Original articles 2007


R. Drebov(1), O. Brankov(1), G. Racheva(1), H. Shivachev(1) and I. Hristozova(2)

(1)Department of Pediatric Surgery, UMHATEM “N. I. Pirogov”
(2)SHATCOHD -- Sofia

Summary: Hematogenous pulmonary metastases (PM) are an indicator for advanced neoplastic disease, because lungs are the first venous filter for most malignant diseases. The primary tumors in children most often are osteosarcoma, nephroblastoma, Ewing's sarcoma, Wilms' tumor, rhabdomyosarcoma, hepatoblastoma, neurosarcoma, malignant schwanoma, etc. The aim of surgery is to achieve longer survival. The purpose of this paper is to analyse our 18-yeas experience with surgical management of pulmonary metastases in children. For a period of 18 years (1989-2006), 18 children with pulmonary metastases from different malignant primary tumors were admitted and treated at the ward of pediatric thoracic surgery at Emergency University Hospital “N. I. Pirogov”. The patients' age ranged from 1 year 9 months to 18 years. The primary tumor most often was osteosarcoma – 6 children, followed by Wilms' tumor – 5, Ewing's sarcoma – 4, carcinoma of salivary gland – 1, hepatoblastoma – 1, and malignant teratoma – 1. In most of the patients single metastases were found – 13 children (72.2%), two metastases were found in 4 children and only one patient had more than four metastases. In cases with single metastases, one-stage operations were performed – metastasectomy – 4, atypical resection – 5, segmentectomy – 2, lobectomy – 2. The surgical procedures were different in children with 2 metastases: two-stage operation for both lungs in 2 children, one stage thoracotomies for bilateral metastases in one patient, palliative VATS with obliteration of the pleural cavity in one child. In patients with numerous metastases, there were performed: metastasectomy in 3 and metastasectomy with lobectomy – 1. 5-year survival was achieved only in two patients with Wilms' tumor who had single metastases – 11.1%. PM are usually diagnosed until one year after the primary operation – 77.2%. The aggressive surgical approach in management of PM in children correlates with better survival. Prognostic factors are the histologic type of the primary tumor, the number of PM and the type of operation performed.

Key words: hematogenous pulmonary metastases, children, surgical management, prognostic factors

Address for correspondence:
R. Drebov, MD, Section of Pediatric Sugery, UMHATEM “Pirogov”, 21 Totleben blvd., Bg – 1606 Sofia, e-mail: r_drebov@yahoo.com

V. Tasev, N. Popadiin and V. Dimitrova

Department of General and Liver-Pancreatic Surgery, UH ”Alexandrovska” -- Sofia

Summary: Cavernous hemangioma is the most frequent benign liver tumor. It affects mainly women and may cause symptoms such as abdominal pain, mass, and early satiety, or complications such as rupture, hemorrhage. There are several options for treatment in symptomatic patients. However, it seems that surgical operation is the only curative treatment. Aim of the study was to evaluate indications and results of surgical treatment in patients with cavernous hemangiomas and hepatic hemangiomatosis. We conducted a retrospective analysis of clinical files of patients treated at the Department of General and Liver – Pancreatic Surgery, UH “Alexandrovska” – Sofia, during a 17-year period. Epidemiological data as well as diagnostic work-up and treatment were analyzed. From January 1990 to January 2007, 89 patients with liver hemangiomas were treated surgically at the institution. Sixty- seven were female (75,3%) and twenty-two, male (24,7%). Indications for surgery were presence of symptoms in 69 patients (77,5%), undefined diagnosis in 16 (18%), and rapid growth in 14 (15,7%). Most frequent symptoms were abdominal pain in 72 (80,1%) patients. Abdominal computed tomography (CT) scan and ultrasound (US) were used in all patients, MRI – in three of cases. Size of lesion ranged from 5 – 28 cm. Forty patients underwent major liver resection (44,9%) – left and right lobectomy, left and right hemihepatectomy, twenty-three – enucleation (25,9%) and twenty-six various segmentectomy (29,2%). Thirteen patients presented postoperative complications (14,6%) that included bleeding in two, fever in five, bile leakage – two, wound suppuration – two and pleural effusion – two. One patient died (1,1%). Eighty-one patients were asymptomatic at time of evaluation (91%). This lesion affects mainly women, and presence of symptoms is the most common indication for treatment. Choice of surgical procedure to be carried out depends on location and morphology of the lesion. Liver resection or enucleation are safe forms of treatment that properly controlled symptomatology.

