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 Original papers

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Volume 51, 2015

 



bullet 6'2015

 

Pain after breast cancer surgery: 2-years study of prevalence and risk factors - Medical Review (Meditsinski pregled), 51, 2015, № 6, 27-33.
D. Tzoneva(1) and S. Maslyankov(2)
(1)Clinic of Anaesthesiology and Intensive Care, University Hospital “Aleksandrovska”, Medical University -- Sofia, (2)Clinic of Surgery, University Hospital “Aleksandrovska”, Medical University -- Sofia
Summary: According to the Bulgarian National Cancer Registry breast cancer is the first most common cause of cancer in women. The persistent pain after breast cancer surgery is severe and unpleasant symptom, and represents a significant clinical problem. It may be related to some patients' characteristics, surgical techniques, and adjuvant treatment. Aim: To determine the prevalence and risk factors associated with persistent pain after breast cancer surgery. Methods: In this study were enrolled 59 women aged 33-85 years old, who underwent breast cancer surgery in the Clinic of Surgery at the University Hospital Aleksandrovska -- Sofia in the period 2013-2014 and received subsequent adjuvant therapy. All patients completed standardized questionnaire to characterise the pain on the day before surgery, on day 2, day 7, and more than two third of patients at the 6 months after the surgery. Clinical data were collected from medical records and were statistically analysed together with the questionnaire findings via SPSS package. Results: A total of 23 (39%) patients reported pain. Two (9%) of them had severe pain (VAS >= 7), 10 (43%) had moderate pain (VAS = 5-6), and 11 (48%) had mild pain (VAS = 1-4). Factors associated with chronic pain were: younger patients (33-41 years; P < 0.001), adjuvant radiotherapy (P < 0.05), pain not related to localization of breast cancer (P < 0.001), and higher preoperative levels of anxiety and sleep disturbances (P < 0.001). Conclusion: Determination of the risk factors associated to persistent pain after breast cancer surgery helps to identify the highest risk patients. This group specify the target population that could take advantage of preventive interventions.
Key words: breast cancer, breast cancer surgery, persistent postoperative pain, risk factors
Address for correspondence: Doshka Tzoneva, M. D., Clinic of Anaesthesiology and Intensive Care, University Hospital “Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230 602, e-mail: dochka_tobova@abv.bg

 

 

 

Assessment of the risk of an outbreak of measles using data herd immunity - Medical Review (Meditsinski pregled), 51, 2015, № 6, 34-37.
M. Karcheva(1), I. Makaveev(2), A. Blazhev(1), I. Gencheva(1, 3) and M. Rachev
(1)Medical University -- Pleven, (2)Department of Preventive Medicine -- Military Hospital -- Pleven, (3)University Hospital "Dr. G. Stransky" -- Pleven
Summary: Measles is a highly contagious infection caused by the measles virus. Complications occur in about 30% and may include blindness, encephalitis, severe diarrhoea, ear infection and pneumonia. The vaccine is applied by the 60s of the last century. Measles is progressively occurring in Europe despite the availability of an effective vaccine. The aim of the study was to determine the prevalence of measles IgG antibodies in people in Pleven of working age. Material and methods. We performed a prospective seroepidemiological study. For the period January-June 2014 samples were collected and tested in 194 sera. Used is the enzyme immunoassay (ELISA) test for the detection and quantification of specific IgG antibodies in serum against measles. Results. Analyzed were serum samples from persons aged 23 to 53 years (mean age 35 +/- 0.871). Distribution of serum sex of the studied individuals was as follows: men -- 146 (75%) and women -- 48 (25%). From the survey it was found that’ 88% of the studied group of persons are positive in terms of measles IgG antibodies. Susceptible to infection are persons of both sexes. The average age of the negative persons is 34 years for men and 36 years for women. Conclusions. There are risk groups to measles against which should to recommend and organize events for their immunization.
Key words: measles IgG antibodies, prevalence, immunity
Address for correspondence: Assoc. Prof. Milena Karcheva, M. D., Sector "Epidemiology", MU -- Pleven, e-mail: milena_karcheva@abv.bg

 

 

 

