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 Original papers

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Volume 49, 2013

 

bullet 4'2013

 

Clinical significance of the investigation of cryoglobulins- 49, 2013, № 4, 45-49.
M. Nikolova(1), M. Baleva(2) and K. Nikolov(3).
(1)Department of Internal Medicine, Medical University -- Sofia, (2)Department of Clinical Laboratory and Clinical Immunololgy, Medical University -- Sofia, (3)Clinic of Clinical Immunology, University Hospital Alexandrovska -- Sofia
Summary: Cryoglobulins are immunoglobulins that undergo reversible precipitation or gel formation at low temperatures. We investigated the levels and contents of cryoglobulins found in patients with systemic lupus erythematosus (SLE), scleroderma, Raynaud phenomenon, dermato/polymyositis. The highest cryoglobulin levels were detected in patients with SLE and scleroderma. In SLE patients their levels were higher in those with lupus nephritis than in patients without renal involvement (p < 0.002). In patients with lupus nephritis, positive cryoglobulins correlated with the presence of oral ulcerations, the number of criteria used for the diagnosis of SLE, ESR levels, SLEDAI and SLICC, and showed reverse correlation with total protein and albumin levels, C3 and C4 complement fractions. The dynamic follow-up of cryoglobulin levels in lupus nephritis patients revealed a gradual decrease over time. The percentage of patients with positive cryoglobulins decreased from 15.9% at the initial investigation to 7.9% at month 6, were as low as 5.9% at month 12, and on month 24 none of the investigated patients had high cryoglobulin levels. The following components were detected in the cryoprecipitate of the SLE patiens: IgG, IgA, IgМ, κ and λ light chains, ANA, DNA, Sm and RNP antibodies. The authors discuss the diagnostic value of cryoglobulins.
Кey words: cryoglobulins, systemic lupus, lupus nephritis
Address for correspondence: Prof. Marta Baleva, MD, DSc, Department of Clinical Immunology, University Hospital “Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia

 

 

Significance of inherited thrombophilic factors according to their prevalence in the population- 49, 2013, № 4,50-54.
P. Ivanov (1, 2), Tsv. Tsvyatkovska(1), R. Komsa-Penkova(1), Z. Kamburova(4), E. Konova(2, 3) and St. Tanchev(5)
(1)Department of Biochemistry, Medical University -- Pleven, (2)Clinical Institute for Reproductive Medicine -- Pleven, (3)Center of Clinical Immunology, University Hospital -- Pleven, (4)Department of Medical Genetics, Medical University -- Pleven, (5)Department of Obstetrics and Gynecology, Medical University -- Pleven
Summary: Inherited predisposition to arterial and venous thrombosis (thrombophilia) has been discussed as an important part of the recurrent thrombosis risk evaluation. There is a need to establish the real distribution of thrombophilia in healthy subjects because of the wide fluctuation of thrombophilic polymorphisms among different populations. Carrier state for factor V Leiden (FVL) and prothrombin (FII) 20210 G>A has been determined in 155 healthy subjects (70 men and 85 women) with a mean age of 38.9 years, and without previous history of arterial or venous thrombosis. FVL was found in 7.1% of the investigated healthy subjects. The distribution among women and men was equal. There was one subject with homozygous state for the mutation (0.6%). FII 20210 G>A was established in 3.9% of the examined population, all in heterozygous state. Because of the relatively high prevalence of FVL and FII 20210 G>A among the population, and because of the multifactorial genesis of thrombophilic states, an individual approach to patients with thrombotic events should be considered.
Key words: thrombophilic factors, population distribution

Address for correspondence: Petar Ivanov, M. D., Ph. D., Department of Biochemistry, Medical University, 1, Sv. Kliment Ohridski St., Bg -- 5800 Pleven, fax +359 64 801398, e-mail: mdivanov@gmail.com

 

 

Lymphocytic subpopulations in patients with newly diagnosed chronic hepatitis B- 49, 2013, № 4,55-58.
A. Mihaylova (1), P. Yankova(1), V. Atanasova(1), A. Georgieva(1), D. Petrova(2), K. Tzhernev(2), M. Baleva(1) and E. Naumova(1)
(1)Clinic of Clinical Immunology, (2)Clinic of Gastroenterology, UMHAT “Aleksandrovska”, Medical University -- Sofia
Summary: We investigated the total T (CD3+) lymphocyte count, helper-inducer (CD3+CD4+) and suppressor/cytotoxic (CD3+CD8+) count, B lymphocytes (CD19+) and NK cells (CD3-CD16+CD51+), cytotoxic (CD8+CD11b-) and suppressor cells (CD8+CD11b+); CD8+CD28+ T cells with effector (cytotoxic) and/or memory activity; CD8+CD57+ highly differentiated cell subpopulation with probable memory effector function; CD3+HLA-DR+, CD8+HLA-DR+ and CD8+CD38+ activated T-cells; T lymphocytes with NK-cell markers (NKT -- CD3+CD16+56+); CD57+CD8- cells with NK activity in 27 treatment naïve patients with newly diagnosed chronic hepatitis B (HBV, mean age 43.96 +/- 14.22 years) and in 29 random non-related healthy Bulgarian individuals using flow cytometry. In HBV patients, we found significant decrease in the total CD3+ Т cell count with decrease in helper-inducer, suppressor-cytotoxic and cytotoxic subpopulations (CD8+CD11b-; CD8+CD28+) compared to healthy individuals (p < 0.001). We found increased CD57+CD8- NK cells and increased percentage of B cells, decreased CD8+CD38+ cells. The results of the investigated patients with chronic and untreated HBV infection suggest that the studied cell markers (CD), defining the different cell populations and subpopulations, using flow cytometry, are informative concerning the inborn and the acquired immune response in chronic hepatitis B infection.
Key words: chronic hepatitis B infection, cellular immunity
Address for correspondence: Prof. Anastasia Mihaylova, M. D., D. Sc., Clinic of Clinical Immunology, University Hospital Aleksandrovska, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, e-mail: mihaylova_ap@abv.bg

