Original articles: Vol. 9, 2015


Famous physicians

Scientific reviews

Original articles

Clinical practice


arrow Vol. 9, 3/2015


Microbiological investigations related to new human casesof tularemia – preliminary results - Bulgarian medical journal (Български медицински журнал), 9, 2015, №3, 27-31.
I. Tomova1, R. Nenova1, I. Ivanov1, M. Nikolova2 and Т. Kantardjiev1

1 - National Centre of Infectious and Parasitic Diseases, Bulgaria
2 - BulBio – NCIPD, Bulgaria
Summary. During the past fi ve years 0 to 3 cases of tularemia were reported annually in Bulgaria. Aim. Presentation of preliminary results from studies carried out in connection with sixteen new cases of tularemia diagnosed for a short period at the beginning of 2015. Materials and methods. Serum samples and aspirates from patients, lymph nodes, materials from hares and water samples were tested, using tube agglutination test, culturing and Real-time TaqMan PCR. Results. Tularemia was confi rmed in 16 of the 17 suspected patients. The cases were in a wide age range and mainly presented with glandular and ulceroglandular clinical forms. Some
of the proven cases were associated with the 1997-2005 epidemic foci, while others − with areas of the country where the disease was unknown. Tularemia infection was found in all tested hares. There was no evidence for contamination of the water samples. Conclusion. The geographical distribution of tularemia in the country is expanding, most likely through dissemination of the enzootic process among rodents.
Key words: tularemia, Bulgaria, endemicity, serology, culture, PCR
Address for correspondence: Iskra Tomova, NRL HMRI, NCIPD, 44A General Stoletov Blvd., 1233 Sofi a, tel. 00359 2/ 8319125, e-mail: iskra.tomova@gmail.com


Epidemiological assessment of IgG аntibodies titer during an epidemiological outbreak - Bulgarian medical journal (Български медицински журнал), 9, 2015, №3, 32.
M. Karcheva1, I. Gencheva1, 3, A. Blazhev1, I. Makaveev2 and M. Rachev

1 - Medical University – Pleven
2 - Department of Preventive Medicine – Military Hospital – Pleven
3 - University Hospital „Dr. G. Stransky“ – Pleven
Summary. The importance of rubella infection as a public health issue is determined by the teratogenic effect of the rubella virus during pregnancy. The goal of this study was to determine prevalence of rubella IgG antibodies in individuals at a young age in the city of Pleven. Material and methods. A prospective seroepidemiological study was performed. For the period of January-June 2014, 194 serum samples of 23- to 53-year old (average age 35 ± 0.871) individuals were collected and tested. The enzyme immunoassay (ELISA) for the detection and quantifi cation of specifi c IgG antibodies against rubella in serum is attached. The results are presented in Microsoft Offi ce Excel. Results. The survey found that 188 (97%) subjects from the studied group were seropositive in regards to rubella IgG antibodies and 6 (3%) subjects were seronegative, respectively. In the latter it was found that the majority were women – 4 (66%). The men were – 2 (44%), respectively. The seronegative subjects were 34-year-old – 4 (66%) and 36-year-old – 2 (44%). Conclusion. The goal of the World Health Organization is to eliminate the congenital rubella in the European region. It is necessary to monitor the susceptibility to rubella among women of childbearing age.
Key words: rubella IgG antibodies, prevalence, immunity
Address for correspondence: Assoc. Prof. Dr. Milena Karcheva, MD, Sector „Epidemiology“ Medical University, 1 Sv. Kliment Ohridski St., Bg − 5800 Pleven, email: milena_karcheva@abv.bg

Pharmacology and toxicology

The role of ibuprofen on the phospholipid composition of the alveolar surfactant in the case of septic respiratory distress syndrome caused by an experimental fecal peritonitis - Bulgarian medical journal (Български медицински журнал), 9, 2015, №3, 35-41.
S. Lazarov1 and R. Nikolov2
- Department of Pathophysiology, Medical University – Sofi a
2 - Department of Pharmacology and Toxicology, Medical University – Sofia

