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Original papers

Vol. 43, 2007


bullet 4'2007

Diastolic dysfunction in patients with congestive heart failure with preserved and reduced ejection fraction – 43, 2007, No 4, 44-49.
E. Kinova, N. Zlatareva, K. Koleva and A. Goudev
Department of Cardiology, University Hospital “Tsaritsa Ioanna” -- Sofia
Summary: Although the prevalence of congestive heart failure (CHF) with preserved ejection fraction (EF) has increased in recent years, data concerning diastolic properties of the left ventricle (LV) in this condition are not sufficient. The objective of our study was to compare LV diastolic function in patients with CHF with preserved and reduced EF and to propose diastolic indices for differentiation of these patient subgroups. Fifty-eight patients admitted to Department of Cardiology with signs and symptoms of severe CHF (NYHA class III and IV) were analyzed. Echocardiography was performed during first 24-48 hours of hospitalization. Patients were divided into two groups according to LV EF -- group 1 with preserved EF >/= 50% and group 2 with reduced -- EF < 50%. Patients with preserved EF (23 patients, 40%) were older (75 +/- 11 years vs. 67 +/- 14 years, (p = 0.01) and they had 100% history of hypertension (p = 0.03), lower incidence of diabetes (17% vs. 57%, p = 0.003) and lower heart rate at admission (79.8 +/- 19/min vs. 98.4 ± 17/min, p < 0.0001). Deceleration time of early filling (196.9 v 65.9 ms vs. 147.1 v 54.7 ms, p = 0.002) and flow propagation velocity Vp (59.4 +/- 16.7 cm/sec vs. 50.0 +/- 12.0 cm/sec, p = 0.019) were significantly higher in this group. Ejection fraction was positively correlated with deceleration time (correlation coefficient 0.38, p = 0.005) and Vp (correlation coefficient 0.29, p = 0.03) but the relationships were weak. In conclusions, no single diastolic parameter was sufficient to differentiate patients with diastolic CHF from those with systolic CHF. Left ventricular diastolic dysfunction was more severe in patients with reduced EF.
Key words: echocardiography, diastolic filling, heart failure
Аddress for correspondence: Еlena Kinova, M. D., Clinic of Cardiology, University Hospital “Tsaritsa Ioanna”, 8, Bialo more Str., Bg -- 1527 Sofia, tel. +359 2 9432 297, e-mail: ekinova@hotmail.com



Disturbances of the nonvestibular eye movements in patients with multiple sclerosis -- videooculographic study  – 43, 2007, No 4,  50-54.
R. Ikonomov(1), Z. Zhelyazkova(2), K. Kostov(1), K. Tsalovski(1), I. Petrov(1) and R. Benchev(2)
(1)Neurologic Clinic, (2)Clinic of Otolaryngology, Medical Institute of Ministry of Internal Affairs -- Sofia
Summary: The aim of this study is an assessment of the nonvestibular eye movements (saccadic, smooth pursuit and optokinetic) in patients with multiple sclerosis by infrared videooculography. Thirteen patients (seven men and six women) with average age 38.3 years with cerebrospinal form of multiple sclerosis are examined. All of the patients are with definitive diagnosis multiple sclerosis according to McDonald’s diagnostic criteria (2001). Infrared videooculograrhy (IRO) for registration of the eye movements (Videonystagmograph Synapsys) is used. Saccadic, smooth pursuit and optokinetic eye movements are examined. The different characteristics of the eye movements are measured and calculated with automatic computerized analysis. Different disturbances of the eye movements are determined in eleven patients (84.6%). 69.2% of the patients have abnormalities of the saccadic eye movements. The different patients have dissimilar abnormal characteristics -- latency, average saccadic velocity, precision, but with relatively unchanged symmetry. The most sensitive is the investigation of saccadic velocity – 61.5%. The smooth pursuit eye movements are abnormal in 30.3% of the patients. Their gain is better, but in the more cases they are saccadic. Optokinetic nystagmus is often abnormal (61.5%). Its gain is commonly decreased with relatively normal symmetry. The results of the presented study show that the videooculograrhic investigation of the nonvestibular eye movements and the computerized analysis of their disturbances are a useful objective test for assessment of the functional condition of the brainstem in patients with multiple sclerosis.
Key words: videooculography, eye movements, multiple sclerosis
Address for correspondence: Rosen Ikonomov, M. D., Neurologic Clinic, Medical Institute, Ministry of Internal Affairs, 79, Skobelev Blv., Bg -- 1606 Sofia, tel. +359 2 9821410



Effect of therapy with recombinant erythropoietin on the oxidative stress in patients with chronic renal failure – 43, 2007, No 4, 55-60.
А. Tolekova(1), G. Ilieva(1), B. Popov(2), S. Rоrоvа(2), V. Gadjeva(2) и Т. Мircheva(3)
(1)Department of Physiology, Pathophysiology and Pharmacology, (2)Department of Chemistry and Biochemistry, (3)Department of Internal Diseases and Clinical Laboratory, Medical Faculty, Trakian University -- Stara Zagora
Summary: The aim of our study was to investigate the role of erythropoietin therapy on oxidative stress in patients with chronic renal failure. Malondialdehyde and catalase activity were measured before and after short-time treatment with erythropoietin in two groups of patients with: pyelonephritis (1st) and glomerulonephritis (2nd). The plasma concentration of malondialdehyde and the activity of catalase in erythrocytes in both patient groups were significantly elevated, than in controls (malondialdehyde and catalase: 1st group -- 2.50 +/- 0.57 mcmol/l, 26325 +/- 4087 U/gHb and 2nd group -- 2.97 +/- 0.47 mcmol/l, 28174 +/- 9401 U/gHb versus controls -- 1.77 +/- 0.44 mcmol/l p < 0.01; 16721 +/- 2361 U/gHb, p < 0.001). After one week treatment, malondialdehyde significantly decreases only in group 2 (1.50 +/- 0.09 mcmol/l, p < 0.001) versus that before treatment and versus that of 1st group. In the second week, malondialdehyde markedly rose in both groups. Catalase was significantly higher after two weeks of erythropoietin treatment in both groups (1st group -- 33976.96 +/- 9690 U/gHb and 2nd group -- 51 930.11 +/- 6161.5 U/gHb) compared with the value before treatment and after 1 week treatment). The lack of positive effect of erythropoietin therapy upon oxi­da­tive stress could be explained with insufficient correction of the renal anemia that in itself could be a reason for development and maintenance of oxidative stress.
Key words: Erythropoietin, catalase, malondialdehyde, oxidative stress, renal anemia
Аddress for correspondence: Anna Tolekova, M. D., Department of Physiology, Pathophysiology and Pharmacology, Medical Faculty, Trakian University 11, Armeyska Str., Bg -- 6000 Stara Zagora, e-mail: annatolekova@yahoo.com



Sustained virological response after combined Peginterferon alfa-2a plus Ribavirin therapy in patients with chronic hepatitis C – 43, 2007, No 4, 60-63.
D. Petrova(1), A. Tzvetanska(2), A. Donkova(1) and K. Tchernev(1)
(1)Department of Internal diseases and Gastroenterology, University Hospital “Alexandrovska” – Sofia, (2)Viral Laboratory, University Pediatric Hospital -- Sofia
Summary: Sustained virological response is achieved in > 50% of the cases with chronic hepatitis C and genotype 1, and in > 80% of the cases with genotype 3 after combined Peginterferon alfa-2a plus Ribavirin therapy. Aim was to assess the rate of sustained virological response after combined Peginterferon alfa-2a plus Ribavirin therapy in Bulgarian patients with chronic hepatitis C. Eighty eight patients with chronic hepatitis C were included in the study. The infection was confirmed by the presence of anti-HCV antibodies (ELISA) and PCR analysis (Cobas Amplicor HCV Monitor Test, v. 2.0, Roche Diagnostics). Viral genotype was identified using the Germer’s method. Liver biopsy was performed to assess the necro-inflammatory activity and degree of fibrosis. Sustained virologial response was defined as no detectable viraemia with qualitative PCR test 6 months after the end of the treatment. Sustained virological response was found in 63/88 patients (71.6%). Sustained virological response was achieved in 49/68 of the cases with genotype 1 (72.1%), and in 14/20 of the cases with other genotypes (70.0%). The rate of virological response did not show associations with age, gender, viral load, genotype, the way of contamination and the status of the patients (naive, relapsers, or non-responders to previous interferon therapy). Virological response was worse in the patients with cirrhosis, as compared to those with hepatitis (33.3% vs 81.4%). Twelve patients did not respond, and thirteen showed a relapse 6 months after the end of therapy. It is concluded Peginterferon alfa-2a plus Ribavirin therapy can be used effectively in the treatment of chronic hepatitis C, even in the difficult to treat genotype 1, and in the special groups of patients (relapsers and non-responders to previous interferon therapy), as well. The treatment should be started before the development of liver cirrhosis, which compromises virological response.
Key words: hepatitis C, sustained virological response, Peginterferon alfa-2a, ribavirin
Address for correspondence: Prof. Konstantin Tchernev, Department of Internal Diseases and Gastroenterology, University Hospital “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg --1431 Sofia, tel. +359-2-9230223, Fax: +359-2-9230728, e-mail: ktchernev@alexandrovska-hospital.bg