Clinical presentation and treatment of patients with common variable immunodeficiency at University Hospital “Aleksandrovska” ” - Medical Review (Meditsinski pregled), 51, 2015, № 6, 38-46.
S. Mihailova(1), N. Gesheva(1), S. Lesichkova(1), M. Baleva(1), A. Temelkov(2) and E. Naumova(1)
(1)Department of Clinical Immunology with Stem Cell Bank, (2)Third Clinic of Anesthesiology and Intensive Care, University Hospital “Aleksandrovska”, MU -- Sofia
Summary: Common variable immunodeficiency (CVID) is an antibody deficiency with a high variability in its clinical presentation and individually adjusted treatment approach. The objective of this study was to evaluate the role of intra­ve­nous/subcutaneous immunoglobulin therapy on the clinical outcome of patients with CVID for 18 months period. The analysis involved 10 patients (average age 34,7 years, 4 males, 6 females) with follow-up period before replacement therapy ranging from 2002 to 2014 year. Average disease onset was between 4 and 39 years and the average diagnostic delay of CVID was 11,7 years. Almost all patients demonstrated pulmonary infections. Initially the patients received intravenous immunoglobulin (IVIG) for different period depending on immune response and infectious complications. Over time 7 patients switched to sub­cu­taneous routе of application. Immunoglobulin doses ranged from 400 to 780 mg/kg/month. During therapy, median serum IgG levels increased from 0,7 g/l to 6,6 g/l. The mean number of respiratory infections per patient per year de­creased from 9.1 to 3.2. The mean annual number of antibiotics used decreased significantly from 7.3 to 2.6 per patient. In half of the patients negative results for persistent microbial colonization with CVID related pathogens were achieved. In conclusion IgG replacement therapy prevents infections and improves quality of life in patients with the disease.
Key words: common variable immune deficiency, clinical features, replacement therapy
Address for correspondence: Snezhina Mihailova, M. D., Department of Clinical Immunology with Stem Cell Bank, UMHAT “Aleksandrovska”, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230 690, e-mail: sneji_jm@yahoo.com

 

 

MANAGEMENT IN HEALTHCARE


Health technology assessment as a base for pharmacotherapeutic recommendations for treatment of metastatic colorectal cancer with targeted drug therapies - Medical Review (Meditsinski pregled), 51, 2015, № 6, 53-60.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: The main aim of this study is to define direct costs on targeted oncological therapies for metastatic colorectal carcinoma (mCRC) treatment, calculate the incremental cost-effec­tiveness ratio (ICER) and life years gained (LYG). Our ultimate aim is to elaborate pharmacotherapeutic manual for treatment of mCRC in relation to administration of monoclonal antibodies, tyrosine kinase inhibitors and recombinant fusion proteins based on evidence of comparative therapeutic efficacy and cost effectiveness.
Key words: metastatic colorectal cancer, targeted drug therapies, pharmacotherapeutic recommendations, cost effectiveness
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

 

Stages of the policy of human rights, particularly the rights of patients - Medical Review (Meditsinski pregled), 51, 2015, № 6, 61-66.
A. Zlatareva
Faculty of Public Health, MU -- Varna
Summary: Purpose of this study is to trace the stages in the policy of protection of human rights, particularly the rights of patients. A literature search in the PubMed, Google Scholar, Scopus was made and the most important publications discussed. The analysis of the literature makes explicit the vision, that traditional description on the topic of EU involvement in human rights begins with „timid beginnings” in the three Treaties of the European Community in the 50 years of the twentieth century: the Treaty establishing the European Coal and Steel Community, the European Economic Community and European Atomic Energy Community -- all of them describing the gradual appearance and subsequent development of the subject and the process to protect human rights in the European Union in the coming decades. The European Court is the centerpiece of this description in the role of actor who through his pioneering jurisprudence encourages major political actors to accept human rights in their capacity as a key element of the constitutional framework of the EU. Against this background, are considered acts of the European Union and the Council of Europe in protecting the rights of the patient and recommendations of WHO and other international organizations on this issue.
Key words: EEC, EC, EU, human rights, patients' rights
Address for correspondence: Albena Zlatareva, M. D., Faculty of Public Health, Medical University, 55, M. Drinov St., Bg -- 9000 Varna

 

