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 Original papers

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Volume 52, 2016

 



bullet 6'2016

Resistance to trimethoprim/sulfamethoxazole in clinical isolates of Stenotrophomonas maltophilia – Medical Review (Medicinski pregled), 52, 2016, № 6, 35-39.
M. Bozhkova1, T. Stoeva1, R. Markovska2 and I. Mitov2
1Medical University – Varna, Department of Microbiology and Virology
2Medical University – Sofia, Department of Medical Microbiology
Summary: Stenotrophomonas maltophilia is a typical opportunistic pathogen, frequently associated with severe infections, including invasive ones. Because of its intrinsic antimicrobial multidrug resistance, the therapy of infections associated with this bacterial species is especially problematic. The aim of this study is to investigate the level and mechanisms of resistance to trimethoprim/sulfamethoxazole (the drug of first therapeutic choice) among 77 clinical isolates of S. maltophilia, as well as to compare the resistance levels to other antibiotic groups in the group of trimethoprim/sulfamethoxazole susceptible and trimethoprim/sulfamethoxazole resistant isolates. The results reveal a high rate of susceptibility to trimethoprim/sulfamethoxazole – 94.8%. The isolates, resistant to this agent, demonstrate multidrug resistance. All trimethoprim/sulfamethoxazole resistant isolates carry sul 1 gene which is the major mechanism that mediates the resistance to this drug.
Key words: Stenotrophomonas maltophilia, trimethoprim/sulfamethoxazole, sul 1 gene
Адрес за кореспонденция: Dr Milena Bozhkova, MD, Medical University, Department of Microbiology and Virology, 55 “Marin Drinov” Str., 9002 Varna,
tel.: +359 887 997 762, e-mail: Milena.Bozhkova@mu-varna.bg

 

 

MANAGEMENT IN HEALTHCARE

Analysis of the incremental ratio of costs and health benefits of biologicl drug therapies for the treatment of ankylosing spondylitis in Bulgaria, 2016 – Medical Review (Medicinski pregled), 52, 2016, № 6, 49-53.
T. Vekov1 and S. Dzhambazov2
1Faculty of Pharmacy, Medical University – Pleven
2Faculty of Public Health, Medical University – Pleven
Summary: Biological drug products alone or combined with other medications are used as a second or further treatment line in the treatment of ankylosing spondylitis (AS). By August 2016 etanercept (ETA), infliximab (INF), adalimumab (ADA), golimumab (GOL), cetrolizumab (CER), secukinumab (SEC) are authorized for use in Bulgaria. The aim of the study is to evaluate additional costs (Δ costs), extra health benefits (Δ QALY) and their incremental ratio (ICER), of alternative biological drug therapies for treatment of AS in Bulgaria. Pharmacotherapeutic guidelines based on clinical data for the therapeutic efficacy andsafety and the economic data for comparative cost effectiveness of eventual biological therapeutic alternatives recommend SEC as the first choice for second treatment line for the treatment of AS in Bulgaria after failed conventional therapy as well as a third treatment line after failed anti-TNF therapy.
Key words: ankylosing spondylitis, biological therapeutic alternatives, additional costs, additional health benefits
Address for correspondence: Prof. Toni Vekov, Faculty of Pharmacy, Medical University, 1, Sv. Kl. Ohridski St., Bg – 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

HELPING PRACTICE

Pediatric diaphyseal fractures of the forearm: radiological classification and complications – Medical Review (Medicinski pregled), 52, 2016, № 6, 54-55.
T. A. Al-Sadek1, N. I. Dimitrov2, D. Niklev3, A. Al-Sadek4
1Department of Orthopaedics and Traumatology, Belhoul European Hospital – UAE, Dubai
2Department of Special Surgery, University Hospital “Prof. Dr. St. Kirkovich” – Stara Zagora
3Orthoapedic and Trauma Clinic, University Multiprofile Hospital for Active Treatment and Emergency Medicine „N. Pirogov“
4Medical University – Sofia
Summary: In a retrospective study of 70 children with diaphyseal forearm fractures, we measured the radiographic angulation and sideways displacement initially, after reduction, at 1 week and at union. Statistical analysis was performed with a multivariate log linear regression model to evaluate the correlation between variables. We showed that the initial displacement of the fracture and the age of the patient had only a minor influence on the position at union. We constructed a radiological classification using the measurements initially, after reduction, and at 1 week and showed that the prognostic value of the classification system could be improved during the period of treatment. We recommend that all displaced diaphyseal forearm fractures in children should be
radiographed after 1 week and after 2 weeks.
Key words: pediatric, diaphyseal forearm fractures, radiographic classification
Address for correspondence: Tabet Al-Sadek, MD, Belhoul European Hospital, UAE  Dubai, tel.: 00971551503964 e-mail: drthabet@abv.bg

 

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bullet 5'2016

Application of septoplastics and radiofrequency induced thermotherapy in chronicnasal diseases  – Medical Review (Medicinski pregled), 52, 2016, № 5, 34-40.
G. Shivarov
Division of Otorhinolaryngology, Sv. Anna Hospital  Varna
Summary: Objective: Chronic hypertrophic rhinitis (CHR) and nasal septum deviation (NSD) combined either with compensatory turbinate hypertrophy, or with CHR, are common diseases at middle age. The purpose of the presented communication was to demonstrate the results from the treatment of CHR and NSD combined either with compensatory turbinate hypertrophy, or with CHR. We examined 108 patients, 79 males and 29 females, treated in the Division of Otorhinolaryngology at Sv. Anna Hospital of Varna during the period from January 1, 2007 till December 31, 2015. There were 71 patients with NSD and CHR, 52 males and 19 females, 18 patients with NSD and compensatory turbinate hypertrophy, 13 males and 5 females, and 19 patients with CHR only (14 males and 5 females). The patients from the first two groups underwent septoplastics and radiofrequency induced thermotherapy (RFITT) while those from the third group – RFITT only. In some patients, one of two energy magnitudes of CelonProCut apparatus (of 8 W or of 16 W) was used.  Patient’s objective status was assessed by means of acoustic rhinometry and active anterior rhinomanometry. In all the cases, there was considerable objective and subjective improvement. The results achieved enable us to recommend the broader RFITT application into the rhinological practice among the patients with these chronic nasal diseases.
Key words: radiofrequency induced thermotherapy, septoplastics, chronic rhinopathy, acoustic rhinometry, active anterior rhinomanometry
Address for correspondence: Galen Shivarov, MD, Division of Otorhinolaryngology, Sv. Anna Hospital, 100 Tzar Osvoboditel blvd. Bg – 9000 Varna, tеl. +359 888 734287, е-mail: docshivarovbg@abv.bg

