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Reviews 2007

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NOSOCOMIAL PNEUMONIA -- FREQUENCY, ETIOLOGY, CLINICAL MANAGEMENT, TREATMENT
R. Anastasova (1) and V. Zachariev (2)

(1)Department of Propedeutics of Internal Diseases, Medical University -- Sofia
(2)Department of Social Medicine and Health Management, Medical University -- Sofia

Summary: Nosocomial pneumonia is the second most frequent nosocomial infection. The etiologic pathogens, major risk factors, the problems related to correct clinical and microbiological diagnosis are considered in the article. Different treatment` schemata and the advisable use of adequate antibacterial drugs are discussed. The necessity of appropriate antibacterial treatment is emphasized whosе goal is the limitation of multidrug resistant pathogens and of the healthcare costs. Prevention methods restricting the nosocomial pneumonia development are presented.

Key words: nosocomial pneumonia, frequency, diagnosis, multidrug resistant pathogens, treatment

Address for correspondence:
Ralitsa Anastasova, MD, Clinic of Pulmology, UMHAT “Alexandrovska”,
1 Sv. G. Sofiiski Str., Bg – 1431 Sofia, tel. 92-30-470; 92-30-604, e-mail: ralitza1@yahoo.com

INFECTIOUS DISEASES -- PRESENT AND FUTURE
T. Tcherveniakova (1) and K. Plochev (2)

(1) UMHAT ”Sv. Iv. Rilski”, Medical University -- Sofia
(2) MMA -- Sofia

Summary: WHO analyses show that public health continues to encounter serious problems, associated with infectious morbidity. Epidemic spread of the infectious diseases in different parts of the world results in high lethality and tremendous losses for overcoming them. They remain a first level problem in developing countries. Vaccinal programs proved priceless help to people, but there are diseases where medicine is helpless to propose vaccine ( HIV, hepatitis C). In 2004, bird-flu cases brought the world before the threat of pandemy. The increasing antimicrobial resistence creates serious problems. In Bulgaria, there is observed a tendency of decreasing the number of registered infectious diseases, which hardly corresponds to reality. In the recent years, a challenge are imported cases of infectious diseases. Knowledge of infectious diseases and their prophyilaxis are key mechanisms for their fast eradication.

Key words: infectious diseases, new infectious agents, vaccinal programs, epidemiology of infectious diseases

Address for correspondence:
Assc. Prof. Tatyana Cherveniakova, MD, SHATIPD “Prof. Iv Kirov”,
17 Acad. Iv. Geshov, Bg ??1431 Sofia, tel. 9520101; e-mail: taniacher@abv.bg

INDOOR RADON -- A HEALTH HAZARD?
At. Yagova

National Centre of Radiobiology and Radiation Protection -- Sofia

Summary: Radon is a natural noble radioactive gas. It is a part of the environment and penetrates into the houses. Its solid, short–living daughter products are alpha-emitters. If inhaled, they can be deposited on the bronchial epithelial cells. The exposure to radon and its products can lead to stochastic effects. Risk factors for radon irradiation are: a high radium content in the soil, unconsolidated house foundations, insufficient home ventilation, tobacco smoking, unproper construction materials.

Key words: radon, housing, health

Address for correspondence:
Atanaska Yagova, MD, National Centre of Radiobiology and Radiation Protection,
132 Kliment Ohridski, blvd., Bg – 1756 Sofia, tel. (+359 2) 862 6036 (232), e-mail: a.yagova@ncrrp.org

CONTEMPORARY ASPECTS OF THE REHABILITATION OF PATIENTS WITH RHEUMATOID ARTHRITIS
T. Troev and E. Konakchieva

Clinic of Physiotherapy and Rehabilitation, Academy of Military Medicine -- Sofia

Summary: During the last few decades, the number of people suffering from rheumatoid arthritis is increasing and there is a tendency toward lowering of the age of the affected population. Because of that, special attention is paid to treatments, different from the basic therapy. In this article, new tendencies for the application of kinesitherapy of the rheumatoid arthritis are reviewed. Information is given about the achievements in physiotherapy and rehabilitation in the treatment of this significant social disease. Application of active kinesitherapy is part of the healing complex. Participation in long term high intensity exercise programs (including improvement of the aerobic form) is recommended. It is emphasized that the medicamentous therapy ensures improved everyday life of the patients, and physical therapy (kinesitherapy in particular) – their autonomy which has a direct economical and social effect.

