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Original papers

Volume 42, 2006



Clinical and echocardiographic features of scleroderma patients with pulmonary hypertension - 42, 2006, No 4, 44-47.
K. Yablanski(1) and Zl. Kolarov(2)

(1)Clinic of Rheumocardiology, Medical University - Pleven
(2)Clinic of Rheumatology, Medical University - Sofia
Summary:  Pulmonary hypertension is recognized as an important complication of both limited and diffuse systemic sclerosis. It is difficult to treat and is associated with high mortality. Patients were classified as having secondary pulmonary hypertension (SPH) if there was evidence of pulmonary fibrosis. In the absence of this finding, the patients were classified as having isolated (primary) pulmonary hypertension РРН. The study included 69 patients (63 women and 6 men) with progressive systemic sclerosis. In the study, we found a prevalence of PPH of 5,8% and SPP of 17,4% among the patients. The prevalence of pulmonary hypertension in this patients cohort was similar to that of other catheter based studies. Methods based on the use of clinical examination and electrocardiography are insensitive in the detection of early stages of pulmonary hypertension.
Key words:  pulmonary hypertension, systemic sclerosis
Address for correspondence: K. Yablanski, M. D., Clinic of Rheumocardiology, Medical University, 1, Kl. Ohridski Str., Bg   5800 Pleven


Overlapping neuropsychiatric manifestations in patients with systemic lupus erythematosus erythematosus – 42, 2006, No 4, 48-52.
S. Monov
Clinic of Rheumatology, Medical University – Sofia
Summary:  The systemic disorders of the connective tissue are a heterogenous group of rheumatic diseases that may at certain developmental stage exhibit an overlap of clinical and laboratory manifestations. Different variants and degrees of overlap are possible – between the particular nosological entities as well as between the clinical manifestations associated with injury of some body system.In the present study, 162 patients with systemic lupus erythematosus were investigated, of whom 104 were with clinically manifested impairment of the nervous system and 58 had incomplete systemic lupus.A complex of investigation methods was used for diagnosing as well as for establishment of nervous system injuries. An overlap of neuropsychiatric manifestations was found in 93 (89,42%) of the patients with clinically manifested?nervous system involvement, and in 24 (41,38%) of the patients in the second group. In both groups, the cognitive and autonomous disorders mostly overlapped the other   neuropsychiatric manifestations.
Key words:  systemic lupus erythematosus, overlap syndromes, neuropsychiatric systemic lupus erythematosus
Address for correspondence: Simeon Monov, M.D., Clinic of Rheumatology, Medical University, 13, Urvitch Str., Bg 1612 Sofia, tel. +359 2 958-29-27


Secondary hemorrhagical complications in the myocardium in patients with acute myocardial infarction with ST segment elevation and the risk of mechanical heart complications – 42, 2006, No 4, 53-58.
J. Uzunangelov(1), T. Vesselinovà(2), R. Ivanova(2) and À.Velkovà(3)
(1)Clinic of Cardiology and Intensive Treatment, UMHAT – Pleven
(2)Centre of Common and Clinical Pathology, UMHAT – Pleven
(3)Department of Public Health, Medical University Pleven(3)
Summary:  The aim of this study is to evaluate the frequency, clinical course and outcome in patients with STEMI, treated or not with thrombolysis (ÒRL) with proven at authopsy secondary hemorrhagical complications in the myocardium leading to cardiac rupture (ÑR). We analysed retrîspectively the data of 1440 patients with STEMI divided into 2 groups – treated or not with ÒRL. We followed up the patients with mechanical complications during the acute phase of the infarction from hospitalization to hospital discharge or to the appearance of infarct complications (operation or death). These data àre collected by clinical, non-invasive (2D-echocardiography) and pathoanathomical methods and calculated with standard statistical methods. We found mechanical complications in 8 (2.2%) of the patients with STEMI treated with ÒRL (n = 366). In the group without ÒRL (n = 1074), we detect similar complications in 14 patients (1.3%). Total mortality in the investigated groups was 14.9% (n = 214), ànd the mortality due to mechanical complications???95% (n = 21). The mechanical complications accounted for 8.9% of all deaths. One of the patients with SR treated surgically was alive at the end of the investigation. Secondary hemorrhagical complications in the myocardium were rare in patients with STEMI treated or not with ÒRL. Cardiac rupture in patients with STEMI and TRL was significant higher than in those without TRL. Using more frequent echocardiographic investigation in cases with pericardial effusion and hemodynamic unstability or repeated chest pain will help the physicians early to find CR and to treat the patients surgically.
Key words:  acute myocardial infarction, thrombolysis, secondary hemorrhagical complications, cardiac rupture
Address for correspondence: Jordan Uzunangelov, M. D., Clinic of Cardiology and Intensive Treatment, UMHAT „Dr. Georgi Stranski”, Bg   5800 Pleven, tel./fax +359 64 886-227, e-mail:


The ratio of early mitral flow velocity to flow propagation velocity E/Vp – prognostic index of heart failure development – 42, 2006, No 4, 59-62.
E. Kinova, N. Zlatareva and A. Goudev

Department of Cardiology, University Hospital “Tzaritza Ioanna” – Sofia
Summary: Left ventricular (LV) diastolic dysfunction is related to clinical signs and symptoms of heart failure and has prognostic value in heart diseases. The aim is to assess the relationship between LV diastolic function in acute phase of myocardial infarction (MI) and development of in-hospital heart failure using flow propagation velocity (Vp). Two-dimensional, PW- and color M-mode Doppler echocardiography were performed during 72 hours of a first MI in 119 patients. Patients were divided into two groups according to E/Vp ratio (early diastolic peak-E velocity to Vp ratio): group 1 – with E/Vp < 1.5 (35 patients) and group 2 – with E/Vp >= 1.5 (84 patients). During hospitalization, heart failure (Killip >= ІІ class) was followed-up. Sixty patients developed heart failure and 51 of them were from group 2. Multiple logistic regression analysis identified E/Vp ratio >= 1.5 (RR 4, CI 95% 1.6-9.9, p = 0.002) to be the most powerful independent predictor of development of in-hospital heart failure. The second predictor was Wall Motion Index = 1.7 (RR 2.5, CI 95% 1.1-5.5, p = 0.02). Conclusions: Е/Vр ratio >= 1.5 in the acute phase of MI is the best predictor of in-hospital congestive heart failure and allows early detection of patients at risk.
Key words:  acute myocardial infarction, left ventricular diastolic function, heart failure, flow propagation velocity, echocardiography
Address for correspondence:  E. Kinova, M. D., Department of Cardiology, University Hospital “Tzaritza Ioanna”, 8, Bialo more Str., Bg 1527 Sofia


Are metoprolol succinate with controlled release and metoprololtartrate retard in a dose ratio 1:2 equipotent regarding their antihypertensive effect? - 42, 2006, No 4, 63-65.
D. Raev(1), Ml. Grigorov(2), St. Milanov(3), M. Tsekova(4) and L. Mihov(5)

(1)MI-MIA  Sofia, (2) ІІ МHAT - Sofia, (3)MHATEM “N. I. Pirogov” - Sofia, (4)MHAT - Pleven, (5)MHAT - St. Zagora
Summary: The study aimed at comparing the efficiency of two slow-release forms of metoprolol – 50 mg metoprolol succinate controlled release tablets (MSCR) and 100 mg metoprolol tartrate retard (MTR) regarding the 24-hour arterial blood pressure control (ABP) in patients with non-optimally controlled light or moderate essential hypertension treated with MSCR 50 mg (monotherapy or combined therapy). The observation was multi-centered, prospective, crossed, open, held with 78 (51 men) ambulatory patients, average age 48.2 +/- 7.2, ABP 147.4 +/- 8.4/95.0 +/- 4.3 mmHg and heart rate (HR) 78,5 +/- 8.1 b.p.m. Before beginning the observation, a 24-hour ambulatory blood pressure monitoring (ABPM) was made on basis of the regular therapy, including MSCR 50 mg/day; then MSCR 50 mg was substituted by MTR 100 mg daily for 8 weeks; at the end of the period a second ABPM was held. The ABP and HR 24 hours after the MTR 100 mg dose had considerably lower rates than the ones with MSCR 50 mg (138.9 +/- 7.0/86.6 +/- 5.6 mm Hg, compared to 147.4 +/- 8.4/95.0 +/- 4.3 mm Hg and 72.4 +/- 7.4 compared to 78.5 +/- 8.1 b.p.m., p < 0.001). During all time intervals (24-hour, day, night, morning and the last 4 hours of the dose period), MTR 100 mg realized a more significant reduction of ABP and HR compared to MSCR 50 mg. Regarding their antihypertensive effect, MSCR and MTR in a dose ratio 1:2 are not equipotent. Their effect on ABP and HR is dose-dependant. Our results show that even the better way of releasing the active substance (zero-order kinetics) cannot compensate the insufficient effect of its lower dose.
Key words:  ambulatory blood pressure monitoring, metoprolol tartrate retard, metoprolol succinate controlled release
Address for correspondence: D. Raev, M. D., Medical Institute of Ministry of Internal Affairs, 79A Skobelev Blvd., Bg 1606 Sofia


Importance of the ECG phase at hospitalization for the prognosis of patients with acute myocardial infarction, treated without fibrinolysis – 42, 2006, No 4, 68-73.
T. Taseva

Internal Diseases Clinic, University Hospital “Sv. Anna” – Sofia
Summary:  A comparison has been made between the near and distant prognosis of patients with acute and sub-acute myocardial infarction with ST-elevation. Two groups of patients have been formed according to the ECG and clinical criteria. ECG group 1 is comprised of patients, hospitalized during the acute phase – with elevation of the ST-segment, without complete Q-waves, with positive biochemical markers for fresh myocardial necrosis, and time offset of less than 12 hours since the beginning of the infarction pain; ECG group 2 is comprised of patients in sub-acute phase: ECG with stretched image of MI but still positive or normalized biochemical characteristics for fresh myocardial necrosis. Offset from the beginning of infarction pain of more than 12 hours renders, the patients not eligible for fibrinolysis. The patients from both groups present without statistically significant difference regarding sex, age and heaviness of the risk profile for IHD, and they have been treated in like manner.
Key words:  acute myocardial infarction, acute ECG phase, sub-acute ECG phase, pre-hospital delay, complications during acute phase, clinical decease rate, progression of IHD, distant survival rate
Address for correspondence: Tatyana Taseva, M. D., Internal Diseases Clinic, University Hospital “Sv. Anna”, 1, D. Mollov Str., Bg – Sofia, tel. +359 2 9759213, GSM +359 888 97 33 05, e-mail:


