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 Original papers


Vol. 46, 2010




Enteroviral neuroinfections in Bulgaria in 2008-2009 - 46, 2010, № 4, 42-48.
N. Korsun(1), М. Tiholova(2), V. Petkova(3), L. Pekova(4), А. Mangarov(2), К. Kostova(5), Z. Mladenova(1) and P. Petrov(6)
(1)National Centre of Infectious and Parasitic Diseases -- Sofia, (2)Infectious Hospital “Prof. Iv. Kirov” --Sofia; (3)Sofia University “Sv. Kl. Ohridski”, (4)Medical University --Stara Zagora; (4)MHAT -- Shumen; (6)UMHAT “Sv. Anna” --Sofia
Summary: Enteroviruses are a leading cause of aseptic meningitis and meningoencephalitis. Diagnostics of enteroviral infections is generally based on viral isolation and identification on cell cultures. Recently, molecular methods based on RT-PCR have been used for routine diagnostics of enteroviral neuroinfections. The aim of the present study is to determine the frequency of enteroviral neurological infections among children and adults in 2008-2009 in Bulgaria as well as to analyse their clinical and epidemiological features. A total of 110 patients aged 5 months75 years hospitalized in different regions with fever and neurologic manifestations are included in this study. A total of 57 stool specimens and 107 cerebrospinal fluid (CSF) samples are processed through viral culture and result in respectively 5 (4,5%) and 0 cultures positive for enterovirus. 59/107 (55%) CSF samples tested are positive for the presence of enteroviral RNA by RT-PCR. The clinical and laboratory survey results of enterovirus positive and negative patients are analysed. Enteroviruses play an important role in the etiology of CNS infections among the children and adults in Bulgaria. The RT-PCR is more rapid and sensitive than viral culture for diagnostics of enteroviral neuroinfections and should be performed routinely in clinical practice as part of the initial management of the patients with meningitis.
Key words: enteroviruses, aseptic meningitis, encephalitis, RT-PCR
Address for correspondence: Assoc. Prof. Neli Korsun, MD, PhD, National Reference Enterovirus Laboratory, National Centre of Infectious and Parasitic Diseases, 44A Stoletov Blvd, Bg -- 1233 Sofia, phone: +359 2 831 00 42, e-mail: polionl_nk@abv.bg




Epidemiological aspects of mumps in Pleven and Razgrad districts - 46, 2010, № 4, 49-53.
M. Karcheva(1) and N. Valkanova(2)
(1)Department of Epidemiology, Parasitology and Tropical Medicine, Medical University -- Pleven, (2)Department of Infectious Diseases, Tropical Diseases and Epidemiology, Medical University -- Varna
Summary: Mumps is vaccine preventable infection. During the recent years, there was registered increase of the incidence in the country and displacement to higher age groups. At the conditions of mass specific immunoprophylactics, changes in the characteristics of the epidemic process are being observed. Our aim was to survey and compare the epidemic characteristics within the course of epidemic mumps in the districts of Pleven and Razgrad for the period 2000-2008. Information from reports and analyses of National Center of Infectious and Parasitic Diseases, data from Regional Authority on Protection and Control of Public Health -- Pleven and Razgrad, have been used. Applied are epidemiologic method, epidemiologic analyses and documentary method. The incidence of mumps in the country for the reference period shows downward trend. The epidemic process in the reference districts develops with different intensity -- slight decrease of the incidence is detected in Pleven district and slight increase in Razgrad district is observed at the end of investigated period. Men suffer more frequently at the ratio 2:1 in both districts. Higher age groups have been affected: 10-14 years old in Pleven district and 15-19 years old in Razgrad district respectively. The incidence spreads out year-round in Pleven district, suspension of the epidemic process during summer months being noted in Razgrad district. Multiple localization of the mumps infection is registered. The relative share of hospitalization is higher in Razgrad district -- 19,37% compared to the one in Pleven district -- 16,53%. 51% immunized persons in Pleven district and 92% in Razgrad district have been recorded to suffer the disease. The epidemic process during last decade is going on with reduced intensity and develops in direct dependency on the applied in the country specific immunoprophylactics.
Key words: mumps, epidemic process, rate of incidence
Address for correspondence: Milena Karcheva, M.D., Department of of Epidemiology, Parasitology and Tropical Medicine, Medical University, Sv. Kl. Ohridsky, Str., Bg -- 5800 Pleven, tel.: +359 64 884 269, e-mail: milena_karcheva@abv.bg




A new instrument for assessment of psycho-social rehabilitation - 46, 2010, № 4, 54-59.
G. Onchev(1), A. Fercheva(1), S. Alexiev(1) and H. Killaspy(2)
(1)Department of Psychiatry, Medical University -- Sofia, (2)Department of Mental Health Sciences, University College -- London
Summary: The concept of recovery from long-term mental illness involves achievement of autonomous functioning even in the absence of full symptomatic control. This model is in contrast with care in the institutions for long-term psychiatric patients where standards are still bad, especially in Bulgaria. The study “Development of a European measure of best practice in institutions for people with longer term mental health problems” (DEMoBinc) was carried out in 10 European countries (including Bulgaria) with the aim to develop an instrument for assessment of long term care in psychiatric and social institutions. Phases of the instrument’s development are presented, including Delphi groups, reliability testing, and cross-validation against individual markers in 203 institutions and in 1749 service users. The final product is a web based, self-report tool called the Quality Indicator for Rehabilitative Care (QuIRC), which describes unit’s performance on seven domains of care: living environment, therapeutic environment, treatments and interventions, self-management and autonomy, human rights, social interface, and recovery based practice. The results are compared with the average for similar units in the same country. The QuIRC is the first instrument for quality assessment in psycho-social rehabilitation with international validation and consent. Perspectives for its implementation in routine practice across Europe, as well as in future research, are briefly presented.
Key words: recovery, schizophrenia, psychiatric disability, psycho-social rehabilitation, good practice
Address for correspondence: Assoc. Prof. Georgi Onchev, Department of Psychiatry, Medical University, 1, Sv. G. Sofiisky Str., Bg --1431 Sofia, email: georgeonchev@hotmail.com