Key words: rheumatoid arthritis, kinesitherapy, high intensity heavy exercises

Address for correspondence:
Assc. Prof. Troycho Troev, MD, Clinic of Physiotherapy and Rehabilitation, Academy of Military Medicine,
3, Sv. G. Sofiyski Str., Bg-1606 Sofia, tel. 952-13-36

THE T-SPOT-TB METHOD FOR MORE PRECISE DIAGNOSTICS OF TUBERCULOSIS AND LATENT TUBERCULOSIS INFECTIONS
S. Velizarova

Child Clinic, “Sv. Sofia” University Pulmonary Diseases Hospital – Sofia

Summary: Considered is the subject related to the tuberculinodiagnostics, its history and its importance in stating the tuberculosis. The morbidity rate in the different parts of the world is examined. There is an analysis of the immunity in the tuberculosis cases and the cell's elements and their substances which take part. The newly discovered antigens typical only for the virulent type of tuberculosis bacteria and the significance of the T-SPOT-TB, discovered by Dr Lalvani are considered. A part of the examinations which compare the tuberculosis test with the new T-SPOT test are mentioned. The importance of the test in the case of LTBI as well as for stating the outpulmonary forms of tuberculosis is underlined. The comparative studies of different authors and the advantage of T-SPOT test in comparison with the quantum ferronis test are indicated. In conclusion, it is stated the need of using it particularly for children suspected to be ill or suffering from confirmed tuberculosis, as criterium for the efficiency of the applied treatment.

Key words: tuberculosis, immunology, diagnosis, tuberculin skin test, Т-SPOT-TB

Address for correspondence:
S. Velizarova, MD, Child Clinic, Sv. Sofia University Pulmonary Diseases Hospital, 17 Acad. Iv. Geshov blvd., Bg – 1606 Sofia

THYROID AUTOANTIBODIES AND REPRODUCTIVE FAILURES
К. Todorova-Ananieva

HATOG ”Maichin dom” – Sofia

Summary: At recent ten years have concluded influence of thyroid autoantibodies in normal beginning, development and growing up of pregnancy. Changing in thyroid autoimmunity, even in the absence of evident thyroid dysfunction, is associated with an increased risk of subfertility. The disturbances in thyroid autoimmunity have associated with a significantly increased risk of recurrent pregnancy loss. Although of pathophysiologic mechanism is still not unclear has suggested that thyroid autoantibodies started abnormal immune response and following disturbances in maternal-fetal thyroid function. This can easily be prevented by systematic screening for thyroid dysfunction and antibody presence during early gestation, followed by the administration of levothyroxine treatment.

Key words: thyroid autoantibodies, reproductive failures, immune response, abortion habitual

Address for correspondence:
K. Todorova-Ananieva, MD, SHATOG “Maichin dom”, 2 Zdrave str., Bg – 1431 Sofia

DIABETES MELLITUS TYPE 2 – CURRENT THERAPEUTIC APPROACHES
E. Kojouharova and V. Ivanov

Clinic of Endocrinology, Military Medical Academy – Sofia

Summary: Diabetes mellitus type 2 is a widespread disease. Its development is related to two pathophysiologic mechanisms – insulin resistance and β-cell dysfunction. Management of hyperglycaemia and the achievement of certain glycaemic goals is a top priority of the therapy. Eight types of medications are used in the treatment of type 2 diabetes. They are divided mainly into two big groups according to their mechanism of action. If monotherapy does not succeed, a combination is recommended.

Key words: diabetes mellitus type 2, glycaemic goals, medications, monotherapy, combined therapy

Аddress for correspondence:
E. Kojouharova, MD, Clinic of Endocrinology, Academy of Military Medicine,
3, Sv. G. Sofiyski str., Bg – 1431 Sofia, tel. 92-26-091, e-mail: med@abv.bg

SHOULD DRUG-ELUTING STENTS BE USED IN ALL PATIENTS?
D. Trendafilova1, Y. Dzhorgova1 and N. Runev2

1University Hospital “Sv. Ekaterina” – Sofia
2University Hospital “Alexandrovska” – Sofia

Summary: In this review article, the main characteristics, mechanism of action, advantages and disadvantages of drug-eluting stents (DES), compared to bare metal stents (BMS) are presented. The results of studies, concerning effectiveness and safety of Cypher and Таxus stents, as well as factors with predictive value for increased risk of late stent-thrombosis in DES (intracoronary thrombus, diabetes mellitus, bifurcation lesions, underdeployment of the stent, early termination of clopidogrel and aspirin therapy) are discussed. The current guidelines for DES implantation are analysed, moreover the authors share their personal opinion on the reviewed issues.

