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 Original papers



Vol. 45, 2009




Catheter-associated urinary tract infections in patients undergoing operative and intensive care treatment - 45, 2009, No 4,    65-70.
A. Kirchevа(1), D. Paskalev(2), L. Petkova(1) and M. Grigorova(1)
(1)MHAT “Sv. Anna” -- Varna, (2)Medical University -- Varna
Catheter-associated urinary tract infections (CAUTI) represent the main part of all nosocomial UTI. In principle, they originate during a transurethral catheterization, but often remain underdiagnosed because of the concomitant antibacterial therapy. The problem is of great medical importance because statistical data point out that a quarter of all in-hospital patients need a transurethral catheterization, and the risk of UTI increasesby 5% for every hospital day. The aim of the present study was to investigate the current frequency of CAUTI in patients with indwelling catheter who were hospitalized in the Clinics of Urology and Neurology (both of them with increased risk of UTI) at MPHAT “ Sv. Anna” -- Varna. In a 3-month prospective study, 64 neurogical pts and 45 pts with urological diseases were included. The actual CAUTI-frequency was estimated using the adopted quotient (E. S. Wong, 1981):

CAUTI-frequency  =  number of UTI in all catheterized pts  х 1000
                      days with indwelling catheter

It was demonstrated increased symptomatic CAUTI-frequency in the urological pts compared with pts suffering from ischemic cerebral stroke (28,99 vs 17,21). In conclusion, our results point out that estimating the actual CAUTI is useful in clinical practice. It could be helpful for adequate prevention of UTI in pts with indwelling catheter.
Key words: catheter-associated urinary tract infections, frequency
Address for correspondence: Anna Kircheva, M. D., Ph. D., Department of Clinical Epidemiology, MHAT “Sv. Anna“,100, Tzar Osvoboditel Blvd., Bg-- 9000 Varna, tel. +359 52 6926 572, e-mail: kircheva@svetaanna-varna.com


Angiotensin-receptor blockade -- renoprevention or renoprotection: A four-year prospective study - 45, 2009, No 4, 71-76.
Pl. Yovchevski(1), Zh. Boneva(2), V. Marinov(2), St. Yordanova(2) and V. Evtimova(2)
(1)Department of Nephrology, Medical Institute -- Ministry of Interior -- Sofia, (2)Department of Endocrinology, Medical Institute -- Ministry of Interior -- Sofia
It has been shown that blockade of the renin-angiotensin system reduces proteinuria and slows down the progression of renal impairment in diabetics. The purpose of our study was to find out if early, before onset of microalbuminuria, treatment with angiotensin-receptor blockade prevents the development of diabetic nephropathy and protects renal function. 22 insulin-dependent diabetics with arterial hypertension, but without microalbuminuria were enrolled in a prospective, double-blinded, placebo-controlled four-year study for prevention of diabetic nephropathy. After randomization 12 of them were treated with candesartan -- 16 mg/day, the other 10 received placebo. During the study period, one patient in the candesartan group developed macroproteinuria. In the rest of the candesartan group, albuminuria rose from 9,9 +/- 4,7 mg/l to 13,8 +/- 9,1 mg/l, one patient had microalbuminuria. In the placebo group, albuminuria rose from 8,2 +/- 3,2 mg/l to 10,4 +/- 8,7 mg/l, one patient was with microalbuminuria also. The study found no statistically significant difference between both groups. Creatinine clearance remained unchanged for the four year period: in the candesartan group -- baseline value 119,9 +/- 24,1 ml/min/1,73 m2; end value -- 117,1 +/- 22,8 ml/min/1,73 m2. In the placebo group, creatinine clearance decreased from 144,2 +/- 25,6 ml/min/1,73 m2 to 119,8 +/- 19,7 ml/min/1,73 m2 (р < 0,05). Inhibition of the renin angiotensin system with candesartan plays a renoprotective role -- it preserves renal function assessed by creatinine clearance, while the treatment with сandesartan cannot prevent the development of microalbuminuria in the studied insulin-dependent diabetics. For renoprevention, it is necessary to treat earliest stage of disease: by intense metabolic control and influence on the initial pathobiochemical processes.
Key words: renin-angiotensin system, angiotensin receptor blockers, diabetic nephropathy, microalbuminuria, candesartan
Address for correspondence: Plamen Yovchevski, M. D., Department of Nephrology, Medical Institute -- Ministry of Interior, 79, Skobelev Blvd., Bg -- 1606 Sofia


Combined therapeutic approach in patients with proliferative diabetic retinopathy - 45, 2009, No 4, 77-80.
D. Petrov(1) and H. Blagoeva(1, 2)
(1)“Sv. Sofia” Hospital -- Sofia, (2)University Hospital “Tsaritsa Ioanna” -- Sofia
The purpose of this study is to evaluate the effect of intravitreal injection of Avastin, bevacizumab (IVA), on diabetic vitrectomy and on the postoperative course. 28 patients undergoing diabetic vitrectomy were distributed to standard vitrectomy (group 1) or vitrectomy with preoperative IVA (group 2). Bevacizumab was injected 10 days before surgery. Patients of both groups were matched as much as possible according to surgical indication and preoperative visual acuity. Feasibility of surgery was evaluated through recording intraoperative bleeding, use of endodiathermy, relaxing retinotomies, use of perfluorocarbon liquid (PFCL) and silicone oil or gas tamponade. There was significant reduction of mean surgical time, bleeding frequency, and diathermy use in group 2 compared to group 1. Postoperative bleeding was reported to be more frequent in group 1 than in group 2. In group 2, no complicаtions related to avastin injection or progression of traction were reported. Follow up ranged 12 months. The main conclusion is that preoperative IVA was helpful in achieving the surgical and anatomical goals by reducing the time of surgery, the intraoperative and postoperative bleeding.
Key words: intravitreal bevacizumab, proliferative diabetic retinopathy, pars plana vitrectomy
Address for correspondence: Hristina Blagoeva M. D., Ph. D., Department of Ophthalmology, “Sv. Sofia” Hospital, 104, Bulgaria Blvd., Bg -- 1680 Sofia, tel. +359 2 818 46 23, e-mail: ch_blagoeva@abv.bg