The medical algorithms of clinical pathways -- main factor for the absence of control over the surplus diagnostics and hospitalization in the mandatory health care insurance system in Bulgaria - 46, 2010, № 4, 60-66.
T. Vekov(1), D. Petrova(2), V. Hristov(2) and B. Kuzmanov(2)
(1)Bulgarian Cardiac Institute, (2)Specialized Cardiac Hospital for Active Treatment -- Pleven
Summary: This article presents an analysis of the criteria for execution of specific invasive and interventional procedures and, at the same time, compares the respective criteria of the Bulgarian Health Insurance Fund (NHIF) with these of the European Society of Cardiology (ESC). The collation reveals a major distinction between the two models -- the national criteria introduced by the NHIF are broader and more general in comparison to these of the ESC, which entails a considerable increase in the number of such procedures during the last three years. On the other side, the comparison clearly indicates that if the execution of certain procedure is accompanied by precise, detailed and concrete criteria neither the number of such procedures nor the NHIF expenditures rise. On account of these findings, the authors conclude that the introduction of such concrete, precise and detailed criteria for invasive and interventional procedures will curb the incremental outlays of the NHIF for this specific kind of inpatient service.
Key words: cardiology, invasive and interventional procedures, clinical pathways, criteria
Address for correspondence: Assoc. Prof. Toni Vekov, Bulgarian Cardiac Institute, 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




Comparative study of pleurodesis potential of talc, iodоpovidone, silver nitrate, doxycycline in experimental model with rabbits - 46, 2010, № 4, 67-72.
A. Yankulov(1), D. Staykov(2), G. Paskalev(1), B. Anavi(2), K. Mourdzhev(1), A. Uchikov(1), V. Uzunova(1), I. Dimitrov(1), A. Batashki(1)
(1)Department of Special Surgery, Medical University -- Plovdiv, (2)Department of Pathoanatomy, Medical University -- Plovdiv
Summary: Chemical pleurodesis has its place as a treatment option in patients with pneumothorax, also in these with malignant pleural effusion. In world publications, there are no unique criteria about the optimal pleurodesis agent. Aim of the study was to compare pleurodesis potential of talc, iodopovidone, silver nitrate and doxycycline in experimental conditions. We used in our study 28 New Zealand white rabbits with body mass from 3,5 to 4 kg, divided into four groups. We autopsied rabbits at 28th day after pleural injection of different agents. We compared the difference between macroscopic pleurodesis, microscopic one and pleural fibrosis initiated by four agents. Silver nitrate and iodopovidone pleurodesis had a higest potential compared with talc’s one. According to our experimental model with New Zealand white rabbits with four pleurodesis agents we can conclude that pleurodesis with iodopovidone and silver nitrate is su­perior to the one with talc and doxycycline.
Key words: experimental model, talc, silver nitrate, iodopovidone, doxycycline, pleurodesis
Address for correspondence: A. Yankulov, M. D., Department of Special Surgery, Medical University, 15, V. Aprilov blvd., Bg -- 4000 Plovdiv




Moral-ethical and legal-deontological problems in the medical expertise of work capacity - 46, 2010, № 4, 77-79.
M. Nikolov
National Oncological Hospital --Sofia
Summary: The doctors performing medical expertise of the work capacity have a difficult, responsible and varied work. Each of the participants in the relationship “doctor-patient” has his own place, position, role, rights, responses, but the doctor has the leading position. He must be familiar with the basic principles of the medical moral, deontology, bioethics and medical law. Thus will help to resolve successfully and correctly the problems of the patients regarding their work capacity.
Key words: deontology, ethics, medical expertise, work capacity
Address for correspondence: M. Nikolov, M. D., National Oncological Hospital, 6, Plovdivsko pole Str., tel. +359 888408089, e-mail: mdn@mail.bg




Zh. Surcheva and I. Miteva. Digital institutional repositories -- a world practice and Bulgarian experience - 46, 2010, № 4, 84-88.
Central medical library, MU Sofia
Summary: It is represented a review on institutional repositories history, current status and future.






Factors, affecting functioning during remission in patients with bipolar affective and recurrent depressive disorder. - 46, 2010, № 3, 34-40.
V. Stoyanova, G. Genchev, S. Krastev, R. Vladimirova and V. Milanova.

(1)Psychiatric Clinic, “Alexandrovska” University Hospital -- Sofia, (2)Section of Medical Informatics and Biostatistics, Medical University -- Sofia
Summary: Affective disorders are widespread, recurrent disorders with multiple faces and with high social significance. Primary prevention of recurrence happens during remission. This important period of illness is influenced both by biological and by environmental factors. The purpose of this study is to determine which factors influence the quality of remission achieved after treatment of recurrent depression (RDD) and bipolar affective disorder (BD). The design of the study was naturalistic, the data were processed with SPSS 17.0.1 and 37 patients with BD and 28 patients with RDD were included. Applying multiple regression analysis and using the "Backward" procedure, five major clinical diagnostic factors that significantly affect the quality of remission, measured by the scale of Sheehan (R2 = 0,711, p < 0.001) remained. The biggest influence exerts the presence of residual depressive symptoms, followed by the number of phases and residual symptoms of hypomania. A professional commitment positively impacts on social functioning, and reduces the scale of Sheehan. The duration of remission is negatively correlated to the severity of social dysfunctioning. In conclusion: The quality of remission is a dynamic indicator and depends on the subsyndromal manifestations of the disease, on the trend for recurrence, biological or psychosocial determinated, and in a much lesser extent on the polarity.
Key words: bipolar affective disorder, recurrent depressive disorder, quality of re­mis­sion, clinical and social characteristics
Address for correspondence: Vessela Stoyanova, M. D., Ph.D., Psychiatric Clinic, University Hospital ,“Alexandrovska”, 1. G. Sofiisky Str., Bg -- 1431 Sofia, tel: +359 2 92 30 979, е-mail: vestoyan@yahoo.com



Relation between periampullary duodenal diverticulum and pathology of the pancreas (Retrospective analysis) – 46, 2010, № 3, 41-44.
St. Dineva, Pl. Getsov, I. Dimov и B. Vladimirov.
(1)Department of Diagnosting Imaging, Medical Institute, Ministry of Interior, (2)Department of Diagnosting Imaging at University Hospital “Tsaritsa Yoanna” -- Sofia, (3)Clinical Center of Gastroenterology at University Hospital " Tsaritsa Yoanna” -- Sofia
Summary: The purpose of the present work is to compare our analysis of the relation between duodenal diverticulum and pancreas pathology with some of the results, published by foreign authors. In our research, endoscopic retrogra­de cholangiopancreatography (ERCP) was performed on 3259 patients for the period between 1989 and the first half of 2009. The examinations were done in the Endoscopic department of the University hospital “Tsaritsa Yoanna”. The protocols were processed in a table with different indicators. In the present analysis, there are compared some of them -- age, gender, presence of duodenal diverticulum, attendant pancreas pathology. The latter includes acute or chronic pancreatitis, cancer, benign tumor, inborn anomalies. The patients were divided into two groups -- with or without periampullary duodenal diverticulum. It should be taken into consideration the level of the endoscopic diagnostics and the X-Ray equipment in Bulgaria, as well as the conditions for making ERCP. For example, patients with acute pancreatitis are rarely undergoing endoscopic examination, that is why the number of such cases was small. The analysis of the data showed that overall there was no significant difference in the frequency of pancreas pathology in patients with and without duodenal diverticulum. It was observed age peak in males at 50 years with acute pancreatitis in both groups.
Key words: duodenal divertilum, endoscopic retrogra­de cholangiopancreatography, pancreatit
Address for correspondence:
Stoyanka Dineva, M. D., Department of Diagnosting Imaging, Institut of Medicine of Ministry of Interior -- Sofia, e-mail: dineva_g@abv.bg



