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 Original papers


Vol. 48, 2012


bullet 4'2012

Early and long-term complications after renal transplantation: clinical observation and management - 48, 2012, 4, 32-40.
St. Hinev(1), D. Tsoneva(1), M. P. Atanasova(1), Al. Todorov(1), Y. Borisov(1), K. Dafinova(1), E. Paskalev(2), B. Zlatkov(2) and Zh. Filipov(2)
(1)Clinic of Anesthesiology and Intensive Care, (2)Clinic of Nephrology and Transplantation, UMHAT “Alexandrovska” -- Sofia
Summary: Renal transplantation (RT) is an optimal treatment for patients with advanced stage renal failure, which improves their survival and quality of life. However, RT is associated with complications and problems specific to patients with organ transplants, such as: side effects of potent immunosuppressive drugs and drug interactions, renal tract problems, respiratory infections, post-surgical complications, cardiovascular, gastrointestinal, neurological disorders and etc. The improvement of surgical techniques and the appearance of more potent immunosuppressive agents reduce the incidence of early complications associated with RT. At present, the prevention of long-term complications takes a priority. Patients with transplant complications usually enter intensive care units mostly in case of emergency, which requires adequate training and experience of the medical staff in the diagnosis and treatment of post-transplantation complications. The article presents the problems of early and long-term complications in post-RT patients, based on available literature data and own clinical experience. Post-transplantation complications in patients, who have undergone RT, are frequent, severe and life-threatening, which requires better understanding of the problem by the medical staff and a multidisciplinary approach in treating these patients.
Key words: advanced renal failure, renal transplantation, post-transplantation complications, intensive care
Address for correspondence:
St. Hinev, M. D., Clinic of Anesthesiology and Intensive Care, UMHAT “Aleksandrovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia


Carrier status for polymorfism A1/A2 in platelet glycoprotein IIB/IIIA of patients with ischemic stroke - 48, 2012, 4, 41-45.
M. Ivanov(1), S. Gecheva(2), P. Ivanov(1), P. Laleva(3), B. Stamenov(4), R. Komsa-Penkova(1), I. Ivanov(1) and Vl. Ivanov(3)
(1)Department of Biochemistry, Medical University -- Pleven, (2)Department of Clinical Immunology, Medical University -- Pleven, (3)Clinical Laboratory, UMHAT “G. Stranski“, Medical University -- Pleven, (4)Department of Neurology and Neurosurgery, Medical University -- Pleven
Summary: The classic risk factors for ischemic stroke (IS) include smoking, heart failure, atrial fibrillation, advanced age, dyslipidemia, hypertension and diabetes, but the role of genetic risk factors in IS development has been recently discussed. The platelet fibrinogen receptor glycoprotein (GlPr) IIb/IIIa A1/A2 polymorphism (PL A1/A2) affects platelet aggregation and could be a possible risk factor for cerebral artery occlusion. This study explored the association of PL A1/A2 polymorphism with ischemic stroke in 30 patients with cerebral artery occlusion and 60 healthy controls without a history of arterial or venous thrombosis. A strong association between the development of IS under the age of 60 years and PL A1/A2 was established (43.3% and 18.3% carrier status in the studied patients and healthy controls, respectively), OR = 3.41, 95% CI (1.16-10.14, p = 0.02). An increased prevalence of polymorphism in women with IS was found, compared to men (63.6% and 31.6%, respectively). A further larger investigation with examination of additional factors could confirm the presented correlation between the inherited increased platelet aggregation and the development of IS. The establishment of carrier status for PL A1/A2 could have a relation with the administered IS treatment, because of the resistance to aspirin in polymorphism‑positive individuals.
Key words: polymorphism A1/A2, platelet aggregation, ischemic stroke
The investigation was supported by a grant of the Medical University -- Pleven.
Address for correspondence: Petar Ivanov, M.D., Department of Biochemistry, Medical University, 1, “Sv. Kliment Ohridski” Str., Bg -- 5800 Pleven, e-mail: mdivanov@gmail.com


Human BK polyomaviral activity in patients with renal transplants - 48, 2012, 4, 46-50.
Zl. Kalvatchev(1), Il. Tsekov(1), V. Vladimirov(2), E. Paskalev(2), B. Zlatkov(3), Zh. Filipov(3) and M. Gicheva(4)
(1)Molecular Virology Laboratory, Military Medical Academy -- Sofia, (2)Department of Urology and Transplantations, University Hospital "Aleksandrovska" -- Sofia, (3) Department of Nephrology and Transplantations, University Hospital "Aleksandrovska" -- Sofia, (4)Еxеcutive Agency for Transplantation
Summary: Reactivation of the Human Polyomavirus BK (BKV) and the resulting events have been extensively studied at the renal transplant centers worldwide. The virus leads to direct cytopathic alterations in the transplanted organ, which may explain the growing interest among the researchers. We have studied the influence of BKV on 50 patients with renal transplants from Bulgaria. The results showed a high level of viruria (84%), compared to rare development of BKV-associated disease and permanent dysfunction of the transplanted organ (4% of all cases). However, a relationship between the applied combination of three immunosuppressive medications and the reactivation of BKV was established. We consider that the employed non-invasive diagnostic approach may be routinely used for monitoring of patients with renal transplants in our country.
Key words: BKV, BK-associated nephropathy, transplant rejection
Address for correspondence: Prof. Zlatko Kalvatchev, M. D., D. Sc., Molecular Virology Laboratory, Military Medical Academy, 3, Sv. G. Sofiyski Blvd., Bg -- 1606 Sofia, e-mail: kalvatchev@gmail.com


Antibodies against phospholipids in patients with systemic lupus erythematosus with and without antiphospholipid syndrome - 48, 2012, 4, 51-56.
M. Baleva(1) and M. Nikolova(2)