Summary. The respiratory distress syndrome in adults (ARDS) represents a highly expanded clinical syndrome. In most cases it is a component of the multiple organ dysfunctions syndrome (MODS). Usually it is resulting from the complications of Gram-negative sepsis and septic shock, which in their turn are caused by the acute fecal peritonitis, as a result of intra-abdominal infections – one of the basic problems of abdominal surgery. ARDS is developed due to irreversible structural and functional injuries in the lung surfactant system (LSS) and mainly in
the alveolar surfactant (AS). Despite of serious improvement in the therapy and in the intensive cares for the patients with ARDS, the mortality is about 50-60% for the last ten years. We investigated the АS of rats in experimental model of sepsis ARDS, treated by Ibuprofen. We studied the total quantity and the percent ratio of the surfactant phospholipids and the quantity ratio between the basic phospholipid fractions in the AS. We found a statistically true favorable changes in the studied indicators of the treated with Ibuprofen animals.
Key words: Adult respiratory distress syndrome, acute fecal peritonitis, sepsis, septic shock syndrome, alveolar surfactant, surfactant phospholipids, Ibuprofen
Address for correspondence: Assoc. Prof. Simeon Lazarov, PhD, Department of Pathophysiology, Medical Faculty, Medical University, 1 Sv. G. Sofi yski St., Bg – 1431 Sofi a, GSM: 00359 987 751 493


Public health

State of legislation in Bulgaria on the issue of health risk among workers exposed to biological agents in the branch „Collection, disposal and treatment of wastewater“ - Bulgarian medical journal (Български медицински журнал), 9, 2015, №3, 42-51.
E. Toseva.
Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University – Plovdiv, Bulgaria
Summary. The risk to health and safety during exposure to biological agents at work exists in many economic activities in Bulgaria. Policy to protect workers is regulated in a number of laws and regulations. However, it is questionable if all of them correspond to modern occupational conditions. The purpose of this article is to review the legislation in Bulgaria on the problem of „Risk of exposure to biological agents“, with a focus on workers in the „Collection, disposal and treatment of wastewater“ branch. There are analyzed 56 legislative documents, published in the period 1973-2015, valid through 2015. The review demonstrates the Bulgarian commitment to this problem at all legislative level – ratifi ed ILO Conventions, EU Directives, the Constitution, the laws issued by different governments, and regulations. Conclusion: The legislation of Bulgaria after accession to the EU in 2007 is harmonized with European law, but there are legal documents prior to this period, which need to be updated.
Key words: biological agents at work, legislation, waste water.
Address for correspondence: Dr. Elka Toseva, MD, PhD Student, Specialization: Occupational Medicine, Assistant Professor at Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University, 15A Vasil Aprilov Blvd., Bg – 4002 Plovdiv, tel. +359 878405947, e-mail: elka_toseva@ abv.bg