Polymorphisms in the vitamin D-receptor gene and bone mineral density in men of Bulgarian population – 42, 2006, No 4, 74-80.
J. Ivanova(1), P. Doukova(1), M. Boyanov(2) and P. Popivanov(2)

(1)Chair of Clinical Laboratory and Clinical Immunology, University Hospital “Alexandrovska”, Medical University - Sofia
(2)Endocrinology Clinic, University Hospital “Alexandrovska”, Medical University???Sofia
Summary:  Bone mineral density (BMD) is a major determinant of fracture risk. The gene for the vitamin D receptor (VDR) is the first one distinguished to contribute to BMD. Assessment of the association between BMD and FokI and BsmI polymorphisms in the VDR gene is performed in a case-control study on 74 unrelated men (30 controls and 44 cases with low BMD). BMD is measured at lumbar spine by DXA. PCR is used to amplify exon 2 and intron 8. PCR products are digested and electrophoresed through an agarose gel. The association we find between f allele (FokI) and B allele (BsmI) and low BMD confirm the contribution of the VDR gene to osteoporosis. The relative risk (RR) calculated for low BMD is higher for the BsmI marker (4,84) compared to the FokI marker (2,97). The etiological factor which reflects the association between the investigated polymorphisms and the illness on populational level is assessed as EF=0.53 for FokI marker and EF=0.69 for BsmI marker. On account of this, we conclude that the FokI and BsmI polymorphisms are closely related to low BMD at lumbar spine and both are useful genetic determinants of BMD and osteoporotic risk.
Key words:  osteoporosis, low bone mineral density, biochemical markers of bone turnover, genetic markers, polymorphisms, vitamin D receptor
Address for correspondence: Mihail Boyanov, M.D., Endocrinology Clinic, University Hospital "Alexandrovska", 1, Sv. G. Sofiiski Str., Bg 1431 Sofia, tel. +359 2 9230 784, e-mail:


Lipid profile, HOMA index and fibrinogen in healthy late postmenopausal women, treated with tibolone – 42, 2006, No 4, 81-86.
M. Todorova(1), Z. Kamenov(2) , V. Christov(2) and M. Baleva(3)

(1) Department of Pathophysiology, Medical University - Sofia
(2) Clinic of Endocrinology, Hospital “Alexandrovska”, Medical University - Sofia
(3) Clinic of Allergology, Hospital “Alexandrovska”, Medical University - Sofia
Summary:  The aim of the study was to investigate glucose, lipid metabolism and fibrinogen in healthy postmenopausal women in the course of tibolone administration. Twenty seven clinically healthy postmenopausal women were included in the study and were divided into two groups: control group (n = 11, mean age 54.8 +/- 4.0 years) and a treatment group (n = 16, mean age 56.4 +/- 4.6 years) who were allocated to tibolone at a dose of 2.5 mg/d for 6 months. Both groups did not differ significantly in mean age, years of amenorrhea, BMI and BP. Lipid profile, fasting blood glucose (BG), immunoreactive insulin (IRI), HbA1c and HOMA index were determined at entry and on the sixth month. Fibrinogen was determined at baseline, 1, 3 and 6 months after treatment. Triglycerides (TG), VLDL-C and HDL-C significantly decreased in the tibolone group (p < 0.01 vs baseline) and (p < 0.05 vs controls). Total cholesterol (TC) and LDL-C remained unaffected. BG and HbA1c did not change, and both IRI and HOMA index significantly decreased at the sixth month (p < 0.05). Fibrinogen did not change during tibolone treatment. These data indicate that tibolone had beneficial effect on TG, VLDL and insulin sensitivity. It did not change fibrinogen. These favorable effects may counterbalance the adverse influence on HDL-C and tibolone may be considered a good alternative of HRT.
Key words:  menopause, tibolone, lipids, HOMA index, inflammatory activity
Address for correspondence: Zdravko Kamenov, M. D., Clinic of Endocrinology, Alexandrovska Hospital, Medical University, 1, Sv. G. Sofiiski Str., Bg 1431 Sofia, tel. +359 2 9230 244, GSM +359 887 726683


Rosiglitazone in the treatment of type 2 diabetes mellitus – 42, 2006, No 4, 87-90.
S. Vladeva

Clinic of Endocrinology, Medical University - Plovdiv
Summary: The phenomenon of insulin resistance is observed in the majority of patients with type 2 diabetes. Great expectations in the treatment of type 2 diabetes have been entrusted in the glitazones, such as rosiglitazone (Avandia) that are aimed at decreasing insulin resistance. The aim of our study was do evaluate the efficacy of rosiglitazone as monotherapy and in combination with other antidiabetic drugs in patients with type 2 diabetes. We investigated 102 patients divided in four therapeutic groups: on rosiglitazone monotherapy, on combined treatment with rosiglitazone + metformin, rosiglitazone + sulphonylurea, rosiglitazone + acarbose. We observed а significant decrease in prandial glycaemia in the first group, followed by the groups on combined treatment with sulphonylurea and acarbose. The largest decrease of hemoglobin A1c levels (1.2%) was observed in patients on rosiglitazone + metformin. We also observed decrease in HDL-cholesterol and triglyceride levels, but these changes did not reach statistical significance. In conclusion, rosiglitazone, as monotherapy or in combination with the traditional oral antidiabetic medications, achieves the target goals in the treatment of type 2 diabetes.
Key words:  type 2 diabetes mellitus, rosiglitazone, metformin, sulphonylurea, acarbose
Address for correspondence:  Stefka Vladeva, MD, Clinic of Endocrinology, Medical University, 15a Vasil Aprilov Str., Bg???4000 Plovdiv, e-mail:


Utility of homocysteine determination in cardiovascular disease: a randomized trial of folic acid effect on serum homocysteine levels – 42, 2006, No 4, 91-93.
I Boncheva, A. Stancheva, V. Koleva and K. Lazarova

University Hospital “Lozenetz” - Sofia
Summary: The results from a prospective study showed that serum homocysteine levels were significantly higher in men who died of ischaemic heart disease (IHD) than in men who survived. Thus lowering serum homocysteine with folic acid is expected to reduce mortality from IHD. The homocysteine reduction is known to be maximal at a folic acid dose of 1 mg/day but the effect of lower doses (relevant to food fortification) is unclear, particularly in diseased subjects. 114 patients with IHD were randomised to one of five doses of folic acid (0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1.0 mg per day) or placebo. Fasting blood samples for serum homocysteine and serum folate analysis were taken initially and after three months supplementation, and three months after folic acid was discontinued. Serum homocysteine was determined by a fluorescence polarization immunoassay (FPIA, AxSYM Homocysteine). Serum homocysteine decreased with increasing folic acid dose, up to a maximum of 0.8 mg folic acid/day when the homocysteine reduction was 3.07 mcmol/L (27 %) similar to the known effect of folic acid doses of 1 mg/day and above. The higher a person’s initial homocysteine level was the greater was the response to folic acid, but there was a statistically significant reduction in homocysteine regardless of the initial level. About 70% of the effect were attained with a dose of 0,4 mg/day but a dose of 0.8 mg/day was needed for full effect at low initial serum homocysteine levels. Serum folate increased approximately linearly (5,08 nmol/L for every 0.1 mg folic acid). Conclusion: A dose of 0.8 mg/day folic acid appears necessary to achieve the maximum reduction in serum homocysteine across the range of homocysteine levels in this patient population.
Key words:  homocysteine, ischaemic heart disease, folic acid
Address for correspondence: Margarita Boncheva M.D., Phd, University Hospital Lozenetz, 1 Koziak Str.,Bg - Sofia 1407, e-mail:


Experimental study for effects of 17-beta-estradiol on pituitary
T. Shumkova-Tucheva and N. Boyadjieva

Department of Pharmacology and Toxicology, Medical Faculty, Medical University – Sofia
Summary:  Tumors of the pituitary are one of the most frequent tumors in the brain. The etiology of these tumors is not known. In vivo and in vitro experiments on pituitary of Wistar rats demonstrated that 17-beta-estradiol activates the proliferation of lactotropic cells and cause development of prolactinoma. The results also demonstrated that 17-beta-estradiol stimulates the secretion of prolactin from cultured pituitary cells. The data suggest that estrogens activate tumorogenesis in anterior pituitary of Wistar rats.
Key words:  17-beta-estradiol, pituitary, tumor
Address for correspondence: Teodora N. Shumkova, Medical Faculty, Medical University, 2, Zdrave Str., Bg 1431 Sofia, e-mail:   tel.: +359 887 349 268


Inhibitory effect of Bulgarian propolis on clinical isolates of Prevotella and Porphyromonas strains – 42, 2006, No 4, 98-102.
L. Boyanova(1) , R. Kolarov(2) , G. Gergova(1) and I. Mitov(1)

(1)Department of Microbiology, Medical University – Sofia
(2)University Hospital of Maxillo-Facial Surgery - Sofia
Summary: The aim of the study was to evaluate the effect of Bulgarian propolis (EEP, 30% ethanolic extract) on 25 Prevotella and Porphyromonas clinical strains. The strains were tested by both agar-well diffusion (wells, 7 mm diameter) and disk-diffusion (disk diameter, 6 mm) methods. Most (88%) of the strains were inhibited by 30 mcL propolis extract per well and almost all strains (96%) were inhibited by 90 mcL propolis extract per well. Propolis extract was significantly more active than the solvent of ethanol (P < 0.02). By 30 mcL extract per well, the mean inhibitory diameter of the strains was 11.7 mm, and that by 90 mcL was 15.2 mm, respectively. Mean inhibitory diameters of the strains by 30 and 90 mcL ethanol were only 8 and 8.3 mm. Moist propolis disks inhibited 23 (92%) of the strains. The propolis exhibited some activity against a multi-drug resistant Prevotella oralis strain. In conclusion, the propolis extract was highly active against most strains of the genera Prevotella and Porphyromonas. The results could focus on a higher interest in the use of the Bulgarian propolis for prophylaxis or supplementary treatment of some anaerobic infections, e.g. oral and orofacial infections, involving anaerobes from the genera Prevotella and Porphyromonas.
Key words:  anaerobic bacteria, Prevotella, Porphyromonas, propolis, inhibition, activity
Address for correspondence: Assoc. Prof. Ludmila Boyanova, Department of Microbiology, Medical University, 2 Zdrave, Str., Bg - 1431 Sofia, tel. +359 2 91-72-730, e-mail:


Comparison of clinical laboratory parameters performed by two clinical chemistry analyzers – 42, 2006, No 4, 103-105.
P. Jordanova-Laleva(1) , A. Ruseva(1) , V. Petkova(1) , A. Velkova(2) and I. Gencheva(1)

(1)Clinical Laboratory, University Hospital ”G. Stranski - ”Pleven
(2)Faculty of Public Health, Medical University - Pleven
Summary:  Biochemical investigations of enzymes ASAT, ALAT, AP, GGT, CK and substrates urea, creatinine, total protein, albumin, cholesterol, triglycerides, glucose and total bilirubin, performed on biochemical analyser Pentra 400, are compared to those performed on the analyser Cobas Integra 400. Fifty serums for each parameter were assayed with reagentsand materials provided by the producers of the two systems, respectively Horiba ABX and Roche Diagnostics. The CV and Bias values of the utilized control materials of both analysers for the month in which the analysis was performed are presented. The correlation coefficients for all parameters showed a significant correlation, r > 0.9. This makes it possible to perform and observe the laboratory tests of each patient regardless of the biochemistry analyser used.
Key words:  clinical laboratory parameters: enzymes, substrates; biochemical analyzers: Pentra 400, Cobas Integra 400
Address for correspondence: P. Jordanova-Laleva, M. D., Clinical Laboratory, University Hospital "G. Stranski", Bg - 5800 Pleven



Rene Laennec (1781 - 1826): a prominent physician and pathologist – 42, 2006, No 4, 112-116.
D. Paskalev(1), A. Kircheva(2) and D. Radoynova(3)

(1)Clinic of Nephrology and Dialysis, University Hospital “Sv. Marina” - Varna
(2)Department of Clinical Epidemiology, Multi-Profile Hospital for Active Therapy “Sv. Anna” – Varna
(3)Chair of Forensic Medicine, University Hospital “Sv. Marina” - Varna
Summary: Rene Laennecwas born in Quimper, in Brittany, in the far west of France, on February 17, 1781, in the family of lawyer. His mother died of tuberculosis when he was a few years old. The young Renе was placed in the care of his uncle, Guillaume Laennec, a physician in Nantes. In 1795, Rene Laennec began his study in medicine under his uncle in a hospital in Nantes. In 1801, he went to Paris in order to contunue his medical education at L’Ecole de Medicine. There his teacher was Jean-Nicolas Corvisart, the physician who revived Auenbrugger’s technique of percussion (described in 1761). In 1803, R. Laennec made a classical description of atrophic cirrhosis of the liver. Between 1803 and 1804, after more than a thousand autopsies, he was able to bring great order to the contemporary clinical thinking about the tuberculosis. Laennec demonstrated that tubercles serving as typical pathological lesions of the disease could be find in every tissue of the body. Laennec pointed out also that the term “phthisis pulmonum”, often applied to an undifferentiated group of pulmonary diseases, was in fact tuberculosis of the lungs. In 1816, he invented a new instrument called “stethoscope” for the purpose of auscultation of the heart and the lungs. Using the stethoscope in the clinical practice, Laennec described many pulmonary symptoms such as rales, pectoriloquy and egophony. He also described cardiac sounds and murmurs. In 1819, Laennec published his famous book “Trate de l’auscultation mediate”. In 1826, he died of tuberculosis.
Key words:  history of medicine, Rene Laennec, stethoscope
Address for correspondence: Assoc. Prof. Dobrin Paskalev, MD, PhD, Clinic of Nephrology and Dialysis, University Hospital “Sv. Marina”, Medical University, 55, Marin Drinov Str., Bg - 9002 Varna, tel. +359 52 302 851, ext. 296, e-mail:





Coronary revascularization in conditions of "beating heart" - 42, 2006, No 3, 32-36.
L. Spasov, V. Pushev and G. Georgiev

University Hospital "Lozenets" - Sofia
Summary: The complications observed in the coronary bypass operations under conditions of extracorporeal circulation (EC) prompt the authors to adopt the coronary revascularizations on "beating heart" without EC. In the period May 2000 - December 2004, the authors made 151 coronary revascularizations on "beating heart". They emphasize the low diagnostic value of EKG in patients at rest. Of greatest significance are the selective coronarography, echocardiography and exercise-test. The authors consider the indications and contra-indications for coronary operations under the conditions of "beating heart". The technical problems facilitating the operative intervention are considered: undulating sternotomy, mechanical stabilization of the heart ventricles, fixing the electrodes for electrostimulation, endoscope techniques for taking the autovenous grapht. Intraoperatively, in 19 patients the operation of "beating heart" without EC had to be changed by operation with EC. Coronary operations without EC under conditions of "beating heart" are followed by an easier postoperative period, lesser need of hemotransfusion, early extubation, fewer postoperative complications and lowering of the postoperative lethality to 2.17%.
Key words: coronary surgery, conditions of beating heart, operative techniques, postoperative period, complications, mortality
Address for correspondence:
Lubomir Spasov, M. D., University Hospital "Lozenets", 1, Koziak Str., Bg - 1407 Sofia, e-mail:



Association between angiographic coronary lesion morphology and different clinical manifestation in patients with angina - 42, 2006, No 3, 37-42.
I. Manoukov
(1), J. Jorgova(1) and A. Djurdjev(2)

(1)Clinic of Invasive Cardiology, University Hospital "Sveti Georgi", Plovdiv
(2)Clinic of Cardiology, University Hospital "Sveti Georgi", Plovdiv
Summary: Patients with acute coronary syndromes often have complex morphology of coronary stenoses at angiography. We evaluated the association between different qualitative angiographic types of coronary stenoses and clinical forms of angina. A total of 112 patients with single vessel coronary artery disease were divided into two groups: a control group with simple coronary stenosis (n = 46) and a group with complex coronary stenosis (n = 66). Qualitative analysis of coronary angiograms was performed using a modified Ambrose classification. Both groups were compared according to the manifestation and distribution of different clinical forms of angina. Both groups have similar severity of coronary stenoses (79.8% +/- 10.7% vs. 82.7% +/- 8.2%, > 0.1). The extent of effort angina was similar between the groups (89.47% +/- 4.97% vs. 91.67% +/- 3.56%), but the amount of cases with variable threshold of angina was higher in the group with complex stenosis. There was a prevalence of rest angina, angina after emotion, as well as at cold or wind exposure in the group with complex stenosis. The coronary stenosis complex morphology is associated mainly with stable angina modified by vascular spasm, and thus provoked by mental stress, cold or wind exposure, as well as rest angina.
Key words: angina, vascular spasm, complex stenosis, Ambrose classification
Address for correspondence:  Clinic of Invasive Cardiology, University Hospital "Sveti Georgi", 66, Peshtersko shose Blvd., fl. 8, Bg - 4000 Plovdiv, tel. +359 32 602925 , GSM +359 888 986 892, 5-mail:



Haemorrhagic stroke in patients with acute myocardial infarction with ST segment 5levation and thrombolytic treatment - 42, 2006, No 3, 42-46
J. Uzunangelov
(1), P. Tzvetanov(2) and A. Velkova(3)

(1)Clinic of Cardiology and Intensive Treatment, UMHAT Pleven
(2)IIrd Clinic of Neurology, UMHAT Pleven
(3)Department of Health Management, Medical University - Pleven
Summary: The aim of this study is to estimate the frequency of the haemorrhagic stroke in patients with STEMI who underwent treatment with thrombolytic agents, and to analyse the most important risk factors. The current retrospective study comprises 1440 patients with STEMI (mean age 61 +/- 11; 34-81; 985 males) admited to ICCU 0t the Clinic of cardiology of UMHAT Pleven during the last 6 years (2000-2005). Diagnosis haemorrhagic stroke was established by clinical and CSF examination and confirmed by CT scan. Brain haemorhage in the acute phase of myocardial infarction was observed in 6 patients (0,4%), 4 underwent TRL (1,0%) and 2 without TRL (0,2%). Haemorhagic strokes were most frequent in patients taken rPA
- 2 (1.2%), rarely in these with Streptokinase - 1 (1%) and tPA - 1 (0.75%). The mean age was significantly higher in patients with haemorhagic stroke compared with those without stroke (p < 0.001); they had more frequent high blood pressure at hospital admission (p < 0.01) as well as low levels of fibrinogen (p < 0.05). Fatal outcome was found in 4 patients (66,7%). The frequency of haemorhagic stroke in patients with STEMI treated with TRL is rare. The more frequent risk factors for this complication are not assotiated as much with the presence of high blood pressure, as with prolonged 0PTT, low levels of serum fibrinogen and their combination.
Key words: acute myocardial infarction, thrombolysis, haemorrhagic stroke
Address for correspondence:
Jordan Uzunangelov, M. D., Clinic of Cardiology and Intensive Treatment, UMHAT "Dr. Georgi Stranski", Bg - 5800 Pleven, tel./fax +359 64 886-227, 5-mail:



Hypertension control in urban and rural populations of Varna region - 42, 2006, No 3, 47-51.
K. Dokova
(1), K. Stoeva(1), N. Feschieva(1), Ph. Kirov(2), S. Petrova(3), J. Jotov(2), A. Sanz(4) and J. Powles(5)

(1)Department of Social Medicine and Healthcare Organization, MU - Varna
(2)University Hospital "Sv. Marina" - Varna
(3)National Healthcare Centre - Sofia
(4)Department of Preventive Medicine and Public Health, University of the Basque Country - Bilbao, Spain
(5)Department of Public Health and Primary Care, Institute of Public Health - Cambridge, UK
Summary: Few studies have reported on the effectiveness
of hypertension control in Bulgaria. 80 rural and 80 urban residents aged from 45 to 74 took part in the study. Blood pressure was measured with a standard mercury sphygmomanometer in the subjects' home twice daily in 2 cycles (in the winter and in the summer) each lasting 8 days. Hypertension was defined as a mean systolic blood pressure (SBP) higher than 140 mm Hg or a mean diastolic blood pressure (DBP) higher than 90 mm Hg or verified drug treatment for hypertension. Hypertensives were classified as "aware", "treated" or "controlled", if mean pressure values were below 140/90 mm Hg. Urban women had the best experience of hypertension control while rural men had the worst. Of 41 women 30 were hypertensive and of these 29 were "aware", 28 were "treated" and 15 were controlled. Among rural men, 30 of 37 were hypertensive and of these, 23 were "aware", 18 were "treated" but none were controlled. The effectiveness of blood pressure control is poor - especially in the rural areas where stroke risks are highest. Development of strategies to improve the cost-effectiveness of hypertension control is a public health priority in Bulgaria.
Key words: hypertension, awareness, treatment, control, Bulgaria
Address for correspondence:
Klara Dokova, M. D., Department of Social Medicine and Healthcare Organization, Medical University, 55, M. Drinov Str., Bg - 9002