Development and validation of spectrophotometric method for determination of polyethylenglicole 25-paraaminobenzoic acid in cosmetic products for sun protection at individual and combined presence with physical ultraviolet filters zinc oxide and titanium dioxide - 45, 2009, No 4,  81-86.
A. Tachev
National Center of Public Health Protection, Ministry of Health
-- Sofia
Duе to the changes in the ultraviolet radiation during the last years and the common practice of the people to expose to the solar rays, there is a higher risk of skin cancer, respectively the number of cases causal of this kind of canser increases nowadays. This enforces using of different protective products, mainly cosmetics with various UV filters with combined protective power from UVB and UVA rays -- chemical and physical (with two or more components). The content of these products is strongly regulated in European and in Bulgarian legislation. On the other hand, the insufficient concentration of the UV filters for reaching the labeled level of protection could lead to unfavourable consequences for the human skin. There is no available referent method for determination of UV filter polyethylenglicole 25-paraaminobenzoic acid (PEG-25 PABA) in cosmetic products for sun protection. The aim of the study is to develop and validate a comprehensible spectrophotometric method for its determination. A total of 312 tests were conducted to derive the method parameters: selectivity – specific absorption at 304 nm; linearity -- from 1,25 to 100 mcg/cm3 (from 0,625% to 50%); stability for 24-h stay of PEG-25 PABA concentration 10 mcg/cm3 -- RSD = 0,25%; repeatability -- at 2% PEG-25 PABA – standard deviation (SD) -- 0,0589%; recovery -- at 2% PEG-25 PABA -- relative standard deviation (RSD) – 3,10%, in conditions of repeatability; analytical recovery at PEG-25 PABA concentration in the cosmetic product of 2% -- 95,80% (89,50-100,20%), at 4% -- 91,35% (85,60-100,40%). The developed and validated spectrophotometric method for determination of UV filter PEG-25 PABA in sunscreens is rapid, with good sensitivity, accuracy and recovery, does not require complex ex­pen­si­ve equipment and can be easily implemented for control of cosmetic products for sun protection.
Key words: ultraviolet filters, ultraviolet A rays, ultra-violet B rays, solar-protection cosmetic products, absorption, concentration
Address for correspondence: Anton Tachev, National Center of Public Health Protection, Ministry of Health, 15, Ivan Geshov Blvd., Bg1431 Sofia, е-mail: A.Tachev@ncphp.government.bg



Online scientific medical information: user’s choice and medical website quality evaluation - 45, 2009, No 4, 98-104.
Zh. Surcheva and I. Miteva
Central Medical Library, Medical University -- Sofia
The review emphasizes some of the criteria for accurate online medical information retrieval. Presented are evaluation methods in terms of user ability to recognize the adequate quality of online resources. An attempt of quality certification is introduced.
Key words: online resources, specialized information, quality evaluation
Address for correspondence: Zhenya Surcheva, D. D., Central Medical Library, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: surcheva_j@abv.bg







Prеdictive indices for development of cardiac dysfunction in patients with hepatic cirrhosis and portal hypertension. Algorithm for early diagnosis of cirrhotic cardiomyopathy – 45, 2009, No 3, 26-33.
E. Manov, T. Donova, K. Chernev, Hr. Velinov and M. Apostolova
Department of Propedeutics of Internal Diseases, Medical University -- Sofia
Summary: Hepatic cirrhosis (HC) is a severe and irreversible liver disease, caused by a variety of etiological factors. Late diagnosis, progressive liver injury, refractory medical and non-medical treatment and the progress of patients’ disability point out the medical, social and economic consequences of this disease. Development of cardiac dysfunction to extent of a varying in severity heart failure is a common complication in patients with HC. This condition was named “cirrhotic cardiomyopathy”. The pathophysiological mechanisms for these changes are not clarified yet. In our research, we studied 142 consecutive patients -- 94 men and 48 women (average age 54 +/- 10 years) with HC and portal hypertension (PH), aiming at precise determination of the causal relationship between the degree of portal hypertension in HC and the corresponding cardiovascular changes and thus clarifying the possible mechanisms for these changes. Our results show significant deterioration in the indicators of cardiovascular function in patients with HC, correlating highly with the severity of PH. Meanwhile we found no significant correlation between the etiological causes of the liver injury and cardiac disorders. Based on our results, we proposed a model for early diagnosis of cirrhotic cardiomyopathy, which is verry important for the complex medical management of patients with liver cirrhosis, idicated for liver transplantation.
Key words: hepatic cirrhosis, portal hypertension, cardiac dysfunction, cirrhotic cardiomyopathy
Address for correspondence: Emil Manov, M. D., Department of Propedeutics of Internal Diseases, Medical University, 1, Sv. G. Sofiiski Str., Bg -1431 Sofia, tel. +359 2 92-30-281


Primary orbital lymphoma: neurosurgical experience of thirteen cases – 45, 2009, No 3, 34-39.
Ch. Tzekov(1), T. Spiriev(1), E. Naydenov(1), K. Minkin(1), S. Hristova(2), V. Bussarsky(1), K. Romansky(1), M. Marinov(1), O. Kalev(3), R. Tanova(1), D. Kolarov(1), L. Laleva(1), V. Dermendzhieva(1), A. Cekov(1) and Y. Enchev(1)
(1)Clinic of Neurosurgery, University Hospital “Sv. Ivan Rilski” Sofia, (2)Department of Pathology, University Hospital "Alexandrovska -- Sofia, (3)Laboratory of Neuropathology, University Hospital “Sv. Ivan Rilski” --Sofia
Summary: Herewith we present 13 patients (seven women, six men) diagnosed with primary orbital lymphoma and operated in the Clinic of Neurosurgery at University Hospital “Sv. Ivan Rilski” Sofia, Bulgaria for the period 1998-2006. The main symptoms were exophthalmus -- 85% (11 patients), edema or bulging mass of eyelids 54% (7 patients), ptosis -- 38% (5 patients), impairment of eye movements -- 38% (5 cases) or impairment of vision -- 38% (5 patients). Six patients had intra- or extraconal invasion of the tumor. Computed tomography and magnetic resonance imaging were the primary methods for diagnosis. None of the individuals had history of systemic lymphoma and all the patients were immunocompetent. “Gross” total resec­tion of the tumor mass was achieved in 46% of the cases, subtotal  in 23%, partial  in 23%, and decompression in 8%. Early postoperative improvement with no significant complications was established. On immunohistochemical study, 12 of the lesions were diagnosed as low-grade B-cell small lymphocytic non-Hodgkin's lymphoma and one  as high-grade. We consider accurate histological diagnosis and staging, as well as individual and multidisciplinary approach to the patient essential for the proper treatment of the disease.
Key words: orbital tumors, primary lymphoma, neurosurgery
Address for correspondence: Assoc. Prof. Christo Tzekov, M.D., Clinic of Neurosurgery, University Hospital “Sv. Ivan Rilski”, 15, “Akad. Ivan Geshov” Blvd., Bg -- 1431 Sofia, tel. +359 2 852-56-27, е-mail: tzekovchr@abv.bg