 

 

Is intramedullary nailing osteosynthesis a suitable treatment method for fractures of the distal tibia - 49, 2013, № 4,59-61.
K. Tsonkov, V. Tsanov and S. Asyov.
UMHATEM “N. I. Pirogov” -- Sofia
Summary: The treatment of the distal metaphyseal tibial fractures remains controversial. Treatment selection is influenced by the proximity of the fracture to the plafond, fracture displacement, comminution, and injury to the soft-tissue envelope. The purpose of this study was to estimate the reliability of intramedullary nailing osteosynthesis in the treatment of the distal tibial fractures according to our achieved results. Over a ten-year period, 73 tibial fractures were treated by this method and followed up by the authors. The achieved results were: 51% -- excellent, 23% -- good, 16.4% -- satisfactory, 1.4% -- poor. They allow us to consider, that the used method is suitable and reliable for the treatment of this type of fractures.
Key words: distal tibial fractures, intramedullary nailing osteosynthesis, treatment
Address for correspondence: K. Tsonkov, M. D., MHATEM “N. I. Pirogov”, 21, Totlebem Blvd., Bg -- 1606 Sofia

 

 

Retrospective analysis of the incidence and type of hematoma after a renal biopsy: ultrasound evaluation
M. Lubomirova, T. Tzocheva, M. Hristova, R. Djerassi and B. Bogov.

Clinic of Nephrology, University Hospital “Aleksandrovska” -- Sofia
Summary: The aim of the study was to examine the frequency and the type of renal hematomas after percutaneous renal biopsy (RB), performed by spring-loaded biopsy gun system. One hundred and forty-one RBs, performed by automated reusable spring-loaded biopsy gun, using 16- and 18-gauge Magnum dis­po­sable needles, Bard, UK, were examined retrospectively. 79 male and 62 female patients, average age 47.5 +/- 21.3 years were included in the study. 120 biopsies were made using a 16 G needle, and 21 -- using an 18 G needle. Renal ultrasound examination was performed up to 24 hours after biopsy to assess hematoma formation. Successfully performed were 95% of all RBs. The rest 5% were unsuccessful. Out of all unsuccessful RBs, 60% were made with 18 G needles. 90% of the studied patients did not show any post-biopsy com­pli­ca­tions. Hematomas were observed in 14 out of all 141 cases, corresponding to overall complication rate of 10%. Of those, 85% (12 out of 14 cases) were assessed as small hematomas with an average size of 28.4 +/- 9 mm and they appeared to be asymptomatic. We registered 2 large perirenal hematomas with diameter > 5 cm, 5 small intrarenal hematomas < 2 cm, and 7 small hematomas with intra- and perirenal localization. While 10 of all 14 cases of hematomas (72%) were a result of two passes of the needle, only 4 (28%) hematomas were observed as a result of one pass of the needle (p < 0.01). The number of hematomas obtained with 16 G needle was significantly higher than those registered in the group with an 18G needle (11 vs. 3 cases, p < 0.05). However, when the number of hematomas in both groups was referred to the number of all biopsies in the corresponding group, the prominent significant difference in the incidence of this complication decreased from p < 0.01 to p < 0.05. The incidence of major complications was 1.4% (2 hematomas from 141 biopsies).
Key words: renal biopsy, post-renal biopsy complications, hematomas, spring-loaded biopsy gun system
Address for correspondence: Mila Lubomirova, M. D., Clinic of Nephrology, University Hospital „Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230263, e-mail: mljubomirova@yahoo.com

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bullet 3'2013


Prevalence of atopic dermatitis in Bulgaria - 49, 2013, № 3, 41-49.
G. Hristov(1), E. Karova(2) and I. Stoeva(3)
(1)Department “Health Economics”, Faculty of Public Health, Medical University -- Sofia, (2)Department “Conservative Dentistry”, Faculty of Dental Medicine, Medical University -- Sofia, (3)Department “Allergology, Physiotherapy and Clinical Radiology”, Faculty of Dental Medicine, Medical University -- Plovdiv
Summary: The objective of the cross sectional study was to examine the prevalence of eczema (atopic dermatitis) in Bulgaria with regard to the different definitions of the disease used. Adapted International Study of Allergy and Asthma in Children (ISAAC) and European Community Respiratory Health Survey (ECHRS) questionnaires were used to address the specific needs of the study. Prevalence of eczema (atopic dermatitis) in Bulgaria (95% CI) is high: 17.9% (16.5-19.4), second after that of allergic rhinitis -- 39.3% (37.5-41.1) and before asthma -- 14.9% (13.5-16.2).
Key words: asthma, allergic rhinitis, atopic dermatitis, allergic diseases, prevalence
Address for correspondence: Assoc. Prof. Gеorgi Hristov, M. D., Department “Health Economics”, Faculty of Public Health, Medical University, 8, Bialo more St., Bg -- 1504 Sofia, e-mail: christoff_g@yahoo.com

 

 