 

 

Seroepidemiological investigation of hepatitis B virus core antibody (anti-HBc total) carriers in Northeastern Bulgaria – Medical Review (Medicinski pregled), 52, 2016, № 5, 40-45.
D. Tsaneva-Damyanova1, L. Ivanova2
1Department of Microbiology and Virology, Medical University – Varna; Laboratory ”Status” – Varna
2Department of Microbiology and Virology, Medical University – Varna; University Hospital ”Sv. Marina” – Varna
Summary: Hepatitis B virus (HBV) is one of the most common infectious pathogens causing acute and chronic serologically manifested infection. In recent years, it becomes clear the existence of occult HBV infection (OBI) with long-term consequences for the infected patients. As a general rule, the patients with OBI show anti-HBc total positive result when serologically tested in the absence of HBsAg. The purpose of this study is to track the spread of OBI carriers in Northeastern Bulgaria during the last 5 years. The total number of the investigated individuals is 3922, divided into two groups: group A – 2326 randomly selected humans and group B – 1596 patients with various chronic diseases, including liver injury. The tests used were standardized and commercially available enzyme-linked immunosorbent assay (ELISA) and chemiluminescent immunoassay (CLIA) for determination of different hepatitis markers including HBsAg and anti-HBc total. In group A, we found positive results in 8,25% of the individuals while the positive results in group B were 23,6% of the investigated patients. Our data showed that OBI is more widespread than expected and can be identified as a significant risk factor for the presence of more severe liver damage, leading to a faster progression to liver fibrosis and other complications, especially in patients on immunosuppressive drugs.
Key words: HBsAg, anti-HBc total, оccult hepatitis B Infection
Address for correspondence: Denitsa Tsaneva-Damyanova, Department of Microbiology and Virology, MedicalUniversity, 55, „Мarin Drinov“ st., Bg – 9002 Varna, e-mail: dr.tsaneva@gmail.com  

 

 

MANAGEMENT IN HEALTHCARE

Analysis and assessment of the targeted health technologies(antibodies and kinase inhibitors) for treatment of chronic lymphocytic leukemia in Bulgaria in 2016 – Medical Review (Medicinski pregled), 52, 2016, № 5, 49-55.
T. Vekov1 and S. Dzhambazov2
1Faculty of Pharmaci, Medical University – Pleven, 2Faculty of Public Health, Medical University – Pleven
Summary: An analysis and assessment of the targeted health technologies (antibodies and kinase inhibitors) administered for treatment of chronic lymphocytic leukemia (CLL) in Bulgaria in 2016 are presented. The aim is to create pharmacotherapeutic guidelines for treatment of CLL based on clinical data for comparative therapeutic efficacy and the economic data for comparative cost-effectiveness of practicable therapeutic alternatives (comparators). A systematic review of data concerning assessments of health technologies for treatment of CLL published in MEDLINE, EMBASE, Web of Science, and Cochrane Library in the period January 2005 – June 2016 is made. Data for health benefits expressed as additional QALY are directly transferred from other countries. Data for expenditure on drug therapies are based on local reference costs available in Positive Drug List by July 2016. The analysis of economic data and assessment of health technologies in Bulgaria for treatment of chronic lymphocytic leukemia recommends RIT in combination with FLU and CYC as a potential efficacious and cost-effective first therapeutic line in patients with CLL and the second therapeutic line in the patients with relapsed or refractory CLL. Combined therapy using IDE and RIT is recommended as first therapeutic line in patients with CLL and 17p deletion or ТР53 mutation.
Key words: chronic lymphocytic leukemia, antibodies, kinase inhibitors, pharmacoeconomic assessments, therapeutic alternatives, cost-effectiveness
Address for correspondence: Prof. Toni Vekov, Faculty of Pharmacy, Medical University, 1, Sv. Kl. Ohridski St., Bg – 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

HELPING PRACTICE

Vascular lesions – concepts and classifications – Medical Review (Medicinski pregled), 52, 2016, № 5, 56-60.
A. Shef1, Y. P. Yordanov2, J. M. Lasso3
1Department of Dermatovenereology and Allergology, Military Medical Academy, Sofia, Bulgaria
2Department of Plastic Reconstructive and Aesthetic Surgery, Uni Hospital, Panagyurishte, Bulgaria
3Unit of Plastic Reconstructive and Aesthetic Surgery  University Hospital Gregorio Marañón, Madrid, Spain
Summary: Vascular lesions are heterogeneous group of anomalies with different clinical behavior and histopathological features although many times they look quite similar. The adequate diagnosis is of paramount importance for the appropriate management. From the other hand, historically the descriptive and histologic terms have led to confusion in the communication among medical professionals involved in the treatment and investigation of this group of diseases. The aim of the present article is to make a brief review of the main classifications of vascular anomalies stressing on the most contemporary concepts in the taxonomy of this motley group of lesions.
Key words: vascular lesions, vascular anomalies, classification, hemangiomas, port wine stains.
Address for correspondence: Aylin Shef, MD, Department of Dermatovenereology and Allergology, Military Medical Academy, 3 Sv. G. Sofiysiki st. Bg – 1606 Sofia, е-mail: ailin_shef@abv.bg

 

 