(1)Clinic of Clinical Immunology, (2)Clinic of Nephrology, University Hospital Alexandrovska, Medical University -- Sofia
Summary: The aim of this study was to compare the levels of several anti-phospholipid antibodies in patients with systemic lupus erythematosus (SLE) with and without anti-phospholipid syndrome (APS) and to evaluate the diagnostic significance of these auto-antibodies. We investigated the serum levels of IgG and IgM anti-cardiolipin (ACL), anti-beta-2-glycoprotein I (B2GPI), anti-phosphatidyl serine (PS), anti-prothrombin (PT), anti-annexin V (AnV) and anti-ethanolamine (Eth) antibodies using an ELISA method (Orgentec, Germany) in 26 patients with SLE/APS, 24 patients with SLE without APS, and in a control group of 30 healthy persons. The mean levels of IgG and IgM ACL, B2GPI, PS and Eth were significantly higher in SLE/APS patients compared to the SLE patients without APS and to the control group (p < 0.05). The mean levels of IgG and IgM AnV and PT were comparable in both SLE groups but were higher than the mean levels of these auto-antibodies in the control group. Overall 85% of the SLE/APS patients had positive IgG ACL, 62% had positive IgG Eth, 50% -- positive IgM B2GPI, 46% -- IgM ACL, and 35% -- positive IgG B2GPI. In SLE patients without APS the most prevalent anti-phospholipid antibodies were IgG PS (29%) and IgG Eth (25%). The results of our study pose several questions: 1. Do we have to evaluate the levels of anti-phospholipid antibodies in all SLE patients? 2. If we have to, then which anti-phospholipid antibodies should we recommend? 3. What is the significance of the positive anti-phospholipid antibodies in the absence of past history and clinical data for thrombosis? 4. Could the positive results precede the development of thrombosis? Having in mind that APS is even more systemic disease than SLE and is probably one of the most prevalent conditions in humans, the investigation of different anti-phospholipid antibodies and the comparison of results with clinical symptoms is of great importance.
Key words: systemic lupus erythematosus, anti-phospholipid syndrome, anti-phospholipid antibodies
Address for correspondence:
Prof. Marta Baleva, M. D., DMSc, Clinic of Clinical Immunology, University Hospital Aleksandrovska, 1, Sv. G. Sofiyski Str., POBox 45, Bg -- 1431 Sofia, e-mail: marta_baleva@yahoo.com


Psychological problems in the adaptation period of dialysis patients - 48, 2012, 4, 57-60.
Sv. Staykova and R. Dimitrova-Zlatkova
Clinic of Nephrology and Dialysis, Medical University -- Varna
Summary: Chronic disease patients often succumb to a state of depression and despe­ra­tion, which not only accompanies the primary condition, but also creates a number of difficulties for the treatment and adaptation processes. Medicine presumes too much on the mystical power of doctors and patients’ faith in physcians’ capacity to overcome the disease. For dialysis patients, actual dialysis treatment, communication with the medical staff and social realization are perceived individually. To improve the quality of life of chronically ill people, the clinician must focus her/his efforts not only on therapeutic interventions, but also on her/his impact on their emotional states, by applying the methods of psychotherapy. The process of acceptance and adaptation to the new way of life, imposed by the illness, is difficult and continuous.
Key words: dialysis, adaptation period, chronic renal failure, quality of life
Address for correspondence:
Svetla Staykova, M. D., Clinic of Dialysis, Medical University, 55, Marin Drinov Str., Bg -- 9002 Varna, tel. +359 885 841 663, e-mail: svetlastaykova@abv.bg


Pharmacoeconomic analysis of the aniemetic therapy with palonosetron caps. 500 mcg - 48, 2012, 4, 61-65.
M. Dimitrova and G. Petrova

Faculty of Pharmacy, Medical University -- Sofia
Summary: Chemotherapy-induced nausea and vomiting significantly deteriorate the quality of life of oncological patients and may decrease their compliance with further chemotherapy. The 5-HT3 receptor antagonists effectively control nausea and/or vomiting induced by chemotherapy. Palonosetron is a second generation 5-HT3 rector antagonist. It is applied only once before chemotherapy and has a prolonged action. Palonosetron can be applied as an injection for intravenous infusion or orally, as a capsule. The aim of this pharmacoeconomic analysis is to evaluate the cost of therapy with palonosetron capsules and its impact on the budget. Palonosetron capsules increase the possibilities to treat emesis after medium or highly emetogenic therapy. Clinical studies and meta-analyses have proven the similarity between the antiemetic effects of setrones. Due to its unique dosage, one capsule for 5 treatment days, palonosetron increases the patient’s compliance and guarantees a stable antiemetic response. The cost of therapy with palonosetron is almost identical with those of all other setrones. The budget impact analysis has shown that the introduction of palonosetron in the Positive Drug List will not change the overall cost of antiemetic therapy and will just transfer the cost from other products.
Key words: setrones, palonosetron, ondasetron, dolasetron, tropisetron, granisetron, pharmacoeconomics
Address for correspondence:
Maria Dimitrova, Faculty of Pharmacy, Medical University, 2, Dunav Str., Bg -- 1000 Sofia





Reimbursement of medicinal products in Germany in the light of measures to reduce drug costs - 48, 2012, 4, 66-72.
I. Balkanska, A. Stoimenova, Al. Savova and G. Petrova
Department of Social Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Medical University -- Sofia
Summary: The current publication comments on the reforms of reimbursement of medicinal products in Germany during 1989-2011, with a particular emphasis on measures to reduce drug costs. For this purpose, we have reviewed 10 publications that focus on the strategies taken by the German government during the studied period. A wide range of measures directed to marketing authorization holders, wholesalers, pharmacists and patients was considered, which generally forms the pharmaceutical market in the direction of changing habits of prescription to such that will favor generic medicinal products. Each participant in the health system has its role for reducing drug costs. Similarly to the German experience, this should be included in the cost-reducing strategy, in order to realize a fair spread of the financial risk.
Key words: medicinal products, costs, reimbursement, reforms, Germany
Address for correspondence:
Assoc. Prof. А. Stoimenova, Department of Social Pharmacy and Pharmaco­economics, Medical University, 2, “Dunav” Str., Bg -- 1000 Sofia, e-mail: assena_stoimenova@mail.bg