Key words: liver, benign tumors, hemangiomas, diagnosis, surgery

Address for correspondence:
V. Tasev, MD, Clinic of General and Liver-Pancreatic Surgery, UH “Alexandrovska”,
1 Sv. G. Sofiyski str., Bg – 1431 Sofia, tel. 359 2/92-30-262, e-mail: vntasev@abv.bg 

P. Tokov, G. Kolchagov and E. Zhivkov

Clinic of General and Liver-Pancreatic Surgery, UH “Alexandrovska”

Summary: Gastrointestinal stromal tumors (GIST) are the most frequent sarcomas of the alimentary tract. They originale form myoneural cells that initiale and control the peristaltic waves. Their size varies from millimeters to 30-40 cm. GIST metastasize through the blood stream or through lymph channels. These tumors possess a malignant potential whereas malignancy depends on the tumor size and the mitotic index of the cells. There are no specific symptoms and physical findings. GIST are identified immunohistochemically by the tumor antigens c-kit and CD34. Main treatment is surgery. Chemotherapy with Imatinib is also effective. Analysed is the authors' experience with GIST. For a period of 15 months, 5 patients with GIST were treated by them. All patients were operated and the results were retrospectively analysed. No specific physical and laboratory findings were observed. The tumors were located as follows: 3 in the stomach, 1 in the small intestine and 1 in the free abdominal cavity. In two cases, metastases were found. All patients were operable, radicality was achieved in 4 cases.

Key words: gastrointestinal stromal tumors, metastasis, resectability, results

Address for correspondence:
Assoc. Prof. Petyo Tokov, MD, Head of Section of general and liver-pancreatic surgery,
Clinic of general and liver-pancreatic surgery, UH “Alexandrovska”,
1 “Sv. G. Sofiiski” str., Bg – 1431 Sofia, tel. 0888-67-50-10, e-mail: george25mh@hotmail.com


R. Gergova1, I. Iankov1, I. Haralambieva1, P. Minchev2, D. Osmanliev3, S. Gergov4, M. Dikova5 and I. Mitov1

1Department of Microbiology, Medical University – Sofia
2University Clinic for Lung Diseases in Children, Medical University – Sofia
3University Clinic for Lung Diseases, Medical University – Sofia
4Clinic for “Head and Neck Surgery”, SNAT of Oncology – Sofia
5Clinic for Diseases in Children, SNAT of Orthopaedy – Sofia

Summary: Moraxella catarrhalis is an emerging respiratory pathogen. We have investigated samples of sera from Bulgarian patients with different respiratory monoinfections, due to M. сatarrhalis. Detected were high levels of antibodies against M. сatarrhalis serotype A in the majority of patients, and rarely against serotype B and C. We have examinated clinical isolates of M. сatarrhalis from patients with otorhinolaryngological and bronchopulmonary infections and from healthy children by the use of monoclonal antibodies, produced in our laboratory against the three serotypes M. сatarrhalis. Most frequent is M. сatarrhalis serotype A – about 70%, serotype B is in the range 18-20%, serotype C – less than 7,32%. There were no dependence between the serotype and the localization and the gravity of the infection.

Key words: Moraxella catarrhalis, lipooligosaccharide, serotypes

Address for correspondence:
Raina Gergova, MD, Department of Microbiology, Medical University, 2 Zdrave str.,
Bg – 1431 Sofia, tel. 0887 940 996, e-mail: renigergova@mail.bg


E. Dzhambazova, H. Nocheva and A. Bocheva

Department of Pathophysiology, Medical University of Sofia

Summary: MIF-1 and Tyr-MIF-1 are neuropeptides isolated from bovine hypothalamus and cortex of human brain. MIF-1 and Tyr-MIF-1 interacts with opioid receptors and specific non-opiate receptors in the brain. It's known that the synthesis of new peptides, containing cinnamic acid amides, changed their opioid activity. The aim of this study was to investigate the analgesic effects of newly synthesized analogues of MIF-1 and Tyr-MIF-1, containing non-protein amino acids canavanine (Cav) and lysine (sLys), and sinapic acid (SA). The changes in the nociceptive effects were examined in the male Wistar rats in acute pain by paw-pressure and hot-plate tests. An antagonist naloxone (Nal) was used to clarify whether opioidergic system is involved. The obtained results showed that MIF-1 analogs enhanced analgesic activity while Tyr-MIF-1 analogues decreased it. Naloxone also decreased analgesic effects of investigated peptides.

Key words: MIF-1 and Tyr-MIF-1 analogues, sinapic acid, non-protein amino acids, nociception, opioidergic system

Address for correspondence:
Ass. Prof. Adriana Bocheva, MD, PhD, Department of Pathophysiology, Medical University,
2 Zdrave str., Bg – 1431 Sofia, е-mail: аdriana_bocheva@abv.bg


R. Nikolova and S. Danev

National Center of Public Health Protection

Summary: The analysis of heart rate variability is a diagnostic non-invasive method for investigation and assessment of functional state of cardiovascular system under the effects of psycho-social stress, mental work load, environmental and occupationally-induced risk factors. The method for examination of the heart rhythm variability enables determining and assessing the functional activity of cardiovascular control mechanisms. The detection of functional disturbances in the autonomic control mechanisms is of primary importance for the early diagnostics of stress-induced somatic diseases, and environmentally-induced health risk factors.