Waist circumference - predictor of insulin sensitivity in patients with type 2 diabetes mellitus - 42, 2006, No 3, 52-57.
Clinical Center of Endocrinology, Medical University - Sofia
Summary: Aim of the present study was to establish easily applicable in clinical practice predictor of insulin sensitivity, determining highest percent of it
's variance in patients with type 2 diabetes mellitus. 63 patients of mean age 52 +/- 8.7 yrs., with good glycaemic control of glycosylated hemoglobin (HbA1c) 6.38 +/- 0.58%, participated in the study. The diabetic men were with the following anthropometric parameters: BMI 28.86 +/- 4.94 kg/m(2), waist circumference (WC) 101.5 +/- 13.6 cm and the diabetic women were with BMI 33.81 +/- 6.53 kg/m(2), WC 102.1 +/- 15.8 cm. Insulin sensitivity (IS) was measured with a manual hyperinsulinaemic euglycaemic clamp technique and expressed as an amount of glucose utilized by the tissues, mainly skeletal muscles (M). Statistical analysis included analysis of variance, Pearson correlation analysis with p value = 0.05 considered significant and multiple linear regression analysis. The diabetic men with visceral obesity according to the WC >/= 102 cm were characterized by a significantly lower IS (M) - 2.371 +/- 1.370 in comparison to that of men without visceral obesity - M 6.703 +/- 3.386 mg/kg/min, p < 0.001.The diabetic women with visceral obesity according to the WC ³ 88 cm were characterized by a significantly lower IS (M) - 2.834 +/- 1.453 in comparison to that of women without visceral obesity - M 5.514 +/- 1.678 mg/kg/min, p < 0.01. They were also notified by a significantly higher level of uric acid and arterial blood pressure. The waist circumference was an independent predictor of IS in female sex, determining 50.5% of it's variance. Independent predictors of insulin sensitivity in male sex were waist circumference and diastolic blood pressure, defining 60.4% of it's variance. In conclusion, waist circumference is an easily applicable in clinical practice predictor of insulin sensitivity. The simple measurement of waist circumference would be useful to the physicians for screening and early treatment of the patients with insulin resistance.
Key words: type 2 diabetes mellitus, insulin resistance, waist circumference, visceral obesity, cardiovascular risk
Address for correspondence:  Petya Kamenova, M. D., Clinical Center of Endocrinology, 6, D. Gruev str., Bg -1303 Sofia, e-mail:



Clinical study and changes of lymphocyte receptors in patients with acute exogenous intoxications - 42, 2006, No 3, 58-61.
J. Radenkova-Saeva
(1) and A. Mihova(2)

(1)Emergency Hospital "N. I. Pirogov", (2)NCIPD - Sofia
Summary: The authors have carried out a study on somatic damages and changes of lymphocyte receptors/markers in a group of patients with acute heroin poisoning and associated with other psychoactive substanses intoxications. The study involved 7 patients (5 men and 2 women), long-standing heroin abusers, treated in the Clinic of Toxicology, MHATEM
"N. I. Pirogov", Sofia. Clinical studies revealed polyorganic damages and post-intoxication complications. By laser flowcytometry with monoclonal antibodies, CD markers of the basic lymphocyte populations and subpopulations were determined. The study of the lymphocyte receptors demonstrated a decreased level of NK cells (CD3- CD56+), as well as tendency to a decreased level of T-helper lymphocyte population (CD3+ CD4+). The data show, that the immune system is sensitive to psychoactive substances, including opiates. It is possible that the immune system is included in the pathogenesis of polyorganic damages.
Key words: heroin, psychoactive substances, lymphocyte receptors, intoxication
Address for correspondence:
J. Radenkova-Saeva, M. D., Clinic of Toxicology, MHATEM
"N. I. Pirogov", 21, Totleben Blvd., Bg - 1606 Sofia, tel. +359 2 91-54-346, e-mail:



Apoptosis, cell cycle and malignant melanoma - 42, 2006, No 3, 62-71.
G. Tchernev
(1, 3), N. Tsankov(2) and C. E. Orfanos(1)

(1)Department of Dermatology and Allergy, Skin Cancer Cente, Charite-Universitaetsmedizin, Campus Benjamin Franklin, Berlin
(2)Clinic of Dermatology and Venereology, University Hospital Alexandrovska, Sofia, Bulgaria
(3)Department of Dermatology and Immunology, Municipal Hospital Dessau, Academic Educational Hospital of the Martin-Luther-University, Halle-Wittenberg, Germany
Summary: Apoptosis is a form of programmed cell death with typical morphological signs. It has an important role in physiological conditions during the embryonic period for supporting the cell homeostasis. Apoptosis is regulated by many genes and gene products which are in complicated interrelations. In malignant melanoma, there is a disturbed cell control because of reduced apoptosis and uncontrolled cell proliferation. Immunohistological investigations in melanoma determine decreased or increased expression of proapoptotic proteins like Bax and Bak in correlation with the stage of tumor growth. Occurrence and progress of malignant melanoma are connected with genetic changes in the processes of apoptosis and proliferation. Beside the main suppressor genes p53 and p16, the proteins Rb, p21 and p27 participate in the disturbed regulation of the cell cycle. The immunohistochemical determination of the expression of inhibitors and regulators of cell cycle in malignant melanoma is of considerable meaning for the prognosis of the disease. The processes of tumorigenesis, programmed cell death (apoptosis), and the control of cell cycle are intertwined in a "disentangled net" and cannot be considered separately. The simultaneous immunohistochemical examination of a larger number of marker molecules characterizing these processes (programmed cell death, cell cycle) provides more precise information compared to the detection of 1 or 2 markers in a larger number of patients.
Key words: apoptosis, cell cycle, malignant melanoma, tumor growth regulation
Address for correspondence:
 Georgi Tchernev, M.D., Department of Dermatology and Immunology, Municipal Hospital, Academic Educational Hospital of the Martin-Luther-University, Halle-Wittenberg, Auenweg 38, 06847 Dessau, tel. 0049 340 501 4050/4056, 5-mail:



Effect of the apolipoprotein E epsilon4 allele on the efficacy of donepezil in the treatment of Alzheimer's disease - 42, 2006, No 3, 72-75.
L. Traykov
(1, 2), F. Latour(2), F. Moulin(2) and A-S. Rigaud(2)
(1)Clinic of Neurology, University Hospital "Alexandrovska", Medical University - Sofia
(2)Broca Hospital, Paris - France
Summary: In the past ten years or so, there have been several advances in the therapy of Alzheimer's disease (AD) and some medications are already available to produce some symptomatic improvements in selected patients. From all data available, it became evident that certain patients respond better to the treatment than others. However, factors that can predict a response to acetylcholinesterase (AChE) inhibitors have not been yet established. Some authors showed a negative effect of the apolipoprotein (ApoE) epsilon4 allele on the response to acetylcholinesterase inhibitors, while others did not. Our objective was to evaluate the effects of the E (ApoE) genotype and gender on the response to donepezil treatment in AD. We analysed the ApoE genotype of 86 mild to moderate AD patients who took part in a 36-week open label trial of donepezil therapy. Patients were treated blindly in relation to ApoE phenotype with incremental donepezil dosages. The cut-off point for being considered a responder to treatment was a 4-point decrease in the ADAS-Cog score. The results clearly show lack of tendency for the epsilon4- carriers to respond better than the epsilon4+ carriers. When patients were stratified by gender, no differences were found between the effects of the treatment on men and women. In conclusion, the results of the present work do not support the hypothesis that the ApoE phenotype and gender are predictors of the response to AChE inhibitors in AD patients.

Key words: Alzheimer's disease, dementia, apolipoprotein E, epsilon4 allele, donepezil
Address for correspondence:
 Assoc. Prof. Latchezar Traykov, M. D., Clinic of Neurology, University Hospital "Alexandrovska", 1 "Sv. G. Sofiski" Str., Bg - 1431 Sofia, e-mail:



Problems in orbital fracture reconstruction - 42, 2006, No 3, 76-79.
E. Zenev

Central Clinic - Augsburg,
Summary: Orbital fractures take a highly significant share in facial traumatism, especially after the introduction of a series of extreme kinds of sport. Among 3438 patients treated for a 6-year period, we observed 554 cases of orbital fractures comprising 12% of the total number of patients. Improper reposition of these fractures may lead to significant deformities occurring after incorrect adaptation of fragments and leading later on to very unpleasant esthetic defects in the area of the facial skeleton. This from the very beginning made us use new osteosynthetic means for reconstruction of the fractures before callus formation.

Key words: orbital fractures, reposition, osteosynthesis
Address for correspondence:
 E. Zenev, M. D., Central Clinic - Augsburg, Germany



Anaerobic bacteriology in 55 patients with cellulitis of the mouth floor - 42, 2006, No 3, 80-85.
L. Boyanova
(1), R. Kolarov(2), E. Deliverska(2), G. Gergova(1), P. Sapundjiev(2), J. Madjarov(2), M. Marinov(2) and I. Mitov(1)

(1)Department of Microbiology, Medical University - Sofia
(2)University Hospital of Maxillo-Facial Surgery - Sofia
Summary: The aim of the study was to evaluate the prevalence of anaerobes in 55 patients with cellulitis of the mouth floor as well as the susceptibility of the isolates to penicillins (amoxicillin), clindamycin, ampicillin/sulbactam and metronidazole. Isolates were identified by Crystal anaerobes identification system, API System rapid ID 32A, and routine methods. Totally 93 strains of anaerobic bacteria were found in 81.8% of all patients with approximately 2.1 anaerobic isolates per positive specimen. The predominant isolates were Prevotella (32), Eubacterium (11), Actinomyces (10), Fusobacterium species (8) and Gram-positive anaerobic cocci (7). Three B. fragilis group strains were detected (in 5.4% of all specimens) and one Clostridium tertium was found in one case. All anaerobic isolates were susceptible to ampicillin/sulbactam. Metronidazole, clindamycin and penicillin were active against 100, 85 and 67.4% of Gram-negative strains and 41.5, 90 and 87.8% of Gram-positive anaerobes respectively. Low rate of double resistance to penicillins + metronidazole was found in 3.2% of all strains. The results highlight the role of anaerobic microbiology in cases of deep-space head and neck infections. The involvement of B. fragilis group in severe orofacial infections should be considered.
Key words: cellulitis of the mouth floor, anaerobic, susceptibility, incidence
Address for correspondenAe:
Assoc. Prof. Ludmila Boyanova, M. D., Department of Microbiology, Medical University, 2, Zdrave Str., Bg - 1431 Sofia, tel. +359 2 91-72-730, e-mail:



Radiological image and prognosis of the pneumoconioses in fundamental industries in Bulgaria - 42, 2006, No 3, 86-90.
E. Petrova and Ch. Nachev

Center of Occupational Diseases, Medical University - Sofia
Summary: The object of the study were the lung X-ray findings and lung diseases in 480 quartz exposed miners and 120 asbestos exposed workers. We have used the ILO-80 radiological classification for x-ray findings assessment and for dust diseases diagnostics. The X-ray findings were assessed in 28 individuals of non  exposed control group. The nestled screening cross sectional case control study, including posterior-anterior chest radiographs and summarizing of information for dust exposure levels in work environment air were done. The software SPSS was used, and Pearson Chi-Squar5, Likelihood Ratio and significance ( ) were calculated. 16 cases with @1/1 initial silicosis from mane mines in Bulgaria due to quartz dust exposure, 4 @1/1 mixed pneumoconiosis from KZM "Plovdiv", 43 manifested asbestoses from the Steam power plant, and from production of the asbestos brakes with average exposure length 16 y. and 17 y. average latency were detected. 15 were the cases with asbestos induced pleural fibrosis and asbestos pleural plaques; 90, resp. 116 were the boundary pneumoconioses @0/1 and @1/0. 36, resp. 30 were s0/1-s and the t0/1 boundary asbestoses. The asbestos induced pleural fibrosis, fibrous and calcified plaques predominated. The high dust levels in the mines,and the asbestos exposure, as well as the dose/effect studies, and the dynamics of the dust lung diseases allow to prognosticate a growth of the silicosis incidence, as well as of asbestosis and asbestos induced pleural diseases in the future 10-15-20 years.
Key words: dust, ILO-80, chest radiography, silicosis, asbestosis, mixed pneumoconiosis
Address for correspondence:
  Assoc. Prof. Elisaveta Petrova, M. D., Clinic of Occupational Diseases, University Hospital "Sv. Ivan Rilski", 15 Akad. Ivan Geshov Blvd., Bg - 1431 Sofia, e-mail:



Transforming growth factor-beta1 in pleural empyema progression - experimental study - 42, 2006, No 3, 91-95.
I. Novakov(1), G. Ivanov(2) and V. Hodgev(3)

(1)Department of Thoraco-Abdominal Surgery, Medical University - Plovdiv
(2)Department of General and Clinical Pathology, Medical University - Plovdiv
(3)Department of Pulmonology, Medical University - Plovdiv
Summary: Pleural empyema progresses into three phases  acute (exudative), transitional (fibrinopurulent) and chronic (phase of organization). The final result of empyema progression is development of fibrothorax. It is thought, that the process of pleural fibrosis is stimulated by transforming growth factor-beta1 (TGF-beta1). It is a cytokine and an important mediator of inflammation and angiogenesis. The aim of our study was to demonstrate the role of TGF-beta1 in empyema progression and development of pleural fibrosis. Our hypothesis was that TGF-beta1 levels in effusion correlate with the degree of fibroblast proliferation, increased collagen production and pleural visceral thickness. It was used a model of empyema in rabbits. TGF-beta1-levels were measured on days 2nd, 4th, 6th and 8th. Cell-surface localization of TGF-beta1 was determined by immunohistochemistry staining. TGF-beta1 levels in pleural effusion correlated with fibroblast count in empyema progression. TGF-b1 is localized on macrophages. In conclusion, TGF-beta1 is responsible for empyema progrresoin and development of pleural fibrosis.
Key words: empyema, pleural fibrosis, cytokines, transforming growth factor-beta1
Address for correspondence: 
Ivan Novakov, M. D., Department of Thoracoabdominal Surgery, Medical University, 54 "Petrova niva" Str., Bg - 4004 Plovdiv, e-mail:



G. Milchev. Therapeutic cloning or umbilical cord blood banking - 42, 2006, - 3, 103-105.



Ethics in Medicine and Biotechnology: - European Information Network provides practical assistance for Bulgarian health professionals - 42, 2006, No 3, 106-109.
Zh. Surcheva
(1), I. Alexandrov(1), L. Tacheva(1) and S. Tomova(2)
(1)Central Medical Library, MU - Sofia
(2)Rectorate, MU - Sofia
Summary: An overview was made on the structure and basic functions of the - Euroethics Information Network
"Ethics in Medicine and Biotechnology". Short instructions for searching in the database Euroethics are given. A representation of the Bulgarian web-site - a part of the project - and it elements, are given too.
Key words: bioethics, medical ethics, databases -organization and administration; documentation - standards, internet, interdisciplinary communication, international cooperation
Address for correspondence: Zh. Surcheva, Central Medical Library, Medical University
- Sofia, 1, "Sv. G. Sofiiski" Str., Bg 1431, Sofia, tel. +359 2 952-62-60; e-mail:



Methods for evaluation of primary information in Bulgarian medical web-sites - 42, 2006, 3, 110-115.
J. Vinarova, P. Pencheva and I. Penjurov

Department of Biomedical Sciences, NBU Sofia
Summary: In the course of time Internet acquires leading significance as a mass media between the professional users, because it is the most powerful information source for references and research needs. Leaded by the ambition to propose a standardized method for content evaluation of the Bulgarian health and medical sites, we would like to present an original tool, which is influenced by a well-adopted and good working standard and it's completely conformable to the Bulgarian conditions and practice.
Key words: medical information, web site evaluation, Internet-searching, reference investigation
Address for correspondence:
 J. Vinarova, Department "Biomedical sciences", NBU, 21 Montevideo Str., Bg
- 1618, Sofia, e-mail:



Relationship between forearm bone mineral density and body composition - 42, 2006, № 2, 53-57.
M. Boyanov

Endocrinology Clinic, University Hospital “Alexandrovska”, Medical University Sofia
Summary: Bone mineral density (BMD) is the major determinant of fracture risk. The idea to predict BMD from body weight seems very attractive. We conducted a bone densitometry study including 78 female patients (52 were menopausal) aged 30-65 years. BMD was measured at the distal and ultra-distal forearm by dual X-ray absorptiometry (Hologic QDR 4500 A). Body composition (fat mass, fat-free mass and total body water) was measured by bio-impedance on a Tanita TBF-215 device. BMD and age-matched Z-score data as dependent variables were then regressed on weight and body composition indices as dependent variables. In the majority of cases, we did not find any model. When a model was found, it was quadratic or linear with a low correlation R (R < 0,40) and statistical significance (p > 0,05). For practical purposes, a model including body weight might be sufficient. In conclusion, it is impossible to screen patients at risk of forearm osteoporosis based solely on body weight. More sophisticated models including other important risk factors are needed.
Key words: forearm bone densitometry, body weight, body composition, regression models
Address for correspondence:
Mihail Boyanov, M. D., Endocrinology Clinic, Alexandrovska Hospital, 1, G. Sofiiski Str., Bg 1431 Sofia, tel. +359 2 9230-528, e-mail:



Advanced diagnostic methods for community acquired pneumonia caused by Chlamidophila pneumoniae and
Mycoplasma pneumoniae
- 42, 2006, № 2, 58-60.
T. Kantardjiev, N. Braneova, E. Dobreva, S. Panaiotov and V. Levterova

Department of Microbiology, NCIPD Sofia
Summary: C. pneumoniae and M. pneumoniae cause acute respiratory tract infections such as atypical community-acquired pneumonia, chronic bronchitis, asthma and less frequently upper respiratory tract infections. The investigation presents the application of modern methods for detection of C. pneumoniae and M. pneumoniae in respiratory tract specimens, based on species-specific omp1 and P1 genes. All clinical specimens were examined with PCR method. Epidemic outbreaks among children in Kliuch village (2002) and town of Pavlikeni (2005) of atypical pneumonia caused by M. pneumoniae were confirmed. The positive results were obtained from nasopharyngeal specimens and sputums. The PCR methods have high specificity and sensibility and can be used as reliable methods in the routine laboratory diagnostics for C. pneumoniae and M. pneumoniae.
Key words: Chlamydophila pneumoniae, Mycoplasma pneumoniae, acquired community pneumonia, PCR
Address for correspondence
: Nadia Brankova, Department of Microbiology, NCIPD, 26 Janko Sakasov Blvd., Bg1504 Sofia, e-mail:



Brain natriuretic peptide and tumor necrosis factor-alpha in the prognostic evaluation of patients with heart failure - 42, 2006, № 2, 61-65.
N. Stancheva(1), Sn. Tischeva(1), St. Cholakov(2), St. Kurkchiev(3) and A. Goudev(4)

(1)Clinic of Cardiology and Rheumatology, UMHAT “G. Stranski” – Pleven
(2)Department of Functional Diagnosis, UMHAT “G. Stranski” – Pleven
(3)Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences – Sofia
(4)Clinic of Cardiology with Intensive Care Unit, UMHAT “Tsaritsa Ioanna” – Sofia
Summary: The relationship of neurohormones and cytokines with poor prognosis in chronic heart failure (HF) has already been established. The aim of this study was to evaluate the role of plasma concentration of N-terminal proBNP (NTproBNP) and tumor necrosis factor (TNF-alpha) as predictors of outcome in HF. One hundred and twenty-seven patients with symptomatic HF ranging from II to IV NYHA functional class were included, of them 69 males (57%) with mean age 61.9 +/- 8.4 years. The patients were consecutively hospitalized due to exacerbated HF. On the day of discharge, standard laboratory samples were obtained, echocardiography was performed and venous plasma for NTproBNP and TNF-alpha was collected. The primary endpoint was defined as rehospitalization for exacerbated HF within 6 months after discharge, more than 2 hospitalizations in 1 year or cardiac death. One hundred and twenty-one (95.3%) patients were followed for a mean of 387 +/- 117 days. Fifty-four (44.6%) of them reached at least one of the endpoints. At univariate analysis, NTproBNP proved to be significant predictor of outcome (chi square = 32.93, ? < 0.0001) while TNF-alpha did not (chi square = 1.17, ? = 0.76). In hospitalized patients with HF, plasma concentration of NTproBNP at discharge is predictive of outcome in HF.
Key words: brain natriuretic peptide, tumor necrosis factor, heart failure, prognosis
Address for correspondence:
Nadia Stancheva, M. D., Clinic of Cardiology and Rheumatology, UMHAT “G. Stranski, 8 Georgi Kochev Str., Bg – 5800 Pleven