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bullet 5'2015

Utility of serum biomarkers for the assessment of disease severity in hospitalized children with community-acquired pneumonia - Medical Review (Meditsinski pregled), 51, 2015, 5, 27-32.
I. Tzotcheva(1), V. Issaev(1), S. Parina(1), L. Raycheva(1), P. Perenovska(1), A. Tzakova(2) and M. Velizarova(2)
(1)Clinic of Pediatrics, University Hospital ”Alexandrovska” -- Sofia, (2)Central Clinical Laboratory, University Hospital ”Alexandrovska” -- Sofia
Summary: In patients with pneumonia traditional criteria of infection based on clinical signs, leukocytosis, microbiology cultures and radiographic imaging, are often with low sensitivity and unreliable to determine the etiology and guide the antibiotic treatment. We investigated the diagnostic and prognostic values of serum biomarkers hsCRP, PCT and sTREM-1 in hospitalized children with community-acquired pneumonia. 50 children, with the mean age of 9 years and 1 month, are included. The changes in numbers and differential count of leucocytes, ESR and serum hsCRP, PCT and sTREM-1 on admission and 5 days after the beginning of the parenteral antibiotic therapy were analyzed. A highly positive correlation between hsCRP and PCT (r = 0.81, p = 0.000), leukocytosis and neutrophilia (r = 0.44, p = 0.002) was found. The levels of hsCRP were statistically significantly elevated in the children with a more severe clinical picture, infiltrative pneumonia and parapneumonic effusion. PCT on admission was significantly higher in children with fever, lasting more than 72 hours after the beginning of parenteral antibiotic therapy. CRP and PCT contribute to the assessment of pneumonia severity, but we did not find significant correlations for sTREM-1.
Key words: pneumonia, children, biomarkers, CRP, PCT, sTREM-1
Address for correspondence: Iren Tzotcheva, M.D., Clinic of Pediatrics, University Hospital “Alexandrovska”, Medical University, 1, Sv. G. Sofiiski St., Bg -- 1431 Sofia, tel. +359 29230373, GSM +359 887207028, e-mail: irenmd@yahoo.com

 

 

In vitro activities of antimicrobial combinations against clinical isolates of Stenotrophomonas maltophilia - Medical Review (Meditsinski pregled), 51, 2015, № 5, 33-37. - Medical Review (Meditsinski pregled), 51, 2015, № 5, 33-37.
М. Bojkova(1), Т. Stoeva(1), R. Markovska(2), K. Bojkova(1) and I. Mitov(2)
(1)Department of Microbiology, Medical University -- Varna, (2)Department of Medical Microbiology, Medical University -- Sofia
Summary:
Aim: Тo study the susceptibility of clinical isolates of Stenotrophomonas maltophilia to antimicrobial agents and to determine the in vitro activities of antibiotic combinations against these isolates. Material and methods: А total of 27 clinical isolates of S. maltophilia, isolated during the period 2007-2014 from patients hospitalized in University Hospital “Saint Marina” -- Varna, were studied. The minimal inhibitory concentration of ten antimicrobial agents was determined by E-test. The effect of five different combinations (levofloxacin + ceftazidime, ticarcillin/clavulanic acid + trimethoprim/sulfamethoxazole, ciprofloxacin + tigecycline, doxycycline + colistin, chloramphenicol + polymyxin B) was studied by E-test based method. Results: The most active antimicrobial agents were tigecycline (96.3% susceptibility), followed by polymyxin B, doxycycline and trimethoprim/sulfamethoxazole (85.1%). In the group of beta-lactam antibiotics, limited in vitro activity of ticarcillin/clavulanic acid (25.9%) and ceftazidime (37%) was detected. The combinations levofloxacin + ceftazidime and ticarcillin/cla­vul­anic acid + trimethoprim/sulfamethoxazole were associated with synergistic effect against the clinical isolates in more than 50% (55.6 -- 66.7%). The combinations of polymyxin antimicrobial agent (colistin/polymyxin B) with doxycycline and chloramphenicol respectively as well as the combination tygecycline + ciprofloxacin exhibited predominantly indifferent effect (74.1-88.9%). Conclusions: This study demonstrated the good activity of trimethoprim/sulfametoxazole and levofloxacin and their in vitro synergistic effect when combined with the beta-lactam antimicrobial agents ticarcillin/clavulanic acid and ceftazidime.
Key words: Stenotrophomonas maltophilia, antibiotic combinations, synergy, Е-test
Address for correspondence: Milena Bojkova, M.D., Department of Microbiology, Medical Universit, 55, Marin Drinov St., Bg -- 9001 Varna, tel. +359 52 978538, e-mail: drbojkovam@abv.com