Pharmaceutical drug marketing -- marketing strategies, manufacturers and drugs - 48, 2012, 4, 73-77.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: In the last decade pharmaceutical drug marketing in Bulgaria scores over a 300% rise. The basic factors implemented into this are the increased drug use, the raised drug prices, the lack of drug policy, stimulating generic penetration in the market, the reimbursement system, which motivates the prescription of expensive trademarks and the clever marketing strategy of drug manufacturers. For the same period, a rise of 260% in drug stores average year sales has also been observed, and a factor which may play a role in this, is the amalgamation of retail trade, trade diversion to local and national chain drug stores and, therefore, increased market influence. Marketing strategies of pharmaceutical manufacturers are various, depending on the type and length of product lines: full marketing coverage, promotion of different trade marks in one segment (market specialization) or in different segments (selective specialization), etc., which allows improvement of the effectiveness of sales.
Key words: pharmaceutical marketing, marketing strategies, differentiation of products, price formation, selective specialization
Address for correspondence:
Prof. Toni Vekov, Bulgarian Cardiac Institute, 1, G. M. Dimitrov Str., Bg -- 1172 Sofia, tel. +359 2 962 54 54, e-mail: t.vekov.mu.pleven@abv.bg


bullet 3'2012

Co-morbidities in COPD -- a cumulative effect of exogenic and endogenic factors - 48,  2012, № 3, 40-45.
Zl. Yankova(1, 4), R. Ivancheva(1), F. Shterev(1), V. Yurukova(2), G. Belev(1), N. Boyadzhiev(3), I. Damyanov(3), D. Popov(3), S. Genovа(3) and S. Kartev(1)
(1)Clinic of Pulmonology, Medical University -- Plovdiv, (2)Сlinic of Pulmonology, Medical University -- Sofia,(3)Сlinic of Physiology, Medical University -- Plovdiv, (4)First MHAT -- Sofia
Summary: An analysis of our observations and literature data was made on the cumulative effect of exogenic and endogenic factors resulting in comorbidities of COPD. The relation between COPD and lung carcinoma (COPD + Ca) was clinically and experimentally examined. 120 smokers with COPD + Ca and 181 smokers with COPD, as well as 50 patients with lung Ca and 50 healthy smokers (a control group) were clinically examined. We found that the number of cigarettes smoked (p = 0.009) and occupational air pollutants (exogenic factors) are more risky for developing COPD + Ca than start smoking at an early age (p = 0.821). Familial aggravation for Ca (endogenic factors) was more risky for developing COPD + Ca (20%) than other lung diseases in a familial history (14.17%). There was a difference in co-morbidity rates between smokers with COPD + Ca and these with COPD. Smokers with COPD + Ca had significantly lower rates of cardiovascular, metabolic and thromboembolic diseases than these with COPD. In lung carcinoma patients, familial aggravation for cardiovascular and metabolic diseases exceeded that of the control group (2-4%). The lungs and bone marrow of rats were morphologically examined after a 30-day period of treatment with tobacco smoke. At higher exposures, we found bronchiolitis and centroacinar emphysema with predominant destruction. In the alveoli, alveolar ducts and round terminal bronchi, accumulation of macrophages and diffusive interstitial pneumonitis were observed. In the bone marrow, the number of micronuclei (erythrocytes with nuclear chromatin) was 3 times higher, compared with the controls, 4.35 +/- 0.5 versus 1.58 +/- 0.33, which shows that simultaneously with local changes, systemic effects (clastogenesis) also occur due to cytotoxic effects. Smoking results in local and systemic changes. Comorbidities of COPD are related with the cumulative effect of exogenic and endogenic factors. An individually based evaluation of risk factors may improve patient prognosis.
Key words: chronic obstructive pulmonary disease, lung cancer, risk factors, comorbidity
Address for correspondence: Assoc. Prof. Zl. Yankova, M. D., Clinic of Pulmonology, I MHAT, 35 P. Evtimiy Blvd., Bg -- 1000 Sofia, 1431 София, тел. 02 91 72 730, е-mail: l.boyanova@hotmail.com; l.boyanova@lycos.com



Helicobacter pylori resistance to clarithromycin in different geographic regions in Bulgaria - 48,  2012, № 3, 46-49.
L. Boyanova
(1), Ju. Ilieva(2), I. Evstatiev(3), L. Davidkov(3), G. Gergova(1), R. Nikolov(4), V. Kamburov(5), N. Katsarov(6) and I. Mitov(1)
(1)Department of Medical Microbiology, MU -- Sofia, (2)Department of Social Medicine and Health Management, MU -- Sofia, (3)Clinic of Gastroenterology and General Surgery, UMHAT “Sv. Ekaterina” -- Sofia, (4)Clinic of Gastroenterology, UMHAT “Iv. Rilski” -- Sofia, (5)Clinic of Gastroenterology, І MHAT -- Sofia, (6)Clinic of Gastroenterology, SHATEM „N. I. Pirogov” -- Sofia
The aim of the study was to evaluate the primary resistance of Helicobacter pylori to clarithromycin, according to the place of residence and geographic regions. A total of 650 H. pylori strains from untreated adults were included in the study. Strain susceptibility to clarithromycin was evaluated by the method of susceptibility breakpoints. The primary resistance to clarithromycin was 20.2%, which has shown the advantages of the method of pre-tested bacterial susceptibility, compared to empiric therapy. The resistance rate was not related with the age, gender and type of disease, but it was higher in Sofia (23.8%), compared to these for other towns (15.8%) and villages (4.3%). The resistance rate in the North-Eastern/Central Bulgaria (5.4%) was significantly lower than that in Sofia (23.8%) and other settlements in the South-Western part of the country (19.0%). In conclusion, the H. pylori primary resistance to clarithromycin is estimated as already high in Bulgaria. For the first time to our knowledge, both the geographic region and the type of residence place (e.g., the capital) are reported as risk factors for a primary H. pylori resistance to clarithromycin. These factors should be considered when prescribing the empiric anti-infectious therapies. Furthermore, the need of H. pylori susceptibility testing is of increasing importance, especially in the large towns.
Key words: Helicobacter pylori, resistance, clarithromycin, geographic region, residence place, risk factor
Address for correspondence: Prof. Lyudmila Boyanova, M. D., Department of Medical Microbiology, MU, 2, Zdrave Str., Bg -- 1431 Sofia, tel. +359 2 91 72 730, е-mail: l.boyanova@hotmail.com; l.boyanova@lycos.com



Analysis of diagnostic red cell cytograms, generated by the ADVIA 2120 hematology analyzer  - 48,  2012, № 3, 50-54.
M. Velizarova, T. Yacheva and K. Tzatchev
Department of Clinical Laboratory and Clinical Immunology, MU -- Sofia
Summary: The laboratory staff is familiar with the basic interpretation of numerical results, obtained by the automated hematology analyzers, but seemingly complex cytograms and histograms are often ignored. The purpose of this study was to identify characteristic red cell (RBC) cytogram patterns in various hematological conditions. Numerical and graphical results of the RBC data in 946 (342 healthy individuals and 620 patients with hematological diseases/conditions) were analyzed by the automated hematology analyzer ADVIA 2120 (Siemens Healthcare Diagnostics Inc). The graphical pattern of red cell distribution according to RBC volume/hemoglobin concentration (V/HC) was evaluated in iron deficiency anemia, heterozygous and homozygous thalassemia, megaloblastic and non-megaloblastic macrocytosis, dual deficiency anemia, and post-transfusion findings. Red cell cytograms and other automated results were correlated with the clinical profiles and biochemical data.
ey words: automated hematology analyzers, Advia 2120, cytogram, RBC
Address for correspondence: Milena Velizarova, M. D., Department of Clinical Laboratory and Clinical Immunology, MU, 1, Sv. G. Sofiyski Str., 1431 Sofia, tel. +359 2 92-30-916, e-mail: mvelizarova@abv.bg