Mycophenolate in renal transplantation – 45, 2009, No 3, 40-45.
E. Paskalev
Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska” -- Sofia
ummary: Мycophenolate (mofetil, sodium) interrupts de novo synthesis of guaninе nucleotides and thereby blocks essentially purine synthesis of T- and B-lymphocytes. The Long period of its clinical use determines its priority over another immunosuppressants. The aim of the study is to denonstrate the efficacy of mycophenolate as a immunossuppresant for primary induction and maintenance immunosuppressive therapy after kidney transplantation and its effect in chronic allograft nephropathy. The study included 243 renal transplant patients -- 106 of them on therapy with mycophenolate mofetil and 137 on therapy with mycophenolate sodium. We used a control group of 40 kidney transplant patients on immunosuppressive therapy without mycophenolate. We established that therapy with mycophenolate led to reduction of frequency of acute rejection by 35%, lowering of proteinuria and in proteinuria under 1 g/24 hours -- even to aproteinuria. The including of mycophenolate in immunosuppressive therapy of chronic allograft nephropathy and cyclosporine nephrotoxicity as a secondary induction leads to improvement of renal function demonstrated by changes of creatinine clearance and serum creatinine.
Key words: kidney transplantation, immunosuppression, mycophenolate mofetil, mycophenolate sodium
Address for correspondence: Assoc. Prof. Emil Paskalev, M. D., Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, tel. +359 2 9230 240, e-mail: emilpaskalev@abv.bg


Lithium prophylaxis of affective disorders -- effectiveness during long-term treatment – 45, 2009, No 3, 46-52.
V. Stoyanova(1) and G. Genchev(2)
(1)Psychiatric Clinic, University Hospital “Alexandrovska” -- Sofia, (2)Department of Medical Information and Biostatistics, Medical University -- Sofia
Summary: Affective disorders are widespread, often recurrent, socially significant diseases, therefore timely diagnosis and correct treatment are essential for their favorable course. Maintenance treatment, also known as prophylaxis is an important part of management of these conditions. The purpose of this study is to evaluate the effectiveness of lithium prophylaxis in terms of long-term treatment. The design of the study is naturalistic, following up 34 patients with affective disorders with unipolar and/or bipolar course, who undergo therapy with lithium for at least 2 years with regular serum monitoring and adherence to therapeutic levels. The number of mood episodes after the start of lithium treatment is reduced more than 3 times, and suicide attempts are reduced approximately 12 times. These changes reach statistical significance (p < 0.001). Diagnosis regarding polarity does not have predictive value. More important is the presence of psychotic symptoms which are an indication of the lack of therapeutic response to lithium, and this fact has a statistical significance (p < 0.05). It is concluded that lithium prophylaxis has a high efficiency in naturalistic conditions in long-term treatment of affective disorders, with frequent visits and regular serum monitoring being important conditions for this result.
Key words: affective disorders, lithium, prophylaxis, therapeutic effectiveness
Address for correspondence: Vesela Stoyanova, M. D., Psychiatric Clinic, University Hospital “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, е-mail: vestoyan@yahoo.com


Perceived coercion during psychiatric treatment in Bulgaria: results from the European survey on coercion in psychiatry – 45, 2009, No 3, 53-60.
G. Onchev(1), I. Gerdzhikov(2), Ts. Ivanova(2), Yu. Pulchev(2), R. Trendafilova(3), S. Alexiev(1), M. Vukov(4), K. Ganev(5) and L. Kjellin(6)
(1)Department of Psychiatry, Medical University -- Sofia, (2)State Psychiatric Hospital “Sv. Ivan Rilski” -- Novi Iskar, (3)Child and Adolescent Psychiatric Clinic “Sv. Nikola”, University Hospital “Alexandrovska” -- Sofia, (4)National Centre for Health Information -- Sofia, (5)Dinamika Centre -- Sofia, (6)Psychiatric Research Centre -- Oerebro, Sweden
Summary: The aim was to study perceived coercion in hospitalized psychiatric patients, irrespective of the legal status of hospitalization. 309 involuntary and 50 formally voluntary (but with perceived coercion at admission) Bulgarian patients consecutively admitted to acute psychiatric wards are assessed, as part of the larger European survey on coercion in psychiatry (EUNOMIA). The assessments are done in 3 time points (T1-T3) in the course of three months, with standardized instruments including the Cantril’s Ladder of Coercion. High perceived coercion is found in 42.9% of the voluntary and in 78.5% of the involuntary patients at admission. At the end of the follow-up period (T3), high perceived coercion still persists in two thirds of the involuntaries. Clinical and socio-demographic profiles of the patients are described. Predictors of high perceived coercion at admission are female gender and absence of previous involuntary hospitalizations. Staff consistently underrates coercion as compared to patients, the difference between both sets of ratings being significantly higher -- although relatively steady in the course of time -- among the involuntary patients (mean 3.49 for all time points), while the tendency for increase of the difference in the course of time is significantly more prominent in the group of the coerced voluntaries. Subjective experience of being coerced is consistently underestimated in psychiatric care in this country. Patients who are hospitalized for the first time on involuntary basis are more at risk for high perceived coercion than those with previous involuntary hospitalizations. A focus in care on this vulnerable group may contribute to their long-term adherence to treatment.
Key words: coercion in psychiatry, perceived coercion, Coercion Ladder, psychiatric care
Address for correspondence: Assoc. Prof. Georgi Onchev, Department of Psychiatry, Medical University, 1, Sv. G. Sofiisky Str., Bg -- 1431 Sofia; e-mail: georgeonchev&hotmail.com