 

 

Surgical interventions in the Oral surgery -- a retrospective and prospective study of the patients treated in the Department of Oral Surgery, Faculty of Dental Medicine, Меdical University – Plovdiv - Medical Review (Meditsinski pregled), 51, 2015, № 5, 38-41.
B. Blagova(1), P. Pechalova(1), N. Petrova(2) and E. Poryazova(3)

(1)Department of Oral Surgery, Faculty of Dental Medicine, Medical University -- Plovdiv, (2)Department of Social Medicine and Public Health, Faculty of Public Health, Medical University -- Plovdiv, (3)Department of General and Clinical Pathology and Forensic Medicine, Faculty of Medicine, Medical University -- Plovdiv
Summary:
The aim of the study was to establish the surgical interventions most commonly performed in the oral surgery. It presents also the cases in which a complication might occur and turn a typical tooth extraction into an atypical one and thus the oral surgeon’s attendance be required. The official documentation of the Department of Oral Surgery at the Faculty of Dental Medicine in Plovdiv was used as a main data source for statistical analyses. The open ex­trac­tion of the wisdom teeth in the lower jaw was found to be the surgical intervention most commonly performed. The cases in which a typical extraction can turn into an atypical are few. Results of the research work presented in this article provide data about the common interventions in the practice of the oral surgeon. They also give information about the cases in which an extraction will have to be finished in a surgical way.
Key words: oral surgery, impacted teeth, complications, osteotomy
Address for correspondence: Bistra Blagova, M.D., Department of Oral Surgery, Faculty of Dental Medicine, 3 Hris­to Botev Blvd., Bg -- 4000 Plovdiv, tel. + 359 878843408, e-mail: bistra_blagova@abv.bg

 

 

MANAGEMENT IN HEALTHCARE

Pharmacotherapeutic recommendations for treatment of non-small cell lung carcinoma with targeted medicinal products based on the adapted health technology assessment in Bulgaria - Medical Review (Meditsinski pregled), 51, 2015, 5, 46-50.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: The study aim is to define direct costs on targeted oncological therapies for non-small cell lung carcinoma treatment, calculate the incremental cost-effec­tiveness ratio (ICER) and life year gained (LYG) using data from randomized clinical trials cited in the summaries of product characteristics (SmPCs) of the medicinal products, authorized by centralized procedure under the Regulation (EC) No 726/2004 of the European Parliament and of the Council of 31 March 2004. The results of our study show that pharmacotherapeutic recommendations of the Bulgaria Oncological Society are not in compliance with comparative assessments of therapeutic efficacy, which are based on data of randomized clinical trials. This results in significantly lower levels of the 5-year relative survival in Bulgaria (males -- 5.9%, females -- 10.4%) than average levels in the copuntries of EU (12.6%). Pharmacotherapeutic recommendations in Bulgaria are not in com­pli­ance with accepted criteria of cost effectiveness -- ICER <= 32,700 BGN/LYG. This reflects in a tremendous increase of public expenses by 140% for the pe­riod 2013-2015 and threatens financial stability of the health-insurance model.
Key words: non-small cell lung carcinoma, targeted medicinal therapies, pharmacotherapeutic recommendations, cost effectiveness
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

Economic impact of cystic echinococcosis - Medical Review (Meditsinski pregled), 51, 2015, № 5, 54-58.
M. Muhtarov
Gastroenterology Ward, Multi-Profile Hospital for Active Treatment -- Kardzhali
Summary: Cystic echinococcosis is a parasitic zoonosis caused by infestation with tapeworm Echinococcus granulosus. Definitive hosts (domestic and wild carnivores) harbour the adult parasite in intestines. The intermediate hosts (a number of farm animals and wild ungulates) harbour the larval stages. Humans are accidental intermediate hosts become infected by ingesting Echinococcus eggs. Since cystic echinococcosis is a disease affecting both man and agricultural animals it has potentially economic effects to both agriculture and to human health. Thus it is important to develop a financial approach to calculate the losses from both sectors and to gain an overall insight into the cost of the disease. The estimated monetary losses worldwide in humans and farm animals from cystic hydatid disease amounted to US$ 3 billion. Research on economic losses caused by cystic echinococcosis prove that funds invested in the creation and implementation of control programs with substantial anticipated return on invested funding.
Key words: cystic echinococcosis, economic losses
Address for correspondence: Marin Muhtarov, M.D., Gastroenterology Ward, Multi-Profile Hospital for Active Treatment "Kardzhali", 19, Trakia Blvd., Bg -- 6600 Kardzhali, tel. +359 361 66528, е-mail: mukhtarov@abv.bg