The role of IL-6 in the diagnosis of breast diseases - 48, 2012, № 3, 55-57.
V. Uzunova(1), A. Uchikov(1), M. Murdzheva(2), K. Murdzhev(1)and Zh. Grudeva-Popova(3)
(1)Clinic of Thoracic and Abdominal Surgery, (2)Clinic of Microbiology and Immunology, (3)Clinic of Oncology and Hematology, Medical University -- Plovdiv
Summary: Serum levels of IL-6 in benign breast diseases, as well as the comparison between them and these in breast carcinoma, are insufficiently studied. The aim of this study was to examine the serum levels of IL-6 among the various groups of benign breast diseases, as well as in breast carcinoma. 31 female patients with benign breast diseases and 13 patients with breast carcinoma were examined. An increase of the IL-6 levels was found in the patients with breast carcinoma, while it was not observed among the various groups of benign breast diseases. The serum levels of IL-6 can assist diagnosis, differential diagnosis, as well as postoperative monitoring of breast diseases.
Key words: IL-6, benign breast disease, breast carcinoma
Address for correspondence: V. Uzunova, M. D., Clinic of Thoracic and Abdominal Surgery, Medical University, 15A, Vasil Aprilov Str., Bg -- 4002 Plovdiv



Analysis of the National Insurance Fund financial policy in the hospital medical services for the period 2011-2012 - 48,  2012, № 3, 58-62.
T. Vekov
Faculty of Public Health, MU -- Pleven
In order to manage increasing expenditures and achieve control on excessive hospitalizations, the government is going to implement mandatory delegated budgets for all contracting parties involved in provision of hospital medical services. The cost of an individual delegated budget of a hospital is formed by rules for determining the compulsory prognostic annual costs, approved by the NC of the NIF. The basic annual value of expenditures for services, provided for 2012, is calculated on a basis of the average monthly expenditure of a health institution for the fourth quarter of 2011 (not including the over-the-limit payments) multiplied by twelve. The application of this methodology reflects largely in both budget reductions and financial increases in the different spheres. Data on the application of delegated budget methodology are presented, which lead to the conclusion that the determination of costs is non-transparent and incompatible with public health care needs, thus impeding the patient’s choice of a provider of hospital medical services.
Key words: hospital medical services, NIF, finance
Address for correspondence: Prof. Toni Vekov, Bulgarian Cardiac Institute, 1, G. M. Dimitrov Str., Bg -- 1172 Sofia, tel. +359 2 962 54 54, e-mail: t.vekov.hq@comleague.com



Comparative pharmacoeconomic study of ticagrelor for the treatment of acute coronary syndrome in Bulgaria - 48, 2012, № 3, 63-66.
E. Grigorov(1), I. Getov(1), H. Lebanova(1)and E. Naseva(2)

(1)Faculty of Pharmacy, Medical University -- Sofia, (2)Faculty of Public Health, Medical University -- Sofia
The aim of this study was to perform, by applying a modified "cost-effectiveness" method, a comparative pharmacoeconomic analysis of two different pharmacotherapeutic strategies for preventing atherothrombotic incidents during treatment of acute coronary syndrome (ACS) in all patient groups (MI with and without ST elevation, and unstable angina pectoris) undergoing invasive or noninvasive procedures. In this pharmacoeconomic analysis of antithrombotic prophylaxis in all ACS patient groups, we compared ticagrelor with clopidogrel, the latter being the most commonly used alternative therapeutic option at present. The set of patients followed the sample of patients included in the PLATO study. The comparative analysis was prepared from the perspective of the payer (the Health Insurance Fund). In the study, we assumed the estimated cumulative cost of each pharmacotherapeutical approach for antithrombotic prophylaxis of ACS for a 12-month period, as a final result of efficiency. With regard to cost increases within a short period of time, we did not use discounting in the study.
Key words: acute coronary syndrome, cost-effectiveness, antithrombotic therapy
Acknowledgments: This study was funded by AstraZeneca company.
Address for correspondence: Еvgeni Grigorov, Faculty of Pharmacy, Medical University, 2, Dunav Str., Bg -- 1000 Sofia, е-mail: evgeni.grigorov@pharmfac.net


Evolution of hospital architecture - 48, 2012, № 3, 67-72.
D. Kostadinova

Historical aspects of time management времето - 48, 2012, № 3, 73-80.
M. Draganova and T. Vekov



bullet 2'2012

Virological surveillance over cases of A(H1N1)2009 influenza virus in Bulgaria - 48, 2012, 2, 17-26.
S. Pavlova and R. Kotseva

National Laboratory of Influenza and Acute Respiratory Diseases, Department of Virology, NCIPD -- Sofia
Summary: During the period May 4, 2009--January 8, 2010, 2,429 samples of suspicious patients have been examined and in 792 (32.6%) of them, the RNA of the new influenza subtype А(Н1N1)2009 was verified. The distribution of these cases, based on accompanying clinical diagnosis, showed that the highest per cent of positive samples (35.4%) was registered in the group of patients with acute respiratory disease (ARD), which was also the prevailing patient group (62.5%). The per cent of positive pneumonia cases (24.6%) was relatively low against the per cent of contact persons (27.5%). The individuals aged between 15 and 30 years (group of efficient adults) were mostly affected (11.9%). In addition, 47 samples of pregnant and postpartum women were examined. 24 of the cases were positive for the new influenza subtype, as 3 of them were fatal. During the epidemic peak in Bulgaria (Week 45), the new pandemic influenza virus accounted for almost 99% of the positive detections. The National pandemic influenza preparedness plan, adopted in 2006, was an essential precondition for deciphering influenza pandemic in Bulgaria. Virological surveillance data are reported on a weekly basis to the WHO and ECDC virological databases, thus adding to information about the new influenza virus spread in Europe.
Key words: influenza virus pandemic, new influenza subtype А(Н1N1)2009
Address for correspondence: Assoc. prof. R. Kotseva, M. D., National Laboratory of Influenza and Acute Respiratory Diseases, Department of Virology, NCIPD, 44А, Stoletov Blvd., Bg -- 1233 Sofia, e-mail: kotseva@ncipd.org