The frequency of АV fistula after renal biopsy – 46, 2010, № 3, 45-48.– 46, 2010, № 3, 45-48.
M. Lubomirova, E. Andreev and B. Bogov.
Clinic of Nephrology, University Hospital “ Alexandrovska” -- Sofia
Summary: The aim of the study was to examine the frequency of AV fistula after renal biopsy. We studied from January 2007 until July 2010 283 patients -- 125 M and 129 F, average age 52 +/- 11,5 years. 29/283 patients were children: 13 -- boys and 16-gilrs, average age 12,6 +/- 3,75. The incidence of AV fistula was low  2,4% -- 7 cases. Doppler ultrasound allows noninvasive detection and follow up study of postbiopsy arteriovenous fistulas, thus helping to define adequate management after interventional procedures.
Key words: renal biopsy, AV fistula, postrenal biopsy complications, Tru-cut needle, spring-loaded biopsy gun
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



Quality of life in patients with malignant pleural effusions treated  by diagnostic thoracoscopy and pleurodesis – 46, 2010, № 3, 49-54.
A. Yankulov, G. Paskalev, K. Mourdjev, A. Uchikov, A. Chapkanov, V. Uzunova, I. Dimitrov and A. Batashki.
Department of Special Surgery, Medical University -- Plovdiv
Summary: Malignant pleural effusion is a disease including different kind of symptoms, leading to a high level of morbidity in patients with cancer. In last years, as a principal treatment in these patients, first choice is pleurodesis. The aim of our study is to investigate how pleurodesis changes the quality of life in patients with malignant pleural effusions. For the period april 2007 -- august 2009, we investigated 100 patients with malignant pleural effusion. In 20 of them, we made only diagnostic thoracoscopy for histological verification of cause of effusion, and in other 80 patients we made pleurodesis with talc, silver nitrate, iodpovidone, doxycycline. According to our results, we can conclude that in four groups treated by pleurodesis, global health status and quality of life are better than in patients undergoing only diagnostic thoracoscopy. Conclusion: Chemical pleurodesis can be used as an effective treatment option in patients with malignant pleural effusions.
Key words: chemical pleurodesis, quality of life, trapped lung
Address for correspondence:
Alexandar Yankulov, M. D., Department of Special Surgery, Medical University, Bg -- 4000 Plovdiv



Crimean-Congo hemorrhagic fever in South Bulgaria – 46, 2010, № 3, 55-60. – 46, 2010, № 3, 55-60.
R. Komitova, I. Christova, S. Zhelyazkova, M. Marinova and I. Boev.
(1)MHAT “Dr G. Stranski” -- Pleven, (2)NCIPD -- Sofia, (3)MHAT -- Yambol, (4)MHAT -- Kardzhali, (5)MHAT “Sv. Georgi” -- Plovdiv
Summary: Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus. Aim of this retrospective study was to characterize epidemiological, clinical and laboratory features of CCHF cases. The study was conducted on patients with CCHF between 2001-2006, in South Bulgaria. Diagnosis was confirmed through virus isolation by inoculation of a blood sample into newborn mice. Seventeen patients were enrolled in the study and13 of them were laboratory confirmed. Majority had a history of tick exposure (tick-bite or tick removing from an animal). A nosocomial infection and a cluster of cases within a family were observed. Nearly half the patients a initially misdiagnosis with various infections other than CCHF. The most frequent symptoms were fever, myalgia and fatigue. Conjunctival injection was the most common finding. Hemorrhagic manifestations were observed in all cases: bleedings from venepuncture sites (17), epistaxis (7), petechiae (3), hematuria (3) and only in a few -- visceral bleedings. All had thrombocytopenia and majority -- leucopenia and еlevated serum aminotransferase activities. All cases received fresh frozen plasma, platelet suspensions and packed erythrocyte infusions when indicated. Four cases were fatal with massive hemorrhage. Nearly half of the patients were diagnosed as CCHF with delay and initially received inappropriate treatment. Continuous medical education regarding this severe infection in the endemic area is essential for achieving a better survival rate.
Key words: Crimean-Congo hemorrhagic fever, nosocomial infections, ribavirin
Аddress of correspondence:
Radka Komitova, M. D., Ph. D., Infectious Diseases Clinic, University Hospital -- Plovdiv, e-mail: radkakomitova@yahoo.com



Application of tacrolimus in kidney transplantation - 46, 2010, № 3, 61-66.
E. Paskalev.
Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska” -- Sofia
Summary: Application of new immunosuppressants in kidney transplantation is associated with improvement of function and survival of renal allograft. Such immunosuppressant is tacrolimus. It is wide used in the world but in Bulgaria its usage started routinelly in a large number of patients two years ago. Before this period, tacrolimus was used in a few patients for quite a long time. Tacrolimus is a calcineurin inhibitor. Its part in the calcineurin inhibitors is around two thirds in Europe and so it is a mainly used immunosuppressant. The goal of the study was to show the results of using tacrolimus in renal transplant patients in Bulgaria. We studied 56 renal transplants patients on treatment with tacrolimus of mean age 34 +/- 7 years, a proportion M:F -- 1:1, cadaveric:living donor proportion 1,2:1, and duration of treatment with tacrolimus 10 +/- 3 months. Patients were divided into two groups: group A -- 26 patients on tacrolimus treatment immediately after transplantation; and group B -- 30 patients who switched from cyclosporine A to tacrolimus because of chronic rejection episode or calcineurin nephrotoxicity that required low dose of calcineurin inhibitor. The main criteria for change in renal funcion were serum creatinine and the level of proteinuria. There was not a case of acute rejection in group A. We estimated mean serum creatinine 114 +/- 12 ncmol/l in patients of group A at the 3-th month after transplantation. Serum creatinine remained unchanged at the end of the study -- 116 +/- 15 ncmol/l (p -- n. s.). Proteinuria maintained a very low level in this group -- < 0.4 g/24 h during the study (p -- n. s.). In group B, we determined improvement of renal function after switching to tacrolimus -- creatinine 174 +/- 18 ncmol/l at the 3-th month after switching and 180 +/- 11 ncmol/l at the end of the study compared with creatinine 202 +/- 15 mcmol/l before the switching on tacrolimus when patients had a therapy with cyclosporine A -- p < 0.05. The changes of proteinuria remained very low without statistical significance (p -- n. s). In conclusion, we can say that the treatment with tacrolimus achieves stability of renal allograft function as well as of immunosuppression after transplantation.
Key words: kidney transplantation, immunosuрpression, tacrolimus
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



Trends in the resistance of most frequent bacterial isolates in University Hospital “Sv. Marina” -- Varna, and the usage of some antibiotics in the period 2004-2008 – 46, 2010, № 3, 67-72.
T. Stoeva, К. Bozhkova, V. Snegarova and М. Bozhkova.