Non-union rates following crossed compression screw fixation for 1st mtpj arthrodesis: a single centre study – Medical Review (Medicinski pregled), 52, 2016, № 5, 61-62.
T. A. Al-Sadek1, N. I. Dimitrov2, D. Niklev3, A. Al-Sadek4
1Department of Orthopaedics and Traumatology, Belhoul European Hospital – UAE, Dubai
2Department of Special Surgery, University Hospital “Prof. Dr. St. Kirkovich” – Stara Zagora
3Orthoapedic and Trauma Clinic, University Multiprofile Hospital for Active Treatment and Emergency Medicine „N. Pirogov“ 4Medical University – Sofia, Bulgaria 
Summary: The fusion of the first metatarsophalangeal joint is a well described procedure that has been shown to have a dramatically positive effect on pathology of the joint. These include a variety of indications such as hallux rigidus, hallux valgus and rheumatoid arthritis. There are a myriad of methods described in the literature on how this fusion can be achieved. These range from simple Kirschner wire fixation, dorsal plates with or without screws, to the sole use of screw fixation. This study is aimed at analyzing the success of crossed compression screws with regards to union and complication rates.
Key words: fusion, MTPJ, screws, compression
Address for correspondence: Tabet Al-Sadek, MD, Belhoul European Hospital, UAE  Dubai, tel.: 00971551503964; e-mail: drthabet@abv.bg

 

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bullet 4'2016


Main characteristics in the clinical and etiological diagnosis  of acute infections of the central nervous system – Medical Review (Medicinski pregled), 52, 2016, № 4,  35-38.

T. Valkov(1, 2), D. Strashimirov(1, 2), M. Slavova(2), E. Alexandrova(2), V. Krustev(2), M. Ilieva(2), I. Tomova(2), I. Gabarska(2) and M. Tiholova(1, 2 )
(1)Department of Infectious Diseases, Parasitology and Tropical Medicine, Medical University -- Sofia
(2)SHIPD “Prof. Iv. Kirov” – Sofia
Summary: Objective: Monitoring and analysis of key clinical and clinical laboratory characteristics in hospitalized patients with neuroinfections. Etiological diagnosis is proof in specimens of CSF. Materials and methods: Tracked the main characteristics of 88 patients hospitalized with neuroinfections in SHIPD "Prof. Iv. Kirov". Results: In 83 (94.7%) patients was established expressed initial toxic syndrome. The most common neurological abnormalities were: a symptom of nuchal rigidity -- 71 patients (87.7%), symptom of Kernig -- 53 (60.2%), changes in tendon reflexes -- 69 patients (78.4%). To record the conscious state of patients was used the Scale of Glasgow. At 70 patients (79.5%) was found viral and in 18 (20.5%) purulent meningitis and meningoencephalitis. The etiological diagnosis was defined in a total of 42 (47.3%) patients. In 13 (14.8%) of total 88 patients studied proved etiological bacterial meningitis and in 29 (32.9%) viral. In 46 (52.8%) patients the cause is not proved by microbiological methods. In patients with unproven etiology significantly prevailed those with viral meningitis -- 34 (85%). Among the virus most frequent was flu virus -- in 15 patients (17%), followed by enteroviruses -- 9 patients (10.2%). When proven bacterial meningitis prevalent was pneumococcus -- 7 patients (8%). Discussion and conclusions: We believe that acute onset with fever in combination with symptoms of neck stiffness, a symptom of Kernighan and symptom of upper Brudzinski is an important early diagnostic sign of neuroinfections and requires immediate decision to perform a lumbar puncture. A major determinant of severe course of the disease is low valuation level of consciousness on a scale of Glasgow. Influenza meningoencephalitis is with the most severe course. Modern diagnostic criteria of neuroinfections require placement of microbiological diagnosis in specimenf only of CSF.
Key words: neuroinfections, meningitis, meningoencephalitis, CSF diagnostics
Address for correspondence: Trifon Valkov, MD, SBALIPB “Prof. Ivan Kirov”, 17 “Akad. Iv. Geshov” Blvd, Bg -- 1431 Sofia, GSM +359 889264597, e-mail: trifon_heim@abv.bg

 

 

Etiological reasons for fever of unknown origin  and low-grade fever among Bulgarian patients – Medical Review (Medicinski pregled), 52, 2016, № 4,  39-46.
M. Baymakova(1), K. Plochev(1), T. Kundurdjiev(2), G. Popov(1), R. Mihaylova-Garnizova(1) and V. Kovaleva(3 )
(1)Department of Infectious Diseases, Military Medical Academy -- Sofia
(2)Department of Occupational Health, Faculty of Public Health, Medical University -- Sofia
(3)Center of Military Epidemiology and Hygiene, Military Medical Academy – Sofia
Summary: The aim of this study was to estimate the etiological reasons for fever of unknown origin (FUO) and low-grade fever (LGF) among patients hospitalized at the Department of Infectious Diseases, Military Medical Academy (Sofia, Bulgaria). The study was done for the period of 3.5 years. Based on inclusion and exclusion criteria a population of 117 patients was selected. FUO is presented in 75.2% of all patients, cases with LGF were 24.8% of the whole population. Among patients with FUO, infectious causes were estimated in 55.7%, neoplasm in 4.5%, non-infectious inflammatory diseases (NIID) -- 12.5%, miscellaneous causes -- 4.5% and 22.8% were undiagnosed. The etiological distribution in group of LGF is the following: infectious diseases were found in 58.6%, neoplasm in 0.0%, NIID -- 0.0%, miscellaneous causes were 6.9% and 34.5% were undiagnosed.
Key words: fever, fever of unknown origin, etiology, infections
Address for correspondence: Magdalena Baymakova, MD, PhD, Department of Infectious Diseases, Military Medical Academy, 3 Sv. G. Sofiyski St., Bg -- 1606 Sofia, e-mail: dr.baymakova@gmail.com

 

 

Cellular immune response in pregnant women with high blood pressure – Medical Review (Medicinski pregled), 52, 2016, № 4,  47-52.
E. Dimitrakova, E. Uchikova and M. Mladenova.