Antipsychotic medication adherence in outpatients with schizophrenia - focusing interventions for adherence improvement - 48, 2012, 2, 27-31.
I . Vassileva, V. Milanova and T. Hristova

Department of Psychiatry, UMHAT “Alexandrovska”, Medical University -- Sofia
Summary: The present study aimed at assessing the rates of adherence to neuroleptic therapy in a sample of Bulgarian schizophrenic outpatients and facilitating the selection of more appropriate interventions for improving therapy adherence based on individual needs. The adherence behavior, severity of psychopathology and socio-demographic factors were assessed in a total of 226 patients with schizophrenia on a long-term antipsychotic treatment in community based settings. Different types of non-adherence, partial or complete, revealed 58.4% of the subjects. Adherence rates showed correlations with the number of hospitalizations during the past year and the participation in outpatient rehabilitation programs, and were higher in males on depot-neuroleptic therapy. Patients appeared to be rather informed about than motivated for treatment. Interventions based on motivational approaches along with psychoeducation of the patients and their families are needed to enhance therapy adherence in schizophrenia.
Key words: schizophrenia, adherence, antipsychotic therapy, motivation, informativeness
Address for correspondence: I. Vasileva, M. D., Department of Psychiatry, UMHAT Alexandrovska, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia



Epiretinal membrane peeling complications - 48, 2012, 2, 32-35.
H.Blagoeva and D. Petrov

“Sv. Sofia” Hospital -- Sofia
Summary: The aim of this study was to show epiretinal membrane peeling complications in macular surgery. The complications in 21 patients (21 eyes) who passed macular surgery were analysed. The surgeries were performed in the Eye Clinic of “Sv. Sofia” Hospital. The follow-up period was 12 months. There were complications of anterior and posterior eye segment such as cataract formation in 3 eyes, retinal holes in 1 eye, retinal detachment in 1 eye, fibrous macular changes in 1 eye. The complications of epiretinal membrane peeling can be diminished by using different methods such as an exact OCT preoperative retinal evaluation, different dyes, 23 G and 25 G techniques, etc.
Key words: epiretinal membrane peeling, complications, retina
Address for correspondence: Hristina Blagoeva M.D., Ph.D., Department of Ophthalmology, “Sv. Sofia” Hospital, 104, Bulgaria Blvd., tel. +359 2 818 46 23, e-mail: ch_blagoeva@abv.bg



Evaluation of analytical reliability of hematology analyzer ADVIA 2120: verification and comparison with COULTER LH 750 - 48, 2012, 2, 36-43.
M.Velizarova, T. Yacheva and K. Tzatchev
Departnent of Clinical Laboratory and Clinical Immunology, MU -- Sofia
Summary: The ADVIA 2120 hematology analyzer is a new fully automated hematology analyzer designed to improve work-flow efficiency for high-volume laboratories through elimination of preanalytical sample preparation and sorting, as well as reduction of postanalytical manual confirmation of results. This instrument operates with a cyanide-free method for hemoglobin measurement. The random access modes are complete blood count (CBC), reticulocyte analysis, 6-part differential including large unstained cells (LUC), nucleated red blood cells count, morphological changes in erythrocytes, percent of immature granulocytes and blasts, hemoglobin content in reticulocytes. The ADVIA 2120 has extended dynamic ranges for white blood cell (WBC) count (0.02-400 х 109/L), hemoglobin (0-225 g/L) and platelet count (5-3500 х 109/L). Accuracy of ADVIA 2120 versus COULTER LH 750 was excellent for all CBC and white cell differential parameters (all correlation coefficients except for basophiles > 0.96). Correlations of white blood cell differential and reticulocytes with the standard manual method and within-run and day-to-day precisions of the ADVIA 2120 also were very good.
Key words: hematology analyzers, ADVIA 2120, automated cell count
Address for correspondence: Milena Velizarova, M. D., Departnent of Clinical Laboratory and Clinical Immunology, MU, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, tel. +359 2 92 30 928; e-mail: mvelizarova@abv.bg



Analysis of hospital care expenditures and patient accessibility in the mandatory health insurance sector for 2010 - 48, 2012, 2, 44-50.
T. Vekov
Bulgarian Cardiac Institute
Summary: The aim of this paper was to present and analyze hospital care expenditures in the mandatory health insurance sector, measures for limiting over-expenditures and patient accessibility to hospital care services. Conclusions of the analysis on accessibility and management of public health care funds prepared by the Supervisory Board of the NHIF, present a number of objective factors affecting the demands of hospital care services by districts. Sofia and Plovdiv districts are the leaders in utilized amounts of funds for hospital care per capita and, hence, in improved patient accessibility, due to the great number of hospitals that have contracts with the Regional Health Insurance Funds: 62 and 42 hospitals for Sofia and Plovdiv district, respectively. In the districts, where a higher access to hospital care services was registered, compared with the national average, improved patient accessibility due, to a greater degree, to development of private hospitals and, to a lesser degree, to availability of university hospitals, was found. The group of districts with underdeveloped patient accessibility was characterized by lacking investments in hospital care services, regardless of their origin, i.e. state, municipal or private funds. The general economic conclusion of the study is that in order to achieve a mean patient accessibility of 0.792 for all districts in the country, it is necessary to ensure conditions for investments in the districts with underdeveloped patient accessibility.
Key words: hospital care, expenditures, patient accessibility, mandatory health insurance
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



