• Down Association, Oradea Romania
• Association of Persons with Psychical Handicap, Oradea Romania
• National Association of Deaf Persons, Oradea Romania
• National Association of Blind Persons, Oradea Romania
• Coalition of the Organizations of the Patients with Chronic
Diseases - C.O.P.A.C., Bucharest, Romania
• National League for Rare Diseases (APWR), Zalau, Salaj, Romania
• National Association for Patients’ Protection, Bucharest, Romania

62
Medical media need for building
the EPMA National Network
MEDICA – the review of the MD’s Romanian National College
http://www.medicalnet.ro/index.php
ROMANIAN JOURNAL OF GASTROENTEROLOGY
http://www.rjge.ro/
BRAIN AGING INTERNATIONAL JOURNAL
http://www.brainaging.ro
ROMANIAN JOURNAL OF HAND AND RECONSTRUCTIVE MICROSURGERY
http://www.rjhrm.ro/
THORAX
http://www.umfcluj.ro/
BULLETIN OF MOLECULAR MEDICINE
http://www.umfcluj.ro/
VIATA MEDICALA
http://www.vmr.ro
ROMANIAN REVIEW OF HEPATOLOGY
http://www.ficat.ro/?unde=rh
ROMANIAN REVIEW OF LEGAL MEDICINE
http://www2.cmb.ro/romjlegmed
ROMANIAN REVIEW OF UROLOGY
http://www.aru.ro/aru/ie/navigation.jsp?node=1375
JOURNAL OF CELLULAR AND MOLECULAR MEDICINE
www.blackwellpublishing.com/jcmm
ROMANIAN MEDICAL RESOURCES
http://www.medical-romania.com

ANA ASLAN
INTERNATIONAL
ACADEMY OF AGING
ANA ASLAN
INTERNATIONAL
FOUNDATION
Thank you for attention
and your feedback
Healthy
Brain Aging
Healthy Aging Prof. Luiza Spiru, MD, PhD

Preventive predictive-and-personalized-medicine

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