Left main coronary artery stenting -- a single operator experience over 18 months 45, 2009, No 3, 61-64.
Vl. Grigorov
Medical Centre ARWYP, Glynnwood Hospital -- Johannesburg, South African Republic
Summary: Left main coronary artery stenting is a more and more acknowledged method for stenosis treatment. The surgical treatment of such stenosis that has been preferred by physicians for so many years is now decreasing. The operator’s experience is crucial for the procedure. Short term, as well as long term observation of these patients showed no complications.
Key words: left coronary artery, angiography, PCI, restenosis
Address for correspondence: Vladimir Grigorov, M. D., Medical Centre ARWYP, Glynnwood Hospital, Johannesburg, South African Republic, e-mail: vgrigorov2001@yahoo.com


Metabolic syndrome in normal-weight individuals in a Bulgarian population sample – 45, 2009, No 3, 65-70.
Zh. Boneva(1), M. Boyanov(2), P. Jovchevski(3) and Y. Assyov
(1)Department of Endocrinology -- Medical Institute, Ministry of Interior -- Sofia, (2)Clinic of Endocrinology -- University Hospital „Alexandrovska” -- Sofia, (3)Department of Nephrology, Medical Institute, Ministry of Interior -- Sofia
Summary: This study provides the first reported estimates of the prevalence of the metabolic syndrome in a normal-weight Вulgarian population sample. The study population consisted of 140 patients (both male and female) aged >= 20 years with normal body mass index (18.5-24.9 kg/m2 for both genders). The metabolic syndrome was defined according to the IDF guidelines. The overall prevalence of metabolic syndrome in normal-weight men and women was 10%. In our study, the prevalence of metabolic syndrome in normal-weight Bulgarian adults is relatively high. Therefore, interventions for prevention of cardiovascular diseases should be considered in this population.
Key words: metabolic syndrome, рrevalence, metabolically obese normal-weight individuals
Address for correspondence: Zhivka Boneva, Department of Endocrinology, Medical Institute, Ministry of Interior, 79, Gen. Skobelev Blvd., Bg -- 1606 Sofia, tel. +359 2 9821 (351), fax +359 2 9814594, e-mail: zhbonevaa@abv.bg


Alternatives for pluripotent stem cell induction: genes or proteins? – 45, 2009, No 3, 88-92.s
G. Milchev
IMB -- Bulgarian Academy of Sciences -- Sofia
Summary: Induced pluripotent stem (iPS) cells have been generated from somatic cells by transgenic expression of Oct4, Sox2, Klf4 and c-Myc. A major difficulty in the application of this technology for regenerative medicine is the use of viruses encoding the reprogramming factors. Human iPS cells free of reprogramming factors have been derived using Cre-recombinase excisable proviruses. Factor-free iPS cells maintain a pluripotent state and show a global gene expression profile, more closely related to human embryonal stem (ES) cells than to iPS cells carrying the transgenes. Recently, human foreskin fibroblasts have been treated with recombinant reprogramming factors fused with 9 arginine residues (Oct4-9R, Sox2-9R, Klf4-9R, and c-Myc-9R). Repeated protein treatment cycles (16 hr protein treatment followed by 6-day incubation in ES media 1) result in alkaline phosphatase-positive colonies. Propagated in ES media 2 and ES media 3 two cell lines (p-hiPS01 and p-hiPS02) have been successfully maintained for more than 35 passages. "This method eliminates the risks associated with genetic and chemical manipulation, and provides for the first time a potentially safe source of iPS cells for translation into the clinic,” said Robеrt Lanza.
Key words: induced pluriptent stem cells, Oct4, Sox2, c-Myc, Klf4, Nanog
Address for correspondence: Georgi Milchev, MD, 54 Skobelev Blvd., Bg -- 1606 Sofia, tel. +359-2-953-0983, e-mail: gmilchev@bio21.bas.bg



Internet information resources. Retrieval of medical information – 45,2009, No 3, 93-100.
J. Surcheva and I. Miteva
Central Medical Library, Medical University -- Sofia
Summary: Main aim of the paper is to make medical specialists better acquainted with the principles of online information searching -- a knowledge of crucial importance for information competence of healthcare professionals. Some basic terminology is presented as well as an overview of search engines, important medical por­tals and web-sites which offer free access to high quality scientific information.
Key words: internet, information dissemination, utilization, storage and retrieval, online systems
Address for correspondence: Jenia Surcheva, M. D., Central Medical Library, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: surcheva_j@abv.bg






The role of the chronic inflammation for development of subclinical atherosclerosis in patients with inflammatory rheumatic diseases – 45, 2009, No 2, 45-53.
I. Gruev and A. Toncheva
Clinic of Cardiology and Lipidology, Clinic of Internal Diseases, NMTH ”Tsar Boris III” -- Sofia
Summary: The inflammatory rheumatic diseases (IRD) are characterized by chronic autoimmune inflammation and high cardiovascular morbidity and mortality, due to accelerated atherosclerosis. The measurement of intima-media thickness (IMT) is a non-invasive method for detection of subclinical atherosclerosis. Several clinical studies have shown that the patients with IRD have significantly higher values of IMT, compared with healthy controls. The aim of our study was to identify the role of the chronic inflammation for the development of subclinical atherosclerosis. We investigated 105 IRD patients and 72 high-risk hypertensive patients. Results: both groups had significantly higher IMT than the threshold values indicating increased cardiovascular risk. In the IRD group, IMT correlated with the longevity of the disease, the number of affected joints and the age. In order to underline the role of the chronic inflammation as a cardiovascular risk factor, we divided the whole group of 177 patients into three subgroups according to the ESR values: ЕSR up to 30 mm -- patients with low inflammatory activity; ESR 30-60 -- patients with mo­de­ra­te inflammatory activity and ESR above 60 mm -- high inflammatory activity. The groups with high and moderate inflammatory activity had significantly higher IMT, compared with the low activity group. We concluded that IRD should be considered a clinically significant risk factor and should be included in the guidelines for calculation of the cardiovascular risk.
Key words: inflammatory rheumatic diseases, atherosclerosis, intima-media thickness
Address for correspondence: Ivan Gruev, M. D., Clinic of Cardiology and Lipidology, NMTH “Tsar Boris III”, 108, Maria Luiza Blvd., Bg -- 1233 Sofia, tel. +359 2 932-22-37, +359 2 932-37-18