Organ-sparing surgical treatment in relapse of carcinoma mammae - Bulgarian medical journal (Български медицински журнал), 9, 2015, №3, 52-59
P. Chervenyakov 1, G. Vassilev 2, A. Chervenyakov 3, A. Mladenov 2 and D. Gemedzhiev 2
1 - Multiprofi le Hospital „Serdica”;
2 - First AG clinic "Cv. Sofia" Sofia
3 - University Hospital of Emergency Medicine “Pirogov”
Summary. Surgical problems in the treatment of breast cancer (BC) are still not fully solved. We present our experience based on 24 patients with local recurrence (LR) after performed modified radical mastectomies (MRMs) and organ-sparing surgeries for BC in the last five years (2008-2013). 13 patients underwent MRMs, while additional 11 patients – radical organ-sparing surgeries (sector resections and quadrantectomy). The average age of patients was 53 years. Right localization of malignant process was found in 17 patients, while only 7 patients had left localization of tumor process. Our studies in 24 patients with BC showed that LR occurs infrequently against applied modern surgical methods in both MRMs and organ-sparing surgeries. LR occurs most frequently in the first five years after surgical treatment of primary tumor against performed preoperative neoadjuvant therapy and postoperative adjuvant radiotherapy and hormonal therapy. LR is observed most frequently in sector resections and quadrantectomy. Proportion of LR is lower in MRMs, especially in patients with negative metastases in axillary lymph nodes. According to our research LR comprises a total of 3.2% of all patients underwent surgery for BC, while the patients with performed organ-sparing surgery only this proportion is 48%. Non-radical surgeries are not the only base of LR, although timely Gefrier study of resection lines is often skipped. Imaging exams and mammography are not adequately interpreted and necessary advanced studies as magnetic resonance imaging are not performed. The principles of ablastics and antiablastics – replacement of surgical instruments in closing surgical wound, change of surgical clothing and gloves, – are not followed. Late diagnoses, the size of tumor mass and histological character are of importance. It is known that LR in postoperative period is most common in invasive ductal carcinoma. According to our observations, 86% of patients were diagnosed with invasive ductal carcinoma. Of course, the stage of disease, hormonal status and HER2 are of utmost importance. Immunobiological state of patients is often unexplained and underrated. Our observations show that in the distant metastases, especially when they are single – even in pulmonary localization, their operative treatment leads to a significant survival. Therefore surgical treatment of LR in the surgical treatment of BC, including in distant organ metastases is still the primary method of treatment followed by radiotherapy, chemotherapy and hormonal therapy.
Key words: mammary tumors, surgical treatment, modifi ed radical mastectomy, organ-sparing surgery, lymphatic metastases, local recurrence
Address for correspondence: Prof. Peter Chervenyakov, MD, DSci, MHAT "Serdika" LTD, 6 "D. Gruev" Str., Bg – 1303 Sofia



arrow Vol. 9, 2/2015


Migration of melamine and formaldehyde from the market melamine products - Bulgarian medical journal (Български медицински журнал), 9, 2015, №2, 43-47.
T. Vrabcheva, Sv. Chavdarova and T. Barakova.

National Center of Public Health and Analyses
Summary. Melamine formaldehyde resins are used in the manufacturing of kitchen products that come into contact with food. Melamine is a heat-resistant and that allows its use for storage of hot food or in microwave ovens. As a result of technological problems, and when heated, there is a possibility of migration of melamine and formaldehyde in the food. Our preliminary studies in 2013 showed migration of melamine in 69% of samples analyzed. In a subsequent study in 2014 on children‘s melamine products melamine was found in 33% of samples, and there was no evidence of formaldehyde migration. The aim of this study was to examine again the quality of the China-imported melamine kitchen products for migration of melamine and formaldehyde, as well as compliance with the provisions of Regulation № 284/2011. Purchased from the market were 19 types of kitchen products, a total of 55 samples. Test conditions for some of them were consistent with the guidance of the European reference laboratory. The other products were treated at the recommended temperature and time (2 hours at 70°С). As а simulant was used a 3% aqueous acetic acid solution for all samples. Formaldehyde was determined spectrophotometrically, and melamine – with high performance liquid chromatography. Migration of melamine above the limit (2,5 mg/kg) was found in 29% of samples (16 samples), and migration of formaldehyde above the limit (15 mg/kg) – in 27% (15 samples). The maximum level of migration for melamine reached 6,49 mg/kg, and for formaldehyde – 66,64 mg/kg. It is clear from the study that the import of poor quality melamine kitchen tableware continues to be a problem for the Bulgarian market.
Key words: melamine, formaldehyde, migration, Chinese tableware
Address for correspondence: Assoc. Prof. Terry Vrabcheva, MD, PhD, National Center of Public Health and Analyses, 15 Akad. Ivan Geshov” Blvd., Bg – 1431 Sofia, tel.: 02/8056391, e-mail: t.vrabcheva@ncpha.government.bg


Current concepts in the management of esophageal perforations: a twenty year bulgarian experience - Bulgarian medical journal (Български медицински журнал), 9, 2015, №2, 48- 56.
Ch. Tsekov, A. Loukova, J. Vanev, K. Petrov, L. Svilenov, K. Kostov and A. Cherveniakov.