Therapeutic strategies for Stenotrophomonas maltophilia associated respiratory infections in hospitalized patients - 49, 2013, № 3, 50-56.
M. Bozhkova, T. Stoeva and K. Bozhkova
Department of Microbiology, Medical University -- Varna
Summary: Resistance of S. maltophilia to many of the most commonly used antimicrobial agents reduces the chances for adequate antibiotic therapy of infections, associated with this bacterial species. The aim of this study was to determine the susceptibility of respiratory isolates of S. maltophilia from hospitalized patients to antimicrobial agents and to recommend adequate treatment of respiratory tract infections caused by S. maltophilia. Resistance profile of 86 respiratory isolates of S. maltophilia was studied by disk diffusion test (DDT) and for 30 of them -- by E test. DDT was found to be reliable for trimethoprim-sulfametho­xa­zole, tygecycline and doxycycline, but not for ticarcillin/clavulanic acid, ceftazidime, polymyxin B and E. Trimethoprim-sulfamethoxazole, tygecycline, doxycycline and levofloxacin demonstrated high rates of in vitro activity -- 100%, 96.5%, 98.8%, and 97.7%, respectively. High-level resistance to beta-lactams, such as ticarcillin/clavulanic acid (41.8%) and ceftazidime (35.1%), was found. Trimethoprim-sulfamethoxazole is recommended for empirical treatment of respiratory tract infections caused by S. maltophilia, because of its highest rate of in vitro susceptibility. In case of intolerance to trimethoprim-sulfamethoxazole, therapy with levofloxacin and tetra- or glycylcyclines should be considered.
Key words: S. maltophilia, resistance, respiratory tract infections
Address for correspondence: Milena Bozhkova, M. D., Department of Microbiology, Medical University, 55 Marin Drinov St., Bg -- 9001 Varna, tel. +359 52 978 538, e-mail: drbojkovam@abv.bg

 

 

Apolipoprotein E еpsilon4 and motor symptoms in patients with late-onset Parkinson’s disease - 49, 2013, № 3, 57-62.
R. Pavlova(1), М. Petrova(1), Ya. Zhelev(1), E. Boyadzhieva(2), О. Belcheva(2) and L. Traykov(1)
(1)Department of Neurology, Alexandrovska Hospital, Medical University -- Sofia, (2)Molecular Medicine Centre and Department of Medical Chemistry and Biochemistry, Medical University -- Sofia
Summary: Parkinson’s disease (PD) is a neurodegenerative disorder, characterized by motor and non-motor symptoms. Motor symptoms include rest tremor, brady-/akinesia, rigidity and postural instability, caused by degeneration of dopaminergic neurons in the substantia nigra. The role of apolipoprotein E еpsilon4 (APOE еpsilon4) alelle as a risk factor for cognitive decline and neuropsychiatric features in PD has been widely discussed, although the studies have shown conflicting results. Studies focusing on the effect of APOE еpsilon4 alelle on the motor symptoms in PD are still lacking. The aim of the study was to investigate the impact of APOE еpsilon4 allele on the motor symptoms in patients with late-onset PD (LOPD, age at onset > 40 yrs). The study was performed at the Clinic of Neurology, University Hospital „Аleksandrovska”, in Sofia, Bulgaria. A total number of 54 patients with LOPD and disease duration of 2-5 years were screened. The APOE genotype was tested by PCR and RFLP analyses. Based on the genotype data, all patients were separated into two groups. The first group consisted of 18 patients that carried one APOE еpsilon4 allele (еpsilon4/еpsilon3), and the second -- 36 patients homozygous for the commonest of the APOE alleles -- еpsilon3 (еpsilon3/еpsilon3). There were no patients with еpsilon4/еpsilon4 genotype in our cohort. The presence and the severity of motor symptoms (MS) were evaluated by Unified Parkinson’s Disease Rating Scale, Part III (UPDRS III) and Hoehn & Yahr rating scale. The results of the study showed association of APOE еpsilon4 allele with the severity of some motor symptoms in heterozygous LOPD patients, with 2-5 yrs duration of the disease.
Key words: APOE еpsilon4 allele, APOE еpsilon3 allele, late-onset Parkinson’s disease, motor symptoms
Address for correspondence: Radka Pavlova, M. D., Department of Neurology, University Hospital “Aleksandrovska”, 1 “G. Sofiyski” St., Bg-1431, Sofia, tel. +359 893564375, e-mail: r1312@abv.bg

 

 

Spinal anesthesia: comparison of isobaric ropivacaine (5 mg/ml) with isobaric bupivacaine (5 mg/ml) - 49, 2013, № 3, 63-68.
D. Tzoneva, Vl. Miladinov, Al. Todorov, M. P. Atanasova, Y. Borisov and St. Hinev
Department of Anesthesiology and Intensive Care, University Hospital "Aleksandrovska", Medical University -- Sofia
Summary: Recently, the proportion of loco-regional methods of intraoperative analgesia and pain management has increased. Spinal anesthesia (SA) is a popular, widely used in clinical practice technique for analgesia with a high success rate and good safety profile. Ropivacaine is a new amide local anesthetic, synthesized as a pure S-enantiomer. Its unquestionable advantages are prolonged action and the ability to achieve differential sensorimotor blockade with lower systemic toxicity. The aim of the study was to compare the effects of equipotent doses of isobaric ropivacaine (5 mg/ml) to isobaric bupivacaine (5 mg/ml), administered intrathecally for intraoperative analgesia in adult patients. Thirty-four adult patients scheduled for inguinal hernia repair and anorectal surgery under intrathecal anesthesia were randomized in two groups according to the administrated local anesthetic: group R (ropivacaine; N = 17) and group B (bupivacaine; N = 17). The onset, duration and segmental level of sensory and motor blockade were examined, as well as hemodynamic variables, side effects, and time to first void. The results showed that ropivacaine produced spinal anesthesia with similar clinical profile to bupivacaine. In group R the onset of the sensory blockade was slower with a 1.2 times shorter duration and complete motor block developed rarer than in the group with bupivacaine. The recovery from spinal block was 1.2 times faster, and the time to void was 1.3 times shorter in patients who had received ropivacaine, compared with patients in group B. The hemodynamic changes were similar in both groups. In the early postoperative period no patients reported any complaints. In conclusion, isobaric ropivacaine (5 mg/ml) produces equivalent intrathecal anesthesia for inguinal hernia repair and anorectal surgery with faster recovery compared to bupivacaine. Ropivacaine is a local anesthetic with good tolerability; provides effective intraoperative analgesia with minimal motor function suppression and reduced potential for cardio- and CNS-toxicity.
Key words: spinal anesthesia; ropivacaine, bupivacaine, inguinal hernia repair, anorectal surgery, adult patients
Address for correspondence:
Dochka Tzoneva, M. D., Department of Anesthesiology and Intensive Care, University Hospital "Aleksandrovska", Medical University, 1, Sv. G. Sofyiski St., Bg -- 1431 Sofia, e-mail: dochka_tobova@abv.bg