Department of Obstetrics and Gynecology, Medical University -- Plovdiv
Summary: The objective of this study is to evaluate the changes in lymphocyte sub­po­pu­la­tions and some cytokines during pre-eclampsia. We performed a correlation of some T-lymphocyte subpopulations and IL-2, IL-6, TNF-аlpha, IL-10 in 40 hy­per­tensive pregnant women after the 20th week of pregnancy (pre-eclampsia group) and 30 healthy pregnant women. Metods: Peripheral blood lymphocytes were immunophenotyped using laser flow cytometry (Еpics XL-MCL, Coulter, US) and serum cytokine levels were measured using ELISA (pg/mL), in pregnant women with severe pre-eclampsia (RR > 160/110 mmHg). Data were statistically analyzed using SPSS ver. 11.0 for Windows. Results: Serum levels of some lymphocyte subpopulations and IL-2, IL-6, TNF-аlpha were elevated. We found a correlation between IL-2, TNF-аlpha, IL-6 and some T-lymphocyte subpopulations. Straight correlation was found between IL-2 and CD45-RA+CD62L+ (r = 0.730), significant between CD3+ (r = 0.610) and activated T-lymphocytes (CD4+HLA-DR+) (r = 0.510). One of the most important biologic effects of TNF-аlpha is on the cellular immunity which is supported by the significant association of this cytokine with CD3+CD4+, CD4+CD8+, CD8-CD56+. IL-6 is correlated with CD3+CD4+ and diastolic blood pressure (r = 0.601), IL-10 and systolic blood pressure (r = 0.690). Concusions: Serum levels of some lymphocyte subpopulations and IL-2, IL-6, TNF-аlpha were elevated in women with pre-eclampsia. The correlations between T-lymphocyte populations and subpopulations and the cytokines we studied support the role of cellular immunity in pre-eclampsia and can be used as prognostic markers in determining the severity of pre-eclampsia.
Key words: hypertension in pregnancy, lymphocyte subpopulations, cytokines, pre-eclampsia
Address for correspondence: Assoc. Prof. Elena Dimitrakova, M. D., ”Sv. Georgi” Hospital, Medical University, 66, Peshtersko Shosse St., Bg -- 4000 Plovdiv, e-mail: edimitrakova@gmail.com

 

 

Surgical treatment of children with neuromuscular scoliosis – Medical Review (Medicinski pregled), 52, 2016, № 4,  53-56.
A. Ivanov, V. Yablanski and E. Vlaev
Department of Orthopaedy and Traumatology, Tokuda Hospital Sofia
Summary: Most cases of neuromuscular scoliosis are identified in early childhood and are accompanied with changes in the bone structure (osteopenia) and other congenital anomalies. The progression of the deformity continue even after the end of the growing and can progress through the whole lifetime period. The specifics of this deformity -- large scoliotic curves, change in the sagital balance, pelvic tilt, change of the posture even in a sitting position, cardiac and pulmonary dysfunctions make surgical treatment challenging and difficult task, and require well trained team with technical equipment available. Comorbidity observed within these patients and the high risk of complications requires good preoperative risk/benefits analysis. We present our experience and early results of surgical treatment of children with neuromuscular scoliosis operated in the department of orthopeady and traumatology, Tokuda Hospital Sofia.
Key words: scoliosis, neuromuscular, spine, surgical treatment
Address for correspondence: Adelin Ivanov, M. D., Department of Orthopaedy and Traumatology, Tokuda Hospital Sofia, 51B “Nikola Vaptsarov” Blv., Bg -- 1307 Sofia, tel. +359 884933318, e-mail: a3ivanoff@gmail.com

 

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bullet 3'2016


Prognostic factors in multiorgan resections on the occasion of locally advanced colorectal cancer
– Medical Review (Medicinski pregled), 52, 2016, 3, 36-40.
M. Abdi
Division of Oncologic Surgery, Marko Markov Specialized Hospital for Oncologic Diseases -- Varna
Summary: The purpose of the present study was to analyze the effectiveness of multiorgan resections of primary locally advanced colorectal cancer, to define the preciseness of the intraoperative assessment of the therapeutic opportunities and of the role of surgeon’s experience as well as to identify the prognostic factors of these interventions. The study covered 61 patients at a mean age of 65 +/- 9,1 years with locally advanced colorectal cancer who underwent a multiorgan resection during the period from 2009 till 2015 in Marko Markov Specialized Hospital for Oncologic Diseases of Varna, Ltd. The incidence of postoperative complications was 26,2% but the mortality was 4,9%. A potential radical resection was possible in 67,2% and a histological infiltration was established in 44% of the patients with radical en bloc resection. The incidence of a local relapse following the radical intervention was 9% and the one-year total survival was 55,7%. The mean intraoperative blood loss was 600 mL (between 420 and 2460 mL). The multiorgan resection is safe and warrants a long-lasting survival comparable to that of standard operation.
Key words: locally advanced colorectal cancer, multiorgan resection, complications, prognostic factors
Address for correspondence: Mochamed Abdi, M. D., Division of Oncologic Surgery, Marko Markov Specialized Hospital for Oncologic Diseases, 100 Tsar Osvoboditel Blvd., Bg -- 9002 Varna, tel. +359 898663995, e-mail: abdimsn@hotmail.com

 

 

Phenotypic profiles in chronic lymphocytic leukemia prerequisite for different clinical course – Medical Review (Medicinski pregled), 52, 2016, № 3, 41-46.
R. Vladimirova, E. Vikentieva, D. Popova, I. Kindekov, I. Nikolov, R. Stanchev, N. Petkova, I. Gigov and Yu. Raynov