Viral hepatitis a in Bulgarian prisons – 43, 2007, No 4, 64-68.
G. Popov(1) and V. Kovaliova
(1)Clinic of Infectious, Parasitic and Tropical Diseases, MMA -- Sofia, (2)Center of Military Epidemiology and Hygiene, MMA -- Sofia
Summary: One of the most serious health problems among prisoners is viral hepatitis. The purpose of the present research is to analyze the prisoners with viral hepatitis type A in the Bulgarian prisons and make recommendations for screening and immunoprophylaxis. 466 prisoners (men, women and children) have been investigated in prisons of Sofia (186), Belene (83), Sliven (131) and a correctional facility for children in Boychinovcy (66) from 2003 to 2005. All of them have been investigated for anti HAV total, HBsAg, anti HBc total (positive for HBeAg, anti HBe, anti HBc IgM, anti HDV) and anti HCV by ELISA with diagnostic tests of Dia Sorin. Investigated prisoners were grouped and analyzed according to the length of imprisonment; sex; age; ethnical self-consciousness and sexual orientation. 345 (74%) anti HAV total positive subjects were found among prisoners. Presence of antibodies against viral hepatitis A (аnti HAV total) was indicator for infection in the past and not obligatory for infection in the prisons. On the other side, the percentage of anti HAV total positive prisoners with many convictions and prolonged imprisonment was significantly higher. Recommendations for actualizing the regulation documents for examinations of new prisoners and for immunization were made.
Key words: viral hepatitis A, prisoners, prisons, anti HAV total
Аddress for correspondence: Georgi Popov, M. D., Clinic of Infectious, Parasitic and Tropical Diseases, MMA, 3, Sv. G. Sofiyski Str., Bg -- 1606 Sofia, GSM +359 888517529, e-mail popovg@abv.bg



Unilateral work hypertrophy of the masseteric muscle accompanied by hypertrophy of the adjoining salivary glands Echographic signs – 43, 2007, No 4, 69-73.
Y. Spirdonov(1) and V. Nikolov(2)
(1)SMDL “Medirat” -- Sofia, (2)Specialized Hospital of Maxillofacial Surgery -- Sofia
Summary: The aim of the study is to demonstrate the abilities of echography for recording the hypertrophy of masseter muscle and the accompanying changes in the adjoining large salivary glands. 19 patients, at the age of 17-31, 11 females and 8 males were echographically investigated. Linear high-frequency transducers were used at a frequency of 7,5-9 Mhz. In all patients, there was found unilateral hypertrophy of the masseter muscles, together with work hypertrophy of the adjoining parotid and submandibular glands.
Key words: echography, masseter, salivary glands, hypertrophy
Аddress for correspondence: Yordan Spirdonov, M. D., SMDL “Medirat”, 26, Gen. Danail Nikolaev Blvd., Bg -- 1527 Sofia, e-mail: dspirdonov@abv.bg.



Intubation with fibrobronchoscope in patients with diseases in the maxillofacial region – 43, 2007, No 4,  74-76.
M. Melnicharov(1), A. Djorov(2) and P. Petrov(3)
(1)Department of Otorhinolaryngology, Medical University -- Sofia, (2)Department of OMFS, Dental Faculty, Medical University -- Sofia, (3)Specialized Hospital of Maxillofacial Surgery -- Sofia
Summary: The authors submit methods and indications for intubation with fibrobronchoscope (FBS) prior to surgery in the maxillofacial region (MFS). The methods were used in 24 patients. The fibroscope is a guide, leading the endotracheal tube to place under visual control of the vocal chords. 17 of the patients were suffering from ankylosis of TMJ, micrognathy, contractures, or malignancies in the region. In these patients, the intubation with FBS was previously planned, and in other 7 the method was used after failure of direct laryngoscopy. The latter patients suffered from malignancies in the region and were with anatomo-topographic abnormalties. The results are a ground to recommend the intubation with FBS in patients with pathology in the maxillofacial region, after consulting a MF surgeon, ORL surgeon and anesthesiologist. The visual control of the vocal chords and larynx during intubation determines the high value of the method. We recommend it in patients suffering from ankylosis of TMJ, contractures and pathologies, altering the topography of the region.
Key words: intubation, fibrobronchoscopy, maxillofacial region
Address for correspondence: M. Melnicharov, M. D., Department of Otorhinolaryngology, Medical University, 8, Byalo more Str., Bg -- 1527 Sofia



Forensic characteristics of victims to low-voltage accidents in Varna district  – 43, 2007, No 4,  77-79.
W. Dokov
Department of Forensic Medicine, Medical University -- Varna
Summary: Death by Low Voltage Electric Current (DLVEC) is not sufficiently studied. The purpose of this study is to take a more detailed look into some factors related to DLVEC. Forensic medicine documents from 16,780 autopsies for 42 years have been analyzed. The week days have been identified by the computer program Al Calendar v254r. The results have been processed by the program SPSS 11. DLVEC has been observed in 103 (36.79%) cases out of total (n = 280) cases. The ratio males (74.76%)/females (25.24%) is 4.12 : 1. The average age of victims is 33.48 years. The correlation between domestic and industrial electrical injuries is 4.16 : 1. The most common causes of DLVEC are contact with a household appliance (63.1%) and electrical wiring (23.3%). 66.99% of all fatalities occurred in the period June-September. Two peaks have been registered with reference to the week days: on Thursday (n = 18) and on Saturday (n = 17). Inspection on the scene of accident has been made in the presence of a forensic physician in 66.67% of the cases.
Key words: electrical injuries, low voltage, forensic analysis, Varna district
Address for correspondence: W. Dokov, Department of Forensic Medicine, Medical University, 55 Marin Drinov Str., Bg--9002 Varna, e-mail: Dokov@seznam.cz



bullet 3'2007

Visceral leishmaniosis -- clinical, laboratory features and therapy – 43, 2007, No 3, 26-31.
K. Vutova
Department of Infectious, Parasitic and Tropical Diseases,Medical University -- Sofia
Summary: Clinical, laboratory and еpidemiological data of 20 patients with visceral leishmaniosis, treated over a 30-year period (1976-2005) in Sofia are presented. The etiologic diagnosis is set 1-12 months after illness onset. The markedly varying clinical course, manifesting continuous fever, hepatomegaly, splenomegaly, anemia, leucopenia, thrombocytopenia, not responding to antibiotic treatment and other therapeuticals is the cause of delay of etiological treatment and serious complications. The patients were treated with the 5-valent antimony preparations Glucantime and Pentostam for 15 and 20 days, thus influencing the fever and hematological bioconstants. In one of the patients, treated for 17 days, cli­nical data for two relapses were observed. Two patients had a lethal outcome 12 months after the disease onset.
Key words: visceral leishmaniosis, autochthonous, fever, anemia, hepatomegaly, splenomegaly, leucopenia, thrombocytopenia, complications, treatment, Glucantime, Pentostam, relapse
Address for correspondence: Kamenna Vutova, M. D., Department of Infectious, Parasitic and Tropical Diseases, UMBAL “Sv. Iv. Rilski”, 15, Akad. Iv. Geshov, Blvd., Bg -- 1431 Sofia,  tel. +359 952 36 69, GSM +359 888 381 600, е-mail: K_Vutova@abv.bg