Department of Microbiology and Virology, Medical University -- Varna
Summary: The aim of this study was to investigate the dynamic of antimicrobial resistance in most frequently isolated Gram-negative bacteria and its correlation to antibiotic consumption during the period 2004-2009 in the University Hospital “Sv. Marina”, Varna. Resistance of E. coli, K. pneumoniae and P. аeruginosa to III generation cephalosporins, aminoglicosides, meropenem and ciprofloxacin, as well as annual consumption of these antibiotics (DDD per 100 bed-days) were analyzed. The use of ceftriaxon and ceftazidime was constantly increasing during the studied period, which correlated with the trend of increasing the percent of ESBLs producers among E. сoli и K. рneumoniae. The most affected species was K. pneumoniae, for which we detected increase of ceftazidime resistance from 12% (2004) to 45% (2008) (p < 0.05). In the group of studied antibiotics, ciprofloxacin was the most frequently used during the whole period. A significant trend of increasing the rates of ciprofloxacin resistance was detected in the three bacterial species (p < 0.05). In spite of the increased meropenem consumption, stabilized rates of carbapenem resistance in P. аeruginosa were detected and no resistance in E. сoli and K. рneumoniae. On the background of increased aminoglicoside consumption, increased resistance rates in Enterobacteriaceae were found, although the annual differences were statistically not significant (р>0.05). In P. аeruginosa, gentamicin resistance was on relatively constant level.
Key words: antibiotic consumption, antibiotic resistance
Address for correspondence:
Temenuga Stoeva, M. D., Department of Microbiology and Virology, Medical University, 55, Marin Drinov Str., Bg -- 9001 Varna, tel. +359 887 614 008, e-mail: temenuga.stoeva@abv.bg



Application analysis of the positive drug list requirements and criteria and the influence on the public spendings for medicines – 46, 2010, № 3, 73-77.
T. Vekov, N.Veleva and R. Koleva.
Faculty of Public Health, Medical University -- Pleven
Summary: This article presents an analysis of the criteria for reimbursement of compound pharmaceuticals included in the Positive Drug List (PDL). At the same time, the authors compare these criteria with the criteria and forms of reimbursement of the particular components of compound products when these components are included in the PDL as independent products. Basing his conclusions on the analysis, the authors infer that the regulatory framework reimbursement provisions treat both types of pharmaceuticals equally. At the same time, the application analysis of the above mentioned criteria for reimbursement reveals a discrepancy in the level of reimbursement in the two categories with compound products being reimbursed at a higher level. Having this in mind, the authors recommend an alike application of the criteria in respect of both groups, which will ultimately cut expenses from the NHIF’s budget.
Key words: positive drug list, reimbursement policy, ACE-inhibitors, diuretics, compound medicines, angiotensin receptor blockers
Address for correspondence: Assoc. Prof. Toni Vekov, Bulgarian Cardiac Institute, 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



Results of aesthetic blepharoplasty and operative alternatives in 433 patents – 46, 2010, № 3, 78.
P. Tepavicharova.

Clinic of Plastic, Reconstructive and Aestetic Surgery, UMHAT “Alexandrovska” -- Sofia
Summary: Operative approaches to blepharochalasis correction progressed recently towards tissue sparing techniques. Most contemporary techniques require excision of the structures responsible for the condition and their reposition in selected areas in order to avoid late atrophy related to aging. It is evident on the basis of the present contingent and literature survey that there is no single universal surgical approach. Instead, operative tactics should be tailored to individual requirements of a particular patient. An analysis of 433 blepharoplasty procedures is presented with special emphasize on the unfavorable results, their management and avoidance.
Key words: blepharoplasty, techniques, results
Address for correspondence:
Assoc. prof. P. Tepavicharova, M. D., 16A, Kishinev Str., Bg -- 1407 Sofia, tel. +359 888609947, e-mail: pepi2777@hotmail.com





Position and importance of breast cancer in the structure of total primary disability among women in Bulgaria - 46, 2010, No 2, 31-36.
M. Nikolov
National Oncological Hospital -- Sofia
Summary: The aim of the study is a detailed analysis of the position and importance of breast cancer in the structure of total primary disability with respect to defining the trends. For the period from 2001 to 2008, there were studied 382,314 women evaluated by Territorial medical expert commission throughout the country. Out of them, 50 percent or more were with permanently reduced work capacity. Results, that breast cancer disables mostly women in active and creative pre-retirement age and demographics data, that this is the largest age group of women in Bulgaria prove the social relevance and timeliness of the problem and the practical value of this study. It meets the needs of modern society and of health and social institutions.
Key words: disability, breast cancer, female
Address for correspondence: Manasi Nikolov, M. D., Ph. D., National Oncological Hospital, 6, Plovdivsko pole Str., Bg -- 1756 Sofia, tel. +359 2 8076250, GSM: +359 888408089, e-mail: mdn@mail.bg



Varicella-zoster encephalitis - 46, 2010, No 2, 37-40.
Ts. Doichinova, G. Gancheva, M. Atanasova, Hr. Tsvetanova and P. Ilieva
Infectious Disease Clinic, University Hospital -- Pleven
Summary: Varicella-zoster encephalitis is a severe clinical manifestation of chickenpox infection, affecting mainly children. Objective was to study chickenpox encephalitis for a five-year period (2004-2009), treated at the Infectious Disease Clinic, University Hospital of Pleven. Prospective and retrospective study of varicella-zoster encephalitis in three children and a 38-year old man was performed. Varicella-zoster encephalitis developed during the rash stage of infection until the 5th day from the beginning of the disease. All patients were with intoxication and rash syndrome and specific for infection of CNS clinical manifestations -- body tremor, seizures, coma. All patients were treated with salt-water resuscitation, antibiotic therapy, acyclovir, bioproducts. In the children, the disease had a favorable course, whereas the outcome in the adult man was fatal. Conclusions: Chickenpox encephalitis is more typical for children under 5 years of age, the course is severe, requiring early diagnosis and adequate etiologic and pathogenetic therapy.
Key words: chickenpox, CNS, encephalitis
Address for correspondence: Tsetsa Doichinova, Clinic for Infectious Diseases at University Multiprofil Hospital for Active Treatment, 8a, G. Kochev Bvld, Bg -- 5800 Pleven, tel. +359 888 729 532, е-mail: doichinova_ceca@abv.bg