Summary: Aim: Chronic lymphocytic leukemia (CLL) is a heterogeneous disease. For its accurate prognosis no single specific method is available. The purpose of our study was to identify and differentiate patient groups with different surface antigen expression on CLL-cells and analyze the levels of clinically and labo­ratory established prognostic markers within and between groups. Methods: Peripheral blood from 91 patients with CLL before treatment was stained for flow cytometric assay with: CD19, CD20, CD22, CD79b, CD79a, CD5, CD23, kappa and lambda light chains, CD3, CD4, CD8, CD16+56, Zap-70, CD38, CD49d, CD62L, CD197 and CD267. Results: Three clusters were identified and most important for their grouping were CD19 X 109/L and CD49d, followed by CD79b, CD62L, CD38, percentage of lymphocytes, CD267 and Zap-70: The first group (n = 66) -- has low CD19+ x 109/L, median CD49d, CD38, CD79b and high CD62L, CD267. The second group (n = 15) has medium CD19+ x 109/L, CD62L and CD267, low CD49d, CD38 and CD79b. Group 3 (n = 10) has high CD19 + x 109/L, CD49d, CD38, CD79b and low CD62L and CD267. There were significant differences between groups with well known prognostic markers beta2-mic­roglobulin (P = 0,002), LDH (P = 0,002) and sTK1 (P < 0,001). Con­clu­sions: The cluster analysis showed antigen profiles on CLL-cells which have different levels activation, migration and proliferation.
Key words: chronic lymphocytic leukemia, immunophenotyping, clusters
Address for correspondence: Rositsa Vladimirova Andreeva, Laboratory of Cytogenetics and Immunology, Military Medical Academy, Bg -- 1606 Sofia, 3 Sv. G.Sofiyski St., tel. +359 888 351 777, e-mail: rossy_vladimirova@yahoo.com

 

 

Genetic biodiversity of drug sensitive and multidrug resistant strains of Mycobacterium tuberculosis in Bulgaria – Medical Review (Medicinski pregled), 52, 2016, № 3, 47-54.
S. Panaiotov(1), E. Bachiyska(1), S. Yordanova(1), Yu. Atanasova(1), Ya. Todorova(1), V. Levterova(1), N. Brankova(1), I. Simeonovski(1), K. Tankova(1), Ts. Stefanova(2), A. Karcheva(3) and T. Kantardjiev(1)
(1)National Center for Infectious and Parasitic Diseases -- Sofia, (2)BulBio -- National Center for Infectious and Parasitic Diseases -- Sofia, (3)University Hospital -- Pleven
Summary: Tuberculosis control is a major program priority of the World Health Orga­ni­sation (WHO) and the European Centre for Disease Prevention and Control (ECDC). A long-term analysis of M. tuberculosis genetic biodiversity has not been performed in Bulgaria. The goal of our study was to investigate the phylogeographic spread of circulating genetic lineages of drug sensitive and multidrug resistant (MDR) M. tuberculosis strains across the country. We investigated 694 strains -- 441 drug sensitive strains of M. tuberculosis and 253 multidrug resistant (MDR) strains isolated from across Bulgaria during the period 2002-2014. Strains biodiversity was accessed by spoligotyping. The results from the analysis of 441 drug sensitive strains demonstrated the spread of several phylogeographic specific genotypes. Among the investigated 253 MDR strains we confirmed 50% prevalence of spoligotype SIT41, sublineage TUR which is a marker for MDR tuberculosis in Bulgaria. The modern management of tuberculosis requires continuous analysis of the circulating strains of M. tuberculosis and the dynamics of their spread. Strains genotyping should become а part of patients’ treatment. The reported data deliver valuable information for long-term management decisions for MDR tuberculosis control as a result of emergence and spread of endemic MDR genotype which successfully adapts and avoids the human immune response
Kеy words: biodiversity, tuberculosis, spoligotyping, genotype
Address for correspondence: Assoc. Prof. Stefan Panaiotov, National Center for Infectious and Parasitic Diseases, 26, Ianko Sakuzov Blvd., Bg -- 1504 Sofia, e-mail: spanaiotov@yahoo.com

 

 

Flamexin (Piroxicam-beta-cyclodextrin) and Aulin® (Nimesulide) -- analgesic and anti-inflammatory action to lower third molars removal requiring osteotomy – Medical Review (Medicinski pregled), 52, 2016, № 3, 55-58.
Ts. Tsvetanov and А. Bakardjiev
Department of Oral Surgery, Faculty of Dental Medicine, Medical University -- Plovdiv
Summary: Pain, swelling and trismus are common complications associated with third molar surgery. The aim of this study is to compare the effects of Flamexin®, 20 mg and analgesic Aulin®, 100 mg on postoperative pain, swelling and trismus. Materials and methods: Retained and semiretained lower third molars were extracted on two distinct groups of 30 patients. The anesthesia for the operation to remove 38 and 48 was achieved by application of an inferior alveolar nerve block with 4% Articaine + 1:100,000 epinephrine. Flamexin® was given in doses of 20 mg/daily for 5 days and the first reception was after the transition effect of the anaesthesia. Second group administered Aulin® 100 mg. The analgesic effect was recorded subjectively by means of the Visual Analogue Scale (VAS). To study anti-inflammatory effect, it was measured the ratio on the limited mouth opening distance (in mm), between the mesial-incisal corners and postoperative oedema. The facial swelling was determinated with a linear method before the surgery, 24 hour after intervention and on the 7th postoperative day. Conclusion: the present study shows that Flamexin® reduces the rate of pain and swelling with statistical significance. There wasn't statistical significance between the two groups, Aulin® and Flamexin®, in the management of trismus.
Key words: lower third molars, oedema, postoperative pain, trismus, Flamexin®
Address for correspondence: Tsvetan Tsvetanov, Ph.D, D.D.S., Department of Oral Surgery, Faculty of Dental Medicine, Medical University, 3, Hristo Botev Bvd, Bg -- 4000 Plovdiv, tel. +359 898-32-53-32

 

 

MANAGEMENT IN HEALTHCARE


Analysis of hospital care in Bulgaria for the period 2000-2014 years – Medical Review (Medicinski pregled), 52, 2016, 3, 63-67.
M. Kamburova, S. Georgieva and N. Veleva
Medical University -- Pleven
Summary: Aim of the study is to analyze the utilization of hospital care in Bulgaria for the period 2000-2014 years. Data from the National Center for Public Health and Analysis and European Health for All Database (HFA-DB) was carried out. It was found an increase in the number of hospitals in the country and an optimized number of hospital beds. In the structure of hospitals for 2014 general hospitals were 34.9% -- all for active treatment. The number of patients passed through hospitals steadily increased and the indicator of hospitalization (29.75%) is significantly higher than the European Union (17.59%). Beds occupancy in the country is lower than in the EU -- 76.61%. Bulgaria reached a shorter average of stay than in the member states of the EU -- 8.08 days. The same diseases, regardless of their ranking, determine two third of hospitalizations.
Key words: hospital care, utilization of beds, average stay classes of diseases
Address for correspondence: Mariela Kamburova, M. D., Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: mariela_kamburova@yahoo.com

 

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bullet 2'2016


Changes of resting heart rate and indices of ventricular rеpolarisation in acute phase of coronary syndrome -- association with sex differences and plasma levels of sex steroids – Medical Review (Medicinski pregled), 52, 2016, № 2, 29-37.