Study of the correlation between serum concentrations of sRANKL and OPG and the maximal x-ray diameter of the cysts in patients with radicular jaw cysts - 48, 2012, 2, 50-54.
P. Pechalova(1), P. Pavlov(2), A. Bakurdzhiev(3) and D. Terzieva(2)
(1)Maxillofacial Surgery Department, Faculty of Dental Medicine, Medical University -- Plovdiv, (2)Department of Clinical Laboratory, Farmaceutical Faculty, Medical University -- Plovdiv, (3)Oral Surgery Department, Faculty of Dental Medicine, Medical University -- Plovdiv
Summary: With the discovery of RANKL/RANK/OPG cytokine system, the knowledge of bone tissue biology significantly evolved. The aim of this study was to establish whether a correlation between the serum concentrations of sRANKL and OPG and the maximal x-ray diameter (d(max)) of the cysts exists in patients with radicular jaw cysts. The study involved 35 patients with radicular cysts of the jaws. The RANKL/OPG cytokine system tests were performed on blood samples, pre-operatively taken in the morning, in the fasting state, which, after separation of the serum, were frozen at --18°C. The selected samples were examined by applying an enzyme immunoassay method with the original ELISA-kits Biomedica, Austria, and a double analysis. The maximal x-ray diameter of the cysts was determined by calculating the arithmetical mean of two mutually perpendicular diameters (measured twice, at intervals of at least 48 hours): the first one was parallel to the occlusal line and the second one was the largest diameter, measured in centimeters on the obtained ortho­pan­to­mo­grams. 17 (48.6%) of the patients were with radicular cysts of the maxilla with d(max) 3.11 +/- 0.41 cm and 18 (51.4%) of the patients were with radicular cysts of the mandible with d(max) 4.24 +/- 0.98 cm. The mean serum concentration of sRANKL was 2.14 +/- 0.45 pmol/l, the mean serum concentration of OPG was 4.04 +/- 1.33 pmol/l. Spearman’s rank correlation coefficient between sRANKL and d(max) was r = 0.143 (Р = 0.412) and Pearson’s correlation coefficient between OPG and d(max) was r = 0.286 (Р = 0.096). In the patients with radicular jaw cysts, there was no correlation between the serum concentrations of sRANKL and OPG and the maximal x-ray diameter (d(max)) of the cysts.
Key words: sRANKL, OPG, radicular cysts
Address for correspondence: Petya Pechalova, M. D., Maxillofacial Surgery Department, UMHAT „Sv. Georgi”, Medical University, 66, Peshtersko shose Str., Bg -- 4000 Plovdiv, GSM +359 898 468 498, e-mail: pechalova@abv.bg



Lung carcinoma among workers in iron casting and underground brown coal and lead-zinc ore mining - 48, 2012, 2, 55-58.
E. Petrova
Tokuda Medical Center -- Sofia
Summary: The objective of this study was to perform a medical screening examination of workers in iron casting and underground brown coal and lead-zinc mining, aimed at early diagnosing of lung carcinoma and referring the patients for timely and adequate treatment. A cross sectional case control study, including posterior-anterior lung radiographies of 1,600 brown coal and lead-zinc ore miners and 925 iron casters (81 of them working at Leiarmash JSC -- Sofia, 451 at Chugunoleene -- Ichtiman, 288 at Osam EAD -- Lovech and 107 at Iron and Steel Casting Energoremont -- Kresna) was performed. The chest radiographies were read according to the ILO International Classification of Radiographs, Geneva, 1980. 1,796 of the subjects were miners with exposure to quartz and 256 of the subjects were non-exposed employees. The mean length of service of the iron casters was 13.9 years, while this of the miners was 13.5 years. The mean age of the studied miners was 42.82 years and this of the iron casters was 46.5 years. More than 50% of the iron casters and 64.2% of the miners were smokers. The miners, exposed to quartz-containing dust, were 1,540 (85.7%). They were distributed into three groups, depending on the risk of developing silicosis: the first group comprised miners with the most intensive exposures to quartz, while the second and the third group involved these with moderate and mild exposures to quartz, respectively. By using the SPSS software, a statistical analysis of the radiological findings was performed, suspicious for a lung carcinoma. Radiological findings suspicious for a lung carcinoma were found in 15 miners exposed to quartz and in 4 non-exposed employees (Р < 0.05; Fisher's exact test). Out of 925 screened iron casters, 865 were exposed to quartz and toxic agents. The total number and the proportion of radiological findings, suspicious for a lung carcinoma, were 6 and 0.71%, respectively. All radiological findings, suspicious for a lung carcinoma, were found in workers exposed to quartz and chemicals in the process of iron casting. Underground miners and iron casters are exposed to quartz, bentonite, metal dust, polyacrylic aromatic hydrocarbonates, wood dust, resins and manganese, contained in the air of the working environment and, thus, they are at risk of developing an occupational lung carcinoma, which could be diagnosed after preceding silicosis. In a case of suspicions for a lung carcinoma, it is recommended to refer immediately the patient for precision of diagnosis and timely and adequate treatment. The screening examination, aimed at early diagnosis of lung carcinoma in miners and iron casters, should include a medical history for harmful factors of the working environment and respiratory system symptoms, as well as chest physical examination and conventional chest radiography.
Key words: quartz, chemical factors, mining, iron casting, lung carcinoma
Address for correspondence: Prof. Elisaveta Petrova, M. D., Ph. D., D. Sс., Tokuda Medical Center, 51B, Nikola Vaptsarov Blvd., Bg -- 1407 Sofia



Quality management in pharmaceutical industry: ISO 9001 versus GMP - 48, 2012, 2,  59-66.
A. Stoimenova and G. Petrova

Department of social pharmacy and pharmacoeconomics, Faculty of pharmacy, Medical University -- Sofia
Summary: The aim of this paper was to examine and compare the basic principles of GMP and ISO 9001 and to discuss the achievement of compliance with their requirements. The major differences were analyzed between the ISO 9001 requirements, the European requirements for Good Manufacturing Practice and these of Regulation 15 from 17/04/2009 of the the Ministry of Health on conditions for authorization of production/import and principles and requirements of good manufacturing practice for all types of medicinal products, including medicinal products for clinical trials and active pharmaceutical ingredients. The analysis was focused on the conceptual differences between the approaches and requirements of both standards: ISO 9001 and GMP. The analysis of the major differences between GMP and ISO 9001 in the field of medicinal products production formed the conclusion that GMP-manufacturers that had introduced ISO 9001, have achieved a management advantage over those who had not adopted the international quality management standard. Pharmaceutical manufacturers will benefit from the addition of ISO 9001 to the already established GMP-system, because it adds valuable elements concerning the measurement of processes and customer satisfaction. The expected benefits of successful integration of both standards include return of investments by reducing production and distribution costs, as well as improving efficiency of processes, including reduction of medicinal product shortages. Unlike ISO 9001, GMP is indisputably mandatory for the manufacturers of medicinal products (in some countries, also for the manufacturers of cosmetic products, medical devices, etc.), but the addition of ISO 9001 principles and requirements to the already established GMP-system creates a better management of the system and provides additional benefits. The establishment of the pharmaceutical quality management system ICH Q10 is a clear signal of the necessity of integrating the GMP and ISO 9001 requirements for the purposes of pharmaceutical industry that will facilitate the organizations implementing both standards. Despite their differences, ISO 9001 and GMP have positive effects on manufacturing and distribution of medicinal products worldwide and the ISO 9001 implementation will further guarantee patient safety.
Key words: good manufacturing practice, quality standards, quality management, medicinal products, GMP, ISO 9001
Address for correspondence: Assoc. prof. Asena Stoimenova, Department of Social Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Medical University, 2, Dunav Str., Bg -- 1000 Sofia, tel. +359 2 9236 589, e-mail: assena_stoimenova@mail.bg