 

 

METHODS

Endovascular treatment of acute pulmonary thromboembolism and pulmonary hypertension in patients with chronic pulmonary thromboembolism - Medical Review (Meditsinski pregled), 51, 2015, 5, 59-64.
I. Petrov, Z. Stankov, I. Tasheva and D. Borisova

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SPONSORED PUBLICATION

Anderson-Fabry disease (angiokeratoma corporis diffusum) - Medical Review (Meditsinski pregled), 51, 2015, № 5, 66-68.
Z. Demerdjieva
Department of Dermatology, Tokuda Hospital -- Sofia
Summary: Angiokeratoma corporis diffusum (Fabry disease) is an X-linked inherited di­sor­der caused by a deficiency of the lysosomal enzyme alpha-galactosidase. This inborn error of metabolism results in unremitting deposition of neural glycosphingolipids in the lysosomes of the vascular endothelium, in fibroblasts and in pericytes of the dermis, heart, kidneys, and autonomic nervous system. The Fabry disease gene is now known as the GLA gene, which stands for alpha-galactosidase. The classic presentation of Fabry disease is a male with initial manifestations occurring in childhood or adolescence. The initial findings are intermittent or chronic paresthesias and episodes of severe acral and/or GI distress (Fabry crisis), heat intolerance, hypohidrosis or anhidrosis, and generalized angiokeratomas.
Key words: Fabry, angiokeratoma, alpha-galactosidase, renal failure
Address for correspondence: Zdravka Demerdjieva, MD, PhD, Department of Dermatology, Tokuda Hospital, 51B, Nikola Y. Vaptsarov Blvd., Bg -- 1407 Sofia, e-mail: z.demerdjieva@bol.bg

 

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bullet 4'2015

Rotavirus gastroenteritis in the pleven region during 2014   - Medical Review (Medicinski pregled), 51, 2015, 4, 19-22.
T. Doichinova, N. Jordanova, M. Kostovska, G. Gancheva, I. Angelov and D. Shalamanov
Department of Infectious Diseases, Epidemiology, Parasitology and Tropical Medicine, Faculty of Public Health, Medical University -- Pleven
Summary: Rotavirus gastroenteritis is a common infectious disease with autumn-winter prevalence. It affects most often the ages up to 5 years. The course is with fever and dehydration and prompt hospitalization is required. The disease is vaccine-preventable and vaccination of the healthy children is strongly recommended.
Key words: Rotavirus, gastroenteritis, fluid-saline replacement
Address for correspondence:    Tsetsa Doichinova, Clinic for Infectious Diseases, University Multiprofil Hospital for Active Treatment, 8a “G. Kochev” Bvld., Bg -- 5800 Pleven, tel. +359 888729532, e-mail: doichinova@abv.bg

 

 

Clinical significance of hepcidin in therapeutic approaches with iron supplementation during pregnancy   - Medical Review (Medicinski pregled), 51, 2015, 4, 23-25.
B. Marinov(1), V. Vasilev(2) and K. Tzatchev(3)
(1)University Hospital “Maichin Dom”, Medical University -- Sofia, (2)Central Clinical Laboratory, UMHAT „Aleksandrovska”, (3)Department of Clinical Laboratory and Clinical Immunology, Medical University -- Sofia
Summary: Anemia is common during pregnancy. Identifying and finding the right treatment approach for iron deficiency in pregnant women can prevent unnecessary assignment of therapy with iron preparations. For a period of one year we determined serum hepcidin levels using ELISA assay in 64 pregnant women. We measured serum CRP, iron, soluble transferrin receptors. Patients were divided into three groups: pregnant women with iron deficiency anemia (IDA), pregnancy with anemia of chronic inflammation (ACI) and pregnant women without anemia. We found statistically significant increased serum hepcidin levels in pregnant women with ACI (81.4 +/- 3.9 mcg/l) compared to cases with IDA (4.5 +/- 1.8 mcg/l) and control group (17.9 +/- 4.3 mcg/l); P < 0.001. We conclude that our results support the right choice of therapeutic approach to iron-deficiency anemia. Along with soluble transferrin receptor index, hepcidin differentiates IDA from ACI.
Key words: iron-deficiency anemia, iron metabolism, pregnancy, hepcidin, anemia in chronic inflammation
Address for correspondence: Assoc. Prof. Borislav Marinov, MD, PhD, Clinic of General Pathological Pregnancy, University Hospital “Maichin Dom”, 2, Zdrave Str., Bg -- 1431 Sofia, tel. +359 884735202, e-mail: borislav_marinov33@abv.bg