Third Surgical Clinic, UMHATEM “Pirogov”, Sofia
Summary. Perforation of the oesophagus remains a challenging clinical problem. A retrospective review was performed of patients diagnosed with an oesophageal perforation admitted to the Pirogov Hospital – Sofi a from 1993 to 2013. Univariate and multivariate logistic
regression was used to determine which factors had a statistically signifi cant effect on mortality. There were 54 patients; 11 with cervical, 40 with thoracic, and 3 with abdominal perforations. Fifty one percent of all the perforations were iatrogenic and 33% were spontaneous. Multivariate logistic regression analysis revealed that patients with preoperative respiratory failure requiring mechanical ventilation had a mortality odds ratio of 32.4 (95% confi dence interval [CI] 3.1 to 272.0), followed by malignant perforations with 20.2 (95% CI 5.4 to 115.6), a Charleston comorbidity index of 7.1or greater with 19.6 (95% CI 4.8 to 84.9), the presence of a pulmonary comorbidity with 13.9 (95% CI 2.9 to 97.4), and sepsis with 3.1 (95% CI 1.0 to 10.1). A wait time of greater than 24 hours was not associated with an increased risk of mortality (p = 0.52). Malignant perforations, sepsis, mechanical ventilation at presentation, a higher overall burden of comorbidity, and a pulmonary comorbidity have a signifi cant impact on the overall survival. Time to treatmentis not as important. Restoration of intestinal continuity, either by primary repair or by excision and reanastomosis can be attempted even in patients with a greater time from perforation to treatment with respectable morbidity and mortality rates.
Key words: oesophagus, perforation, rupture, treatment
Address for correspondence: Assoc. Prof. Hristo Tsekov, MD, Third Surgical Clinic, UMHATEM “Pirogov”, 21 General E. I. Totleben St., Bg - 1606, Sofia


Control of the oral vaccination in Bulgaria by tetracycline detection and age determination in tooth samples from foxes vaccinated against rabies - Bulgarian medical journal (Български медицински журнал), 9, 2015, №2, 57-61.

D. Ilieva and R. Petrova.

National Diagnostic and Research Veterinary Medical Institute – Bulgarian Food Safety Agency, Sofia
Summary. Laboratory studies were carried out to age determination and detect biomarker tetracycline to monitor the effectiveness of oral vaccination of foxes against rabies in Bulgaria during 2012-2014. Analyzed data obtained from a study of 1461 samples of tooth foxes (Vulpes vulpes) for the presence of biomarker. The tooth samples were collected from total 533 settlements in 22 districts in Bulgaria, related to places of distribution of the vaccine baits. The data indicate, that the rate of prevalence of positive tooth samples for tetracycline to strike an average ≈ 57%.
Key words: biomarker tetracycline, oral vaccination, rabies, foxes
Address for correspondence: Assoc. Prof. Dr. Darinka Ilieva, PhD, Head of NRL ”Rabies and Monitoring the Effectiveness of the Vaccination”, National Diagnostic ResearchVeterinary Medical Institute, 15А Pencho Slaveykov Blvd., Bg – 1606 Sofia, e-mail: emd@mail.orbitel.bg


arrow Vol. 9, 1/2015


Tularemia monitoring of foxes in some regions of Bulgaria - Bulgarian medical journal (Български медицински журнал), 9, 2015, №1, 41-44.
S. Ivanova and D. Ilieva.

National Diagnostic and Research Veterinary Medical Institute – Bulgarian Food Safety Agency, Sofia
Summary. During the period 2013-2014, 237 blood serums of foxes, from 7 districs of the country were investigated. From North and Northwest Bulgaria 7 regions – Vidin, V. Tarnovo, Lovech, Gabrovo, Kuystendil, Pernik, Sofi a district and 3 regions from Northeast and Southeast Bulgaria – Silistra, Shoumen and Bourgas were covered. There were 39 foxes with signifi cans titer 1:40, with infectious titer 1:80 – 48 and 1:160 – 110 foxes. The infectios titres are indication of initial infection with tularemia bacterii and signifi cant titre implies, that the disease happens, the latent and the infectious cause is kept, so as it is intracellular bacteria.
Key words: tularemia, foxes, serological monitoring, infections titer, signifi cant titer
Address for correspondence: S. Ivanova, National Diagnostic Veterinary Research Institute – Bulgarian, Food Safety Agency, 15A Pencho Slaveykov bvl., Bg - 1606 Sofia

Risk of cross-border passage of animals infected with rabies from neighbour to Bulgaria countries - Bulgarian medical journal (Български медицински журнал), 9, 2015, №1, 45-50.
D. Ilieva.