Key words: drug-eluting stents, restenosis, stent-thrombosis, Cypher, Таxus

Address for correspondence:
Nikolay Runev, MD, MHAT „Alexandrovska”, 1 Sv. G. Sofiyski str., Bg – 1431 Sofia, tel. 92 30 461, 0899 92 95 40

SPECIFIC PREVENTION OF VIRAL HEPATITIS A WITH IMMUNOGLOBULIN AND VACCINE

N. Vatev(1), M. Stoycheva(1), I. Batashki(2) and K. Krastev(1)

(1)Department “Infectious Diseases, Epidemiology, Clinical Parasitology and Tropical Medicine”,
Medical University -- Plovdiv, (2)UMBAL “Sv. Georgi” -- Plovdiv

Summary: With the development and the licensing of vaccines against VHA (in around 1995), a new era in the prevention of the disease has come. The use of vaccines caused a change in the epidemiology of VHA and such change shall be considered in the development of future strategic programmes. The article provides a review of the available modern means (vaccines for active prevention and immunoglobulin for passive prevention) for prevention of the disease and their effectiveness. A review is made on the application of the immunoglobulin and vaccines in different countries -- USA, France, The Netherlands, Spain, Israel, etc. The implemented measures for prevention and control of VHA in Bulgaria according to the applicable statutory documents of the Ministry of Health are also reviewed. Recommendations are given with regard to a more effective use of immunoglobulin and vaccines against the disease in sporadic cases or epidemics.

Key words: viral hepatitis A; antibodies against hepatitis A virus; early antibodies against hepatitis A virus; World Health Organisation; Centre for Disease Control (USA); hepatitis A virus

Address for correspondence: Nikolay Vatev, MD, 29 Dame Gruev str., 4004 Plovdiv, tel. 032/602-931, GSM: 0889 25-75-13, e-mail: nikolai_vatev@abv.bg

 

HISTORY OF AIDS PANDEMY -- EPIDEMIOLOGY AND PROGNOSES

K. Plochev

Military Medical Academy -- Sofia

Summary: The last scientific data and speculations about pandemic origin and its social importance are reviewed as well as its con­sequences – medical, economic and social. Meticulous data about recent HIV spread worldwide and in Southeastern Europe are presented. The history of disease emerging and distribution in Bulgaria is described. Epidemiological information about people infected by years and by mechanisms of contracting the virus is presented. For the first time within Bulgaria, the organization of disease mass distribution prevention is published. Special attention is paid to the lesson learned by scientists from AIDS spread in the pandemic epicenter -- Africa.

Key words: AIDS pandemy, epidemiology, prognoses

Address for correspondence: Assoc. Prof. K. Plochev, MD, Military Medical Academy, 3 Sv. G. Sofiiski str., Bg -- 1431 Sofia, tel. 92-253-36, e-mail: plochev@mail.bg

 

FUNCTIONAL APPLICATION OF METHODS FOR ANALYSIS OF BAROREFLEX SENSITIVITY AND BLOOD PRESSURE MONITORING IN STUDYING INDIVIDUALS EXPOSED TO STRESS

R. Nikolova

National Center of Public Health Protection

Summary: Methods for analyses of baroreflex sensitivity, heart rate, systolic and diastolic blood pressure are used for investigation of functional mechanisms of cardiovascular control under stress exposure and environmental factors influences which might induce CVD. A new non-invasive method for studying functional mechanisms of cardiovascular control is the determination of baroreflex sensitivity through the trigonometric regressive spectral analysis of variability of heart rate and blood pressure. Baroreflex regulation is diminished in conditions associated with change of reactivity, stress exposure, and CVD.  Individuals with decreased baroreflex sensitivity revealed increased blood pressure lability.