N. Еmilova(1), A. Tsakova(2), P. Petrov(3), T. Kundurdzhiev(4), S. Denchev(5), S. Dimitrov(6), M. Gospodinova(5), M. Grigorov(3) and T. Draganov(3)
(1)Clinic of Cardiology, University Hospital “Aleksandrovska”, Medical University -- Sofia, (2)Clinical Laboratory Department, University Hospital “Aleksandrovska” -- Sofia, (3)Clinic of Cardiology, II MHAT -- Sofia, (4)Faculty of Public Health, Medical University -- Sofia, (5)Clinic of Cardiology, Medical Insitute of Ministry of Internal Affairs -- Sofia, (6)Department of Invasive Cardiology, MHAT “Hristo Botev” -- Vratza
Summary : Purpose: The purpose of the present study was comparison of the resting heart rates and electrocardiographic markers of ventricular repolarization between male and female patients in acute coronary syndrome and analysis of the relation of these indices with plasma levels of sex steroids. Material and methods: The resting heart rate (HR) and corrected QT interval (QTc), its minimal (QTcmin), maximal (QTcmax) values, dispersion (QTcd) and the plasma levels of sex hormones: total 17-beta-estradiol, total testosterone and dehydroepiandrosterone-sulphate were measured at admission in 132 patients (75 men, 56,8% и 57 women, 43,2%) treated for acute coronary syndrome in the period VII.2011-IV.2014 in University Hospital “Aleksandrovska”. The same variables were evaluated in a control group consisting of 20 subjects (10 men and 10 women). The electrocardiographic markers of interest were reassessed in 77 of the patients following therapy. For evaluation of heart rate and average QTc interval automatic records were used. QTcmin and QTcmax were measured manually. The validity of this method was checked with measurement of QT interval of 20 subjects by two independent researchers. Electrochemiluminescent enzyme-linked immune assay (ECLIA) was the method used for quantitation of the plasma concentrations of sex steroids. The statistical analysis was performed using hi2-test, t-test, Fischer exact tests, Man Whitney U test, correlation and univariate regression analysis. Results: We found significant sex-based contrasts regarding the examined electrocardiogrphic markers in acute phase of coronary syndrome before applying therapy. Higher resting HR were observed in the female group (p = 0,040) and significantly shorter minimal QTc intervals were detected in male patients (p = 0,013). Our results also demonstrated that the levels of sex steroids were related to some of the electrocardiographic indices. At admission the concentrations of testosterone correlated negatively with the resting HR in male (r = -0,265; p = 0,032) and in all patients regardless of sex (r = -0,209; p = 0,027). Following catheter-based reperfusion and conservative therapy a positive association of total estradiol and the maximal length of QTc was found in the female (r = 0,544; p = 0,009) and the whole group (r = 0,329; p = 0,017) and a negative -- between the plasma testosterone and the average length of QTc in the whole group (r = -0,279; p = 0,045). Conclusion: Sex-based difference exists when concerning HR and repolarisation indices in acute coronary syndrome. High levels of total testosterone are associated with shorter repolarization periods regardless of sex, and of 17-beta-estradiol  -- with longer durations of myocardial refractory periods after achieving control on ischaemia.
Key words: acute coronary syndrome, sex hormones, ventricular repolarisation, heart rate, QTc interval
Address for correspondence: Nia Emilova, M. D., Univertsity Hospital “Aleksandrovska”, 1 Sv. G. Sofiyski St., Bg -- 1431 Sofia, e-mail: niaemilova@yahoo.com

 

 

Etiology and antimicrobial resistance of the most frequently isolated pathogens of bloodstream infections in patients with hematological malignancies – Medical Review (Medicinski pregled), 52, 2016, № 2, 38-45.
Т. Stoeva(1), M. Bozhkova(1), R. Markovska(2) and K. Bozhkova(1)
(1)Department of Microbiology, Medical University -- Varna, (2)Department of Medical Microbiology, Medical University -- Sofia
Summary: We aimed to study the etiology and antimicrobial resistance of the most frequently isolated bacterial pathogens of bloodstream infections in patients with hematological malignancies from the Hematology Department at University Hospital “Sv. Marina”, Varna, during the period 2010-2014. A total of 144 clinically significant bacterial isolates were obtained from blood cultures, collected from 144 patients. Gram-negative bacteria were detected in 54.7% with E. coli (18.8%), Klebsiella pneumoniae (10.4%) and Enterobacter spp. (8.3%) being the dominant pathogens. Gram-positive bacteria were found in 38% of cases and were represented mainly by Staphylococcus aureus (26.4%) and Enterococcus spp. (6.8%). Candida spp. were isolated in 7.6% of patients. The rates of extended-spectrum beta-lactamases (ESBL) producers in Enterobacteriacae were as follows: 25% for Enterobacter spp., 67% for Klebsiella pneumoniae and 73.3% for E. coli. The carbapenems (imipenem, meropenem) demonstrated preserved activity against Enterobacteriacae (no resistance detected). The resistance rate of E. coli and K. pneumoniae isolates to quinolones was 40.7% and 67% respectively. Amikacin was more active against E. coli, K. pneumoniaе and Enterobacter spp. (0-6.6% resistance) than gentamicin (25-80% resistance). Methicillin-resistant Staphylococcus aureus (MRSA) isolates were identified in 10.5% of cases. All Еnterococcus faecium isolates were resistant to ciprofloxacin. High resistance rate to quinolones was found in Enterococcus faecalis (66.6%). Among staphylococci and enterococci, no resistance to glycopeptide antibiotics was detected. This study demonstrated the predominance of Gram(-) negative bacteria in the etiology of bloodstream infections in patients with hematological malignancies and the emergence of difficult to treat multi-drug resistant organisms, a phenomenon that reflects the increasing antimicrobial resistance in the community.
Key words: hematological malignancies, bloodstream infections, microbial spectrum, antimicrobial resistance
Address for correspondence: Assoc. prof. Тemenuga Stoeva, M. D., Department of Microbiology, Medical University -- Varna, e-mail: temenuga.stoeva@abv.bg