Bulgarian Reference Laboratory for Rabies and Control of the Effectiveness of the Vaccination – Sofia

Summary. In 2013 in connection with rabies monitoring were investigated 520 samples - 118 suspect animals (wild and domestic) and 402 shot animals (253 foxes and 149 jackals) from the areas with oral vaccination. Serologicaly were tested 192 blood samples from 133 foxes and 59 jackals. A seroconconversion level by the foxes ranged to 41% and the presence of tetracycline in teeth ranged to 75.5%. The age of the target populations were determinated, through to distinguish them from junior (J) and adult (A) animals. In 2013 in Bulgaria wеre not detected rabies cases. The epidemiological situation in Serbia, Romania, Turkey and some regions of Northern Greece were complicated due to the large number of rabies cases. For Bulgaria there is a real danger of new rabies cases through cross-border passage of animals infected through the territory of the country and the introduction of zoonoses from the neighbour countries.
Key words: rabies, monitoring, oral vaccination
Address for correspondence: Assoc. Prof. Dr. Darinka Ilieva, PhD, Head of NRL ”Rabies and monitoring the effectiveness of the vaccination”, National Diagnostic Research Veterinary Medical Institute, 15А “Pencho Slaveikov” Blvd., 1606 Sofia, e-mail: emd@mail.orbitel.bg, e-mail: emd@mail.orbitel.bg


Pharmacology and toxicology

Anticonvulsive and neuroprotective effects of rosuvastatin in pilocarpine-induced experimental model of epilepsy - Bulgarian medical journal (Български медицински журнал), 9, 2015, №1, 51- 55.
E. Haritov, E. Angeleska and N. Boyadjieva.

Department of Farmacology and Toxicology, MF, MU – Sofia
Summary. Epilepsy is a chroinic neurological disoreder wich affects 50 million people worldwide. The current antiepileptic drugs provide seizure control in 70% of patients. Uncontrolled seizures are found in 30% of adult epilepsy patients. In the last decade emerging evidence supports the role of infl ammation in epilepsy. Apart from its cholesterol lowering properties, have been shown that statins exert neuroprotectiv effect. The objective of our study was to further analize capacity of rosuvastatin to prevent seizures and to elucidate whether this drug exert anti-infl ammatory effect, after neonatal pilocarpine-induced status epilepticus. For these purposes, five groups of rats, of 5 animals each were employed: saline (control), pilocarpine (PILO), pilocarpine plus rosuvastatin (10 mg/kg, per os, for 7 days), pilocarpine plus rosuvastatin (20 mg/kg, per os, for 7 days), pilocarpine plus rosuvastatin (40 mg/kg, per os, for 7 days). Rosuvastatin was administered for 7 days prior to application of pilocarpine. Seizure activity was monitored for 2h. after induction of seizures with pilocarpine. The severity of seizures was evaluated using Racine scale. The onset and number of wet dog shakes (WDS) also was scored. Pilocarpine induced tonic-clonic seizure after it administration. Rosuvastatin in dose-dependant fashion reduce seizure scores, onset and number of WDS, as compared that of control group. Conclusion: Our data suggest that rosuvastatin may reduce epiletoformic activity and could be used as add-on therapy for epilepsy. The mechanism of this, can be attributed to it anti-infl ammatory effects. This assumption needs fuрther investigations.
Key words: epilepsi, rosuvastatin, anticonvulsive and neuroprotective effects, experimental model
Address for correspondence: E. Haritov, Department of Farmacology and Toxicology, MF, MU, 2 Zdrave St. Bg – 1431 Sofi a

Physical medicine and rehabilitation

Complex approach to treatment of people with overweight and obesity - Bulgarian medical journal (Български медицински журнал), 9, 2015, №1, 56-61.
G. Georgiev and M. Georgieva.