Enteroviral aseptic meningitis and encephalitis in Bulgaria in 2006 -- virological and clinical investigation – 43, 2007, No 3, 32-38. 
N. Korsun(1), Z. Mladenova(1), L. Andonova(2), М. Tiholova(2) , P. Petrov(3), А. Mangarov(4), L. Pekova(5) and T. Tcherveniakova(2)
(1)National Center of Infectious and Parasitic Diseases -- Sofia; (2)MU -- Sofia; (3)UMНAТ “Sv. Anna” Sofia; (4)Hospital of Infectious Diseases „Prof. Iv. Kirov” -- Sofia; (5)MU -- Stara Zagora
Summary: Enteroviruses (EVs) are amongst common causes of aseptic meningitis (AM) and encephalitis. The rapid etiologic diagnosis of enteroviral neuroinfections is important from the point of view of therapy, prognosis and epidemiologic measures. The aim of the present study was to assess enteroviral neurological infection incidence among children and adults in 2006 in Bulgaria as well as to compare two diagnostic methods. 96 patients with AM and 28 patients with encephalitis aged 6 months -- 75 years hospitalized in different regions in Bulgaria during 2006 were included in this study. A total of 114 stool specimens and 62 cerebrospinal fluids (CSF) were tested by virus isolation of EV in cell cultures. The method RT-PCR was used for the first time in Bulgaria for detection of EV RNA in CSF tested. Viral cultures were positive in 16 (12,7%) cases of neuroinfections. Different EV serotypes were isolated. RT-PCR results were positive in 24 (38,7%) of CSF tested. The clinical and paraclinical results of patients with proved EV RNA in CSF were analysed. EVs play an important role in the etiology of neuroinfections among the children and adults in Bulgaria. RT-PCR is more rapid and sensitive than viral culture for detection of enteroviral RNA in CSF that has diagnostic value.
Key words: enteroviruses, aseptic meningitis, encephalitis, CSF, cell culture, RT-PCR
Address for correspondence:
Assoc. Prof. Neli Korsun, M. D., National Reference Enterovirus Laboratory, National Center ofInfectious and Parasitic Diseases, 44A Stoletov Blvd, Bg -- 1233 Sofia, tel. +359 2 831 00 42, e-mail: polionl@netbg.com



Dislipidemia and subclinical atherosclerosis in patients with chronic renal failure – 43, 2007, No 3, 39-45. 
M. Lubomirova(1), Y. Petrova(2) and B. Kiperova(1)
(1)Clinic of Nephrology, University Hospital “Alexandrovska” -- Sofia
(2)Clinic of Neurology, University Hospital “Alexandrovska’’ -- Sofia
Summary: The aim of the study was to examine the changes in lipid metabolism as well as changes in intima-media thickness (IMT) in patients with renal failure (CRF). 100 patients with long duration of hypertension were examined. They were recruited into two groups. Group 1 includes 56 pts with renal failure, average age 55,7 +/- 15,22, creatinine clearance 39,19 +/- 10,11 ml/min. Group 2 -- 44 patients, average age 55,7 +/- 15,22, with normal renal function, creatinine clearance 91,11 +/- 19 ml/min. Both groups were divided into two subgroups -- with and without vascular disease. Creatinine clearance in all pts. was measured using Cockroft--Gault formula in ml/min. 20 healthy subjects were examined as control group for IMT measurement. IMT was determined by high resolution ultrasonography. Lipid metabolism was assessed in all patients. Moderate dislipidemia was detected in both groups without significant differences between them. Increased IMT was estimated in patients with CRF, compared to healthy controls (0,74 +/- 0,10 vs 0,59 +/- 0,10, p < 0,0010). After regression analysis, significant predictors for carotid IMT were: age, duration of hypertension and diabetes, renal function -- creatinine clearance, total cholesterol level as well as LDL (r = 0,349, p < 0,05). The study suggestеd that patients with mild renal failure had increased IMT of the common carotid artery. The elevated levels of lipid fractions and renal failure are associated with carotid intima-media thickening.
Key words: chronic renal failure, dislipidemia, intima-media thickness, carotid atherosclerosis
Аddress for correspondence:
Мila Lubomirova, M. D., Clinic of Nephrology, UMBAL “Alexandrovska”, 1, Sv. G. Sofiyski Str, Bg -- 1431 Sofia, tel. +359 2 9230229, e-mail: MLjubomiorva@yahoo.com



Aneurysmas and dissections of the aorta ascendens – 43, 2007, No 3, 46-50 
L. Spasov, V. Pashev and G. Mutafov
University Hospital “Lozenets” -- Sofia
Summary: In the article, the authors discuss the problem of operative treatment of aneurysmas and dissections of the aorta ascendens (ADAA). They discuss the risk factors, which lead to ADAA. The diagnosis of ADAA is easier with the help of contemporary visual diagnostic methods, echocardiography, aortography, CAT, MRI, which assure sensibility and specificity from 96% to 100%. The critical size which sharply increases the risk of complications in ADAA is 6 cm in diameter. The authors share their personal experience in the treatment of 20 patients with ADAA. Surgical intervention was applied in 17 of them. Because of the presence of aortoannuloectasia, in performing alloplastic of the aortic valve, valves with a large diameter (28-30 mm) were used. This reduced the working load on the left ventricular myocardium. This fact is confirmed by increase in the ejection fraction. Among the operated patients, only one with a severe combined heart disease died from acute heart failure. The other 16 patients were discharged from the hospital with a stable improvement.
Key words: aorta ascendens, aneurysmas, dissections, diagnosis, surgical treatment
Address for correspondence:
Lubomir Spasov, M. D., University Hospital “Lozenets”, 1, Koziak Str., Bg -- 1407 Sofia



Assessment of the conventional risk factors in patients with acute myocardial infarction during cerebrovascular incident – 43, 2007, No 3, 51-56. 
М. Tzekova(1), V. Simeonova(2), V. Тоmova(1),B. Stamenov(2), М. Danovska(2), V. Petkova(3) and А. Ruseva(3)
(1)Clinic of Cardiology and Intensive Treatment
(2)Second Neurology Clinic
(3)Medical Diagnostic Laboratory
UMHAT ”Dr. Georgy Stransky”, Мedical University -- Pleven
Summary: Aim of the study was the assessment of risk factors, clinical course and prognosis in patients with cerebrovascular accident (CVA) and acute myocardial infarction (AMI). The population sample of the survey were 49 patients treated for CVA and acute AMIduring cerebrovascular accident, in the Univesity Multifunctional Hospital for Active Treatment ”Dr Georgy Stransky” -- Pleven during last five years. Men to women proportion was 4:1 and mean age of the patients was 62,7 +/- 10,1 years. The outcome of the patients was assessed according to Rankin score scale for global risk stratification of patients with CVA. Prognostic value of the variables was definedbystatistic analysis (regression and correlation). The patients with acute ischemic stroke and acute myocardial infarctionwhich occurred during stroke were with the worst prognosis and with a very high inhospital mortality (40%). The immediate cause of death in the half of the deceased patients were complications of AMI. Risk factors with a highest prognostic value for unfavorable prognosis were: age, permanent atrial fibrillation, congestive heart failure, size of myocardial infarction and the extent of cerebral lesion assessed by CT.
Key words: cerebrovascular accident, stroke, acute myocardial infarction, risk factors, prognosis
Address for correspondence:
Assoc. Prof. Maria Tzekova, Clinic of Cardiology and Intensive Care, UMHAT “Dr. Georgi Stranski”, 8A, G. Kotchev Str., Bg -- 5800 Pleven, tel. +359 64 886 535, e-mail: mariatzekova@abv.bg



Antiphospholipid syndrome, livedo reticularis and multiple sclerosis – 43, 2007, No 3, 57-61. 
Ch. Dikova(1), I. Petrova(1), K. Nikolov(4), M. Baleva(2) and R. Shabani(3)
(1)Clinic of Neurology, University Hospital “Alexandrovska” -- Sofia
(2)Clinic of Allergology, University Hospital “Alexandrovska” -- Sofia
(3)Clinic of Propedeutics of Internal Diseases, University Hospital “Alexandrovska” -- Sofia
(4)Clinic of Dermatology and Venereology, Hospital “Sv. Anna” -- Varna
Summary: Patients with multiple sclerosis (MS) and antiphospholipid syndrome (APS) are reported recently in the literature. APS is manifested with thrombosis, miscarriages, migraine, livedo reticularis and high serum levels of anticardiolipin antibodies (aCL). The aim of our study was to evaluate the clinical and laboratory features of APS in patients with MS and livedo reticularis. We studied 10 women with livedo reticularis and MS. Five patients (50%) had elevated IgM aCL, 2 (20%) had elevated IgG aCL, 6 (60%) had miscarriages of unknown etiology, 2 (20%) had migraine, 2 (20%) had tension type headache, 3 (30%) had deep vein thrombosis and 3 (30%) had episodes of high blood pressure.
Key words: anticardiolipin antibodies, multiple sclerosis, livedo reticularis, antiphospholipid syndrome, miscarriages
Address for correspondence:
Ch. Dikova, M. D., Bg -- 1421 Sofia, 9A, Buntovnik Str., GSM +359 887578569, e-mail: chayka47@yahoo.com