Key words: stress, baroreflex sensitivity, blood pressure monitoring, cardiovascular diseases

Address for correspondence: Rouja Nikolova, MD, National Center of Public Health Protection, Laboratory „Physiology, Psychology and Ergonomy”, 15 blvd. „Ivan Geshov”, Bg -- 1431 Sofia, tel. 8056 207

 

DRUG CARDIOTOXICITY. MECHANISMS AND RISK FACTORS (PART I)

B. Krastev and A. Goudev

Clinic of Cardiology, UMBAL „Tzaritza Ioanna”

Summary: Chemotherapeutic drugs such as doxorubicin, herceptin and others are effective antineoplastic agents that are commonly used in the treatment of solid tumors and hematological malignancies. The most serious side-effect of these drugs is dose dependent cardiotoxicity, which is usually irreversible. The severity of such toxicity depends on many factors such as the molecular site of action, the immediate and cumulative dose, the method of administration, the presence of any underlying cardiac condition, and the аge of the patient. Cardiotoxic effects can occur immediately during administration of the drug, or months or years after treatment. The main contributors of cardiovascular toxicity include free radical formation, apoptosis, inhibited expression of cardiomyocyte-specific gene, altered molecular signaling pathways, but the exact mechanism remains unclear yet. In this article, we review current concepts of mechanisms and risk factors of cardiovascular toxicity induced by chemotherapeutic drugs.

Key words: chemotherapeutic drugs, cardiovascular toxicity, risk factors

Address for correspondence: Bozhidar Krastev, MD, Clinic of Cardiology, University Hospital „Tsaritsa Ioanna”, 8 Byalo more Str., Bg -- 1527 Sofia, e-mail: krustev80@abv.bg

 

MEDICAMENTOUS INFLUENCE ON THE ABDOMINAL OBESITY. CARDIOMETABOLIC RISK AND ROLE OF THE ENDOCANNABINOID SYSTEM AND CB1 RECEPTOR BLOCKADE

N. Runev(1), N. Doncheva(2) and Ch. Panayotov(3)

(1)Cardiologic department, Clinic of Propedeutics of Internal Diseases, UMHAT “Alexandrovska” -- Sofia
(2)Laboratory of Clinical Lipidology, Medical institute of the Ministry of Interior
(3)Department of Cardiology, UMBAL “Alexandrovska” -- Sofia

Summary: There are convincing data that the overweight and obesity increase the risk of cardiovascular death and this risk in male rises proportionately to the extent of obesity. During the last years, the opportunity for treatment of abdominal adiposity and cardio-metabolic risk reduction using blockers of CB1 receptors in endocannabinoid system has been discussed. The clinical effects of CB1 receptor blockade are: decrease of body weight and insulin resistance, as well as a favourable impact on atherogenic dyslipi­demias. Rimonabant is the first selective CB1 receptor blocker, developed for treatment of high-risk abdominal adiposity, which demonstrates promising results in initial studies (included in RIO programme).   

Key words: cardiometabolic risk, abdominal obesity, endocannabinoid system, Rimonabant

Address for correspondence: Nikolay Runev, MD, Cardiologic Unit, Clinic of Propedeutics of Internal Diseases, UMHAT  „Alexandrovska”, 1 Sv. G. Sofiiski str., Bg -- 1431 Sofia, tel: 92-30/461, GSM: 0899 92-95-40

CLINICAL MANIFESTATIONS AND VIROLOGICAL DIAGNOSIS OF ЕВV INFECTION
Т. Cherveniakova¹, А. Gotzeva¹, Т. Кouzmova¹ and D. Velcheva²

(1)Clinic of Infectious, Parasitic and Tropical Dieases ”Sv. Ivan Rilski” University Hospital -- Sofia
(2)National Center of Infectious and Parasitic Diseases, Virology Department, Sofia

Summary: A clinical-serological research on 30 patients was performed with EBV infection, who were hospitalised and treated in the Clinic of Infectious, Parasitic and Tropical Diseases at the University Hospital “Sv. Ivan Rilski”, Sofia in the period 2004-2006. To all these patients the EBV diagnosis was put, which was serologically confirmed by the ELISA method in the Herpes viruses laboratory at the National Center of Infectious and Parasitic Diseases. They have been tested for the presence of specific IgM antibodies towards the EBV capsid antigen (anti EBV VCA IgM) and to the early diffuse antigen (anti EA-D). The analysis of obtained results was made on the basis of prospective and retrospective processing of serological and clinical data. Supervision of the monitored patients showed that the most frequent clinical manifestation of the EBV infection is infectious mononucleosis and EBV hepatitis. Except for the serological diagnostic marker, marker for active infection also are the anti-EBV VCA IgM, which are highly sensitive and specific.