Immunosuppression with monoclonal antibodies in renal transplant patients - 46, 2010, No 2, 41-45.
E. Paskalev
Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska” -- Sofia
Summary: Since twenty years, the using of monoclonal antibodies as a primary induction therapy in renal transplant patients is a real clinical practice. In this way, it is possible to reduce the frequency of acute rejection and to increase the survival of renal transplant. Goal of the study is to show the effect of using monoclonal antibodies on frequency of acute rejection in renal transplants with high risk. We studied 33 patients with primary induction therapy using monoclonal antibodies -- in 22 patients with Basiliximab (Simulect) and 11 with Daclizumab (Zenapax). The study was performed over аn eight-year period. High risk was present in diabetes mellitus, ulcer, second transplantation, high HLA risk, aloantibodies in the past. We had a control group of 25 patients without monoclonal antibody therapy. We established a 6% frequency of acute rejection in investigated group -- in 1 patient on therapy with Zenapax and in 1 patient with Simulect. The frequency of acute rejection in control group was 16% -- 4 patients with rejection. Using of monoclonal antibodies in patients with high risk for acute rejection leads to reduction of acute rejection to 6% compared with 16% in control group -- p < 0.01. Applying of monoclonal antibodies does not lead to increase of infection incidence.
Key words: kidney transplantation, monoclonal antibodies, acute rejection
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



Risk factors for renal biopsy complications - 46, 2010, No 2, 46-51.
M. Lubomirova, R. Djerassi and B. Kiperova
Clinic of Nephrology, University Hospital „Alexandrovska” -- Sofia
Summary: Renal biopsy can be performed in several ways, including using a spring-loaded biopsy gun. As this form of renal biopsy has become more popular, a controversy has developed regarding tissue adequacy and the incidence of complications. The aim of this study was to examine the rate of post-biopsy complications in patients with impaired renal function as well as the importance and influence of the type of biopsy techniques and needle size on the rate of post-biopsy complications. To compare the incidence of post-biopsy complications done by automated biopsy and a manual biopsy, we studied 204 patients -- 106 F and 98 M, average age 49,69 years assigned to one of the two renal biopsy methods. 40 of 204 were with renal failure, defined as serum creatinine > 133 ncmol/l and/or creatinine clearance < 90 ml/min. The biopsies in 107 pts were done with automated needle 16 G or 18 G, in the other 97 -- with Tru cut needle, 16 G. The post-biopsy complications were visualized by ultrasound examination within 12 h after biopsy. Minor complications -- intra- or perirenal hematoma related to renal biopsy occurred in 16% (32 pts) of all the biopsies. There was no significant difference in age, gender, BP, or coagulation studies before the biopsy between patients with or without complications. The number of post-biopsy hematoma with Tru- cut needle was significantly higher compared to those made by automated needle, p < 0,001. The mean size of hematoma made by Tru- cut needle was bigger than those made by automated needle (43,5 +/- 10,2 mm v.s. 25,6 +/- 8,2 mm). A multivariate analysis of features at baseline was performed to determine which, if any, variable was predictive of a complication after renal biopsy. The only variable predictive of a complication was the level of serum creatinine. Biopsied patients with serum creatinine > 400 ncmol/l were 2.0 times more likely to have a complication after renal biopsy (odds ratio, 2.0; 95% confidence interval, 1.3 to 4.1; P < 0.005). The needle size was predictive of a complication after biopsy. The number of renal hematoma (intra or perirenal) was significantly increased when 16 G needle and a Tru cut needle were used, compared to a 18 gauge automated needle. The major complication -- big intrarenal hematoma which indicated blood transfusion appearred in one case in which biopsy was done with Gun system 16G (0,69%). The incidence of A-v fistula was low -- 2% -- 2 cases in group I and 1 -- in group II, p > 0,05. The incidence of postbiopsy hematoma was marginally greater in group I (10% v 5%), p < 0.01. Both techniques rendered adequate tissue sampling, but the extent of bleeding was more severe with the manual 16 G Tru-cut needle biopsy. Unfortunately, there are no certain clinical and laboratory criteria with the exception of coagulation abnormalities, which may point out the patients at a higher risk of post-biopsy complications. Renal failure presence can increase this risk. Despite the possible post-biopsy complications, renal biopsy remains a routine procedure in nephrology necessary for the process of diagnosis and therapy.
Key words: renal biopsy, post renal biopsy complications, Tru-cut needle, spring-loaded biopsy gun, renal failure
Address for correspondence:
Mila Lubomirova, M. D., Ph. D., Clinic of Nephrology, University Hospital “Alexandrovska”, Bg -- 1431 Sofia, 1 “Sv. G. Sofiiski” Str., e-mail: Mljubomirova@yahoo.com, fax: + 359 2 9230248



Cystatin C -- reference intervals, significance for the clinical practice - 46, 2010, No 2, 52-57.
R. Mihailov(1), B. Pencheva(1), V. Vasilev(2), G. Ranchev(2) and V. Stoyanova(3)
(1)Department of Clinical Laboratory, University Hospital “Tsaritsa Ioanna -- ISUL” -- Sofia, (2)Nephrology Clinic, University Hospital “Tsaritsa Ioanna -- ISUL” -- Sofia, (3)Department of Clinical Laboratory, UMHAT “Georgi Stranski” -- Pleven
Summary: During the last decades, the number of patients with chronic kidney diseases has been increasing constantly. This trend is connected with rise in the percentage of the diagnosed cases of diabetes and different kinds of cardiovascular diseases, most commonly hypertension in patients in a relatively young age. Main marker for assessment of the condition of the kidney function is the level of glomerular filtration. During the 80s of the 20th century, different schemes for diagnosis and tracing in the nephrology clinics were developed, which include measurement of the serum concentration of low-molecular-weight protein Cystatin C. With the introduction of a new laboratory indicator each laboratory is obliged to choose concrete reference ranges, which is a prerequisite for more accurate estimation of the condition of the patient. A selection of 101 volunteers with a verified condition of ‘health’ was carried out. A validated immunoturbidimetric test of Dako Cytomation was used. The acquired results were then processed according to the requirements of IFCC with the program Refval Version 3.2.1. Since no symmetric distribution of the results was established, the reference intervals were calculated after a mathematical manipulation (logarithmic transformation). The obtained by us reference intervals for Cystatin C are: 0,168-1,166 mg/L. These intervals are close to the ones recommended in a wide range of literature sources.
Key words: cystatin C, kidney failure, glomerular filtration, referential boundaries
Address for correspondence: Rosen Mihailov, Clinical Laboratory, UMHAT “Tsaritsa Ioanna -- ISUL”, 8, Bialo more Str., Bg -- 1520 Sofia