Therapeutic response to combination therapy with peg-interferon alpha-2a (Pegasys) and ribavirin (Copegus) in patients with chronic HCV infecton in dependence with the presence of cryoglobulinemia – 43, 2007, No 3, 62-68.
D. Petrova(1), Е. Naumova(2), А. Мihailova(2), А. Tzvetanska(3) and К. Tchernev(1)
(1)Clinic of Gastroenterology,
(2)Central Laboratory of Clinical Immunology, University Hospital „Alexandrovska”,
(3)Virological Laboratory, SHAT of Pediatrics  Sofia
Summary: The clinical, immunologic and virologic responses were assessed 6 months after the end of the full course (48 weeks) of combination therapy with PEG-interferon alpha-2a (Pegasys) and ribavirin (Copegus) in 39 naive patients with chronic HCV infection and genotypes 1 or mixed. Cryoglobulins were found in 14 patients at the beginning of therapy. Sustained virologic response (no detectable HCV RNA 6 months after the end of treatment) was found in 20/39 (51.3%) of the patients. Sustained virological response was achieved in 28.6% of the patients with HCV-cryoglobulinemia and in 64% of those without cryoglobulins. A univariate logistic regression model showed that the presence of cryoglobulins was negatively related to sustained virologic response (OR 4.4, 95%CI 1.0-18.3). Correlations existed between the presence of cryoglobulins, the longer duration of infection, and liver cirrhosis, as well. The longer duration of infection reduced the chance of having sustained virologic response 5.5 times (OR 5.5, 95% CI 1.3-22.8), and liver cirrhosis 4.0 times (OR 4.0, 95%CI 1.0-15.2). The quantitative PCR assay for HCV RNA at week 12 was negative in 92% of the patients without cryoglobulins, whereas in 64.3% cryoglobulinemic patients HCV RNA dropped by >/= 2 log10 (OR 20.7, 95% CI 3.3-126.7), but was still detectable. By multivariare analysis, the detectable viraemia at week 12 was the most significant negative determinant of sustained virologic response (OR 21.1, 95% CI 2.3-191.1). The combination therapy with PEG-interferon alpha-2a (Pegasys) and ribavirin (Copegus) reduced clinical complaints of weakness in 100%; skin lesions in 60%; and cryoglobulins disappeared in 57.1% of the cases. Arthralgias did not improve significantly and even worsened in 3 of the cases. The earlier treatment of chronic HCV infection is indicated to prevent the development of liver cirrhosis and/or lymphoproliferative disorders where the results of combination therapy with PEG-interferon alpha-2a (Pegasys) and ribavirin (Copegus) are unsatisfactory.
Key words: hepatitis C, peg-interferon alpha-2a, ribavirin, cryoglobulins
Address for correspondence:
D. Petrova, M. D., Clinic of Gastroenterology, University Hospital „Alexandrovska, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia



Lipid peroxidation in diabetes mellitus – 43, 2007, No 3, 69-74.
P. Goicheva(1), B. Popov(2), V. Gadjeva(2) and S. Popova(2)
(1)Department of Internal Medicine
(2)Department of Chemistry and Biochemistry
Medical Faculty, Thracian University -- Stara Zagora
Summary: Lipid peroxides are thought to be formed by free radicals and have been implicated in the pathogenesis of diabetes complications. A convenient and sensitive method for estimation of lipid peroxide concentration is the quantitative estimation of their metabolic end-product malondialdehyde (MDA) expressed in mmol/l using the thiobarbituric acid test (TBA test). We measured the serum concentrations of MDA in 78 poorly controlled diabetic patients (type 1 -- 15, type 2 -- 63) and 74 age-matched healthy subjects. Patients with diabetes showed significantly increased MDA level (2.506 +/- 0.758) compared to healthy controls (1.824 +/- 0.489) (р < 0,05). The same relations were found in subgroups about type of diabetes (type 1 -- 2.719 +/- 0.665; type 2 -- 2.456 +/- 0.775; controls -- 1.824 +/- 0.489), hypoglycemic therapy (p.o. -- 2.543 +/- 0.712; insulin -- 2.472 +/- 0.807; controls -- 1.824 +/- 0.489), duration of the disease (new-found DM -- 2.649 +/- 0.711; “old” DM -- 2.505 ± 0.786; controls -- 1.824 +/- 0.489) or presence/absence of chronic complications (with complications -- 2.484 +/- 0.799; without complications -- 2.634 +/- 0.483; controls -- 1.824 ± 0.489). Significantly increased MDA level (p < 0.05) was found in type 1 diabetes (2.719 +/- 0.665) compared to type 2 (2.456 +/- 0.775). The serum levels of MDA correlated best with glycosylated hemoglobin. Increased lipid peroxides suggesting increased free radical activity is associated with diabetic chronic complications and this may have pathogenetic implications.
Key words: diabetes mellitus, oxidative stress, lipid peroxidation, malondialdehyde
Address for correspondence:
Petya Goicheva, M. D., Section of Endocrinology, University Hospital, 11 Armeyska Str., Bg -- 6000 Stara Zagora, tel. +359 42 664 382, GSM: +359 888 868 776, e-mail: petya_goicheva@yahoo.com



Non-enzymatic glycation of fibrillin-1 – 43, 2007, No 3, 75-81.   
M. Atanasova(1), E. Konova(2) and St. Baydanoff(2)
(1)Department of Pathological Physiology and Biology, Medical University -- Pleven
(2)Center of Clinical Immunology, University Hospital -- Pleven
Summary: Non-enzymatic glycation of proteins is one of the key mechanisms in the pathogenesis of diabetic complications and is significant in the age-related changes of tissues. We investigated the in vitro glycation of human aortic fibrillin-1 and adapted methods for evaluating the degree and kinetics of glycation. Fibrillin-1 was prepared from thoracic aortas of young accident victims (28-33 years). It was glycated by incubating with different glucose concentrations (25, 50, 75 and 100 mmol/1) in 0.2 M phosphate buffer, pH 7.4 for 30 days, at 37°C. The degree of early products of glycation was measured by three colorimetric methods, i.e. Nitroblue tetrazolium, 2-thiobarbituric acid, and the Randox test. Advanced glycation end products were determined by measurement of the fluorescence. The highest degree of early products of glycation was found on day 2 after the beginning of incubation. Fluorescence, as an index of advanced glycation, consistently increased from days 7 to 20. Investigation of the properties of glycated fibrillin-1 may help in complete understanding the importance of this long-lived protein for the age-related changes in physiological and pathological conditions.
Key words: advanced glycation end products, aging, fibrillin-1, non-enzymatic glycation
Address for correspondence:
Milena Atanasova, M. D., Department of Pathological Physiology and Biology, Medical University, 1, Kl. Ohridski str., Bg -- 5800 Pleven, tel. +359 64 884 140; fax: +359 64 801 603, e-mail: milenaar2001@yahoo.com



Qualitative protein content of the lymphatic liquid in human conjunctiva – 43, 2007, No 3, 82-84.   
Z. Demerdjieva(1) and N. Koicheva(2)
(1)Department of Dermatology and Venerеology, University Hospital “Alexandrovska” -- Sofia
 (2)Department of Clinical Laboratory, University Hospital “Alexandrovska” -- Sofia
Summary: In the accessible literature, there is no data concerning the content of the lymphatic liquid in human conjunctival lymphatic vessels. We generally accept that qualitative protein content of the human lymph is identical with blood serum because the blood and lymphatic vessels have a parallel way in the human body. The methods used were visualization of the conjunctival lymphatic vessels with Patentblau-V after local anesthesia with sol. Alcaini 0,5%. Simultaneously, papaverini hydrochlorici was poured out drop by drop, in order to conduct a slight dilatation of the lymphatic vessels. With the point of sterile needle (27G3 0,4 x 19) washed previously with natrii citrici, we entered a wide conjunctival lymphangion. The other end of the needle was placed in the lumen of laboratory pipette slightly downward inclined. In that way, the lymph slowly filled out the pipette. Immunoelectrophoresis of the lymph liquid was made. We proved presence of albumin, transferin and IgG in the lymph liquid. In that way, we determined the presence of two main fractions of the proteins -- albumin and globulins (with representatives gamma-2-globulin and transferin).
Key words: lymphography, Patentblau-V, conjunctival lymphatic vessels, immunoglobulins
Address for correspondence:
Z. Demerdjieva, Department of Dermatology and Venerology, University Hospital “Alexan­drovska”, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: z.demerdjieva@bol.bg