 

 

Self-monitoring and self-control of chronic kidney disease with impaired renal function   - Medical Review (Medicinski pregled), 51, 2015, 4, 26-30.
M. Lubomirova(1), B. Bogov(1) and M. Mutafova(2)
(1)Clinic of Nephrology, University Hospital "Alexandrovska" -- Sofia, (2)Faculty of Public Health, Department of Social Medicine, Medical University -- Sofia
Summary: The aim of the pilot study is to complete a survey analyzing knowledge of patients with chronic kidney disease (CKD) >= 3 stage, to establish their under­standing of the specifics of CKD, so that they might perform self-monitoring and self-control (self-management) of their condition.
Materials and methods: The study included 30 patients with CKD >= 3 stage who have persistently elevated serum creatinine over 200 mcmol/l, creatinine clearance below 60 ml/min, hospitalized in the Department of Nephrology of "Alexandrovska" Hospital in the period 1 January-7 January 2014. The respon­dents had an average age of 60 +/- 38 years, including 18 males and 12 women. It was a pilot study. The questionnaire, which is included in the analyzed survey, contains the introductory, filtering, basic and ID issues. Current paper analyses only the questions that assess knowledge of the patients about the nature of CKD, which is a major factor for disease self control practicing.
Results: Answering the questions assessing the patients knowledge of CKD only 10% (three patients) gave a correct answer, and the rest indicated partially true answers, however, including only one correct factor. These data are confirmed also by the fact that only 36% responded that they know what needs to be done to delay the progression of CKD. 30% does not know what medications they take, and 60% of patients responded that they are familiar with intended use of drugs; however in 40% of the concrete questions the lack of real knowledge was established.
Discussion: Analysis of the results shows a lack of basic knowledge of patients about the specifics of CKD, and the lack of motivation of self-education in this area.
Conclusion: The practice of self-monitoring and self-control of CKD is underdeveloped in our country and future implementation of training programs for patient self-management of chronic kidney disease is required.
Key words: chronic kidney disease, self-monitoring, self-control
Address for correspondence: Mila Lubomirova, M.D., Clinic of Nephrology, University Hospital "Alexandrovska", Sv. G. Sofiyski St., Bg 1431 -- Sofia, e-mail: MLjubomirova@yahoo.com

 

 

A program for assessment of the attitude of patients treated with tyrosine kinase inhibitors to chronic myelogenous leukemia: initial results   - Medical Review (Medicinski pregled), 51, 2015, 4, 31-37.
G. Vandova(1), Zh. Surcheva(2), G. Tsvetkova(1) and E. Hadzhiev(1)
(1)Clinic of Hematology, UMHAT “Alexandrovska”, Department of Internal Medicine, MU -- Sofia, (2)Central Medical Library, MU -- Sofia
Summary: Introduction of tyrosine kinase inhibitors (TKIs) for treatment of patients with chronic myelogenous leukemia (CML) changed also perspectives for survival of these patients, with the probability of cure becoming a realistic goal. While therapeutic strategy is clearly represented in related methodological manuals for diagnostics and treatment and achieved therapeutic effect is defined according globally accepted criteria for cytogenetic and molecular responses, the problem with the change in quality of life and the attitude of patients to their own condition at the different stages of diagnostic and therapeutic process is not a subject of profound studies until now. We took the aim to examine the attitudes of patients with CML to their own disease, the activity of Specialized Office to University Hospital „Alexandrovska“, a patient organization, work of other medical specialists, and also to examine which information sources for disease, besides therapeutic team, are used. Based on these issues a program for assessment of the attitude of patients with CML to their own disease was developed to facilitate the analysis of social significance of the disease and available organization for supply of medicinal products and control on therapeutic response and their impact on quality of life during treatment with TKIs. This program can serve as a model for organization of care for patients with other chronic diseases.
Key words: leukemia, myelogenous, chronic, tyrosine kinase inhibitors, quality of life, cost of illness, patient acceptance of health care -- psychology, patient compliance, information sources, chronic disease
Address for correspondence: Grozdenka Vandova, Clinic of Hematology, UMHAT “Alexandrovska”, MU, 1, Sv. G. Sofiyski St., Bg -- 1431 Sofia, tel. +359 2 9230 437