Study of the volume of the generic penetration in to the bulgarian pharmaceutical market during the period 2006-2009 - 46, 2010, No 2, 58-62.
T. Vekov
Bulgarian Cardiac Institute -- Sofia
Summary: This article presents a comparative study of the Bulgarian generic medicines market dynamics through analysis of volume of two segments of the pharmaceutical market -- the generic medicines market and the share of the original medicines. A four-year period has been examined, using data of prescriptions implemented in pharmacies, official marketing data from IMS Health for the period 2006-2009 and data from NHIF on reimbursement for medicines. The comparison shows that the consumption of generic products during the period 2006-2009 decreased, respectively, of original medicines increased. The author highlights that as a result of improper drug and reimbursement policy the Bulgarian pharmaceutical market develops illogically, which leads to continuous cost increases of the medicines combined with decreased therapeutic accessibility and to necessity to undertake reforms in this direction.
Key words: public finances, generic penetration, reimbursement, positive drug list
Address for correspondence: Assoc. Prof. Toni Vekov, Bulgarian Cardiac Institute, 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



Pharmacoeconomic evaluation of sublingual tablets buprenorphine 2 mg/naloxone 0,5 mg for treatment of opioid narcotic dependence - 46, 2010, No 2, 63-70.
A. Savova, A. Stoimenova, M. Manova and G. Petrova
Department of Social Pharmacy, Faculty of Pharmacy, Medical University -- Sofia
Summary: Goal of the study was to assess the possible clinical and economic benefits of the treatment of opioid dependence with buprenorphine + naloxone for the Bulgarian healthcare system. Based on published model of “tree of therapeutic decisions”, which compares the treatment with methadone vs buprenorphine + naloxone, the treatment effect for a period of 52 weeks under Bulgarian conditions was evaluated. Analysed were only the direct costs for pharmacotherapy of both alternatives for 1 month and 6 months respectively by producer prices allowed by Ministry of Health. The expected costs for both alternatives were respectively 166 BGN for methadone and 2833 BGN for buprenorphine + naloxone. The proportion of the additional costs to the additional quality-adjusted life year (QALY) was 12 456,79 BGN. It is concluded that the combination of buprenorphine + naloxone is efficacy, safety and profitable for Bulgarian healthcare system and probably for the social system as well.
Key words: methadone, buprenorphine, efficacy, safety, cost-effectiveness, randomised clinical trials
Address for correspondence: A. Savova, Department of Social Pharmacy, Faculty of Pharmacy, Medical University, 2, Dunav, Bg -- 1000 Sofia



Role of methylprednisolone for the phospholipid composition of the alveolar surfactant in septic respiratory distress syndrome caused by experimental fecаl peritonitis - 46, 2010, No 2, 71-78.
S. Lazarov(1), R. Nikolov(2), E. Yanev(1), A. Momchilova(3) and R. Pankov(4)
(1)Department of Pathophysiology, Medical University -- Sofia, (2)Department of Pharmacology and Toxicology, Medical University -- Sofia, (3)Institute of Biophysics, Bulgarian Academy of Sciences, (4)Faculty of Biology, University of Sofia “Sv. Kliment Ohridski”
Summary: Gram-negative sepsis represents a serious problem in the clinical practice, affecting more than 1% of hospitalized patients. Usually it is developed on the basis of acute fecal (bacterial) peritonitis. In 40-45% of patients, Gram-negative sepsis leads to a septic shock and to multiple organ dysfunction syndrome (MODS) being its fatal issue. In more than 90%, it is due to respiratory distress syndrome in adults (ARDS). It is developed because of irreversible structural and functional injuries in the lung surfactant system (LSS) and meanly in the alveolar surfactant (AS). Despite of serious improvements in the therapy and in the intensive cares for the patient with ARDS, the mortality is about 50%-60% for the last ten years. Different glucocorticosteroids are between the most studied drugs for the treatment of ARDS. That’s why we investigated the АS of rats in experimental model of sepsic ARDS, treated with methylprednisolone. We studied the total quantity and the percent ratio of the surfactant phospholipids and the quantity ratio between the basic phospholpid fractions in the AS. We found statistically significant favorable changes of the studied indicators in the treated with methylprednisolone animals.
Key words: acute fecаl peritonitis, sepsis, septic shock syndrome, adult respiratory distress syndrome, alveolar surfactant, surfactant phospholipids, methylprednisolone
Address for correspondence: Simeon Lazarov, M.D., Ph.D., Department of Pathophysiology, Faculty of Medicine, Medical University, 1, Sv. Georgi Sofiiski Str., Bg -- 1431 Sofia, tel. +359 2 951-69-96/318





Creating a system for electronic health record -- current state and “best practices” in Europe and around the world - 46, 2010, No 2, 79-83.
І. Kostov
Second Municipal Hospital for Obstetrics and Gynecology “Sheynovo” -- Sofia
Summary: This article presents the current state and “best practices” in EU Member States, Canada, USA, and New Zealand in creating a system for Electronic Health Record (EHR). The development of electronic health record in European and world perspective and the information-technological provision of the healthcare sector and of EHR in Europe and in rest of the world have been reviewed. The author describes the “best practices” of European and other countries where ePHRs are used.
Key words: e-health, electronic health record, electronic personal health record

Аddress for correspondence: Ivan Kostov, M. D., Execitive Director of Second Municipal Hospital for Obstetrics and Gynecology “Sheynovo”, 19, Sheynovo Str., Bg -- 1504 Sofia





The open access -- fact in the virtual reality - 46, 2010, No 2, 84-88.
J. Surcheva and I. Miteva
Central Medical Library, Medical University -- Sofia
Summary: In the review, there are presented open access sources: journals and materials from open digital archives. Described are the history of their origin, some aspects of copyright, reflection of the open access to scientific information on the behavior of traditional publishers and libraries and digital scientific publication perspectives.
Key words: open access, internet, copyright, publishers, libraries
Address for correspondence: Jenia Surcheva, M. D., Central Medical Library, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: surcheva_j@abv.bg