Inquiry of tobacco smoking among students in Plovdiv – 43, 2007, No 3, 85-89. 
F. Shterev(1), N. Mateva(2), R. Ivancheva(1), G. Belev(1), St. Kartev(1) and Zl. Yankova(1)
(1)Department of Pulmonology, University Hospital “Sv. Georgi” -- Plovdiv
(2)Department of Social Medicine and Health Management, Medical University -- Plovdiv
Summary: Tobacco smoking is a major cause for premature death and serious health problems in the developing countries. Aim of authors was to investigate and analyze some of the aspects of using tobacco products among students aged between 16 and 18 years. A study by a direct anonymous group inquiry among 800 students from Plovdiv schools was carried out. The questionnaire was a translated and adapted version of the WHO project Global Youth Tobacco Survey (GYTS). Only 15.1% never tried to smoke. About one third of the children (33.43%) tried their first cigarette at the age of 14-15 years. For a period of one month, more than half of the students smoked cigarettes -- 53.5%. 82.48% of the students bought themselves cigarettes. In Bulgaria, the young people smoke intensively and start to smoke in young age. There is no effective control over smoking in the schools.
Key words: tobacco smoking, students, Global Youth Tobacco Survey
Address for correspondence:
Filip Shterev, M.D., Department of Pulmonology, University Hospital “Sv. Georgi”, Medical University, 15A, V. Aprilov Blvd., Bg -- 4000 Plovdiv, tel. +359 888 006188, e-mail: filipshterev@abv.bg



R. Komitova. Specific therapy and immunoprophylaxis of varicella – 43, 2007, No 3, 103-110.



bullet 2'2007

Rotavirus gastroenteritis -- clinical and virological investigation –  43, 2007, No 2, 57-61.
М. Tiholova(1), N. Korsun(2), А. Mangarov(3), N. Naydenova(3), S. Aleksieva(3) and Z. Mladenova(2)
(1)Medical University -- Sofia
(2)National Reference Enterovirus Laboratory, NCIPD -- Sofia
(3)Infectious Hospital „Prof. Ivan Kirov” -- Sofia
Summary: Rotavirus infection is the leading cause of acute gastroenteritis among infants and young children worldwide. Rotavirus vaccination program might significantly reduce morbidity and mortality among these age groups. The aim of this study was investigation of rotavirus gastroenteritis among young children and determination of the clinical symptoms of the disease. From 1 January through 1 October 2006 136 children < 5 years old with acute gastroenteritis admitted to Infectious Hospital „Prof. Ivan Kirov”, Sofia were included in the study. Stool samples were collected and tested for rotavirus with latex-agglutination test (LA) and polyacrylamide gel electrophoresis (PAGE), and cultured for bacterial pathogens. Rotavirus was identified in 73 of 136 (56,2%) children hospitalized with diarrhea by LA and/or PAGE. Rotavirus migration profiles were determined in 68 samples, and 9 different RNA electrophoretic patterns were observed. The clinical features of rotavirus positive children were analyzed. Fever, vomiting, diarrhea and dehydration were common symptoms. Rotavirus infection was most prevalent in children in the age group 7 months to 2 years.
Key words: rotavirus, vomiting, diarrhea, dehydration, polyacrylamide gel electrophoresis
Address for correspondence:
Assoc. Prof. Mayda Tiholova, M. D., Hospital of Infectious Diseases,
17, Akad. Ivan Geshov, Blvd., Bg -- 1431 Sofia, tel. + 359 2 952 36 52, e-mail: igmitov@sinetbg.com



Specific cardiovascular risk factors in patients with mild renal insufficiency  –  43, 2007, No 2, 62-67.
M. Lubomirova(1), E Andreev(1), A. Kundurdjiev(1), A. Stanchev(2), A. Tsoncheva(3) and B. Kiperova(1)
(1)Clinic of Nephrology, University Hospital “Alexandrovska” -- Sofia
(2)Clinic of Hematology, University Hospital “Alexandrovska” -- Sofia
(3)Central Clinic Laboratory, University Hospital “Alexandrovska” -- Sofia
Summary: Cardiovascular risk is higher in patients with chronic renal failure (CRF) compared with thе general population. 56 pts. with CRF, creatinine clearance > 20 ml/min and < 90 ml/min were examined and divided into two groups: with and without cardiovascular disease (CD). Both groups were comparable in respect to gender and age. All standard laboratory parameters, as well as intact parathyroid hormone (iPTH), total homocysteine (Hcy) and immunoreactive insulin (IRI) were investigated in both groups. 24-hour proteinuria was examined in all pts. Left ventricular hypertrophy was assessed based on the left ventricular mass and the left ventricular mass index by echocardiography. Cardiovascular risk factors (CVRF) specific for CRF were established early in the course of chronic renal failure. Patients with CRF and CD had a significantly longer duration of CRF, heavy anemia and higher protein loss compared with those without CD. LVH was prominent in pts with CRF and CD compared with those without proven CD.
Key words: chronic renal failure, cardiovascular risk factors, anemia, intact parathyroid hormo­ne, homocysteine, phosphate, immunoreactive insulin, left ventricular hypertrophy
Address for correspondence:
Mila Lubomirova, M. D., Clinic of Nephrology, University Hospital “Alexan­drovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia, tel. + 359 2 92-30-229, e-mail: MLjubomirova@yahoo.com



Frequency of cyclosporine nephrotoxicity in renal transplant patients –  43, 2007, No 2, 68-75.
(1) and T. Todorov(2)
(1)Clinic of Nephrology and Transplantation, (2)Department of Pathoanatomy
University Hospital "Alexandrovska" -- Sofia
Summary: Cyclosporine A nephrotoxicity is a major clinical problem in renal transplant patients. It is an important factor for management of chronic allograft nephropathy which is a main cause of graft loss. The goal of the study was to estimate frequency of histological appearance of CyA nephrotoxicity in byopsies of renal transplant patients. We studied 127 renal byopsies with a mean period after transplantation 4.3 +/- 1.2 years (from 17 days to 11 years). The frequency of interstitial fibrosis was 14.96%, arteriolopathy -- 14.96% and tubular toxicity – 11.81%. Half of cases with CyA toxicity (10 patients – group A, or 7.87% of all patients) had a cause for renal biopsy different of CyA toxicity. The other half of cases with CyA toxicity (group B -- 9 patients or 7.09% of all patients) had a mean cause for renal biopsy CyA toxicity. In cases with pure CyA toxicity, no or lower proteinuria -- 0.47 +/- 2.5 g/day was found. The main cinical manifestation in these cases was a slow increase of serum creatinine or decrease of creatinine clearance. The proteinuria in group A was significantly higher -- 2.1 +/- 0.7 g/day (p < 0.01). In cases with CyA toxicity and following cessation of therapy with CyA (group B) or decrease of the dosis of CyA with maintenance of lower blood levels (group A), we attained improvement of renal function but without attainment of the baseline creatinine levels. This means that it is impossible to restore fully the impaired renal function because the histological changes are not reversible. The blood levels of CyA in studied patients were normal according to the official protocol. There was no significant correlation between blood levels of CyA and CyA toxicity. CyA nephrotoxicity is a major clinical problem with a frequency of 15% of all renal biopsies in renal transplant patients. CyA nephrotoxicity has no main clinical appearance in half of the cases and we diagnose it on occasion of another complications. The removal of the etiologic factor of CyA toxicity does not lead to a full restoration of renal function. Protocol biopsies are necessary for the early diagnosis of CyA nephrotoxicity.
Key words: kidney transplantation, immunosuppression, cyclosporine A nephrotoxicity, biopsy
Address for correspondence:
Assoc. Prof. Emil Paskalev, M. D., Clinic of Nephrology and Transplantation, University Hospital “Alexandrovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia, tel. +359 2 92-30-240, e-mail: emilpaskalev@abv.bg



Fat and lean mass in non-obese and obese women at various ages –  43, 2007, No 2, 76-81.
M. Boyanov(1) and Zh. Boneva(2)
(1)Clinic of Endocrinology, University Hospital “Alexandrovska”, Medical University -- Sofia
(2)Department of Endocrinology, Medical Institute, Ministry of the Interior -- Sofia
Summary: The term “sarcopenia” means the age-related loss of muscle mass and strength. The purpose of this cross-sectional study was to assess the age-related changes in body composition in obese and non-obese women. 120 women participated in the study: 55 non-obese women (BMI < 30.0 kg/mІ) and 65 obese women (BMI >/= 30.0 kg/mІ). The body composition was studied by dual-energy X-ray absorptiometry on a Hologic QDR 4500 A bone densitometer, and fat mass (FM), lean mass (LM) and total body weight were calculated. In the non-obese women, the regression of LM and FM against age was best described by a linear model, an S model and a Power model, whereas that of the body weight was linear. In the obese women, all three parameters – LM, FM and body weight, were best related to age in linear and cubic models. The negative influence of age on LM, FM and body weight was stronger in the non-obese women. In those women, age was much stronger related to LM, than to FM, whereas in obese women age was a stronger predictor of FM. Based on our data, the following conclusions could be made: 1. The sarcopenia is more pronounced in non-obese women; obesity partially counteracts it. 2. The contribution of age to the variability of the body compartments is relatively modest – especially in obese women. 3. The influence of age on FM and LM can be best described for practical purposes by linear equations.
Key words: dual-energy X-ray absorptiometry, body composition, fat mass, lean mass, sarcopenia, obesity
Address for correspondence:
Mihail Boyanov, M.D., Endocrinology Clinic, University Hospital “Alexandrovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofiа, tel. +359 2 9230-784, e-mail: boyanov@alexandrovska-hospital.bg