Clinic of Physical Medicine and Rehabilitation, MMA – Sofia
Summary. Elevated values of the percentage of body fat and waist circumference are part of the characteristics of overweight and obesity. Acupuncture and auricular puncture are effective alternative means of prevention and treatment of overweight and obesity. The purpose of this study is to examine the effect of complex non medicated anti-obesity therapy with аuricular puncture, low calorie diet and a model of moderate physical activity on body weight, BMI, body fat percentage and waist circumference, and the existence of correlation between them in people with overweight and obesity. All patients underwent complete anti-obesity treatment for 8 weeks. At the beginning and at the end of the study period body weight and BMI of 310 persons with overweight and obesity, the percentage of body fat and waist circumference of 227 and 236 persons with overweight and obesity respectively. The results are reviewed by gender and age, and for this purpose six groups are formed – “up to 20 years old”, “21 to 30 years old”, “31 to 40 years old”, “41 to 50 years old”, “51 to 60 years old”, and “over 60 years old”. Low calorie diet is recommended (1450-1500 kcal/24h) and a model of moderate physical activity. Auricular application is performed by its own standardized system, in three areas innervated mainly by n. vagus and n. trigeminus. Statistical methods are used for testing hypotheses, the Kolmogorov–Smirnov criterion, Lavelle and Mann–Whitney. At the end of therapy an average reduction in body weight of 8,04 kg and 2.8 units in BMI from baseline is observed. The best results in lowering the average percentage of body fat, both in women and men, are observed in the age group of 21 to 30 years of age (reduction by 7.9 percentage points in women and 9.3 percentage points in men). In comparison, the reduction in the average values in other age groups ranges from 5 to 7 percentage points. Best results in terms of reduction in average waist values are achieved in women in the group up to 20 years of age, and in men in the group 31-40 years of age (with the highest average values). They reduce their average circumference by 20-23 cm. This study proves that auricular puncture in combination with a low calorie diet and model of moderate physical activity achieves signifi cant reduction in body weight and BMI, correlated to the decrease in the percentage of body fat and waist circumference in eight week treatment of people with overweight and obesity.
Key words: auricular puncture, overweight and obesity, body fat percentage, waist circumference
Address for correspondence: Assoc. Prof. Georgi Georgiev, Clinics of Physical Therapy and Rehabilitation Medicine, Military Medical Academi, 3 Georgi Sofiiski St., Bg – 1606 Sofia



Reconstruction of tissue defects scalp flap rotary - Bulgarian medical journal (Български медицински журнал), 9, 2015, №1, 62-65.
E. Zanzov1, I. Traykov2 and P. Stefanova2

1Clinic for Burns, Plastic, Reconstrutive and Aesthetic Surgery
2Clinic for Child Surgery, Propaedeutics of the Surgical Diseases Department University Hospital "Sv. Georgi" - Plovdiv
Summary. The unique characteristics of the scalp make it one of the biggest challenges for reconstruction, sometimes requiring many different techniques for the same defect. Rotation fl ap of the scalp are the starting point for the reconstruction of these defects. The aim of this study was to clarify the place and importance of rotation fl aps for reconstruction of tissue defects in the scalp. For ten years (from 2003. to 2012.) In the Clinic for Burns, Plastic, Reconstructive and Aesthetic Surgery at the University Hospital "Sv. Georgi" – Plovdiv, were treated 87 patients with head tissue defects. In 24 of them (27.58%) was used the rotary fl ap alone or in combination with other reconstructive method to cover the defect. The adopted durability and success of coverage for primary defect was very good in 16 patients (66.67%); good – in 7 patients (29.16%); satisfactory – in 1 patient (4.17%). We believe that the rotational fl aps are the primary method of choice in the reconstruction of medium and large tissue defects of the scalp and that their use should be the first step in the reconstructive ladder in defects including deep periosteum and/or bones of the skull.
Key words: scalp; reconstruction; rotary flap; defects, aesthetic
Address for correspondence:
E. Zanzov, Clinic for Burns, Plastic, Reconstrutive and Aesthetic Surgery, Medical University, 15A , V. Aprilov St., Bg - 4000 Plovdiv



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