Palliative care in neurology - 48, 2012, №2, 71-75.
E.  Viteva

Department of Nevrology, Medical University -- Plovdiv
Summary: For the majority of progressive neurological diseases, palliative care starts from the diagnosis determination and proceeds through the supporting and terminal phases, where general practitioners, a multidisciplinary team of specialists, as well as patient’s relatives are engaged. More common neurological diseases that require palliative care are: cerebrovascular disease, multiple sclerosis, Parkinson’s disease, acute and chronic demyelinating polyneuritis, dementias, brain tumors, lateral amyotrophic sclerosis. During the course of a disease, palliative care includes: 1. Monitoring of vital functions; 2. Observation for the development of complications and initiation of a timely treatment; 3. Control on accompanying diseases; 4. General care; 5. Symptomatic treatment aimed at improving patient’s comfort and quality of life; 6. Preparing the terminally ill patient and her/his relatives for death. In this review with a practical objective, the more common complications and typically controlled accompanying diseases in severely diseased people are presented. Types of general care, including these, more specific for the above-mentioned neurological diseases, are listed. Guidelines for the symptomatic treatment of more frequently observed neurological conditions, such as fatigue, movement disorders, bulbar symptoms, respiratory, gastrointestinal and urological disorders, pain, cognitive, behavioral and psychiatric symptoms, insomnia, orthostatic hypotension that require palliative care, are given.
Key words: palliative care, multidisciplinary team, monitoring, complications, general care, symptomatic treatment
Address for correspondence: Ekaterina Viteva, M. D., Department of Nevrology, Medical University, 15A, Vasil Aprilov Str., Bg 4002 -- Plovdiv, GSM +359 887752235, e-mail: kiv14477@yahoo.com



bullet 1'2012

Clinical features of influenza in season 2010/2011in hospitalized patients – 48, 2012, №1, 32-37.
A.Kahtan(1), M. Slavova(2), A. Mangarov(1, 2), N. Naidenova(1), V. Krastev(2) , M. Ilieva(2), E. Alexandrova(2), N. Korsun(3), F. Apostolov(1), D. Strashimirov(2), T. Cherveniakova(1, 2) and M. Tiholova(1, 2)
(1)Department of Infectious Diseases, Tropical Medicine and Parasitology, Medical Faculty -- Sofia, (2)SHATIPD "Prof. Ivan Kirov " -- Sofia, (3)National Center of Infectious and Parasitic Diseases -- Sofia
Summary: High morbidity and mortality among certain risk groups, that annual flu poses to public health are the reason for the constant interest to its typical clinical manifestations. Our goal was to trace regularities in the clinical course of the disease among 110 patients hospitalized during the flu season 2010/2011. Etiologic diagnosis was made in 54 cases (49.1%) by Real Time RT-PCR. We established co-circulation of influenza viruses A (H1N1) and B in the society. We observed a significant predominance of childhood patients -- 72 (65.4%). High fever in 106 patients (96.3%) was the main manifestation of the disease. With highest incidence laryngotraheitis was found -- 68 patients (61.8%). Manifestations of the gastrointestinal tract were present in most pediatric patients  68 (57%). Influenza complications ocurred in the overwhelming number of patients -- 82 (74.5%). We did not find significant differences in severity of illness caused by influenza A and influenza В viruses. Complications were observed in patients with influenza A and influenza B. Those of central nervous system were established exclusively in patients with influenza B.
Key words: influenza A (H1N1) and B, clinical signs, complications
Address for correspondence: Assoc. Prof. Mayda Tiholova, M. D., Ph. D., M. D., Department of Infectious Di­seases, Tropical Medicine and Parasitology, Medical Faculty, 17, Acad. Iv. Geshov Blvd., Bg -- 1606 Sofia, tel. +359 2 952 26 97, e-mail: tiholova@gmail.bg



Treatment of anemia in the immediate postoperative periodin renal transplant recipients with darbepoietin alfa  – 48, 2012, №1, 38-42.
E. Paskalev
Department of Nephrology and Kidney Transplantation, University Hospital “Alexandrovska” -- Sofia
Summary: Renal transplant recipients have a high risk of anemia in the immediate post-transplantation period. The goal of the study is to show the effect of darbpoietin alfa for treatment of anemia in the immediate post-transplantation period in renal transplants. We performed a single-center study, including 14 renal transplant recipients with pre-transplantation mean hemoglobin level of 109 +/- 8 g/l. They received a treatment with 60 mcg darbepoietin s. c. five days before operative intervention. Four patients received a second identical dose darbepoietin after transplantation. One patient needed a blood transfusion because of massive perioperative bleeding and two patients had no significant blood loss. Mean hemoglobin level decreased to 97 g/l, there after increased to 119 g/l at the 30th day. These results show that the treatment for anemia with recombinant darbepoietin prior to transplantation is effective and safe to support a high hemoglobin level in the early postoperative period.
Key words: renal transplantation, renal anemia, darbepoietin alfa
Address for correspondence: Assoc. Prof. Emil Paskalev, M. D., Department of Nephrology and Kidney Transplantation, University Hospital “Alexandrovska”, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, tel. +359 2 9230 333, e-mail: emilpaskalev@abv.bg



A study on extended spectrum beta-lactamase producing isolatesof Klebsiella pneumoniae and Escherichia coliin two hospitals in Varna city– 48, 2012, №1, 43- 47.
R. . Markovska(1),T. Stoeva(2), K. Bozhkova(2) and I. Mitov(1)