Clinical and psychosocial characteristics of involuntary psychiatric patients in Bulgaria – 45, 2009, No 2, 54-62.
G. Onchev(1), I. Gerdzhikov(2), Ts. Ivanova(2), Y. Pulchev(2), R. Trendafilova(3), S. Alexiev(1), M. Vukov(4) and K. Ganev(5)
(1)Department of Psychiatry, Medical University – Sofia, (2)State Psychiatric Hospital “Sv. Ivan Rilsky” -- Novi Iskar, (3)Child and Adolescent Psychiatric Clinic “Sv. Nikola”, Alexandrovska University Hospital – Sofia, (3)National Centre for Health Information -- Sofia , (4)Dinamika Centre -- Sofia
Summary: Aim of the study was the clinical and psychosocial characterisation of Bulgarian psychiatric patients hospitalized involuntarily, as well as voluntarily but with perceived coercion. 208 involuntarily admitted on emergency basis, 101 involuntarily admitted on regular basis, and 50 formally voluntary patients (but with perceived coercion at admission) were assessed in the framework of the European survey on coercion in psychiatry (EUNOMIA). The assessments were done in 3 time points (T1-T3) in the course of three months, with standardized instruments. Most of the patients in the sample, irrespective of their legal status, were unemployed, unmarried, residing in family homes, with incomes from pensions or from relatives, and with infrequent social contacts. Patients admitted on emergency basis did not differ significantly from the involuntaries on regular basis in terms of psychopathology (BPRS) and aggressiveness (MOAS). No significant differences were found between patients with differing legal status in the reasons for hospitalization, diagnoses, compliance for treatment and aggressiveness, while involuntary legal status in this sample has significant relation to female gender, lower level of functioning (GAF), lower satisfaction from treatment (CAT) and more severe psychopathology. The factor analysis of the characteristics isolated 5 factors, explaining totally 57.64% of data variance. The emergency procedure for involuntary (“obligatory” in the law) admission was used more frequently than the regular one, despite lack of clinical justification. The clinical and social profiles of involuntary patients were, in general, unfavorable. The characteristics that may differentiate between patients with different legal status, as well as those that may be common for severely ill in-patient population, were ascertained. The determined factor structure assumes operation of at least one major clinical factor and four accessory social factors reflecting different aspects of social dysfunction.
Key words: coercion in psychiatry, informal coercion, emergency hospitalization, psychopathology, satisfaction with treatment
Address for correspondence:
Assoc. Prof. Georgi Onchev, Department of Psychiatry, Medical University, 1 Sv. G. Sofiisky Str., Bg -- 1431 Sofia; email: georgeonchev@hotmail.com



Etiologic role of noroviruses in nosocomial acute gastroenteritis outbreaks – 45, 2009, No 2, 62-66.
N. Korsun(1), Z. Mladenova(1), A. Tsvetanska(2), M. Borisova(3), B. Chakov(3), G. Kamenov(3), M. Tiholova(4), T. Taseva(5) and P. Petrov(5)
(1)National Centre of Infectious and Parasitic Diseases -- Sofia, (2)Pediatric Hospital -- Sofia, (3)RIPCPH -- Sofia region, (4)Infectious Hospital -- Sofia, (5)University Hospital “Sv. Anna” -- Sofia
Summary: Noroviruses are leading causes of nonbacterial acute gastroenteritis outbreaks worldwide. They are increasingly being recognized as etiologic agents in outbreaks occurring in a health care setting. In the present article, four nosocomial outbreaks of norovirus gastroenteritis at a university-based hospital in Sofia in 2008 are described. Noroviruses were detected using method RT-PCR in 50% (5/10), 50% (2/4), 47% (7/15) and 44% (8/18) of investigated stool specimens respectively. The measures of norovirus outbreaks management (e.g., en­vironmental disinfection, cohorting or isolation of infectious individuals, enhanced hand hygiene, etc.) are also presented.
Key words: noroviruses, nosocomial outbreak, gastroenteritis
Address for correspondence: Assoc. Prof. Neli Korsun, MD, PhD, National Reference Enterovirus Laboratory, Department of Virology, National Centre of Infectious and Parasitic Diseases, 44A Stoletov Blvd, Bg -- 1233 Sofia, phone: +359 2 831 00 42



Tissue microarray -- an efficient and economical method for immunohistochemical studies in oncology practice – 45, 2009, No 2, 67-71.
E. Poriazova(1) and Z. Zaprianov(2)
(1)Department of General and Clinical Pathology , Medical University – Plovdiv, (2)University Hospital “Sv. Georgi“ -- Plovdiv
Summary: Tissue microarrays are used in a lot of laboratories and research centres all over the world in the last decade for routine and scientific examinations of biopsy materials. A number of cases of solid tumors are examined immu­no­his­to­che­mically with expensive antibodies. The tissue microarray is convenient to use for diagnosis, therapy and prognosis of oncological diseases. It has not been applied in Bulgaria so far. The aim of the study is to describe the algorithmic steps in the building and application of the tissue microarray for the needs of the morphologigal examination. We examined the immunohisto­che­mical expression of cytokeratin 7, cytokeratin 20, beta-catenin, and CDX2 in primary and metastatic ovarian and colorectal carcinomas in order to solve differential diagnostic problems. Biopsy materials from archive parafine blocks, fixed in formaline were incorporated in new recipient blocks. From them new slices were prepared, stained with hematoxyline-eosine, and serial slices for immunohistochemical examination using streptavidine-biotin immuno­pe­ro­xy­da­se method. Antibodies from DAKO Cytomation, Denmark were used.
Key words: immunohistochemical examination, tissue microarray
Address for correspondence:
Elena Poriazova, M. D., Department of General and Clinical Pathology , Medical University, 15A, V. Aprilov Blvd., Bg -- 4002 Plovdiv, e-mail: eporiazova@abv.bg



Use of SMAS-flap technique in cases of total conservative parotidectomy – 45, 2009, No 2, 72-76.
I. Radev(1) and P. Pechalova(2)
(1)Maxillofacial Surgery Unit, Regional Hospital – Burgas, (2)Maxillofacial Surgery Clinic, Medical University Hospital “Sv. Georgi” -- Plovdiv
Summary: In patients undergoing conservative parotidectomy as an alternative, the SMAS-flap technique can be used. This technique avoids some negative consequences of classical parotidectomy. Our aim was to evaluate the results of SMAS-flap technique in conservative parotidectomy. During the period 2004 -- 2007, eleven patients underwent total conservative parotidectomy according to SMAS-flap technique, the indications being chronic sialoadenitis (2), benign (8) and malignant (1) tumors of the parotid glands. Results: lack of visible scars, as well as retromandibular hollow (in one patient -- lightly shown), lack of Frey’s syndrome. Conclusion: in cases of chronic inflammation, benign and some malignant tumors of the parotid gland, the use of SMAS-flap technique can be an alternative of classical conservative parotidectomy.
Key words: SMAS-flap technique, conservative parotidectomy
Address for correspondence: Ivailo Radev, M. D., Maxillofacial Surgery Unit, Regional Hospital, 73, Stefan Stambolov Str., Bg -- 8000 Burgas, e-mail: vir_bulgaricus@abv.bg, GSM +359 888 973643