 

 

Efficacy and safety of intramuscular administration of dexketoprofen versus meloxicam for short-term inhospital treatment of exacerbated gonarthrosis - 49, 2013, № 3, 69-73.
D. Tonev(1), A. Toncheva(2) and I. Gruev(3)
(1)Department of Anesthesiology and Intensive Care, (2)Clinic of Internal Diseases, (3)Clinic of Cardiology, National Multiprofile Transport Hospital “Tsar Boris III” -- Sofia
Summary: NSAIDS are the most frequently used drugs for treatment of pain, caused by arthrosis. They are effective, but also hide a significant risk of gastrointestinal and cardiovascular adverse events, especially after long-term intake. The aim of our study was to assess the efficacy and safety of intramuscular administration of dexketoprofen vs meloxicam for short-term inhospital treatment of exacerbated gonarthrosis. Both drugs showed to be equally effective during the 7 days long treatment of 30 patients. No serious adverse events were detected and no significant difference between the two medications was found, concerning minor side effects.
Key words: NSAIDS, arthrosis, pain, safety, dexketoprofen, meloxicam
Address for correspondence: Assoc. Prof. Dimitar Tonev, M. D., Ph. D., National Multiprofile Transport Hospital “Tsar Boris III”, 104, “Maria Luiza“ Blvd., Bg -- 1233 Sofia, e-mail: dgtsofia@abv.bg

 

 

Polybacterial immunomodulator “Respivax” regulates the co-stimulatory potential of antigen-presenting cells - 49, 2013, № 3, 74-79.
D. Stankulova, М. Muhtarova and M. Nikolova
Central Laboratory of Immunology, National Center of Infectious and Parasitic Diseases -- Sofia
Summary: The oral polybacterial immunomodulator “Respivax” (BulBio -- NCIPD Ltd.) has a well-established stimulatory effect on immune responses. We studied the effect of “Respivax” on the expression of CD86 co-stimulatory receptor by human antigen-presenting cells (APC). Blood samples from 15 patients with recurrent non-specific respiratory infections subjected to a standard course of “Respivax” treatment, were collected at baseline, day 20 and 80. Multicolor flow cytometry was used to study CD86 expression on circulating dendritic cells (DC), monocytes (Mo, CD14+), and B cells (CD19+). “Respivax” treatment increased CD86+ DC from 68.7% to 76.2% (p < 0.01) and promoted their maturation (a mean of 52% CD86high DC vs. 43% at baseline, p < 0.05), accompanied by increased intensity of CD86 expression on Mo (av. MFI 1318 vs.1071, p < 0.01). Finally, 44.6% of LPS-stimulated B cells expressed CD86 on day 80, and 48.2% on day 20 vs. 38.2% at baseline (p < 0.05). These results suggest that one mechanism of “Respivax”- mediated immune modulation is the induction of APC maturation and the restoration of their co-stimulatory potential in case of pathologic inhibition.
Key words: antigen presenting cell, CD86, polybacterial immunomodulator, “Respivax”
Address for correspondence: Assoc. Prof. Maria Nikolova, M. D., Central Laboratory of Immunology, National Center of Infectious and Parasitic Diseases, 26, Yanko Sakuzov Blvd., Bg -- 1504 Sofia, tel. +359 2 9435636, e-mail: imlab@ncipd.netbg.com

 

 

The role of plasma exchange in nephrology - 49, 2013, № 3, 80-83.
Sv. Staykova(1), K. Nenov(1), Kr. Nenova(2) and G. Valchev(3)
(1)Clinic of Dialysis, UMHAT “Sv. Marina” -- Varna, (2)Department of Internal Diseases, Medical University -- Varna, (3)Department of Diagnostic Imaging, Medical University -- Varna
Summary: The treatment with plasma exchange (PE) is executed with success in more than 110 different illnesses but the effect has been proven in about 30 of them. The method is mostly applied in neurological, nephrological and rheumatological diseases. It shows excellent results in hyperviscosity conditions, a number of intoxications and complicated immunosuppressive therapy protocols. The goal of the research is to analyse the clinical effect of using plasma exchange in 81 patients with nephrological disease in the Clinic of Dialysis, UMHAT “Sv. Marina“, Varna. PE is a therapeutic procedure with immunomodulatory effect, influencing actively the immunologic condition and slowing the progression of kidney insufficiency. PE has an excellent effect as part as the complex treatment approach in patients with severe immune kidney diseases.
Key words: kidney insufficiency, complex treatment, immunosuppressive therapy, plazma exchange
Address for correspondence: Svetla Staykova, M. D., Clinic of Dialysis, UMHAT “Sv. Marina”, 1, Hristo Smirnenski St., Bg -- 9000 Varna, tel. +359 885/841 663, e-mail: svetlastaykova@abv.bg

 

DRUG INFORMATION

What is the place of Aliskiren in the present treatment of arterial hypetension? - 49, 2013, № 3, 84-88.
E. Manov and N. Runev