Key words: EBV infection, infectious mononucleosis, EBV hepatitis, virological diagnosis

Address for correspondence:
Assoc. Prof. Tatyana Cherveniakova, MD, Department of Infectious Diseases, Parasitology and Tropical Medicine, 17 Blvd. Acad. Iv. Geshov., Bg -- 1431 Sofia, tel: 952-01-01, e-mail: taniacher@abv.bg

INDICATIONS FOR SURGICAL MANAGEMENT OF CHILDHOOD BRONCHIECTASIS
O. Brankov(1), R. Drebov(1), P. Perenovska(2), H. Shivatchev(1) and R. Antonova(3)

(1)Clinic of Pediatric Surgery, MBALSM „N. I. Pirogov” -- Sofia, Bulgaria
(2)Clinic of Pediatrics, MBAL „Alexandrovska” -- Sofia
(3)Clinic of Pediatric Anestesiology and Resuscitation, MBALSM „N. I. Pirogov” -- Sofia

Summary: There is a gradual decrease in the prevalence of bronchiectasis in children requiring surgical treatment. The purpose of this study is to estimate the operative indications and prognosis in patients undergoing lung resection. From January 1996 to December 2005, 9 patients undergoing resection for bronchiectasis are analyzed. There were 5 females and 4 males, with a mean age of 8,7 years (range: 2,1-14 years). The most common cause of bronchiectasis was lung infection in 7 children, whereas in two cases there where a underlying pathology. The mean duration of symptoms was 4,8 years (range, 2-7 years). The indications for operation are failure of medical therapy in 5, repeated hemoptysis in 2 and lung abscess in one patient with cystic fibrosis. One child underwent surgery for late recognized complicated lung hypoplasia. Surgical treatment included lobectomy in 5 patients, bilobectomy in 1 and pneumonectomy in 3. There was one postoperative death in a case with pneumonectomy. Seven patients are asymptomatic after surgery. Surgical treatment for childhood bronchiectasis is a reliable method which can be performed with low mortality and morbidity and yields marked improvement in the quality of life. Complete resection should be performed when possible.

Key words: bronchiectasis surgical management, persistent wet cough, lung resection, children

Address for correspondence:
Assoc.Prof. O. Brankov, MD, Dr. Sci. Med., Clinic of Pediatric Surgery, MBALSM „N. I. Pirogov”, 21 blvd. Totleben, Bg -- 1606  Sofia, e-mail: brankov@pedsurg.net

LOW-GRADE GLIOMAS OF THE BRAIN -- DIAGNOSTIC PROBLEMS IN CLINICAL PRACTICE
K. Tsalovski, I. Petrov, K. Kostov and R. Ikonomov

Clinic of Neurology, Medical Institute -- Ministry of Interior

Summary: Low-grade gliomas of the brain represent a real challenge for the clinician-neurologist. In their early stage of growing, these tumors remain clinically undiscerned. Because of their low malignancy, they can be described as tumors with a very slow growth, minimal or absent peritumoral еdema and with no signs of compression or dislocation towards surrounding tissue. Clinically, that reveals a lack of diffuse and poor focal cerebral symptomatology preceded by a long, clinically “masked” period. The low-grade gliomas have the tendency to settle supratentorially in adults, and when they are localized in frontal and occipital regions of the brain, their clinical diagnosis is rather difficult. We present three patients with tumor formation of the brain with MRI picture of a low-grade glioma and a histological confirmation for oligodendroglioma in two of them. Their histories, neurological status, CT and MRI findings are presented in details. It is noticeable that the findings from history and the clinical symptoms are poor. In addition, the CT picture in two of them didn’t reveal convincing proofs for tumor and was wrongly interpreted. The right choice for an accurate diagnosis for this kind of tumor is MRI of the brain. Its periodic application to patients with already diagnosed low-grade glioma enables regular control over the growing of the tumor and its structure in order to choose the right time for surgical intervention.