The urgent need of a national program in the field of cardiac surgery and invasive cardiology in Bulgaria -- prerequisite for the decrease of cardiovascular mortality – 45, 2009, No 2, 91-94.
T. Vekov
UniCardio Clinic -- Pleven
Summary: The article presents a critical analysis of the mortality rates and lifesaving methods of treatment of cardiovascular diseases in Bulgaria in comparison with the EU countries. The author highlights the urgent need of development and implemention of a national program in the field of invasive cardiology and cardiosurgery aiming at rapid reduction of mortality, morbidity and disability to the average levels achieved in the EU.
Key words: cardiovascular diseases, mortality, revascularization, cardiosurgery
Address for correspondence:
Toni Vekov, Chairman of the Directors Board, UniCardio Clinic Pleven, 1, G. M. Dimitrov Str., Bg -- 1172 Sofia, tel. +359 2 962 54 54, fax +359 2 962 50 59, e-mail: t.vekov.hq@comleague.com



The Quality Manual by ISO 15189 as a model of any health establishment – 45, 2009, No 2, 95-99.
D. Shopov
MHAT -- Haskovo
Summary: An attempt is made to use the contents of the Quality Manual on ISO 15189 as a frame, where every clinical structure shall build-in the specific activity, willing to achieve the international standard. It is established considerable similarity in the requirements of the Regulations No 18 of Ministry of Health Care, ISO 15189 and the documents of CLSI (Clinical and Laboratory Standards Institute, USA). The major difference is that while Regulations No 18 is focused on evaluations, ISO 15189 aims at achieving certain standards, the documents of CLSI create opportunities for complete understanding of the processes and procedures in the course of the work flow and thus create administrative base for the introducing a quality control system and implementing the most effective conditions for improved patient service.
Key words: health establishments, quality manual, quality control system
Address for correspondence: Dimitar Shopov, M. D., MHAT, 49, Saedinenie Blvd., Bg -- 6300 Haskovo, tel. +359 038/606999, е-mail: shopov_d@abv.bg



Administration of inhaled tobramycin – 45, 2009, No 2, 100-103.
S. Mihaylova and V. Edreva
Section “Microbiology and Virusology”, Medical University -- Pleven
Summary: TOBI® is a tobramycin solution for inhalation. TOBI® is indicated as a maintenance therapy in chronic pulmonary infections caused by Pseudomonas аeruginosa, in cystic fibrosis patients aged 6 years and older. TOBI® is not recommended for management of acute exacerbations of pulmonary disease in hospitalized cystic fibrosis patients. Factors, which affect aerosol antibiotic administration, include: type of nebuliser; size of inhaled particles; patient respiratory parameters; and patient age. Despite only approximately 10% of the total dose being deposed in the lungs, concentrations obtained from sputum samples are bactericidal. Tobramycin typically administered only parenterally in the past becomes more attractive as a solution for inhalation with respect to its use by outpatients.
Key words: tobramycin, inhalation
Address for correspondence:
Sashka Mihaylova, M. D., Section “Microbiology and Virusology”, Medical University, 1, Kliment Ohridski Str., Bg -- 5800 Pleven, tel. +359 64 884136, e-mail: sashkam@yahoo.com





Parameters of vascular damage in patients with high cardiovascular risk
– 44, 2008, No 4, 33-39.
M. Lubimirova(1), At. Kundurdjiev(1), Y. Petrova(2) and R. Djerassi(1)
(1)Clinic of Nephrology, (2)Clinic of Neurology, University Hospital “Alexandrovska” – Sofia
Summary: 165 patients were examined, average age 50,48 +/- 10,8 years with hypertension, mean duration 15,48 +/- 7.8 yrs. 20 healthy volunteers were also examined. All patients had good control of blood pressure. We determined 5 groups. Group 1 included 95 pts., average age 52,9 +/- 13,8 yrs. with chronic renal failure (CRF), creatinine clearance 39,29 +/- 11,7 ml/min. Diabetes duration in this group was 14,5 +/- 3,8 yrs. Group 2 included 20 pts, average age 48,2 +/- 6,8 yrs. With normal renal function and dibetes but without signs of diabetic nephropathy. Diabetes duration was 8,75 +/- 1,8 yrs. Group 3 -- 20 pts, average age 50,2 +/- 8,8 yrs. with normal renal function, diabetes and diabetic nephropathy. Diabetes duration was 12,1 +/- 2,8 yrs. Group 4 -- 25 pts with hypertension, no diabetes and normal renal function. Group 5 included 20 healthy persons, average age 49,56 +/- 9.8 yrs. In all patients, cardiovascular risk was assessed on the base of classical risk factors, according to Framingham Point Score system. In all 185 persons, echocardiography was performed as well as doppler examination of the renal and common carotid arteries. Patients of group 1 to 4 had high cardiovascular risk > 15% without significant differences between the groups. Group 1 had higher cardiovascular morbidity -- 50%, in all other groups it was 40-48%, without statistically significant difference. Doppler examination of the renal and common carotid arteries revealed high vascular resistance (high RI) in the presence of diabetic nephropathy, which increased significantly when CRF was present. Diabetics and hypertensive pts with normal renal function had tendency to increased vascular resistance and normal but in the higher level resistive indexes. The coexistence of diabetes and CRF increases cardiovascular morbidity and mortality. Vascular changes become visible early in the course of diabetes and vascular resistance increases when diabetic nephropathy appears and renal function deteriorates.
Key words: chronic renal failure, cardiovascular risk, diabetes mellitus
Address for correspondence: Mila Lubomirova, M. D. Clinic of Nephrology, University Hospital “Alexandrovska”, 1, Sv. G. Sofijski Str., Bg -- 1431 Sofia, tel. +359 2 92-30-229, e-mail: Mljubomirova@yahoo.com