Results of operative treatment of 56 patients with open retropubic radical prostatectomy
- 46, 2010, No 1, 40-43.
N. Smilov(1), I. Lozev(2), E. Aleksandrov(1) and P. Lozev(1)

(1)Urologic Ward, (2)Clinic of Surgery, Medical Institute -- Ministry of Interior -- Sofia
Summary: The aim of this study is to assess the surgical complications of open retropubic radical prostatectomy. Fifty-six cases of localized prostate cancer underwent retropubic radical prostatectomy in our department in the last five years. Standard technique of open retropubic radical prostatectomy as described by Walsh was used. During follow-up, cancer control and quality of life indices (potency and urinary continence) were noted. Postoperative recovery of all patients was excellent. Fifty-two out of 56 patients were continent, tree had stress incontinence and one was totally incontinent. Bladder neck contracture was present in one out of 56 patients. Cancer control was established in 50 out of 56 cases. Though retropubic radical prostatectomy is the standard treatment for early prostate cancer, it is not without complications. It has a steep learning curve.
Key words: prostate cancer, radical retropubic prostatectomy
Address for correspondence:
N. Smilov, M. D., Medical Institute Ministry of Interior, 79 Skobelev Blvd., Bg -- 1606 Sofia, tel. +359 888 763 674, e-mail: smilov_nencho@yahoo.com


Gastrointestinal stromal tumors in Bulgaria -- A National Cancer Registry official data - 46, 2010, No 1, 44-48.
Z. Valerianova
(1)National Cancer Registry, Specialized Oncological Hospital -- Sofia
Summary: Discoveries of modern science and published data related to malignant gastrointestinal stromal tumor (GIST) is a basis for conducting this study. It aims to assess the status of newly diagnosed cancer cases of GIST in Bulgaria for the period 1993-2008 and to indicate the main possible causes of their underregistration. All new cases with leiomyosarcoma are determined from the database of the NCR for the period 1993-2006. Coding system of the ICD-10th revision is used. To find the approximate number of new cancer cases of GIST in the country, a study was conducted in oncological dispensaries for the years 2005 and 2006 and in some university hospitals in Sofia for the period 2005-2008. 176 new cases with leiomyosarcoma of gastrointestinal tract are registered in the NCR. For the years 2005 and 2006 only in 14 (39%) of 36 cases with leiomyosarcoma the diagnosis was confirmed by histology and by immunohistochemical investigation for malignant GIST. The median age of patients was 54 years. Most of the malignant GIST (70%) were localized in small intestine and in the stomach. 50% of the cases were in advanced stage of the diseases. All patients investigated have conducted surgical treatment during the first year of diagnosis, and in 6 of them chemotherapy was administered. Study in university hospitals in Sofia showed that of a total of 61 cases with malignant GIST only 44 (72%) were available in the database of the NCR. The main reasons for underregistration of the patients with malignant GIST are a failure of regulation and lack of control, the absence of right codes for classification of the tumors, insufficient number of qualified staff in clinical pathology and others.
Key words: GIST, coding, stage, reasons for hyporegistration
Addressfor correspondence:
Assoc. prof. Zdravka Valerianova, National Cancer Registry, Specialized Oncological Hospital, 6, Plovdivsko pole Str., Bg -- 1756 Sofia, tel./fax: +359 2 8706258, e-mail: bncr_zdravka@netbg.com


Comparative study of deceased patients with leptospirosis and acute viral hepatitis - 46, 2010, No 1,  49-53.
G. Gancheva, Chr. Tsvetanova, P. Tsvetkova and P. Ilieva
Department of Infectious Diseases, Epidemiology, Parasitology and Tropical Medicine, Medical University -- Pleven
Summary: Severe forms of leptospirosis and acute viral hepatitis (AVH) are with high risk for lethal outcome. Aim of the study was to compare deceased patients with leptospirosis and AVH. Retrospective comparative study had been performed in fatal cases with leptospirosis (group A, n1-12) and AVH (group B, n2-12), which had been treated in the Clinic of Infectious Diseases -- Pleven. Etiology on group A -- L. icterohaemorrhagiae -- one case; eleven no confirmed; group B -- hepatitis B virus -- eleven; one no confirmed. Fever was more characteristic in group A, heaviness in the abdomen, somnolence and sleep disorders -- in group B. Adynamia, anorexia, vomiting, jaundice and hepatomegaly were presented equally in two groups; splenomegaly was more frequent in group A. Three of the patients in group A were with meningoencephalitis and all in group B -- with liver encephalopathy. The lethal outcome in leptospirosis was significantly correlated with brain edema, lung edema and severe metabolic disorders. Mortality in AVH was significantly correlated with brain edema and visceral hemorrhages. It is concluded that severe forms of leptospirosis and AVH require early diagnosis and intensive therapy because of severe multiorgan disorders. The lethal outcome is with complex genesis and brain edema is important factor for death.
Key words: leptospirosis, acute viral hepatitis, acute renal failure, acute liver failure, brain edema
Address for correspondence:
Galya Gancheva, M. D., Ph. D., Clinic of Infectious Diseases, University Hospital “Dr G. Stranski”, 8a, G. Cochev Str., Bg -- 5800 Pleven, tel. +359 64 886 416, e-mail: galya_gancheva@abv.bg


Obesity -- risk factor for renal post biopsy complications - 46, 2010, No 1,  54-57.
M. Lubomirova, E. Andreev and B. Bogov
Clinic of Nephrology, University Hospital “ Alexandrovska” -- Sofia
Summary: The aim of the study was to examine renal postbioptic complications in obese patients. From January 2007 until July 2009, 204 biopsies were made in 98 male and 106 female patients, average age 49, 65 +/- 14,9. 40/240 pts were with impaired renal function. Conventional and Doppler ultrasound examination of the kidney were done up to 24 hours after biopsy in all patients. In 97 pts, 97 renal biopsies were done with needle TEM 14 G (Тru-cut). In 107 pts, spring-loaded biopsy gun was used with needle MCA 18 G or 16 G. Minor hematomas were detected in 32 biopsies (16%) -- 10% were with Tru cut technique and 16 G needle, and the rest 6% with Gun system and 16 G needle. Patients with BMI > 30 had significantly higher risk for renal hematomas after biopsy, р < 0,001. A multivariate analysis was performed to determine which, if any, variable was predictive of a complication after renal biopsy. The only variable predictive of a complication was the level of serum creatinine. Patients with serum creatinine > 400 ncmol/l had 2 times higher risk for renal biopsy complications (odds ratio, 2.0; 95% confidence interval, 1.3 to 4.1; P < 0.005). Major complication -- a big perirenal hematoma was detected in one case (0,6%) of all biopsies. А-V fistula was found in 4 pts. (2%). Both techniques ensured sufficient material, but significant complications were found when biopsy was made by 14 G Tru-cut needle as well as in patients with obesity and impaired renal function.
Key words: renal biopsy, postbioptic renal complications, Tru-cut needle, spring-loaded biopsy gun, renal failure, BMI
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