Department of Propedeutics of Internal Medicine, Medical University -- Sofia
Summary: Aliskiren is the first representative of a new class of orally active, non-peptide, low molecular weight, direct renin inhibitors. The efficiency and safety of this product have been assessed in various studies such as: ATMOSPHERE, ASTRONAUT and ALTITUDE. On December, 2011 the ALTITUDE study was discontinued on recommendation of the Data Monitoring Committee, due to preliminary data which showed worsening of the renal function, hyperkalemia, hypotension and increased incidence of nonfatal stroke by 0.6%. These results apply to a relatively limited quota of diabetic patients with arterial hypertension and moderate to severe renal dysfunction (eGFR ≤ 60 ml/min/1.73 m2). The explanation of these results is complex and has to do with some flaws in the study design as well as the fact that in this specific group of haemodynamically unstable patients, a maximal dose of 300 mg Aliskiren was added to the monotherapy with either ACEI or ARB in patients with already well-controlled blood pressure. It is logical to assume that this predisposition to hypotension is owed to the addition of the high dose of Aliskiren to the already controlled arterial hypertension, and not the result of the double blockade of the RAAS system. The summarized data of the numerous studies point that Aliskiren is an efficient anti-hypertensive drug that can also be used in combination with other blockers of the RAAS in order to reach a double RAAS blockade while strictly taking into consideration the comorbidity and adequate precision of the needed dose. The results of the ALTITUDE study do not totally undermine the use of the drug in everyday clinical practice; they just form one categorical contraindication, not to use it in patients with diabetes and renal dysfunction.
Key words: Aliskiren, arterial hypertension, renin-angiotensin-aldosteron system (RAAS), direct renin inhibitor, antihypertensive treatment, diabetes mellitus
Address for correspondence: Assoc. Prof. Emil Manov, M. D., Ph.D., Department of Functional Diag­no­sis, Clinic of Internal Medicine "Kirkovich", University Hospital "Aleksandrovska", 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230 281, +359 898 51 57 57

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bullet 2'2013

Clinical, laboratory and diagnostic features of patients with febrile syndrome - 49, 2013, № 2, 47-54.
M. Baymakova(1), K. Plochev(1), G. Popov(1), R. Mihaylova(1) and V. Kovaleva(2)

(1)Clinic of Infectious Diseases, Military Medical Academy -- Sofia, (2)Science and Application Center of Military Epidemiology and Hygiene, Military Medical Academy -- Sofia
Summary: Most episodes of febrile conditions are self-limiting, short-lived and do not require specific diagnostic investigation and treatment, but other groups are serious, long persistent and difficult to be diagnosed diseases. This work was focused on patients with febrile syndrome. The aim was to analyze the clinical, laboratory and diagnostic features of patients with fever of unknown origin and patients with low-grade fever. We present 10 patients with febrile syndrome who were hospitalized at the Clinic of Infectious Diseases, Military Medical Academy-Sofia. The following methods were used: bibliographic, clinical, diagnostic and comparison methods. Based on the characteristics of febrile illness, the patients were divided into two groups: patients with fever of unknown origin and patients with low-grade fever. Data of history, physical examination, hospital monitoring and diagnostic investigations were compared. These two groups have common lines in the history, but the objective findings of the physical examination and diagnostic tests have shown differences. The nosological entity was not identified in 40% of the cases with low-grade fever, in comparison with the group with fever of unknown origin (0%), but the number of cases with an indefinable etiologic agent in both groups was the same (80%). The presence of the same cause of the febrile syndrome in the cases of both groups is rather impressive.
Key words: fever of unknown origin, low-grade fever, infection
Address for correspondence: Magdalena Baymakova, M. D., Clinic of Infectious Diseases, Military Medical Academy, 3, Sv. G. Sofiyski St., Bg -- 1606 Sofia, GSM: +359 898 767594, e-mail: dr.baymakova@gmail.com

 

 

Incidence and localization of lymph node metastases in patients with invasive cervical cancer - 49, 2013, № 2, 55-58.
Ya. Kornovski and E. Ismail

Clinic of Obstetrics and Gynecology, MHAT „Sv. Anna”, Medical University -- Varna
Summary: The aim of the study was to establish the incidence, localization and distribution of lymph node metastases in patients with cervical cancer FIGO stages IB1 -- IIB. During the period 2002 -- 2011 year 294 patients diagnosed with cervical cancer FIGO stages IB1 -- IIB had been operated (FIGO stage IB1 -- 110 patients; IB2 -- 98 patients; IIB -- 86 patients). The surgical management consisted of radical hysterectomy class III and pelvic lymphadenectomy. In cases with enlarged paraaortic lymph nodes, paraaortic lymphоnodulectomy was performed. Lymph node metastases (LNM) were detected in 82 patients (27.8%). The number of LNM was 1 to 3 in 66 women (22.4%) and more than 3 in 16 women (5.4%). Pelvic LNM were found in 74 patients (25.17%) and paraaortic LNM -- in 8 patients (0.34%). LNM were evaluated as macrometastases in 45 women (15.31%) and as micrometastases -- in 37 women (12.59%). The incidence of LNM in stages IB1, IB2 and IIB was 20.9%, 33.67% and 30.24%, respectively. In conclusion, Bulky cervical lesions, even though in stage IB1, reveal higher aggressiveness and metastatic potential than small cervical lesions.
Key words: cervical cancer, lymph node metastases
Address for correspondence: Assoc. Prof. Ya. Kornovski, M.D., Clinic of Obstetrics and Gynecology,
MHAT „Sv. Anna”, 100, Tsar Osvoboditel Blvd., Bg -- 9000 Varna

 

 