 

 

In vitro comparative release of acetylsalicylic acid from new 100 mg gastro-resistant tablets - Medical Review (Medicinski pregled), 51, 2015, 4, 38-43.
K. Kafedjiyski(1), E. Grigorov(2) and T. Vekov(3)
(1)CTG Bulgaria Ltd -- Sofia, (2)Department of Pharmaceutical Sciences and Pharmaceutical Management,
Faculty of Pharmacy, Medical University -- Varna, (3)Department of Public Health Sciences, Faculty of Public Health, Medical University -- Pleven
Summary: The release profile of acetylsalicylic acid of the product ASA 100 mg gastro-resistant tablets in different media according to the Guideline „Quality of oral modified release product”, EMA/CHMP/QWP/428693/2013, has been studied. The similarity of dissolution profile in comparison with the reference product Aspirin Protect 100 mg gastro-resistant tablets has been proven with statistical similarity factor, f2. In the stability study the behavior of the product in terms of the dissolution characteristics and the content of the degradation product, free salicylic acid, are assessed.
Key words: acetylsalicylic acid, gastro-resistant tablets, release profile
Address for correspondence: Krum Kafedjiiski, M.D., e-mail: k_kafedjiiski@yahoo.com

 

 

MANAGEMENT IN HEALTHCARE

 

Pharmacotherapeutic recommendations for application of target oncological drug therapies for treatment of breast cancer in Bulgaria -- therapeutic efficacy, cost effectiveness   - Medical Review (Medicinski pregled), 51, 2015, 4, 59-64.
T. Vekov(1), H. Lebanova(1) and E. Grigorov(2)
(1)Faculty of Public Health, Medical University -- Pleven, (2)Faculty of Pharmacy, Medical University -- Varna
Summary: One of the main reasons for uncontrolled growth of expenses is the lack of comparative pharmacoeconomic assessments and consensus on threshold of cost effectiveness for QALY (LYG) of innovative target oncological therapies prior to take decisions for their payment with public funds from the National Health Insurance Fund. This requires development of pharmacotherapeutic recommendations for application of target drug therapies based on evidence of therapeutic efficacy and cost effectiveness. The study includes five target therapies approved for treatment of breast cancer (bevacizumab, trastuzumab, lapatinib, pertuzumab, trastuzumab emtansine).
Key words: breast cancer, target oncological drug therapies, therapeutic efficacy, cost effectiveness, corrections in medical standards
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

An analysis of the registered incidence in patients with acute pancreatitis in four emergency rooms in Bulgaria   - Medical Review (Medicinski pregled), 51, 2015, 4, 65-68.
N. Hubanov(1) and P. Stefanovski(2)
(1)Medical University -- Sofia, (2)Medical University -- Pleven
Summary: Epidemiologic data are a factor of the management of activities and resources in any medical structure. A retrospective pilot study of registered incidence of acute pancreatitis in emergency departments of three regional centers and one university center established similar to other European countries features in the registered incidence and seasonality in the patients with acute pancreatitis. The need for change in the management of this group in order to reduce resource losses of emergency rooms was established.
Key words: registered diagnoses; emergency rooms, acute pancreatitis
Address for correspondence: Nikolai Hubanov, M.D., e-mail: houbanov@abv.bg

 