Comparative assay of serum anti-alpha-elastin antibodies in patients with ankylosing spondylitis depending on the clinical presentation – 43, 2007, No 2, 82-85.
M. Bogdanova(1), A. Tchorbanov(2), A. Velkova(3), Kr. Stephanova(4), N. Mihaylova(2), N. Kostova(5) and St. Baydanoff(1)
(1)Department of Biology and Pathophysiology, Medical University -- Pleven
(2)Department of Immunology, Institute of Microbiology, Bulgarian Academy of Sciences -- Sofia
(3)Department of Health Management, Medical University -- Pleven
(4)Rheumatology Dispensary, Diagnostic Consulting Centre ІІ -- Pleven
(5)Clinical Laboratory, Diagnostic Consulting Centre ІІ -- Pleven
Summary: The aim of this study was to assess whether significant differences exist between serum levels of anti-alpha-elastin antibodies (AEAbs) from class IgM, IgG and IgA in patients with ankylosing spondylitis (AS) without extraarticular manifestations and those AEAbs in patients with articular and extraarticular manifestations of AS as amyloid kidney and lung fibrosis. The current study comprised 34 patients with AS without extraarticular manifestations (29-59 yrs.; 22 males and 12 females) and 5 patients with extraarticular manifestations (3 of them with amyloid kidney and 2 with lung fibrosis, 47-55 yrs.; 4 males and 1 female) admitted to Dispensary of Rheumatology of Diagnostic Consulting Centre ІІ, Pleven. The serum levels of IgM, IgG and IgA AEAbs were determined using enzyme-linked immunosorbent assay (ELISA). IgA AEAbs were elevated in patients with articular and extraarticular manifestations of AS in comparison with those in patients with AS without extraarticular manifestations (pz < 0,05). All patients with amyloid kidney died within three years after measurement of AEAbs. The measurement of AEAbs may represent immunological markers of elastin degradation and may provide a tool to study elastin metabolism. The serum levels of the IgA AEAbs may be markers for bad prognosis in patients with AS with amyloid kidney.
Key words: ankylosing spondylitis, antibodies, elastin, clinical presentation
Address for correspondence:
Marieta Bogdanova, M.D., Department of Biology and Pathophysiology, Medical University, 1, Sv. Kl. Ohridski Str., Bg -- 5800 Pleven, tel./fax: +359 64 801 603, e-mail: mbecht02@abv.bg



Results one year after cessation of the treatment with ketoanalogues in patients on a continuous ambulatory peritoneal dialysis – 43, 2007, No 2, 86-88.
L. Kambova(1), A. Koteva(2) and Z. Kraev(2)
(1)Clinic of Therapy of Internal Diseases, UMHAT “Sv. Ivan Rilski”, Medical University -- Sofia
(2)Clinic of Dialysis, University Hospital “Alexandrovska” -- Sofia

Summary: Malnutrition is common in continuous ambulatory peritoneal dialysis (CAPD) patients and is closely related to morbidity and mortality. The aim of the present study was to make investigation of patients with end stage renal disease (ESRD) on CAPD, treated with ketoanalogues for 12 months, one year after cessation of the treatment. 12 patients were investigated -- average age 53.01 years, average duration of CAPD treatment -- 34.03 months. All patients received individual doses epoietin. In the group, there were a significant rise in the levels of albumin (p < 0.01), insignificant rise in the levels of total protein and significant increased epoietin doses (p < 0.01).
Key words: chronic renal failure, malnutrition, continuous ambulatory peritoneal dialysis, ketoanalogues, epoietin
Address for correspondence:
Lilyana Kambova, M. D., Clinic of Therapy of Internal Diseases, UMHAT “Sv. Ivan Rilski”, 15, Acad. Iv. Geshov Blvd., Bg -- 1431 Sofia, tel. +359 2 851 93 97, e-mail: dr_kambova@abv.bg



Тoxicity testing of polymeric nanoparticles of titanium dioxide and silica dioxide with respect to their application as drug carriers   –  43, 2007, No 2, 89-93.
T. Chervenkov(1), B. Galunska(1), D. Gerova(1), D. Ivanova(1), P. Kolova(2), V. Danciu(3), V. Cosoveanu(3), B. Manevska(2) and T. Yankova(1)

(1)Unit of Biochemistry, Medical University -- Varna
(2)Department of General and Clinical Pathology, Medical University -- Varna
(3)Laboratory of Electrochemistry, University “Babes-Bolyai” -- Cluj-Napoca, Romania

Summary: The aim of the present study was to explore the acute toxicity of titanium and silica nanopolymers by monitoring clinical picture of intoxication, macroscopic organ pathology, and biochemical parameters. Titanium and silica nanopolymers were synthesized by acid-catalyzed sol-gel method. Healthy male Wistar rats (210-280 g, age 80 days) were treated with colloidal suspensions of free nanoparticles, applied intraperitoneally and orally in a single dose. Animals were monitored for an 8-hour experimental period and parameters of clinical picture of intoxication (behavioral changes, body weight, and mortality) were detected. At the end of the experimental period, toxicity of nanopolymers was evaluated by monitoring the pathological changes of internal organs (mac­ro­scopically and histologically), and biochemical parameters (aspartate ami­no­transferase and creatinine content). The results will be evaluated for statistical significance by the Students t-test. Maximal applicable concentrations and doses for intraperitoneal (0.2 g/kg body weight) and oral (2 g/kg body weight) administration of SiO2 and TiO2 nanopolymers were established. Both routes of administration of silica and titanium dioxide nanogels did not result in significant variations in the aspartate aminotransferase (AST) characterizing liver function. The intraperitoneal application of silica dioxide gels leads to increased kidney weight and higher creatinine levels, indicating an impaired kidney function. Oral administration of silica dioxide gel did not induce gastric mucosal damage. On the other hand, titanium dioxide gel administered orally in the same dose induced ulcer formation in 60% of the treated animals. The lack of ulcerogenic effect of silica dioxide gel on gastric mucosa suggests that it could be used as a drug carrier matrix in in vivo studies. Both gels show low acute toxicity toward the tested parameters. Further investigations, including chronic toxicity testing are needed to evaluate the applicability of silica and titanium dioxide nanopolymers as drug carriers.
Key words: polymeric nanoparticles, silica and titanium xerogels, acute toxicity, in vivo animal studies
Address for correspondence:
Bistra Galunska, Unit of Biochemistry, Medical University, 55, Marin Drinov Blvd., Bg -- 9002 Varna, tel. +359 52 65-00-61/251, e-mail: bistra.galunska@gmail.com



K. Kostov. Inhalatory corticosteroid therapy. Pharmacodynamic and pharmacokinetic aspects. Kinds of inhalers - 43, 2007, No 2, 105 - 113.




Ivan Vazov’s death: some medical facts   –  43, 2007, No 2, 114-120.
D. Paskalev(1), D. Radoynova(2) and A. Kircheva(3)
(1)Clinic of Nephrology and Dialysis, University Hospital “Sv. Marina” -- Varna
(2)Chair of Forensic Medicine, Medical University -- Varna
(3)Department of Clinical Epidemiology, Multiprofile Hospital for Active Treatment “Sv. Anna” -- Varna