Diagnostic significance of Y-chromosome abnormalities in hematologic diseases - 49, 2013, № 2, 59-62.
L. Mitev(1), M. Velizarova(2), V. Uzunova(1), Yu. Rainov(3), I. Gigov(3), R. Stanchev(3), D. Danchev(1) and K. Tzatchev(2)
(1)Department of Clinical Laboratiory and Immunology, Military Academy -- Sofia, (2)Department of Clinical Laboratory and Clinical Immunology, University Hospital Aleksandrovska -- Sofia, (3)Clinic of Hematology, Military Academy -- Sofia
Summаry: Chromosomal abnormalities of the Y-chromosome are found in both normal bone marrow in elderly males and as a part of karyotype aberrations in hematologic malignancies. We present 13 hematologic cases with cytogenetic aberrations of the Y-chromosome. Karyotypes were performed by analysing 20 cells using conventional cytogenetic methods. We describe a loss of Y-chromosome as the sole karyotypic abnormality in 5 cases (4 with myelodysplastic syndrome (MDS) and 1 with multiple myeloma (MM); a combination of -Y with other cytogenetic aberrations was found in 5 patients (2 cases with acute myeloid leukemia (AML), 2 cases with non-Hodgkin lymphoma (NHL) and 1 case with chronic myeloid leukemia (CML); structural abnormalities were observed in only 3 cases and they were interstitial deletions of the Yq in the q11 and q12 regions (2 cases) and t(Y;1)(q12;q12) (1 case). We discuss the diagnostic significance of cytogenetic aberrations of the Y-chromosome as a clause of clonal evolution.
Key words: Y-chromosome, hematologic diseases, karyotype
Address for correspondence: Milena Velizarova, M. D., Department of Clinical Laboratory and Clinical
Immunology, МU, 1, Sv. G. Sofiyski Blvd., Bg -- 1431 Sofia, e-mail: mvelizarova@abv.bg

 

 

Sensitivity and resistance of the most common Gram-negative and Gram-positive pathogens of urinary tract infections in kidney transplant recipients - 49, 2013, № 2, 63-68.
B. Zlatkov(1), Zh. Filipov(1), E. Paskalev(1), B. Markova(2), Yu. Marteva-Proevska(2) and А. Kolevski(2)
(1)Clinic of Nephrology and Transplantation, (2)Central Laboratory in Microbiology, UMHAT “Aleksandrovska” -- Sofia
Summary: The aim of our study was to analyze the antibiotic resistance of the most common uropathogens -- Enterobacteriaceae and Enterococus spp. among kidney transplant recipients (KTR), followed up in our transplant center. Urinary tract infections (UTI) are one of the most common medical complications after kidney transplantation, with incidence ranging from 30 to 80%. The study was performed between 01.01.2012 and 31.08.2012. The total number of examined patients was 366, males 266 (62.30%), females 138 (37.70%). The total number of tested urine samples was 829, 203 (24.90%) were positive, 606 (73.1%) were negative, 20 samples (2.41%) were contaminated. The most common etiologic agents detected were Gram-negative bacteria (63.90%), as out of these, the strains belonging to the Enterobacteriaceae family accounted for 93.28%. In 28.09% of the patients, Gram-positive pathogens were detected. Enterococcus spp. were the most prevalent group of Gram-positive bacteria (67.79%), with E. faecalis and E. fae­cium being the most important strains. The most prevalent Gram-negative pathogens (Enterobacteriaceae family) revealed almost 100% sensitivity to carbapenems (Meropenem, Imipenem) and aminoglycosides (Amikacin). High sensitivity was established to second and third generation cephalosporins, whereas the lowest sensitivity was detected to aminopenicillins (Ampicillin) -- below 20%. The most common Gram-positive bacteria (E. faecalis and E. faecium) were highly sensitive to Linezolid, Vankomycin and Teicoplanin (100% sensitivity). These strains showed 80% sensitivity to aminopenicillins (Ampicillin) and revealed high resistance to Erythromycin and Tetracycline (more than 82%). The choice of the most adequate treatment of UTI in KTR is of crucial importance in the setting of immunosuppressive therapy and the possibility of asymptomatic picture. They may progress to acute pyelonephritis and urosepsis, thus making UTI a key risk factor for deteriorating transplant function and acute rejection. However, long-term antibiotic prophylaxis and treatment in patients with KTR and UTI is still a matter of discussion.
Key words: kidney transplantation, urinary tract infections, antibiotic sensitivity and resistance
Address for correspondence: Borelli Zlatkov, M. D., Clinic of Nephrology and Transplantation, UMHAT “Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230233, e-mail: dok_zlatkov@abv.bg

 

 

Catechins in Bulgarian white wines - 49, 2013, № 2, 69-72.
S. Tsanova-Savova
Medical College “Y. Filaretova”, Medical University -- Sofia
Summary: Тhe aim of the study is to present precise data of the contents of monomeric catechins, (+)‑catechin and (-)‑epicatechin, in Bulgarian white wines. Three samples per tree different wine varieties, “Chardonnay”, “Muskat” and “Traminer”, were studied by using the HPLC analysis and fluorescence detection. The average values for catechin were 28.5 mg/l, 30.9 mg/l and 27.0 mg/l, and for epicatechin 4.9 mg/l, 6.4 mg/l and 7.1 mg/l for “Chardonnay”, “Muskat” and “Traminer”, respectively. On the basis of monomeric catechin characteristics as potent antioxidants and the knowledge about their contents in white wines, we can recommend a judicious use of wines in the healthy nutrition.
Key words: (+)-catechin, (-)-epicatechin, biologically active compounds, HPLC, white wines
Address for corrwspondence: Silvia Tsanova-Savova, Medical College “Y. Filaretova”, Medical University Sofia, 3, Y. Filaretova St., Bg -- 1606 Sofia, e-mail: silvia_tsanova@abv.bg

 

 