 

 

Single-stage reconstruction of full-thickness defects of the lower eyelid after carcinoma ablation with local flaps -- initial experience – Medical Review (Medicinski pregled), 52, 2016, № 2, 46-53.
Y. P. Yordanov

Unit of Plastic Surgery and Burns, Military Medical Academy -- Sofia
Summary: Introduction: Reconstruction of larger lower eyelid full-thickness defects usually poses a dilemma for plastic surgeons, since the flaps applied in reconstruction are often difficult to design, may be unreliable, often require extensive dissection, and result in scarring. The purpose of the present study is to demonstrate the capabilities and reliability of the lower eyelid reconstruction of full-thickness defects with local eyelid and temporal/lateral periorbital flaps only. Material and method: Eleven patients with lower eyelid full-thickness defects secondary to ablative procedures for neoplasms were selected and studied, including 8 women and 3 men (mean age, 66.2 y; age range, 54-78 y). A retrospective analysis was made identifying patients with full-thickness post-excisional defects affecting the lower eyelid. Results: All the patients underwent one-stage reconstruction with the same eyelid flap and/or temporal flaps. In one of the patients two synchronous neoplasms were observed on the same eyelid which made the reconstruction particularly tricky. The reconstruction was successfully performed in all the patients with the most common technique being the Tenzel flap technique (n = 6). There were no flap losses of any kind and no major complications were observed. Conclusion: In this short preliminary report local tissue flaps have proven to be a sophisticated and reliable option for reconstruction of complex lower eyelid defects; Tenzel flap technique with or without lateral canthotomy with cantholysis has shown to be safe and very useful approach.
Key words: lower eyelid, full-thickness defect, local flaps, Tenzel flap, reconstruction
Address for correspondence: Yordan P. Yordanov MD, PhD, Unit of Plastic Surgery and Burns, Military Medical Academy, 3, Sv. G. Sofiyski St., Bg -- 1606 Sofia, tel. +359 887 56 00 54, е-mail: yordanov_vma@abv.bg

 

 

Validity of different methods for determining the angulations of the lower wisdom teeth and the scales evaluating their surgical difficulty (Preliminary results) – Medical Review (Medicinski pregled), 52, 2016, № 2, 54-58.
B. Blagova(1), N. Petrova(2), P. Pechalova(3), E. Poriazova(4) and I. Angelova(5)
(1)Department of Oral Surgery, Faculty of Dental Medicine, (2)Department Social Medicine and Public Health, Faculty of Public Health, (3)Department of Oral Surgery, Faculty of Dental Medicine, (4)Department of General and Clinical Pathology and Forensic Medicine, Faculty of Medicine, (5)Department of Diagnostic Imaging, Allergology and Physical Therapy, Faculty of Dental Medicine, Medical University -- Plovdiv
Summary: Objective: The methods for classification of the lower third molars’ angulations and surgical difficulty were tested. Our aim was to establish if they are reliable enough. Material and Method: The information for the statistical analyses was collected through the preoperative X-rays of patients who have undergone open ex­trac­tions of their wisdom teeth. The sensitivity and specificity of the different tech­niques were tested. Results: Our data suggest that the classification methods com­monly used for determining the surgical difficulty are not always reliable enough. While Pederson scale is the method with the lowest sensitivity (25.5%), Risk Degree Presumptive Intervention Score has the highest one (75%). Con­clu­sion: The oral surgeon has to interpret very carefully the infor­ma­tion about the three-dimension reality obtained through the two-dimension X-rays.
Key words: mandibular third molars, classifications, surgical difficulty
Address for correspondence: Bistra Blagova, M. D., Department of Oral Surgery, Faculty of Dental Medicine, 3 Hristo Botev Blvd., Bg -- 4000 Plovdiv, tel. +359 878 843 408, e-mail: bistra_blagova@abv.bg
Funding: A research project Grant from Medical University -- Plovdiv, СДП 06МлУ/2015 г.

 

 

MANAGEMENT IN HEALTHCARE


Adapted data of biological drugs evaluation for rheumatoid arthritis treatment to local environment in Bulgaria and pharmacotherapeutic recommendations – Medical Review (Medicinski pregled), 52, 2016, № 2, 59-65.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: Direct costs on targeted biological therapies (TNF inhibitors) for rheumatoid arthritis (RA) treatment were defined. The incremental cost-effec­tiveness ratio (ICER) and quality adjusted life year, QALY in Bulgaria were calculated by transfer and adaptation of data of 14 investigations. Our ultimate aim is to elaborate pharmacotherapeutic manual for treatment of RA with TNFi based on evidence of comparative therapeutic efficacy and cost effectiveness.
Key words: rheumatoid arthritis, TNF inhibitors, pharmacotherapeutic recommendations
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