Summary: The great Bulgarian poet ant writer Ivan Vazov (1850-1921) suddenly died on Septembеr 22, 1921. The post mortem examination of the body revealed severe pathological abnormalities in the cardiovascular sytem. The autopsy established marked generalized atherosclerosis, coronary heart disease, and ruptured aortic aneurysm leading to a fatal hemopericardium with heart tamponade. The heart was enlarged with prevalent left ventricular hypertrophy. This finding could be suggestive for a long-term persisting nontreated arterial hypertension. More interesting was the finding in the brain and the skull. Marked deformations werе revealed both in the right parietal and left occipital brain regiones due to old fractures in these cranial fields. The lesiones were especially demonstrative in the left occipital brain region (i.e. cuneus cerebri) where the vision centrum is localized. On this base, Prof. Dr. Paraskev Stoyanov suggested for the first time that the poet was temporary blind in the past. The writer’s sister told him an unknown family history. When Vazov was 14-15 years old, he fell from a racing horse, was unconscious for a long time and than became blind for about one year. Thus, the autopsy revealed some unknown facts concerning the past traumatic illness of the poet, and demonstrated that his sudden death was result of a severe cardiovascular disease.
Key words: Ivan Vazov, autopsy, history
Address for correspondence:
Assoc. Prof. Dobrin Paskalev, M.D., Clinic of Nephrology and Dialysis, University Hospital “Sv. Marina”, 55, Marin Drinov Str., Bg -- 9002 Varna, tel. +359 52 302 851, int. 296, e-mail: dobrinpaskalev@yahoo.com




bullet 1'2007


Staphylococci species – classical pathogens and commensals in the human ecosystem – 43, 2007, No 1, 38-45.
A. Kircheva(1), D. Paskalev(2) and
K. Bozhkova(2)
(1)Department of Clinical Epidemiology, Multiprofile Hospital for Active Treatment “Sv. Anna” -- Varna
(2)Multiprofile Hospital for Active Treatment “Sv. Marina”, Medical University -- Varna

Summary: Human evolution and the development of man in direction of a harmonious ecosystem where various microflora coexists with the macroorganism has always posed questions and roused scientists’ interest. Staphylococci species are a classical example of pathological microorganisms causing the most suppurative-inflammatory diseases, even at present. Staphylococcus aureus and coagulasa-negative staphylococci (CNS) are among the leading agents which cause many nosocomial infections (NI), approximately 20% of all NI, in particular. Staphylococci can be found in carriers’ organisms not only as classical pathogens but also as commensals. The colonized nasal mucosa of both patients and medical staff serves as a main and long-lasting reservoir spreading pathological microorganisms in hospitals. This paper presents, in parallel with data from literature review, some results from our own investigation of the percentage of staphylococcal carriers among the staff in high-risk hospital wards, such as: maternity, surgical, hemodialysis, as well as among patients on chronic hemodialysis. In conclusion, in order to reduce the percentage of resistant staphylococcal carriers in high-risk wards, complex preventive measures should be taken including both sanitation of nasal mucosa and separation of carriers. The latter measure should be obligatory in cases of isolating methicillin-resistant strains (MRSA and MR-CNS).
Key words: staphylococci, nosocomial infection, staphylococcus carriers
Address for correspondence:
Anna Kircheva, M. D., Department of Clinical Epidemiology, Multiprofile Hospital for Active Treatment “Sv. Anna”, 100, Tzar Osvoboditel Blvd., Bg -- 9000 Varna, tel. +359 52 6926-572, e-mail: anna_kir4eva@yahoo.com


Nosocomial infections in the intensive care units for patients with burns – 43, 2007, No 1,  46-50.
M. Leseva(1), E. Zamfirova(1), M. Lyubomirov(1), O. Hadjiisky(1) and I. Traikov(2)
(1)Burn and Plastic Surgery Centre, Emergency Medical Institute “N. I. Pirogov” -- Sofia
(2)Department of Burn and Plastic Surgery, Medical University -- Plovdiv

Summary: The aim of the present study is to compare the features of the nosocomial infections (NI) in the intensive care units (ICUs) of the Burn and Plastic Surgery Centre, Emergency Medical Institute “N. I. Pirogov” and the Burns and Plastic Surgery Hospital in Tripoli, and to analyze the differences, their reasons and the means for effective control of the emergence and dissemination of the NI and the antibacterial resistance of their causative pathogens. This is a prospective, one-year study (2004) that includes 156 and 109 patients, respectively, from both ICUs. Significant differences between both units in the number of the investigated specimens and the number, species and the in vitro antibacterial susceptibility patterns of the leading nosocomial pathogens were found. The lack of a specially arranged antibiotic policy and a program for permanent monitoring of the burn patients in the Tripoli hospital was identified as a main reason for the differences found. Recommendations for arrangement and introduction of such policy and program in ICU Tripoli were done in order to assist solving of the existing problems. Furthermore, because of some failures found during the screening of the hospital environment, recommendations to both ICUs were done to realize an effective control of the dissemination of the NI.
Key words: nosocomial infection, burns, intensive care unit, nosocomial pathogens
Address for correspondence:
M. Leseva, M. D., Burn and Plastic Surgery Centre, Emergency Medical Institute “N. I. Pirogov”, 21, Totleben Blvd., Bg -- 1606 Sofia


Evolving forms of systemic sclerosis - Clinical and laboratory characteristics – 43, 2007, No 1, 51-54.
K. Yablanski(1), Zl. Kolarov(2) and V. Yordanova(1)
(1)Clinic of Cardiology and Rheumatology, Medical University -- Pleven
(2)Clinic of Rheumatology, Мedical University -- Sofia
Summary: Systemic sclerosis is presented as a moderately evolving disease in 52% of the cases with dominating visceral symptoms -- cardiopathy, nephropathy, serositis, and active skin vessel changes -- digital ulcerations and gangrenes. The slow evolving forms occur in 43.5% of the cases, whereas out of the visceral manifestations only the pulmopathy is significantly expressed. We observed the rapidly evolving forms in as few as three patients manifested by “renal crisis”, pulmonary arterial hypertension and necrotic vasculitis. The moderately evolving forms develop together with expressed 'acute phase' reaction on the part of the hematologic and biochemical blood readings while there is no reaction with the slow evolving forms.
Key words: systemic sclerosis, natural history, clinical manifestations, laboratory findings
Address for correspondence:
Kiril Yablanski, M. D., Clinic of Cardiology and Rheumatology, Medical University, 1, Kl. Ohridski Str., Bg -- 5800 Pleven, tel. +359 64 886 140


Value of somatosensory evoked potentials after stimulation of n. medianus and n. tibialis in patients with cervical spondylotic myelopathy – 43, 2007, No 1, 55-62.
K. Kostov, Iv. Petrov and Iv. Ivanova
Clinic of Neurology, Medical Institute -- Ministry of Internal Affairs -- Sofia
Summary: The aim of the present study was to assess to what extent somatosensory evoked potentials (SEPs) after stimulation of n. tibialis and n. medianus (using different assemblies for registration of the cervical spinal N13 potential) can adequately reveal the cerebrospinal dysfunction in patients with clinically possible cervical spondylotic myelopathy (CSM), their topical and prognostic value. The study covered 28 patients (19 men and 9 women), with clinical evidence for cerebrospinal dysfunction at cervical level with/without radicular symptomatics. All patients were subjected to nerve imaging -- CT and/or MRT, SEPs of n. tibialis and SEPs of n. medianus bilaterally. Recording of N13 and P14 potentials after stimulation of n. medianus using anterior frontal (Fpz) and anterior cervical referent electrode (AC) was made for 16 patients. The nerve imaging methods revealed significant compression and/or pathological impulsation from the medulla in 50% of the patients. SEPs after stimulation of n. tibialis showed abnormality in 82%, of n. medianus (AC) -- 87.8%, of n. medianus (Fpz) -- in 39% of the patients. The abnormalities in the cervical N13 (AC) potentials in our patients wеre associated with disorders of С6, С7 and С8 cerebrospinal segments. Significant correlation relationship was found between SEP abnormality type and the severity of the clinically manifested myelopathic symptomatics. The isolated changes in N13 (AC) potential were associated with clinically less expressed myelopathy while the longer EP-N13 interpeak latent time referred to the more severe forms. The obtained results enable the authors to adopt that SEPs after stimulation of n. tibialis and n. medianus (using anterior cervical referent electrode) are a sensitive method for verification and documentation of the cerebrospinal dysfunction in patients with CSM. Median SEPs with implementation of anterior frontal referent electrode do not reveal adequately the segment cerebrospinal dysfunction. Median SEPs have topical and prognostic value.
Key words: cervical spondylotic myelopathy, somatosensory evoked potentials, diagnosis, prognosis
Address for correspondence: K. Kostov, M. D., Clinic of Neurology, Medical Institute of Ministry of Interior, 79 “Skobelev” Blvd., Bg -- 1606 Sofia, tel. +359 2 9821576, Fax: +359 2 9531235, e-mail: drkostov@abv.bg