MANAGEMENT IN HEALTHCARE

Why management professionalism is needed in medicine and healthcare? - 49, 2013, № 2, 78-81.
E. Vazelov
Clinic of Dialysis, UMHAT “Aleksandrovska” -- Sofia
Summary: Healthcare is an important sphere of the social system of society and the team concept of leadership is truly justified in its governance due to the fact, that healthcare is a collective activity. The individual professionalism, which in medicine is unconditionally a prerequisite, should be managed also professionally in a system, which is already controlled according to the regulations of the economic activity. In Bulgaria, the changing conditions in the last two decades, connected with the evolving function of market economy, create the need of considering the newly occurred conditions and, respectively, of formulating new concepts by the science. In the article, the need of management professionalism in the field of clinical medicine -- hospital and outpatient, as well as in medical education is discussed.
Key words: medical professionalism, management team, managed healthcare, medical education
Address for correspondence: Assoc. Prof. Evgenii Vuzelov, M. D., Clinic of Dialysis UMHAT “Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230 515; е-mail: estev@abv.bg  

 

 

MEDICAL ETHICS

The Hippocratic Oath and the organization of healthcare in contemporary Bulgaria - 49, 2013, № 2, 82-87.
P. Popivanov
Department of Internal Medicine, Medical University -- Sofia
Summary: The main objective of the study was to assess the congruence/incongruity between the messages of the Hippocratic Oath and modern health care organization in Bulgaria from the perspective of its main stakeholders -- patients, doctors and medical students from first and sixth course. By means of depth interviews, focus groups, grounded theory, semi-structured interviews, etc., the necessary empirical data has been collected and processed using the Statistical Package for Social Sciences (SPSS). The results of the study established a significant discrepancy between the humanistic messages of the Oath of Hippocrates and modern health care organization in Bulgaria, according to the perceptions and expectations of all groups interviewed. This contradiction is the problem that focuses the current ethical significance of the Oath and on which the views of all respondents are identical.
Key words: Hippocratic Oath, organization of healthcare, contemporary Bulgaria
Address for correspondence: Plamen Popivanov, M. D., Department of Internal Diseases, Medical University, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, e-mail: ppopivanov@abv.bg

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The effective vascular access for dialysis -- a complicated and hard problem to solve - 49, 2013, № 1, 37-40.
Sv. Staykova
Clinic of Dialysis, University Hospital “Sv. Marina“, Medical University -- Varna
Summary: Creating and sustaining an effective and functional vascular access, together with successful overcoming of the frequent related complications, necessitates even larger colaboration between the medical specialists, involved in morbidity-, hospitalization- and treatment-related problems of patients with CRD. The organization of regular control examinations, including the appropriate evaluation and monitoring of clinical parameters with respect to the vascular access and quality of the dialysis, should be standardized in all dialysis centers. By implementing this active approach and care, a lower rate of trombosis and achievement of better results can be expected. 138 patients with CRD were analyzed, as 21% of them underwent dialysis through a permanent tunneled catheter, while the rest patients -- through an A-V fistula. The problems connected with the vascular access remain hard to solve and give reason for accepting and еxecuting a clear practical doctrine, creating a better perspective in the dialyses centers in Bulgaria.
Key words: vascular access, PermCath, percutaneous venous catheterisation, dialysis
Address for correspondence:Svetla Staykova, M. D., Clinic of Dialysis, Medical University, 55, Marin Drinov Str., Bg -- 9000 Varna, tel. +359 885 841 663, e-mail: svetlastaykova@abv.bg

 

 

Trends in the development of problematic antimicrobial resistance in the most important causative agents of bacteremias in the University Hospital “Sv. Marina” -- Varna for the period 2007-2011 as a part of the European Antimicrobial Resistance Surveillance Network (ЕARS-Net) - 49, 2013, № 1, 41-49.
Т. Stoeva, K. Bozhkova and M. Bozhkova
Department of Microbiology and Virology, Medical University -- Varna
Summary:
The aim of this study is to demonstrate the trends in the development of problematic antimicrobial resistance (a marker for multidrug resistance -- MDR) among the most important causative agents of bacteremia in the University Hospital “Sv. Marina” -- Varna for the period 2007-2011 as a part of EARS-Net. A total number of 620 invasive isolates, obtained from blood cultures were studied: Staphylococcus aureus (n = 209), Enterococcus spp. (n = 47), Streptococcus pneumoniae (n = 32), Escherichia coli (n =177), Klebsiella pneumoniae (n = 106) and Pseudomonas aeruginosa (n = 49). For the studied period, the proportion of E. coli isolates that are III generation cephalosporin resistant remains generally stable, but with resistance rates above 25%, while in K. pneumoniae a stable trend for increasing the proportion of III generation cephalosporin resistant isolates is detected -- from 30% in 2007 to 83.3% in 2011. A similar result for stable increase оf carbapenem resistance rate in P. aeruginosa is found -- from 0% in 2007 to 66.6% in 2011. The trend regarding the penicillin-non-susceptible S. pneumoniae isolates shows an increase of their proportion to 33.3% in 2011, with a peak in 2010 (83.3%), while the proportion of S. aureus found to be MRSA is decreasing -- up to 9% for the last studied year. Susceptibility of Еnterococcus spp. to vancomycin and teicoplanin is fully preserved.
Key words: EARS-Net, bacteremia, antimicrobial resistance
Address for correspondence:Assoc. Prof. Temenuga Stoeva, M.D., Department of Microbiology and Virology, Medical University, 55, Marin Drinov Str., Bg -- 9001 Varna, tel. +359 52 978 538, e-mail: temenuga.stoeva@abv.bg

 

 