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Detection of carbapenemase -- producers among clinical isolates of Klebsiella pneumoniae by phenotypic methods - Medical Review (Medicinski pregled), 52, 2016, 1, 35-41.
T. Stoeva(1), R. Markovska(2), M. Bozhkova(1), D. Dimitrova(1), K. Bozhkova(1) and I. Mitov(2)
(1)Department of Microbiology, Medical University -- Varna, (2)Department of Medical Microbiology, Medical University -- Sofia
Summary: Oblectives: To evaluate two phenotypic tests for detection of different types of Kleb­siella pneumoniae carbapenemases, previously characterized by mo­le­cu­lar-genetic methods. Methods: A total of 46 carbapenem resistant K. pneu­mo­niae clinical isolates, producers of 3 types of carbapeneases were tested: KPC-2 (n = 42), VIM-1 (n = 3) and OXA-48 (n = 1). Susceptibility to imipenem and meropenem was determined by disc-diffusion method and Phoenix authomated system (BD). The results were interpreted according to current CLSI guidelines (2014). We performed the following phenotypic methods for carbapenemase detection: the modified Hodge test, the double disc synergy test (DDST) with boronic acid, dipicolinic acid, EDTA and discs imipenem and me­ropenem, as well as the combined-disc method (CDM) with discs ertapenem/cloxacillin and imipenem/cloxacillin. The results were interpreted according to CLSI-2014 and EUCAST-2013 guidelines. Results: MICs of imipenem and meropenem for the tested isolates varied between 4 mg/L and > 16 mg/L. All isolates demonstrated positive Hodge test. DDST with boronic acid, dipicolinic acid and EDTA identified all KPC-2 and VIM-1 producers, but not the single OXA-48 positive isolate of K. pneumoniae. No synergy of ertapenem and imipenem with cloxacillin (>= 5 mm) was observed in any of the tested isolates. Conclusion: The method ba­sed on the inhibition of carbapenem-hydrolyzing enzymes by specific inhibitors (DDST, CDM) is accurate method for identification of class A and B enzymes, but not for class D enzymes. In these cases the modified Hodge test will ensure the detection of OXA-48 producers. Combined application of the evaluated methods in the diagnostic microbiological laboratory will provide reliable detection of K. pneumoniae isolates, producers of different types of carbapenemases.
Key words: K. pneumoniae, carbapenemases, laboratory detection
Address for correspondence: Assoc. Prof. Temenuga Stoeva, M. D., Department of Microbiology, Medical University, 55, Marin Drinov St., Bg -- 9002 Varna, e-mail: temenuga.stoeva@abv.bg

 

Homocysteine and high sensitive C-reactive protein in dialysis patients as markers for cardiovascular risk - Medical Review (Medicinski pregled), 52, 2016, № 1, 42-45.
I. Gencheva, A. Ruseva, P. Laleva and J. Pastuhov
Clinical Laboratory, University Hospital -- Pleven
Summary: The aim of the stated study is tо determine the serum homocysteine (Hcy) and high-sensitivity C-reactive protein (hsCRP), and to evaluate their effectiveness as potential markers of risk associated with cardiovascular disease in patients on hemodialysis. For serum homocysteine ​​and hsCRP were examined 120 hemodialysis patients. They were followed within one year following the survey for the occurrence of cardiovascular disease (heart attack or stroke), or exitus due to such accident. Positive and negative predictive values were estimated for homocysteine (PPV -- 14,5%, NPV -- 94,8%) and hsCRP (PPV -- 18,3%, NPV -- 93,7%). Using ROC analysis the sensitivity and specificity were assessed for each parameter -- for homocysteine ​​(sensitivity -- 75%, specificity -- 50,96%) and for hsCRP (sensitivity -- 56,25%, specificity -- 72,12%). The area under the curve was determined (AUC), respectively for homocysteine -- 0,632 and for hsCRP -- 0,623. The results showed that serum homocysteine ​​and hsCRP could be regarded as useful laboratory indicators to assess the risk of cardiovascular disease in patients on hemodialysis.
Key words: homocysteine, hsCRP, marker, cardiovascular disease, hemodialysis
Address for correspondence: Irena Gencheva, M. D., Clinical Laboratory, University Hospital, 8А, G. Kotchev Blvd., Bg -- 5800 Pleven

 

MANAGEMENT IN HEALTHCARE


Health technology assessment as a base for pharmacotherapeutic recommendations for treatment of renal cell carcinoma with targeted drug therapies - Medical Review (Medicinski pregled), 52, 2016, 1, 54-60.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: The main aim of this study is to define direct costs on targeted oncological therapies for metastatic renal cell carcinoma treatment, calculate the incremental cost-effec­tiveness ratio (ICER) and life years gained (LYG). Our ultimate aim is to elaborate pharmacotherapeutic manual for treatment of CML in relation to administration of monoclonal antibodies, tyrosine kinase inhibitors and serin/treonin kinase inhibitors based on evidence of comparative therapeutic efficacy and cost effectiveness.
Key words: renal cell carcinoma, targeted drug therapies, pharmacotherapeutic recommendations, cost effectiveness
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

Comparison of the consumption of the drugs affecting alimentary tract between Norway and Kosovo - Medical Review (Medicinski pregled), 52, 2016, 1, 61-64.
A. Jakupi(1) and I. Baholli(2)
(1)Kosovo Medicines Agency, (2)European University -- Tirana
Summary: Comparing different groups of drugs for their consumption data and analyzing it over years give an overview of morbidity of the population, trends of prescribing by doctors if that is analyzed over years, differences among countries in consumption/prescription, differences within the period of the year for the consumption etc. For some classes of drugs the peak consumption is a particular month or season on a year while for some others it is not a matter of time since those drugs might be used in chronic patients every day. The results presented in this paper show that there is a significant difference between drugs affecting alimentary tract that are consumed in Kosovo with those in comparison to Norway and it should be an initiation for decision makers in comparing the morbidity data and/or prescriptions from doctors. This paper analyses drugs used in alimentary tract according to ATC classification model of WHO (A -- drugs) based on DID indicator which in a three year period shows a consumption of 50.14 DID or 15.46% from all 14 drug groups in 2013 respectively 133.33 DID or 14.84% from all 14 drug groups (in three year period 2011-2013) and it will be this ATC class that will further be analyzed. These numbers for drug consumption in Kosovo are based on 84 drugs according to their INN names or 361 different types of drugs according to their brand names that have Marketing Authorization in Kosovo and which are manufactured by 101 manufacturers worldwide.
Key words: alimentary tract, drug consumption, prescriptions, Kosovo, Norway
Address for correspondence: Arianit Jakupi, Kosovo Medicines Agency, e-mail: arianiti@gmail.com

 

 

 

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