Value of resistance index for cyclosporine nephrotoxicity in renal transplant patients
– 45, 2009, No 1, 40-46. 
E. Paskalev
Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska” -- Sofia
Summary: Treatment with cyclosporine A (CyA) is a basic ingredient in immunosuppres­sion at kidney transplantation.
It is complicated by an important side effect -- nephrotoxicity. CyA nephrotoxicity has a high frequency -- it is found in 15% of all renal allograft byopsies. Successful identification of CyA nephrotoxicity needs use of protocol renal byopsies. All that determines the interest in use of another methods to define CyA nephrotoxicity. The goal of the study was to determine the diagnostic value of resistance index for chronic cyclosporine A nephrotoxicity. Our study included 70 renal allograft recipients with renal biopsy proven CyA nephrotoxicity. They were divided into two groups -- group A -- 34 patients with CyA nephrotoxicity and group B -- 36 patients with other reasons for renal biopsy -- chronic rejection or recurrence of basic disease in kidney allograft. We determined a manifested percentage increase of resistance index in both groups. The change in group A was from 0.61 to 0.74 -- 21.3 +/- 2.1%. The change in group B was from 0.56 to 0.63 -- 12.5 +/- 1.4%. Doppler sonography can successfully support diagnostic procedure in CyA nephrotoxicity. In case of CyA toxicity, the change of resistance index is an increase by more than 15% compared with basic stable condition before deterioration of renal function. These results determine necessity of using Doppler sonography as a successful method for control of renal allograft recipients.
Key words: kidney transplantation, cyclosporin A nephrotoxicity, resistance index
Address for correspondence: Assoc. Prof. Emil Paskalev, M. D., Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, tel.: +359 2 9230 240, e-mail: emilpaskalev@abv.bg



-epidemiological study of the rate of late post-streptococcal non-suppurative complications in childhood – 45, 2009, No 1, 47-52.
T. Petkova(1), V. Nedkova(2) and S. Pachkova(3)
(1)Sector of Epidemiology, Parasitology and Tropical Medicine, MU -- Pleven, (2)Pediatric Clinic, UMHAT “G. Stranski” -- Pleven, (3)Department of Microbiology, Virology and Medical Genetics, MU -- Pleven
Summary: In Bulgaria, rheumatic disease (a late manifestation following acute and chronic streptococcal infections) was eliminated as a result of implementation of the programme for prophylactics and treatment of rheumatic disease in certain risk population groups. The aim of our study was to analyse from clinical and epidemiological perspective late non-suppurative complications following streptococcal infections in childhood -- rheumatic fever, acute post-streptococcal glomerulonephrithis and post-streptococcal reactive arthritis. We studied retrospectively the medical records of 14 children with late complications following streptococcal infections -- 2 children with rheumatic disease, 9 children with reactive arthritis and 3 children with acute post-streptococcal glomerulonephritis. All children were patients of the Pediatric clinic, UMHAT “G. Stranski” -- Pleven, from 2000 to 2007. We discovered that late complications of streptococcal infections were manifested in isolated cases; 14.28% of the cases were diagnosed as rheumatic disease, 21,43% -- as acute post-streptococcal glomerulonephrithis, and 64,29% -- as post-streptococcal reactive arthritis. Regular primary penicillin prophylactics in both diseased and high risk groups, as well as regular secondary prophylactics with penicillin in children with rheumatic fever should contribute to the elimination of the disease.
Key words: rheumatic fever, acute post-streptococcal glomerulonephrithis, post-strepto­coc­cal reactive arthritis, streptococcal infections
Address for correspondence:
Tania Petkova, M. D., Sector of Epidemiology, Parasitology and Tropical Medicine, Medical University, 1, Sv. Kliment Ohridski Str., Bg -- 5800 Pleven, tel. +359 64 884 269, GSM +359 885 33 87 74, e-mail: tanja_1973@abv.bg



Viral hepatitis in the Bulgarian army: clinical and seroepidemiological investigation
– 45, 2009, No 1, 53-56.
G. Popov, К. Plochev and I. Dikov
Clinic of Infectious, Parasitic and Tropical Diseases, MМА -- Sofia
Summary: Viral hepatitis continues to be one of the most important problems for the military personnel of the Bulgarian army. The purpose of the present research is to analyze seroepidemiological data of viral hepatitis in the Bulgarian army. 504 military personnel from Sofia (98), Gorna banya (95), Belene (75) and Pleven (236) have been investigated for the period 2003 -- 2007. All of them have been tested for anti-HAV total, anti-HBc total (positives for HBsAg, HBeAg or AntiHBe, anti-HBc IgM, anti-HDV) and anti-HCV by ELISA with diagnostic tests of Dia Sorin. Investigated military personnel were grouped and analyzed according age; ethnic identity, sexual orientation, parenteral manipulations and drug use. 99 (20%) anti-HAV total, 71 (14%) anti-HBc total, 12 (2%) anti-HCV and 9 (2%) anti-HDV positives were found among military personnel. Most spread among soldiers continue to be viral hepatitis A, connected with age and sanitary-hygiene conditions in military barracks. Higher in comparison with the overall for the country is the rate of HCV infection. Following conclusions were made: sanitary-hygiene conditions in military barracks are factor for high morbidity of VHА in conditions of conscript army; the morbidity of viral hepatitis has considerable effect at combat readiness of Bulgarian army causing logistic problems connected with prolonged hospitalization. A necessity for introduction of obligatory immunoprophylaxis with vaccine against viral hepatitis type A and B is discussed after reform of BA towards professional army.
Кey words: viral hepatitis, Bulgarian army, military personnel
Address for correspondence: Georgi Popov, M. D., Clinic of Infectious, Parasitic and Tropical Diseases, MМА, 3, Sv. G. Sofiiski Blvd., Bg -- 1431 Sofia, e-mail: popovg@abv.bg