Determination of etiology and severity of acute pancreatitis using а cluster of several clinical laboratory parameters – 43, 2007, No 1, 63-68.
P. Jordanov(1), G. Grigorov(2), R. Angelov(2), S. Todorova(1) and V. Hristov(2)
(1)Clinical Laboratory Section, MHATEM “N. I. Pirogov” -- Sofia
(2)Second Surgery Clinic, MHATEM “N. I. Pirogov” -- Sofia
Summary: The prompt determination of etiology and severity of acute pancreatitis (AP) is important for the correct institutional treatment of the disease. This study aims to evaluate the role of serum amylase, serum alanine aminotransferase (ALT), gamma glutamyltransferase (GGT) and mean cell volume (MCV) for early differentiating between bile- and alcohol-induced AP, as well as blood glucose, serum creatinine and hematocrit for elucidation of the severity of the disease. Evaluation was performed on 143 patients with acute pancreatitis consecutively admitted to Second Surgery Clinic, MHATEM “N. I. Pirogov” from May 2000 to November 2004. Patients with bile-induced AP were 65 (45%), those with alcohol-induced AP were 38 (27%) and those with idiopathic AP (unknown etiology) were 40 (28%). Using Atlanta criteria, the patients were divided according to the severity of the disease as follows: mild AP -- 102 (71%), severe AP -- 41 (29%). Serum amylase, ALT, GGT, MCV, blood glucose, creatinine and hematocrit were evaluated no later than 24 hours of hospitalization and all values were analyzed using routine clinical laboratory methods. Higher median values of amylase (P = 0.076) and of ALT (P = 0.003) were found in patients with bile-induced AP as compared with alcohol-induced AP. In patients with alcohol-induced AP, higher MCV (P = 0.019) and GGT (P = 0.076) were evaluated. Blood glucose (P < 0.0001) and creatinine (P = 0.014) were identified as markers of AP severity. Conversely, hematocrit did not show satisfactory results (P = 0.675). The simultaneous evaluation of serum amylase, ALT, MCV, GGT, blood glucose and serum creatinine even at the moment of hospitalization could differentiate bile-induced from non-bile-induced forms of the disease, and define the risk for development of severe acute pancreatitis.
Key words: acute pancreatitis, etiology, severity, clinical laboratory
Address for correspondence:
Peter Jordanov, Clinical Laboratory Section, MHATEM “N. I. Pirogov”, 21, Totleben Blvd., Bg -- 1606 Sofia, tel. +359 2 9154-239, email: peter_jordanov@abv.bg


Proinflammatory cytokines in a singlе hemodialysis session  – 43, 2007, No 1, 69-72.
P. Dukova and D. Yonova
Dialysis Clinic, University Hospital ”Alexandrovska” -- Sofia
Summary: Patients with chronic renal failure usually have some abnormalities of the immune responce, related to impaired kidney function and accumulation of uremic toxins. Bioincompatibility of dialyser membranes has an additional role in patients on regular hemodialysis (HD). The aim of the study was to follow the levels of?IL-1beta, IL-6, IL-8, TNF-alfa and CRP before HD and at 20th, 60th and 240th minute of a single dialysis seance in 17 patients, mean age 38 +/- 11 years, on HD, mean duration of HD 65 +/- 12 months, and 12 healthy controls, to determine the influence of the HD on these components of inflammatory status. The results showed constantly increased serum CRP levels of the investigated patients and a decrease of the levels of proinflammatory cytokines during 20 to 60 minutes, followed by an increase of the levels up to the end of the dialysis session. The results are probably due to the both transient complement activation and leucopenia at the begining of HD, followed by a considerable monocyte activation and increased cytokine production.
Key words: chronic renal failure, periodic hemodialysis, proinflammatory cytokines, disturbe phagocytosis, cell activation
Address for correspondence:
Diana Yonova, M. D., Dialysis Clinic, University Hospital “Aleksandrovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia, tel. 9230463, 9230515, e-mail: dr_ionova@email.com


Ambulatory monitoring of the antihypertensive action of two metorpolol forms with prolonged release – 43, 2007, No 1, 73-77.
D. Raev
MI -- MIA, Sofia
Summary: Recently, there is a rise of the interest in using metoprolol with prolonged release. There are two registered retard forms in Bulgaria -- metoprolol tartrate with sustained release (MPSR) and metoprolol succinate with controlled release (MPCR). Both forms have different pharmacokinetic characteristics. To our knowledge, there is no data whether this results in different antihypertensive effect, evaluated in a 24-hour ambulatory blood pressure (BP) monitoring (ABPM). The aim was to compare the efficacy of MPSR and MPCR in terms of 24-hour control of BP and heart rate (HR) in patients with not optimally controlled mild and moderate essential hypertension by a 24-hour ABPM. This was an open-labelled, crossover, prospective study. 43 outpatients were included in the research, 38 of them completed the study (average age 44.1 +/- 6.3 years, blood pressure 147.8 +/- 10.8/96.3 +/- 10 mm Hg and HR 89.1 +/- 9.9 beats/min). Equivalent doses (100 mg) MPCR and MPSR significantly reduced 24-hour, day-time and night-time BP and HR. There was no significant difference in BP and HR between both forms of metoprolol with prolonged release. Their effect on the average hour values of BP and HR was also compatible. During the first 8 hours after intake of the dosage, patients with MPSR registered lower HR as compared to patients with MPCR. Equivalent doses 100 mg MPCR and MPSR reduce equally BP and HR. The difference between them is in the smoothness of HR control, due to their different pharmacokinetic properties. Both retard forms of metoprolol are suitable for single daily dosage.
Key words: sustained-release metoprolol tartrate, controlled-release metoprolol succinate, ambulatory blood pressure monitoring
Address for correspondence: Assoc. prof. D. Raev, M. D., Medical Institute of Ministry of Internal Affairs, 79A Skobelev Blvd., Bg -- 1606 Sofia, tel. +359 2 9821326


Direct expences for bronchial asthma in 2004 - 43, 2007, No 1, 78-83.
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 facilities and health insurance system, the patients, their families and society incur providing medical services for asthmatics are of considerable interest. Pharmacoeconomic analyses describe bronchial asthma nowadays as an illness with great social and economic impact on patients’ and their families’ quality of life through the impairment it causes. The reasons for that are: the chronic course of the disease and the expenses for treatment. Two main kinds of expenses are known – direct expenses for medication, office and emergency visits, hospital treatment, and indirect ones because of work disability and impaired quality of life. Worldwide these two constantly increase. The author analyses the structure and amount of direct expenses for bronchial asthma in Bulgaria in 2004.
Key words: bronchial asthma, statistical and economic indices, hospital expenses, medication expenses, National Health Insurance Fund
Address for correspondence: George Christoff, M.D., Ph.D., Clinical Centre of Allergy, Medical University, 1, “Sv. G. Sofiyski” str., Bg 1431 – Sofia, tel. +359 2 9230-612, e-mail: christoff_g@yahoo.com


Diverse effects of vitamins A and C on tobacco smoke-induced bone marrow clastogenicity and pulmonary emphysema in rats – 43, 2007, No 1, 84-89.
R. Ivancheva(1), Ph. Sterev(1), I. Damianov(2), D. Popov(2), N. Boiadgiev(2) and S. Genova(3)
(1)Department of Pulmonology, University Multiprofile Hospital of Active Treatment “ Sv. Georgi“ -- Plovdiv
(2)Department of Physiology, Medical University -- Plovdiv
(3)Department of Pathological Anatomy, Medical University -- Plovdiv
Summary: Tobacco smoking is the major risk factor contributing to lung pathology including lung tumors. Recently, a new chemopreventive approach has been proposed aimed at diminishing the risk for human health produced by smoking. This approach is based on the use of chemical compounds able to counteract the deletereous effects of tobacco smoking. This experiment was designed to test the possible protective effects of vitamins A and C towards emphysemogenic and clastogenic activity of tobacco smoke (TS). Forty male Wistar rats were divided into groups as follows: a) untreated rats; b) rats treated for 30 days with TS; c) rats treated with TS and vitamin A, and d) rats treated with TS and vitamin C. Exposure of rats to TS produced significant emphysematous changes in their lungs. Simultaneous treatment of rats with TS and vitamins A or C resulted in a significant inhibition of emphysemogenic activity of TS. Furthermore, TS doubled the level of micronucleated polychromatic erythrocytes in bone marrow. No toxicity was observed in these rats as inferred from polychromatic/normochrromatic ratio. Both vitamins had no influence on TS-induced clastogenicity. Vitamins A and C prevented the development of emphysema induced by TS but had no effect on chromosome-damaging activity of this complex mixture.
Key words: tobacco smoking, vitamins, rats, micronucleus, emphysema
for correspondence: R. Ivancheva, M. D., 112, “ V. Aprilov “ Str., Bg -- 4000 Plovdiv, e-mail: rosi_@abv.bg, GSM: +359 896610976




Zl. Yankova, G. Belev, St. Kartev, A. Garova, K. Petrova, F. Shterev, R. Ivancheva and R. Kalinov. The dilemma: Combination therapy -- corticosteroids with long-acting beta2-agonists, or monotherapy in bronchoobstructive disease? – 43, 2007, No 1, 111-115.





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