Resistance index as a predictor of renal transplant survival - 42, 2006, № 2, 66-72.
E. Paskalev

Clinic of Nephrology and Transplantation, University Hospital “Alexandrovska” – Sofia
Summary: Chronic allograft nephropathy is a main cause of the loss of renal allograft function and the decrease of its survival. There is no reliable factor predicting long-term outcome of renal transplantation yet. The goal of the study is to determine whether renal arterial resistance index over 0,80 is predictive of shorter allograft survival. We tested renal resistance index (segmental arteries) by Doppler ultrasonography in 260 patients at least three months after renal transplantation between 2002 and 2006. End points of the study were a decrease of 50% or more in the creatinine clearance rate, allograft failure, indicated by the need of dialysis, or death. A total of 52 patients (20%) of all 260 had resistance index of 0,80 or more. Nineteen of these patients (36,5%) had a decrease of 50% or more in creatinine clearance rate, as compared with sixteen (7,7%)of the 208 patients with resistance index of less than 0,80 (p < 0.001). Eleven patients with higher resistance index (21,1%) required dialysis, as compared with twelve (5,8%) patients with lower resistance index (p < 0.001). Five patients with higher resistant index (9,6%) died, as compared with six patients (2,9%) with lower resistance index (p < 0.001). A total of 45 patients (67,3%) with higher resistant index reached the end point of the study, as compared with 34 patients (14,4%)of those with lower resistance index (p < 0.001). These results showed the importance of renal arterial resistance index of 0,80 or more, measured at least three months after transplantation, as a predictor of shorter survival of renal allograft as compared with a resistance index of less than 0,80.
Key words: kidney transplantation, survival of renal transplant, arterial resistance index
Address for correspondence:
Assoc. Prof. Emil Paskalev, M. D., Clinic of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg – 1431 Sofia, tel. +359 2 923-02-40, e-mail:



Effect of fosinopril on C-reactive protein and blood pressure in post-menopausal women - 42, 2006, № 2, 73-75.
A. Goudev
(1), A. Elenkova(2) and N. Koycheva(3)
(1)Department of Cardiology, University Hospital “Tsaritsa Ioanna” Sofia
(2)University Endocrinology Hospital “Akad. Ivan Penchev” Sofia
(3)Department of Clinical Chemistry, Medical University Sofia
Summary: Arterial hypertension is a complex clinical syndrome and is a well recognized atherosclerotic risk factor. The current understanding is that atherosclerosis is a low-grade inflammation. Activation of renin-angiotensin system evokes induction of redox sensitive genes and activation of immune mechanisms in arterial wall. In the present study, we tested the effect of fosinopril on the concentration of C-reactive protein in postmenopausal women with arterial hypertension for three months. At the end of the study, the blood pressure was significantly reduced. There was a trend to decrease of CRP levels, which was not statistically significant.
Key words: arterial hypertension, C-reactive protein, fosinopril
Address for correspondence:
Assoc. Prof. Asen R. Goudev, Department of Cardiology, University Hospital "Tsaritsa Ioanna", 8, Bialo more Str., Bg 1527 Sofia, e-mail:



Role of the transforming growth factor-beta1 in progression of pleural empyema - 42, 2006, № 2, 76-79.
I. Novakov
(1) and D. Terzieva(2)
(1)Department of Thoraco-Abdominal Surgery, Medical University – Plovdiv
(2)Central Clinical Laboratory, Medical UniversityPlovdiv
Summary: Transforming growth factor (TGF)-beta1 is a cytokine, which is an important mediator of inflammation and angiogenesis. TGF-beta1 stimulates pleural exudation and the process of pleural fibrosis in the course of pleural inflammation. The aim of our study was to demonstrate the role of TGF-beta1 in pleural empyema progression. We hypothesized that TGF-beta1 is a local mediator in pleural inflammation, produced by cells of inflammation. The study was performed with 19 patients with parapneumonic pleural empyema. For every patient, there was established pleural fluid analysis and were determined: total protein, glucose, lactatdehydrogenase, total leukocyte and differential cell count. Concentration of TGF-beta1 in pleural effusion and serum was measured using ELISA-kit. Our results have shown that TGF-beta1 is a cytokine with local action in pleural space. TGF-beta1-levels in pleural effusions correlate with severity of pleural inflammation. The levels of TGF-beta1 in the pleural effusion can be accepted as a diagnostic marker for pleural empyema progression.
Key words: pleural empyema, cytokines, transforming growth factor-beta1, pleural effusion
Address for correspondence:
Ivan Novakov, M. D., Department of Thoracoabdominal Surgery, Medical University, 54, Petrova niva Str., Bg - 4004 Plovdiv, e-mail:



Clinical and functional respiratory impairments in workers exposed to mineral work environment dust - 42, 2006, № 2, 80-85.
A. Petrova andCh. Nachev

Center of Occupational Diseases, Medical University – Sofia
Summary: Subject of the study are the clinical and functional impairments in 480 miners, in 120 workers, exposed to asbestos containing dust in different industrial branches, and in 121 non-exposed to dust individuals. A cross sectional case control study of the subjective complaints, physical respiratory examination, and spirometry (VC, FVC, FEV1, FEV1/VC, FEF25%, FEF50%, FEF75%) were done. There were formed four types ventilatory insufficiency (restrictive, obstructive, mixed insufficiency, and small airway obstruction). The subjective symptoms predominated in asbestos exposed workers, followed by workers from steam power plant without statistical significance. The subjective complaints predominated amongst asbestos exposed workers in comparison with non-exposed individuals in control group (? < 0.0001). More intensive respiratory complaints were found in tobacco smokers. Subjective complaints were found in 239 (96.4%) workers with proven lung disease, and in 9 (3.6%) with acute respiratory disease. Subjective symptoms were present in 33.3% new registered pneumoconiosis, as well as in 34.6% workers with borderline pneumoconioses. 80.0% of the patients with chronic bronchitis had chronic cough with varying expectoration, fatigue, breathlessness during physical efforts. The obstructive ventilatory insufficiency was rarer than the small airways’ obstruction (SAO). Restrictive and mixed ventilatory insufficiency predominated amongst the control group, in comparison to the group of asbestos exposed workers. Asbestos exposed individuals were with predominating obstructive ventilatory insufficiency and SAO. It is concluded that the subjective symptoms dominated in the group of asbestos exposed workers, as well as in the group of the coal miners due to the irritative effect of the dust. Mixed ventilatory insufficiency and SAO predominated in the miners’ group, and the obstructive ventilatory insufficiency and SAO were found amongst asbestos exposed workers. Respiratory questionnaire, as well as spirometry (FEF25%, FEF50%, FEF75%) are the most useful screening methods in dust exposed workers, as well as in early diagnostics of the occupational dust diseases. An active compaign against tobacco smoking in dust exposed individuals is necessary.
Key words: screening, mineral dusts, subjective respiratory complaints, spirometry
Address for correspondence:
Assoc. Prof. Elisaveta Petrova, M.D., PhD, Clinic of Occupational Diseases, University Hospital “Sv. Ivan Rilski”, Medical University, 15 Akad. I. Geshov Blvd., Bg – 1431 Sofia, e-mail:



Primary care anti-asthmatic treatment: types of medication, expenditures of the health insurance system and the patients - 42, 2006, № 2, 86-92.
G. Christoff

Clinical Centre of Allergy, Medical University – Sofia
Summary: Asthma is one of the most common chronic diseases in the world. Its rate, prevalence and incidence are associated with constant increase. The social and economic burden of asthma in many countries is of sufficient magnitude to warrant its recognition as a priority disorder in government health strategies. The expenses that the health insurance system incurs providing outpatient health services for asthmatics are of considerable interest. The published data in the annual reports of the NHIF for 2003 and 2004 are used to analyze the structure of the primary care antiasthmatic treatment programmes as well as the expenditures of the health insurance system and the patients.
Key words: bronchial asthma, NHIF, statistical and economic indices, antiasthmatic medication expenses
Address for correspondence: 
George Christoff, MD, PhD, Clinical Centre of Allergy, Medical University, 1, “Sv. G. Sofiiskistr., Bg 1431 – Sofia, tel. +359 2 9230-612, e-mail:



Idiopathic interstitial pneumonia. Contemporary clinical-roentgenologic-pathologic classification - 42, 2006, № 2, 114-122.
St. Ivanov

Prevention of cardiovascular incidents with fenofibrate in patients with type 2 diabetes: results from FIELD Study - 42, 2006, № 2, 123-125.
Vl. Hristov and V. Karamfilova





Symptoms, functional parameters and exercise capacity in COPD patients with frequent and infrequent exacerbations - 42, 2006, № 1, 53-58.
V. Hodgev
(1) and S. Kostianev(2)
(1)Department of Pulmonology, (2)Department of Pathophysiology,
Medical UniversityPlovdiv
Summary: The objective of this study was to compare symptoms, functional parameters and exercise capacity between COPD patients with frequent exacerbations and those with infrequent exacerbations. The study population included 101 stable COPD patients: age = 59.1 +/- 8.6 год.; FEV1% = 36 +/- 15%; BMI = 23.7 +/- 5.6 kg.m2. The patients were divided into those who had presented with three or more episodes in previous 12-month period (frequent exacerbatorsn = 50) and those who had suffered two or less exacerbations (infrequent exacerbatorsn = 51). We found statistically significant differences between frequent and infrequent exacerbators with respect to chronic symptoms: cough (2.6 +/- 0.8 vs. 2.1 +/- 0.9; Р = 0.001), sputum production (2.3 +/- 0.8 vs. 1.8 +/- 0.8; Р = 0.002), wheeze (1.8 +/- 0.9 vs. 1.3 +/- 1.1; Р = 0.018) and dyspnea (2.9 +/- 0.7 vs. 2.4 +/- 0.6; Р < 0.001); PImax (44 +/- 22 vs. 57 +/- 19 cm H2O; Р = 0.005) and exercise capacity (6MWТ, 6-minute walk test) (345 +/- 131 vs. 410 +/- 93 m; Р = 0.005). There were no differences in age, BMI, packs/yearly of smoking, lung function indices (FEV1%, VC%, TL,CO/VA%, RV/TLC%) and blood gases. It was concluded that: COPD patients who experienced frequent exacerbations in previous year have significantly more severe chronic symptoms, lower PImax and 6MWT, than those who experience infrequent exacerbations.
Key words: chronic obstructive pulmonary disease, exacerbation, 6-minute walk test
Address for correspondence:   Vladimir Hodgev, D.M., Department of Pulmonology, Medical University, 15A Vasil Aprilov Blvd., Bg – 4002 Plovdiv, tel.  +359 32 4-41-70/486, e-mail:



Cor pulmonale and silent myocardial ischemia - 42, 2006, № 1, 59-64.
D. Petrova
(1), O. Georgiev(1), R. Ànastasova(1), E. Manov(1), P. Shoshkov(1), R. Shabani(1), A. Mladenova(2) and E. Vikentieva(3)
(1)Department of Propedeutic of Internal Diseases
(2)Central Clinical Laboratory
(3)Clinic of Allergology and Clinical Immunology
 Hospital “Alexandrovska”, Medical University – Sofia
Summary: The long development of chronic obstructive pulmonary disease (COPD) with respiratory failure leads to disorders in lung circulation and hemodynamics. It seems to play an important role in the pathogenesis of cor pulmonale and of right heart failure. Secondary changes in the left ventricular function develop in these patients. The effect of changed pulmonary hemodynamics and chronic progressive hypoxemia on myocardial dysfunction is still under debates. The aim of the study was to follow-up changes in left ventricular and myocardial function in COPD pa-tients with cor pulmonale. 96 COPD patients with moderate and severe respiratory and right heart failure were investigated. They were divided into two groups ac-cording to the degree of respiratory failure. The following investigations were carried out: spirometry, arterial blood gases analysis, electrocardiogram (ECG), 24 hours Holter-ECG monitoring, and two- dimensional echocardiography. In 8 of them, rest myocardial scintigraphy was realized. The data obtained significant disorders in lung hemodynamics, and in right ventricular heart function: significantly higher mean pulmonary arterial pressure values, right ventricular dilatation and right ventricular wall hypertrophy. There was a relationship between the degree of respiratory failure and changed hemodynamic parameters. In 32 (33.3%) COPD patients, left ventricular hypertrophy was detected. 28.1% (27) of COPD patients were with diastolic heart dysfunction. 28.1% (21) of COPD patients were with left sistolic heart dysfunction. ECG, Holter ECG, ultrasound and myocardial scintigraphy data for myocardial perfusion were found in 41 (42.7%) patients. Only 7 of them were with moderate respiratory failure. In 68.75% (66) of all the patients with COPD, different forms of rhythmic disturbances were established, while in 12.5% (12) of them atrial fibrillation was observed. The progressive disorders in lung circulation and right heart failure and chronic hypoxemia in COPD patients with cor pulmonale lead to secondary myocardial ischemia and left ventricular heart dysfunction, often without clinical symptoms. These processes worsen the prognosis of COPD. Their early diagnosis and treatment are of essential importance for improvement of the prognosis of the disease and the survival of these patients.
Key words: chronic obstructive pulmonary disease, respiratory failure, left ventricular dysfunction, arrythmia
Address for correspondence: Daniela Petrova, M. D., Clinic of Pulmonology, University Hospital "Alexandrovska", 1, "Sv. G. Sofiiski" Str., Bg – 1431 Sofia, tel. +359 2 92 30 656, e-mail:



Nosocomial infections in intensive care patients - 42, 2006, № 1, 65-71.
A. Kircheva and D. Paskalev
Department of Clinical Epidemiology, MHAT “Sv. Anna” – Varna
Clinic of Nephrology and Dialysis, MHAT “Sv. Marina” – Varna
Summary:  Nosocomial infections are unavoidable consequence of medical manipulations worldwide, discrediting the success of treatment and prolonging hospital stay. It is generally acknowledged fact that these infections most commonly occur in patients that have undergone intensive treatment: 5 to 88% according to the information of the World Health Organization and 11 to 20% in this country. The report makes a comparative review and assessment of the most frequently registered nosocomial infections in this country and abroad and the etiologically connected bacterial flora. Underlined is the leading role of nosocomial pneumonia and the risk factors that need to be controlled and prevented. The knowledge of the pathological mechanisms for the occurrence of this infection is also a necessary prerequisite to reassess the routine practices and to develop principles for monitoring and control of nosocomial infections in every hospital. First step in this direction is the observance of the medical standards developed for the respective profiles of medical services in this country.
Key words:  nosocomial infections; nosocomial pneumonia; risk factors; prevention
Address for correspondence:
 Anna Kircheva, M. D., Department of Clinical Epidemiology, MHAT “Sv. Anna” , 100, Tzar Osvoboditel blv., Bg – 9000 Varna, e-mail:



Electrocardiographic changes in acute pancreatitis - 42, 2006, № 1, 72-77.
M. Milanova

Section of Emergency Surgery, Third Surgical Clinic, MHATEM “N. I. Pirogov” – Sofia
Summary: In this study, there are presented data about the frequency and type of the electrocardiographic (ECG) changes in 67 patients with cardiac dysfunction among a total of 114 patients with acute pancreatitis, and potential relations between ECG changes and the course of the acute pancreatitis are analyzed. 50 of the patients were treated inoperativelly, and in 17 cases, single- or multiple-stage surgical procedures were performed. At admission to the hospital, ECG changes were found in 78% of the patients, and during the follow up ECG examinations – in 44% of the inoperativelly treated patients and in 50% of the patients operated on – during the postoperative course. Most common were sinus tachycardia and ST-segment changes. ECG changes were similar in frequency and type among the patients with a history of cardiac diseases and in those without such a history. However, ECG changes were more frequent in patients with severe forms of acute pancreatitis. The analyses of the data enable us to conclude that ECG changes are causally related with the systemic physiological changes and the acute inflammatory response, and that the consideration and the monitoring of the ECG changes are a prerequisite for the prognose and the successful management.
Key words: electrocardiographic changes, acute pancreatitis, cardiovascular complications
Address for correspondence: 
Maria Milanova, M. D., Section of Emergency Surgery, MHATEM “N. I. Pirogov”,21, Totleben Blvd., Bg – 1606 Sofia, tel.
 +359 2 915-43-13



Thrombophilic genetic factors in patients with pulmonary embolism - 42, 2006, № 1, 78-83.
P. Ivanov
(1), K. Kovacheva(2), R. Komsa-Penkova(1), Y. Ivanov(3), P. Pavlov(3) and V. Nojarov(3)
(1)Department of Biochemistry,
)Department of Medical Genetics, Medical University Pleven,
(3) University Lung Diseases Hospital  -   Pleven  
Summary: Pulmonary embolism (PE) is a state started with deep venous thrombosis followed by embolisation and rethrombosis of pulmonary artery. The impairment of coagulation resulting in formation of thrombus (thrombophilic state) has an important role in pathogenesis of PE. Factor V Leiden (FVL), G20210A prothrombin gene mutation (PTM), genetic variant C677T in methylenetetrahydrofolate reductase (MTHFR) gene and PA1/PA2 polymorphism in platelet Glycoprotein IIb/IIIa (PlA2) are more common genetic factors predisposing to thrombotic state. The aim of the study was to estimate frequency of thrombophilic genetic factors among patients with PE and contribution of these factors for recurrent development and onset of thrombotic incidences in carriers of the factors. Thirty two patients with PE and 25 healthy controls were tested with DNA analysis. Eighteen patients (56%) with PE were carriers of at least one thrombophilic factor compared to 4 (16%) in controls (р = 0.0005). FVL was the most common genetic defect found in 25% of patients, versus 8 % in controls, (р = 0.04). Carriers of at least one thrombophilic factor were 65% of patients with recurrent incidences of PE and 74% of patients with onset of the first PE incidence under 45 years. The frequency of FVL and G20210А prothrombin mutation in these subgroups was significant higher compared to controls which emphasizes the clinical importance of genetic defects for development of PE. Testing for thrombophilic genetic factors allows an early detection of patients at high risk for PE as well as individualizing of therapy and prevention of recurrent incidence of PE.
Key words: pulmonary embolism, genetic factors, predisposition, thrombophilia
Address for correspondence:
P. Ivanov, M. D., Department of Biochemistry, Medical University, 8A G. Kochev Str., Bg – 5800 Pleven



Analysis of pleural exudate: role in the diagnosis and predicting the outcome of treatment of complicated parapneumonic effusions - 42, 2006, № 1, 84-87.
I. Novakov
(1) and R. Ivantcheva(2)
(1)Department of Thoraco-abdominal Surgery, Medical UniversityPlovdiv
(2)Department of Pulmonology, Medical UniversityPlovdiv
Summary: From 20 to 57% of patients with pneumonia develope effusions in the course of disease. The presence of complicated parapneumonic effusion is indication for its drainage. The aim of our study was to evaluate the role of some characteristics of pleural fluid as well as for establishing the complicated parapneumonic effusion as for predicting the outcome of effusional drainage. Forty-three patients with complicated parapneumonic effusion were included in the study. Visual, laboratory and microbiology methods were used for pleural fluid analysis. We established large size effusions in all patients with pleural loculation in 14 (32,56%). The data from laboratory fluid analysis were with low sensitivity – 12% for LDH and 23% for glucose. The size of effusion is the main factor to select the patients with complicated parapneumonic effusion, while the results of laboratory fluid analysis have no important role. We also prove that pleural loculation is the only predicting factor for poor outcome of effusional drainage.
Key words: complicated parapneumonic effusion, pleural loculations, predicting factors
Address for correspondence:  Ivan Novakov, M. D. Department of Thoracoabdominal Surgery, Medical UniversityPlovdiv, 54 “Petrova niva” Str., Bg – 4004, e-mail:



Role of oxidized LDL for coronary artery disease in patients with diabetes mellitus type 2 - 42, 2006, № 1, 88-92.
N. Doncheva
(1), P. Holvoet(2), M. Todorova(3), Z. Kamenov(4), V. Christov(4) and Z. Kuneva(5)
(1)Department of Clinical Lipidology, Medical Institute of MIA Sofia
(2)Center of Experimental Surgery and Anesthesiology, Catholic University of Leuven Belgium
(3)Department of Pathophysiology, Medical University – Sofia
(4)Clinic of Endocrinology, Alexandrovska Hospital, Medical University – Sofia
(5)Clinic of Cardiology, Alexandrovska Hospital, Medical University – Sofia
Summary: The imp
оrtance of oxidative stress for the development of diabetic complications is well known. Oxidized LDL (OxLDL) is one of the most atherogenic fractions of LDL. The aim of the study was to make a comparative analysis of the lipid prophile, plasma levels of OxLDL and the atherogenic marker TC/HDL-C in three groups of patients: 1) with coronary artery disease (CAD); 2) with type 2 diabetes mellitus (DM2); 3) combined CAD + DM2. In the study, 68 subjects below 50 years were included: 11 clinically healthy volunteers without laboratory evidence for carbohydrate or lipid metabolic disturbances or cardiovascular disease; 24 patients with CAD; 15 patients with DM2 without evidence for CAD, and 15 patients with DM2 + CAD. The results showed that TC, LDL, TG and the ratio TC/HDL-C were significantly higher in the three groups of patients compared with the controls, the highest values found in DM2 + CAD. The levels of HDL were significantly lower in the three groups, as compared with the control group, and the lowest values were found in the group DM2 + CAD. The values of OxLDL in all patient groups were significantly higher compared to the controls. The values of OxLDL were highest in the group with CAD, but the difference between the patient groups was not significant. In conclusion, the ratio TC/HDL-C has a stronger informative and prognostic value for the risk of CAD in patients with DM2 compared with OxLDL.
Key words: dyslipidemia, coronary artery disease, diabetes mellitus 2, OxLDL
Address for correspondence:  Zdravko Kamenov, M. D., Clinic of Endocrinology, MHAT “Alexandrovska”, 1, “Sv. G. Sofiiski” Str., Bg – 1431 Sofia, tel. +359 2 92-30-244, e-mail:



OCULAR changes in patients with systemic lupus erythematosus and clinically manifested nervous system disorders - 42, 2006, № 1, 93-97.
S. Monov
(1), R. Toncheva(2), R. Rashkov(1), I. Altankova(3) and A. Ivanov(4)
(1)Clinic of Rheumatology, Medical University – Sofia
(2)Ophthalmology, MHATSv. Iv. Rilski Sofia
(3)Immunologic Laboratory, MHAT “Sv. Iv. Rilski ”Sofia
(4)Military Medical Academy Sofia
Summary: Systemic lupus erythematosus (SLE) is an autoimmune multisystem disease affecting the retinal vessels in 3 to 29% of the cases. Ocular injuries in SLE may be associated with the disease itself as well as with the therapy performed with corticosteroids and antimalarials. Ocular symptoms manifesting the systemic character of SLE are: retinal changes, atrophy of the optic nerve and cataract. Subject of this study were the ocular changes in 104 patients with SLE and clinically manifested disorders of the nervous system. The most frequently established pathology at investigation with direct ophthalmoscopy was vasculitis of the retinal vessels (32,69%). Papilledema was diagnosed in 26,92%. Retinopathy was found in 54% of the patients with neuropsychiatric SLE (NPSLE) and positive anticardiolipin antibodies, in 53,57% of those with NPSLE and kidney injuries and in 52,38% of the patients with NPSLE and positive data at MRI (magnetic resonance imaging) for disorders of the central nervous system. Investigation of fundus oculi is necessary in all patients with SLE, as it is an indicator not only of the systemic character of SLE but of its activity as well.
Key words:
  systemic lupus erythematosus, ophthalmoscopy, retinopathy, optic nerve
Address for correspondence:  Simeon Monov, M. D., Clinic of Rheumatology, Medical University, 13, Urvitch Str., Bg – 1612 Sofia, tel.  +359 2 958-29-27



Comparative evaluation of two immunometric methods for detection of antinuclear antibodies - 42, 2006, № 1, 98-101.
I. Manolova
(1), V. Tsoneva(2) and M. Ivanova(3)
(1)Laboratory of Clinical Immunology, University Hospital – Stara Zagora
(2)Central Clinical Laboratory, University Hospital – Stara Zagora
(3)Clinic of Rheumocardiology, University Hospital – Stara Zagora
Summary: The standard method for detecting antinuclear antibodies (ANA) is by indirect immunofluorescence assay (IIF) on HЕp-2 cells as substrate. A more recent approach to ANA screening is the use of enzyme immunoassays (EIA). The aim of our study was to compare BINDAZYME ANA Screen EIA test (Binding Site, UK) with IIF in view of their performances in the detection of ANA. The study was performed on 90 serum samples: 49 specimens were positive by both assays, 27 were negative by both assays, 12 were positive by IIF only, and 2 were positive by EIA only. There was an overall good concordance of 84.4% between both assays. In conclusion, BINDAZYME ANA Screen is a suitable alternative test for ANA screening. However, IIF on HЕp-2 is still a more reliable method for ANA detection.
Key words: antinuclear antibodies, enzyme immunoassay, indirect immunofluorescence
Address for correspondence:
Irena Manolova, MD, PhD, Laboraroty of Clinical Immunology, University Hospital, 11 Armeiska Str., Bg – 6000 Stara Zagora, tel. +359 42 664 385, e-mail:



Lung emphysema in individuals exposed to mineral dust and in patients with pneumoconioses and relation with some risk factors and FEF50% - 42, 2006, № 1, 102-108.
Е. Petrova and Ch. Nachev
Center of Occupational Diseases, Medical University – Sofia
Summary: The object of the study is the X-ray estimated compensatory lung emphysemamaccording to ILO’80) in 480 underground miners and in 120 asbestos exposed workers. The average age of all the investigated dust exposed individuals was 41.38 years, and the average length of the dust exposure in the group of the miners was 11.32 y. The average asbestos exposure was 16.5 y and the average latent period was 17.45 years. All workers were exposed in their work places in the period from 1985 to 2003. The X-ray emphysema findings (еm) were evaluated by two experts using the ILO International Classification of ten Radiographs of Pneumoconioses, Geneva, 1980 (ILO’80) in the conditions of a nestled case control study. A spirometry with an accent to FEF50% was done. The levels of the dust in the work environment air, tobacco smoking habit and alcohol abuse were accounted. A compensatory emphysema (em – by ILO’80) without/with presence of a boundary (0/1,1/0) or initial pneumoconiosis (1/1) was found in 75 (69.4%) asbestos exposed workers, 62 (54.9%) miners from black coal mining, 49 (42.2%) miners from brown coal mining, in 19 (35.8%) underground miners from anthracite coal mining and in 42 (34.1%) miners from lead-zinc mining (Р < 0.0001). Em X-ray findings were established in 91 (31.5%) workers with 10-year mineral dust exposure, 159 (55%) with 11+ years exposure, and in 39 (13.5%) non-exposed controls. We did not detect em in 76 (22.4%) controls, in 154 (45.4%) exposed to 10-year dust exposure, and in 109 (32.2%) workers with 11+ years mineral dust exposure. The absolute number and the relative share of the group of the individuals with 10 years dust exposure without еm findings were 154 (58.6%), and the number and the share of the 11+ years exposure group were 109 (41.4%). The number and the share of em findings in the workers’ group with alcohol abuse were 235 (81.3%); respectively, there were 54 (18.7%) in individuals non-using alcohol. The individuals with alcohol abuse without em findings were 229 (67.6%) against 110 (32.4%) workers non-using alcohol without em X-ray findings (Р < 0.0001). Em was found in 203 (70.2%) workers without data for previous lung diseases, and the individuals with a history of pulmonary diseases with concomitant emphysema (em) were 86 (29.8%) – Р = 0.035. The average value of FEF50% diminished due to appearance of compensatory emphysema in dust exposed workers and in patients with boundary and manifested initial pneumoconioses. Roentgenologically confirmed compensatory emphysema (em) dominated in asbestos exposed workers, followed by miners from the black coal, the brown coal, and the anthracite coal mining, as well as from the lead-zinc ore mining. The em X-ray findings were significantly influenced by the dust exposure length, as well as by the alcohol abuse in workers exposed to mineral dust. There was a lack of influence of previous lung and pleural diseases on the em X-ray findings. This fact confirms the thesis for the multifactorial etiopathogenesis of compensatory emphysema (em), including the proved effect of tobacco smoking.
Key words: еmphysema, mineral dust, FEF50%
Address for correspondence: 
Assoc. Prof. Elisaveta Petrova, M.D., PhD, Clinic of Occupational Diseases, University Hospital “Sv. Ivan Rilski”, Medical University, 15 Akad. I. Geshov Blvd., Bg – 1431 Sofia, e-mail:



Sodium hyaluronate 500-730 кDa (Hyalgan®) intra-articularly after treatment of synovitis in primary active osteoarthritis of the knee joint with betamethasone - 42, 2006, № 1, 109-113.
S. Kuzmanova and P. Solakov

Clinic of Rheumatology, University HospitalPlovdiv
Summary: Sodium hyaluronate (HA) may be a useful additional therapy of symptomatic OA. It has a long duration of action, and demonstrated a good safety profile. Therapeutic efficacy of HA lies in its different mechanisms of action as: unique viscoelastic properties and lubricant abilities, as well as ability to retain fluid in the joint cavity. Objective of the study was to compare efficacy and tolerability of HA intraarticularly (i.a.) in two groups of patients with OA of the knee joint. The 1st group of15 patients with active primary symptomatic knee OA with synovitis and intraarticular effusion was treated prior to therapy with HA with Betamethasone i.a., and 2nd group including 13 patients with primary symptomatic knee OA without clinically active synovitis received intraarticularly weekly injections of HA (2 ml of 20 mg/ml) for 5 weeks. First group patients were with contraindications for immediately HA treatment as per manufacturers instruction of Hyalgan®. They received Betamethasone i.a. as the first step of treatment. After decreasing the signs of joint inflammation, these patients were treated for five weeks with HA i.a. (Hyalgan®). We demonstrate the advantages of the treatment of active synovitiis of the knee in OA with Betamethasone i.a. before injections of HA. The inhibition of joint inflammation with corticosteroid as first step enabled a better effect of HA on the pain and the functional impairment. In summary: in cases of active OA of the knee with manifested synovitis and intraarticular hydrops, it is recommended before treatment with HA i.a. to provide treatment with Betamethasone i.a.
Key words: sodium hyaluronate, Betamethasone, osteoarthritis, knee joint, synovitis
Address for correspondence: 
Assoc. Prof. Stefka Kuzmanova, M.D., DSc, Clinic of Rheumatology, University Hospital, 15A V. Aprilov Blvd., Bg – 4002 Plovdiv, tel./fax: +359 32 602 532, e-mail:


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