Trapped lung in malignant pleural effusions
– 45, 2009, No 1, 57-62.
I. Novakov
Department of Thoraco-abdominal Surgery, Medical University -- Plovdiv
Summary: Trapped lung is a state of unexpandable lung as a result of nonmalignant and malignant pleural diseases. Aim of this study is еvaluation of diagnosis and treatment of patients with malignant pleural effusions (MPI) and trapped lung. 32 patients with MPI and trapped lung were included in the study. Chest radiograph, computed tomography, diagnostic thoracentesis, bronchoscopy and medical thoracoscopy were used for the diagnosis of trapped lung. Permanent tube drainage into a bag was used for treatment of the patients with MPI and trapped lung. Peripheral lung carcinoma is the most common neoplastic disease causing trapped lung (in 75% of the cases). Trapped lung was a result of multiple metastasis on visceral pleura in 26 (81, 3%) of cases and of fibrous visceral pleural peel -- in 6 (18,7%) of patients. Drainage of pleural effusion and effective palliation of clinical manifestations were established after placement of intrapleural catheter. Only direct inspection of the pleural space can establish the definitive diagnosis of trapped lung. Permanent pleural drainage in patients with MPI and trapped lung can reach effective clinical palliation, short hospital duration and low rate of possible complications.
Key words: trapped lung, malignant pleural effusion, pleural drainage
Address for correspondence: Ivan Novakov, M. D., Department of Thoracoabdominal Surgery, Medical University, 54, “Petrova niva” str., Bg -- 4004 Plovdiv, e-mail: inovakov2003@yahoo.com



Prognostic criteria for severity of leptospirosis
– 45, 2009, No 1, 63-67.
G. Gancheva, M. Atanasova, Hr. Tsvetanova and P. Ilieva
Department of Infectious Diseases, Epidemiology, Parasitology and Tropical Medicine, Medical University -- Pleven
Summary: Leptospirosis is an infectious disease with multiorgan disorders and severe course in some cases. Aim of the study was to determine prognostic criteria for severe course of leptospirosis. Retrospective analysis of clinical syndromes and laboratory investigations in ninety six cases with leptospirosis which were treated in the Clinic of Infectious Diseases -- Pleven (1976 to 2008) was done. Mild course in 27,66%, moderate in 40,43% and severe in 31,91% of cases were observed. L. copenhageni was the most frequent causative agent in moderate and severe cases. Comparative study during the acute phase at cases of different severity defined acute renal failure, disorders in myocardial functions and hemorrhagic syndrome as significant for severe course. Moderate and severe course of leptospirosis were observed in 72% of cases. The determination of prognostic criteria is helpful for therapeutic management in leptospirosis.
Key words: leptospirosis, severe forms, prognostic criteria, acute renal failure
Address for correspondence:
Galya Gancheva, MD, PhD, Clinic of Infectious Diseases, University Hospital, 8a “Georgy Cochev Str., Bg -- 5800 Pleven, tel. +359 64 886 339, e-mail: galya_gancheva@abv.bg



of maximal intraoral pressure and vacuum after reconstructive surgery for lip cancer – 45, 2009, No 1, 68-71.
Tsv. Tonchev
Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University -- Varna
Summary: The evaluation of the performance, the functional status and the physiological adaptation of the lips after reconstructive surgery in case of cancer is determined most often subjectively by the surgeon, or by the patient. The article presents the results from a measurement of the maximum intraoral pressure and vacuum in the oral cavity in 61 patients, operated on occasion of lip cancer. For the purpose, the author used his own methodology and an apparatus, allowing to record the data in digital way and in approved by the practice measurement units. The recovery was in a satisfactory volume of the maximal intraoral pressure and vacuum in both directions in the majority of the operated patients.
Key words: reconstructive surgery, lip cancer, intraoral pressure, assessment
Address for correspondence: Tsvetan Tonchev, M. D., Ph. D., Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University, 55 Marin Drinov Str., Bg -- 9002 Varna, e-mail: mfstonchev@mu-varna.bg



Treatment of idiopathic scoliosis with brace and physiotherapy
– 45, 2009, No 1, 72-76. 
H. Hundozi-Hysenaj(1), I. Boshnjaku-Dallku(2), A. Murtezani(2) and S. Rrecaj(1)
(1)Department of Physical Therapy, University Clinical Center of Kosovo, (2)Orthopedic and Physiatric Clinic, University Clinical Center of Kosovo
Summary: Scoliosis is a three-dimensional deformation of the spine with a lateral curvature or deviation greater than 10 degrees and associated with vertebral rotation. Many conservative treatments are available for adolescents with idiopathic scoliosis, but the evidence for their effectiveness is still questioned. The objective of this study was to define the effectiveness of braces and individual physiotherapy for the comprehensive treatment of idiopathic scoliosis in adolescents. 57 children with idiopathic thoracic dextroscoliosis with magnitude of the thoracic curve between 20-35 degrees, treated in Orthopedic and Physiatrist Clinic as well as in National Ortho-prosthetic Center within University Clinical Center of Kosova in Prishtina, during the period of 2003-2006, have been included in the retrospective analysis methodology. Inclusion of kinesitherapy in the comprehensive management of idiopathic scoliosis varied in the improvement of the muscle strength (satisfied and moderate) in almost 80% of the children, while the correction of the curve was small in approximately 42.1% of cases. For children with idiopathic scoliosis, who require braces, an exercise program helps chest mobility, muscle strength, proper breathing flexibility in the spine, correct posture and keeps muscles in tone so that the transition period after brace removal is easier.
Key words: idiopathic scoliosis, rehabilitation, orthosis, exercises
Address for correspondence:
Hajrije Hundozi-Hysenaj, M. D., University Clinical Center of Kosovo, rr. Spitalit pn. 10000 Prishtina UNMIK/Kosovo



Clinical paths -- a standard for quality of medical activity or an instrument for funding inpatient care and a barrier to accessibility
– 45, 2009, No 1, 82-100.
T. Vekov(1), M. Grigorov(1) and S. Djambazov(2)
(1)UniCardio Clinic -- Pleven, (2)Bulgarian Cardiac Institute
Summary: The so called “clinical path” is the basic method for medical and financial control of the NHIF. Unfortunately it is not doing this. The clinical paths, which are currently adopted by the NHIF, are not covering all diseases or are not aligned with the international treatment guidelines. This is the main reason why the hospitals, which are contract partners of the NHIF, are not treating patients properly or are issuing medical information to the patients that is false. This is one of the reasons of the poor quality of healthcare and the rising mortality rate.
Key words: cardiovascular mortality, clinical path, medical standards, NHIF, financing of healthcare
Address for correspondence: Toni Vekov, Chairman of the Directors Board, UniCardio Clinic Pleven, 1, G. M. Dimitrov Str., Bg -- 1172 Sofia, tel. +359 2 962 54 54, fax +359 2 962 50 59, e-mail: t.vekov.hq@comleague.com



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