Key words: low-grade glioma, computed tomography, magnetic resonance imaging

Adress for correspondence:
Krasimir Tsalovski, MD, Clinic of Neurology, Medical Institute -- Ministry of Interior, 79 blvd. Skobelev, Bg -- 1606 Sofia, tel. +35929821581, e-mail: krasi_calovski@abv.bg

IMMUNOLOGICAL ASPECTS OF POSTOPERATIVE ANALGESIA WITH SELECTIVE COX-2 INHIBITOR DYNASTAT®
(PARECOXIB SODIUM) AFTER ABDOMINAL HYSTERECTOMY
B. Tablov(1), S. Stavreva(2), V. Tablov(1), E. Konova(4) and J. Popov(3)

(1)Clinic of Anesthesiology and Intensive Care
(2)Chair of Experimental and Clinical Pharmacology
(3)Chair of Obstetrics and Gynecology
(4)Chair of Dermatology, Venereology, Allergology and Immunology
Medical University -- Pleven

Summary: It was investigated how did usage of selective COX-2 inhibitor Dynastat® (parecoxib sodium) for postoperative analgesia affect the immune response after abdominal hysterectomy by evaluation of pro-inflammatory interleukin-6 and anti-infla­m­ma­tory interleukin-10 blood concentration. We have evaluated 40 women, divided into two groups by the model of postoperative pain treatment: control group (only opioid) and experimental group (combination of i.v. Dynastat® and opioid). We collected blood samples on three points: before surgery, at 24th and 72nd hour after skin incision, and analyzed them via ELISA test. During the hospital stay we registered body temperature and severe complications. Both models of postoperative analgesia have modulated immune response after abdominal hysterectomy in a similar way.

Key words: cytokines, interleukin-6, interleukin-10, Dynastat® (parecoxib sodium), lydol, abdominal hysterectomy

Address for correspondence:
Boris Tablov, MD, Clinic of Anesthesiology and Intensive Care, Medical University -- Pleven,
II clinical basis, Chair of Obstetrics and Gynecology, Bg -- 5800 Pleven, tel. +359 64/886 681, e-mail: boristablov@yahoo.com

FORENSIC MEDICINE ANALYSIS OF FATALITIES DUE TO HIGH VOLTAGE ELECTRIC CURRENT IN VARNA DISTRICT
W. Dokov

Department of Forensic Medicine and Deontology, Medical University -- Varna

Summary: Over a 41-year period, 98 cases of DHVEC (Death from High Voltage Electric Current) have been recorded. The results have been processed by the statistical methods of alternative, variational and graphical analysis. Males prevail: 96 (97.96%). The average age of the victims is 35.69 years. There have been approximately as many domestic electrical injuries as industrial ones. Suicides account for 7 (7.14%). The most common causes of DHVEC (n = 64, 66.33%) are lightning strike, live high-voltage electric wire, electric welding machine and contact with a transformer substation. 64.58% of all fatalities have occurred in the period May-September. Two peaks have been registered with reference to the week days: on Wednesday (n = 21) and on Saturday (n = 17). Inspection on the scene of accident has been made in the presence of a forensic physician in 28 (58.33%) cases.

Key words: electric current, high voltage, forensic medicine

Address for correspondence:
W. Dokov, MD, Department of Forensic Medicine and Deontology, Medical University -- Varna,
55 Marin Drinov str., Bg -- 9002 Varna, e-mail: alfaome@rambler.ru

PHYSICAL THERAPY – ONE MORE ALTERNATIVE FOR TREATMENT OF URINARY STRESS INCONTINENCE IN WOMEN
K. Kazalakova

Urological Clinic, Sector of Physiotherapy and Rehabilitation, MBALSM ”Pirogov” -- Sofia

Summary: The author discusses the effectiveness of physical therapy treatment in patients with stress-incontinence. 48 women with urinary incontinence were treated and it was searched for the successful application of methods for strengthening the pelvis bottom muscles.

Key words: kinesitherapy, physical therapy, urinary incontinence, exercise

Address for correspondence:
Krassimira Kazalakova, MD, MBALSM „Pirogov”, Urological Clinic, Sector of Phisiotherapy and Rehabi­lita­tion, Bg -- 1606 Sofia,21, blvd. Totleben,  tel. 91-54-502, GSM 0887 39-69-06, e-mail: kazalakova@abv.bg


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