The use of Nutridrink in patients with surgical diseases in the maxillofacial region - 49, 2013, № 1, 50-55.
A. Ilieva, R. Kolarov and E. Aleksiev.
Specialized Hospital of Maxillofacial Surgery, MU -- Sofia
Summary: Malnutrition worsens the patient’s quality of life. The aim of this clinical observation is to examine the impact of Nutridrink, a special type of food for medical needs, in patients with surgical diseases in the maxillo-facial region. During a 7-month period, 60 patients were studied, divided into 4 groups. Changes in their general condition, body weight, manifestations of upper and lower dyspepsia syndrome were studied. In compliance with the instructions for reception of the product, the patients succeeded to preserve and increase permanently their body weight. The three flavors of the food were well accepted by the patients, as these in the first group presented the best responses. No allergic reactions, as well as other complications were observed with the administration of the food product.
Key words: malnutrition, Nutridirink, nutrition, maxillofacial area
Address for correspondence:Albena Ilieva, M. D., Specialized Hospital for Active Treatment in Maxillo-Facial Surgery, MU, 1, Sv. G. Sofiyski Blvd., Bg -- 1431 Sofia, е-mail: emd@mail.orbitel.bg

 

 

Self-service among patients with humeroscapularis arthroplasty (personal hygiene and toilet) - 49, 2013, № 1, 56-59.
A. Mircheva, M. Krastanova and D. Vacheva.
Clinic for Rehabilitation and Physical Medicine, University Hospital “Dr. Georgi Stranski” -- Pleven
Summary:
The purpose of this announcement is to examine, study and analyze the recovery of everyday life activities (personal hygiene and toilet) among patients with arthroplastic humeroscapularis. At the Clinic for rehabilitation and physical medicine at MHFAT “Dr. Georgi Stranski” -- Pleven, 15 patients with arthroplastic humeroscapularis have undergone a physiorehabilitation program. The patients did the complex physiorehabilitation program in several consecutive courses until maximum functional recovery of the humeroscapularis was achieved. We entered the results of the held tests in a personal file card of each patient in the beginning and in the end of the rehabilitation period. We observed favourable influence on the functional mobility of the operated limb and improvement of the patients’ self-service.
Key words: articulatio humeroscapularis, arthroplasty, rehabilitation, self-services
Address for corresdpondence:Аnitsa Mircheva, M. D., Clinic for Rehabilitation and Physical Medicine, University Hospital “Dr. Georgi Stranski”, 8A, Georgi Kochev Blvd., Bg -- 5800 Pleven, tel. +359 64 886-197, +359 888 75 61 50, e-mail: hrabri_doc@abv.bg

 

 

The effectiveness of price regulation system for medicinal products in Bulgaria - 49, 2013, № 1, 60-64.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: The macroeconomic analysis of expenditures for medicinal products in Bulgaria for the last 5-year period (2007-2011) has shown that the relative proportion of expenditures for medicinal products, which are a subject of public reimbursement, increases, compared to the total health expenditures. While in 2008, the expenditures for medicinal products accounted for 13.8% of the total health expenditures, in 2011, their relative proportion increased to 20.4%. This suggests the conclusion of insufficient effectiveness and efficacy of the processes of formation and regulation of prices for medicinal products and the need for instituting adequate measures for their improvement.
Key words: medicinal products, expenditures, normative prescriptions
Address for correspondence:Prof. Toni Vekov, Bulgarian Cardiac Institute, 1, G. M. Dimitrov Str., Bg -- 1172 Sofia, tel. +359 2 962 54 54, e-mail: t.vekov.mu.pleven@abv.bg

 

 

A comparative analysis of social satisfaction with health-care systems in Bulgaria, England, Germany and the Czech Republic - 49, 2013, № 1, 65-69.
D. Petrova
Faculty of Public Health, Medical University -- Sofia
Summary:
Social satisfaction with the changes in health-care systems is one of the major determinants in the assessment of health reform development and, therefore, in the substantiation of the changes in the health system which need to be made. A sociological survey including 1342 patients from Bulgaria was performed in order to follow-up the changes in social satisfaction. A comparative analysis of health-care systems social satisfaction was also conducted among the citizens of other three European countries -- Germany, England and the Czech Republic. The results showed that satisfaction is dependent on health systems funding. The comparative analysis resulted in the conclusion that the Bulgarian health-care system is the least effective one as compared to the investigated countries. The main reason for that is the insufficient financing and the low degree of social satisfaction with the health-care system, the latter directly associated with the lack of options concerning the choice of a health insurance fund.
Key words: health-care systems, Bulgaria, England, Germany, The Czech Republic, social satisfaction, comparative analysis
Address for correspondence:D. Petrova, Faculty of Public Health, Medical University, 8, Bialo more Str., Bg -- 1527 Sofia

 

 

MEDICAL ETHICS

The contemporary messages of the Hippocratic Oath in Bulgaria - 49, 2013, № 1, 81-84.
P. Popivanov
Department of Internal Diseases, Medical University -- Sofia
Summary: The main objective of the research was to analyze the contemporary messages of the Hippocratic Oath. Texts of the Oath translated in Bulgarian, selected on the basis of influence and validity, were assessed using the documentary method and qualitative content analysis and were correlated with the current issues of the Bulgarian healthcare. Since 1994, by the provisions of the Health Act, at their graduation all physicians are required to take the Hippocratic Oath, adopted by the Supreme Medical Council. It slightly differs from the authentic Oath, for instance in the text on abortion, due to the perceptions of modern medical ethics. The contemporary Oath truthfully and accurately conveys both the spirit and the messages of the ancient Greek one, which sound amazingly relevant and intransient in their humane imperative.
Key words: Hippocratic Oath, messages of the Hippocratic Oath
Address for correspondence:Plamen Popivanov, MD, Department of Internal Diseases, Medical University,1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia, e-mail: ppopivanov@abv.bg

 

Last update of the page: 06.01.2014.

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