(1)Department of Medical Microbiology, MU -- Sofia, (2)Department of Microbiology, MU -- Varna
Summary: The aim of this study was to confirm the presence of ESBLs in isolates of E. coli and K. pneumoniae, characterize the ESBLs types and susceptibility of their producers to antibiotics and determine the genetic relationship between the studied isolates. A total of 43 clinically significant isolates from Enterobacteriaceae were studied: 27 K. pneumoniae isolates and 16 E. coli isolates with reduced susceptibility or resistant to III generation cephalosporins, isolated in 2006 and 2009 from two medical centers in Varna city. Antibiotic susceptibility, the possibility for conjugation transfer, the presence and the ESBLs types were studied by PCR and sequencing. The genetic relationship between the isolates was studied by RAPD PCR. Production of ESBL was detected in all studied strains with the CTX-M group being the predominant one (97%). Only one strain, isolated in 2006, was a SHV-12 producer. CTX-M-3 enzymes were found mainly in the group of K. pneumoniae isolates (in 89%), while in the group of E. coli isolates, the CTX-M-15 were detected more commonly (in 88%). The CTX-M-15 positive isolates of E. coli belonged to two clones, one of which, clone A, was the predominant (n = 9). The conjugation experiments were successful only in half of the tested isolates of E. coli. Seven different clones, one of which the predominant (in 48%), were found in the group of K. pneumoniae isolates. High rate of conjugation transfer in the collection of CTX-M-3 producers (100%) and identical phenotype of the transconjugates were detected. The ESBLs producers demonstrated high resistant rates to tobramycin and gentamicin. K. pneumoniae isolates were significantly more resistant to amikacin in comparison to E. coli isolates (p < 0.001), as well as more resistant to trimethoprime/sulpho­methoxazole and significantly more susceptible to ciprofloxacin. On the base of these results, it can be concluded that the clonal dissemination plays the major role for the high percentage of the CTX-M-15 E. coli producers, while the horizontal plasmid transfer plays a role for the dissemination of the CTX- M-3 enzymes in K. pneumoniae.
Кey words: extended spectrum beta-lactamase (ESBL), isoelectric focusing (IEF), CTX-M-15
Address for correspondence: Rumyana Markovska, M. D., Department of Medical Microbiology, Medical University, 2, Zdrave Str., Bg -- 1431 Sofia, е-mail: markovska73@abv.bg



Factors affecting medic’s choice of localflap based breast oncoplastic models -– 48, 2012, №1, 50-56.
V. Molov, (1), I. Traikov¹, B. Hadzhiev¹, I. Doychinov(2) and P. Timonov(2)
(1)Clinic of Burns, Plastic, Reconstructive and Aesthetic Surgery, MU -- Plovdiv, (2)Department of Forensic Medicine, MU -- Plovdiv
Summary: Medical society acceptance is an important factor for successful clinical intro­duction of any new treatment modality. A few researches revealed how medical society in Bulgaria accepts oncoplastic surgery as a treatment option for breast cancer patients. The aim of this study is to reveal the influence of age, gender, specialty and carrier years on the acceptance of local flap based breast oncoplastic models. Nine oncoplastic models, based on local breast flaps were created on a cadaver dissection study and 3-D computer modeling. Based on Likert scale, a multimedia assessment research session was performed. Oncoplastic surgery, based on local flap by its nature is a form of breast conserving surgery. At the end of the operation, there is a newly shaped breast without tumor. Oncological part of the operation may be close to theory of Veronesi or that of Fisher, and depends on surgeon’s decision -- lumpectomy or quadrantectomy through dermopexy or reduction model. Our results showed that influence of age, gender and carrier years is insignificant in breast oncoplastic model acceptance. Conclusions: 1. 3-D computer animation model is effective in assessment of the acceptance and expectation concerning breast oncoplastic surgery. 2. There is a high expectation among medics about oncoplastic breast cancer surgery. 3. Rating scale of local flap based oncoplastic surgery is mainly influenced by shared medical information, personal and professional experience.
Key words: breast cancer, oncoplastic surgery, local flaps
Address for correspondence: Veselin Molov, M. D., Ph.D., е-mail: oncoplasticsgbg.@abv.bg



Hearing loss and its prophylaxis among mine workers – 48, 2012, №1, 57-61.
E. Petrova(1), D. Medzhidieva(2), M. Antonov(2) and V. Zahov(2)

(1)Tokuda Medical Center -- Sofia, (2)Clinic of Profesional Diseases, MHAT “Sv. Iv. Rilski” -- Sofia
Summary: Aim of the study is to achieve an early diagnostics of occupational and important general otorhinolaryngological diseases among workers in coal and ore mining industry, as well as to propose measures for medical service and surveillance. A cross sectional case control study of 1949 workers and officers in coal and lead-zinc ore mining were performed. Anamnesis about occupational noise exposure, tobacco smoking and alcohol abuse as well as history of diseases of hearing organs in screening conditions were token. Otorhinolaryngological examination and audiometry were performed. 87.6% of examined workers were exposed to noise and 12.4% were nonexposed (Р > 0.05). Non-parametric, variation, and correlation analysis using SPSS software were done. Occupational bilateral hearing neuropathy was established among 43 (74.1%) exposed persons, noise syndrome -- in 67 (81.7%), and initial auditory neuropathy -- in 7 (75.0%) workers exposed to high noise levels. Unilateral hearing neuropathy was detected in 19 (86.4%) workers from coal mining as well as in 3 (13.6%) workers -- from ore mining. Bilateral auditory neuropathy was diagnosed among 28 (43.8%) workers from brown coal mining and in 36 (562%) persons from lead zinc ore mining. Initial bilateral occupational auditory neuropathy was detected in 10 workers from brown coal mining. Noise induced hearing impairments were related to long term exposure to occupational noise, and they were frequently met in 41 -- 60 years age group, followed by workers aged between 21 and 40 years (P < 0.0001). The absolute number and share significantly predominated (P < 0.01) among workers exposed to harmful noise in brown coal and led-zinc mining. Occupational otorhinolaryngological diseases as hearing loss syndrome, bilateral auditory neuropathy, and initial auditory neuropathy predominated in brown coal mining workers. Established frequent hearing impairments among workers from mine industry require systemic screening and miners surveillance, including anamnesis, otorhinolaryngological examination, tonal and supraliminal tonal audiometry.
Key words: noise, coal, ore mining, hearing impairments, hearing loss
Address for correspondence: Prof. Elisaveta Petrova, M. D., Ph.D, Tokuda Medical Center, 51B, Nikola Vaptsarov Blvd., Bg -- 1407 Sofia


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