Diabetic neuropathy as an indicator for the global health risk of patients with type 2 diabetes - 46, 2010, No 1, 58-64.
Z. Kamenov(1), R. Parapunova(1) and R. Georgieva(2)
(1)Clinic of Endocrinology, Medical University -- Sofia, (2)Sofia University
According to the fourth edition of IDF Diabetes atlas (2009), today 6.6% of the world’s adult population have diabetes, predominantly type 2 (DM2). Results from the epidemiological studies show, that DM2 is unrecognized for years in almost half of the patients, but during this subclinical prediagnostic period macro- and microvascular complications occur, which increases the total risk of the patient. The aim of this retrospective study was to evaluate the global health risk profile of the patients with diabetic neuropathy (DN) based on the diabetic micro- and macrovascular complications. A documentary method with selective analysis of special aspects of the source document was applied. The clinical records from the archives were used as source documents. The primary information was extracted in an electronic database including: anthropometric indices, diabetes data, arterial hypertension (AH), dyslipidemia, coronary artery disease (CAD), brain vascular disease (BVD), peripheral artery disease (PAD), nephropathy, retinopathy, metabolic syndrome (MS) etc. DN was accepted if this diagnosis was mentioned in the record and/or neuropathic symptoms were present and/or neurological tests (incl. EMG) were positive and/or specific treatment was performed. The analyzed time interval included the years between 1990 and 2007. It was divided into 4 periods, starting every 5 years and covering the first 3 years of each period. The patients were included only during their first admission to the hospital. 1705 patients were included (female 56.4%) at a mean +/- SD age of 60,0 +/- 11,9 years. DN had 1344 (78,8%). The patients with DN had a higher level or higher prevalence of (*р < 0.05; **р < 0.01; ***р < 0.001): age (56,8 +/- 13,2 / 60,8 +/- 11,5 years.***), waist (97,3 +/- 16,7/100,3 +/- 15,8 cm**) and hip circumferences (104,1 +/- 12,1 / 106,0 +/- 13,2 cm*), diabetes duration (5,6 +/- 7,2 / 11,0 +/- 8,3***), AH (78,3/84,1 %**), nephropathy (14,2/26,6 %***), retinopathy (10,8 / 51,4 %***), CAD (37,6 / 56,7 %***), BVD (7,6 / 16,2 %***), stroke (3.2/9.2%**), PAD (7.2/11.8%*), MS (71,2/77,9 %**) etc. Patients with DN had higher risk (OR(CI)) for having also retinopathy 9,934 (7,230-13,651***), nephropathy 2,769 (2,058-3,726***), stroke 2,422 (1,199-4,894)*, and for the other macrovascular complications the ORs were significant and less than 2. Concluded is that presence of DN defines a patient population with consistently increased global health risk, determined by micro- and macrovascular diabetes complications. The evaluation of this global risk of a diabetic patient must be comprehensive and followed by a complex therapeutic approach, targeted on all established diabetic complications.
Key words: diabetes type 2, diabetic neuropathy, late diabetes complications; global health risk
Address for correspondence:
Zdravko Kamenov, M. D., Clinic of Endocrinology, Medical University, 1, Sv. G. Sofiiski str., Bg –1431 Sofia


Spontaneous pneumomediastinum: self experience and review of the literature - 46, 2010, No 1, 65-70.
I. Novakov(1), G. Paskalev(1) and S. Novakova(2)
(1)Department of Thoraco-abdominal Surgery, Medical University -- Plovdiv, (2)Internal Consultation Department -- Allergology Unit, Medical University -- Plovdiv
Summary: Spontaneous pneumomediastinum is a rare condition. Thoracic surgeons are involved in this disease because every presence of free air in the mediаstinum (pneumomediastinum) must be considered as a potentially life-threatening condition. The aim of this study was to present how to deal with this entity based on our experience and a review of the literature. Four patients with spontaneous pneumomediastinum were included in this study (2005-2008 year). Predisposing factors, clinical presentation, data of imaging diagnostics (chest radiography and computed tomography) were analyzed. Length of hospitalization, result of the treatment with outcome were observed. Violent coughing (bronchial asthma) and physical exertion were precipitating factors. Acute retrosternal pain was the main symptom. Subcutaneous emphysema on the neck and the thorax was established in all of the patients. Free air in the mediastimun and soft tissue of the neck was demonstrated by chest radiography and computed tomography. Esophageal perforation and tracheobronchial rupture were excluded. All patients were hospitalized (length of hospitalization -- 6,25 +/- 1,5 days). They were treated conservatively (analgesics, antibiotics, treatment of bronchial asthma, oxygen therapy). Patients were discharged without any complaints. No complications were established. Spontaneous pneumomediastinum is a rare entity in young individuals, with a benign natural course, that responds to conservative treatment very well. Esophageal perforation and tracheobronchial rupture must be excluded while diagnosing the disease.
Key words: pneumomediastinum, spontaneous pneumomediastinum, subcutaneous emphysema
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


The lack of objective assessment of drug efficacy, safety and risk -- the main deficiency of the national drug policy - 46, 2010, No 1,  71-74.
T. Vekov(1), D. Petrova(2), O. Yaneva(2) and A. Ivanova(2)
(1)Bulgarian Cardiac Institute -- Sofia, (2)UniCardio Clinic -- Pleven
Summary: The article presents the results of the assessment of efficacy, safety and phar­maco-economic indicators of 3-hydroxy-3-methylglutaryl-CoA inhibitors (sta­tins). This article was conducted over a period of 6 months and evaluated main parameters that determine the risk-benefit ratio as safety and efficacy. For this purpose, two groups of patients aged 50-70 years were studied. The authors concluded that reimbursment of medicines and their inclusion in the reimbursment list of medicines is not consistent with the objective assessment of efficacy, safety and risk, and in most cases there is even a lack of assessment.
Key words: drug policy, rosuvastatin, simvastatin, safety, reimbursment, statins
Address for correspondence:
Assoc. Prof. Toni Vekov, Bulgarian Cardiac Institute, 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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