Key words: stress, work load, heart rate variability, autonomic mechanisms, cardiovascular diseases, health risk

Address for correspondence:
Ruzha Nikolova, MD, National Center of Public Health Protection, 15, Acad. Iv. Geshov, BG – 1431 Sofia, tel. 80-56-207

W. Dokov1 and Т. Ivanov2

1Department of Forensic Medicine and Deontology, Medical University – Varna
2Department of Pathology and Forensic Medicine, Multiprofile Hospital for Active Treatment – Silistra

Summary: Mortality from electrical injuries is 1.27 per 100 000 per year. Electrical injuries are the cause of death of 1.85% of all cases of violent and non-violent deaths that underwent autopsy at the department of pathology and forensic medicine at the Multiprofile hospital for active treatment in Silistra. The mean age of the victims is 41.14 years (range from 5 to 74 years). Mean age of male cases is 40.46 years, and for female cases – 47.75 years. 90.69% of cases of death from electrical injuries are among men. Low currency is the cause of death of 72.09% of the cases, аnd high currency is causing death of 27.90% оf cases. 67.44% of cases of electrical injuries can be classified as home accidents, 25.58% as work related accidents and 6.97% as suicides. Among studied cases there is pronounced seasonality of electrical injuries – 76,76% of all accidents occur in the summer period (june-september).

Key words: electrical injuries, Silistra region

Address for correspondence:
W. Dokov, MD, Department of Forensic Medicine, Medical University, 55 Marin Drinov str., Bg – 9002 Varna

J. Radenkova-Saeva

Toxicology Clinic, MHATEM “N. I. Pirogov” – Sofia

Summary: “Drugs” are psychoactive substances (PAS) and when they penetrate into the human organism, they provoke changes in “psychical life” and make the organism to become addicted by them. Annually in the whole world by overdosing with drugs die between 160 000 and 210 000 people. The hardest addiction is toward the opioids and specially – toward heroin. We studied the acute intoxications with heroin and/or other PAS to heroin-addicted people. Subjects of the study are 90 people with acute heroin and/or combined intoxication, chosen by lottery method from all of the hospitalized heroin-addicted people in the period 2001-2005 with acute heroin and/or combined with other psychoactive substances intoxication. We applied clinical, clinical-laboratorial, toxic-chemical and instrumental methods for researching. The results of the study show that 2/3 (65%) of the researched people are in the age between 20 and 25 years. Men predominate than the women. The highest is the relative part (40%) of the abusers to heroin from 2 years. The basic way of taking heroin by 87% of the patients is by injecting it into the veins. The reason of the acute intoxication shown by 82% of the researched patients is accidental overdosing with heroin or combination with other PAS; 18% of them have had a suicidal attempt. Monotoxic heroin intoxication is registered in 41 people (46%); the other 49 (54%) have combined intoxication of heroin and other psychoactive substances. Most often the heroin is combined with alcohol and benzodiazepinеs. Insignificantly predominate the mild intoxications, shown by 52% of the patients. People who are addicted to PAS are an increasing group of young people and they need more medical, social, legal, educational and other services. Furthermore, PAS-addicted people show increasing disposition of criminalization, which will bring rapid growth of the cost paid by the society.

Key words: heroin, psychoactive substances, intoxication, addiction, epidemiology

Address for correspondence:
Julia Radenkova-Saeva, MD, Clinic of Toxicology, MBALSM „Pirogov”,
21 Makedoniya blvd., Bg – 1606 Sofia, tel. 51-53/346, e-mail: jrsaeva2@yahoo.co.uk


A. Bocheva, E. Dzambazova and H. Nocheva

Department of Pathophysiology, Medical University of Sofia

Summary: Tyr-MIF-1 is a member of family of neuropeptides and showes anti-opioid and opioid-like actions. The N-terminal Tyr(1) ring is typical for endogenous opioid peptides and it is considered to be responsible for the opioid action. The aim of this study was to investigate the effects of four newly synthesized analogues of  Tyr-MIF-1 with modified Tyr(1) residue: N-(Me)-Tyr-MIF-1, D-Tyr-MIF-1-(Me), Tyr(Cl2)-MIF-1, Tyr(Br2)-MIF-1. They were examined in male Wistar rats by two nociceptive tests -- paw-pressure (PP) and hot-plate (HP). Non-competitive opioid-receptor antagonist naloxone (Nal) was used to clarify whether opioidergic system was involved. The results showed that all investigated newly synthesized analogues applied alone exerted short lasting antinociceptive effects compared to the control group but not versus Tyr-MIF-1 in both tests used. Naloxone decreased significantly their anti­nociceptive effects in PP and HP tests. We suggest an involvement of the opioidergic system in antinociceptive effects of N-(Me)-Tyr-MIF-1, D-Tyr-MIF-1-(Me), Tyr(Cl2)-MIF-1 and Tyr(Br2)-MIF-1.

Key words: Tyr-MIF-1 analogues, nociception, opioidergic system

Address for correspondence: Assoc. Prof. Adriana Bocheva, Chair of Pathophysiology, Medical University, 2 Zdrave str., Bg -- 1431 Sofia, е-mail: аdriana_bocheva@abv.bg



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



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



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



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



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



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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