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bullet 3'2015

Application of the conventional and molecular methods in the diagnostic algorithm of vulvovaginal candidiasis - Medical Review (Medicinski pregled), 51, 2015, № 3, 39-43.
R. Baykushev(1), V. Ouzounova-Raykova(1), E. Ivanova(2) and I. Mitov(1)
(1)Department of Medical Microbiology, Medical University -- Sofia, (2)Medical College “Iordanka Filaretova” -- Sofia
Summary: Vulvovaginal candidiasis (VVC) is the second most common infection among those of the vagina. Aim of this study is the determination of representatives of the genus Candida through the conventional and molecular genetic methods. The need for species identification is determined by the fact that some of the infection agents are primarily resistant to widely used in therapy azoles and hence could be a reason for the development of chronic relapsing forms of VVC. Materials and Methods: A total of 234 vaginal secretions were examined. Each of them was subjected to Gram staining method and cultured on CHROMagar Candida and SDA Chloramphenicol (Becton Dickinson). Identification of fungal pathogens was carried out by assimilation and fermentation tests, as well as molecular diagnostic methods. Results: In 64 (27%) of all patients a positive result for the presence of fungal agent was found. The presence of various forms of fungi in slide preparation was proved only in 52 (81%) of the above. The results of the identification of Candida species by fermentation and assimilation tests showed: C. albicans in 54 (84%) smears, C. glabrata -- in 8 (13%), C. krusei -- in 2 (3%). The obtained by molecular genetic technology results confirmed the findings previously identified by conventional methods. Conclusion: Microscopic methods are fast, easy and affordable, but not sufficiently reliable. Cultivation techniques give good results for the species identification of fungal agents, especially combined with fermentation and assimilation tests. PCR technology shows comparable results. Its implementation in a few hours makes the method not only competitive with conventional methods, but also preferable in laboratory practice. The high frequency of established fungal infection among the studied materials -- 27%, confirms the need for testing for vulvovaginal mycotic infection, regardless of whether or not clinical symptoms of the patient are present.
Key words: vulvovaginal candidiasis, cultivation, PCR
Address for correspondence: Radoslav Baykushev, M.D., Department of Medical Microbiology, Medical Faculty, 2, Zdrave St., Bg -- 1431 Sofia, e-mail: radoslav1961@abv.bg

 

 

An in vitro study of a new Alginate Raft-forming oral suspension - Medical Review (Medicinski pregled), 51, 2015, № 3, 44-46.
K. Kafedjiyski(1), E. Grigorov(2) and T. Vekov(3)
(1)CTG Bulgaria Ltd -- Sofia, (2)Department of Pharmaceutical Sciences and Pharmaceutical Management, Faculty of Pharmacy, Medical University -- Varna, (3)Department of Public Health Sciences, Faculty of Public Health, Medical University -- Pleven
Summary: In vitro comparative studies are conducted with the new Alginate Raft-forming oral suspension in comparison with the commercial product Gaviscon Cool Mint Liquid oral suspension (Reckitt Benckiser Healthcate, UK). Results have shown that at any pH, Alginate Raft susp. and Gaviscon susp. form alginate gels with similar characteristics. The presented data confirm the proposed mechanism of action of the new Alginate Raft suspension.
Key words: Alginate Raft-forming oral suspension, comparative studies, mechanism of action
Address for correspondence: Krum Kafedjiiski, M.D., e-mail: k_kafedjiiski@yahoo.com

 

 

MANAGEMENT IN HEALTHCARE

A metaanalysis of pharmacoeconomic assessments of targeted oncological therapies based on tyrosine kinase inhibitors -- opportunities for updating and application in Bulgaria - Medical Review (Medicinski pregled), 51, 2015, № 3, 55-68.
T. Vekov(1) and S. Dzhambazov(2)
(1)Faculty of Public Health, Medical University -- Pleven, (2)Faculty of Public Health, Medical University -- Sofia
Summary: The study is aimed at an analysis of cost effectiveness of targeted oral oncological therapies based on tyrosine kinase inhibitors (TKIs) to support the decisions of the National Committee on Prices and Reimbursement of Medicinal Products in Bulgaria regarding inclusion of TKIs therapies in the Positive Medicinal List (PML). Literature search within data bases was made as follows: PubMed, Cochrane Library and reports published on UK HTA Programme. The study only included trials published in the last 5 years and following the good practices in presentation and reporting of pharmacoeconomic assessments. The published data for cost effectiveness of 16 TKIs therapies, 13 of which are included in the Bulgarian PML (axitinib, crizotinib, dasatinib, erlotinib, gefitinib, imatinib, lapatinib, nilotinib, pazopanib, ruxolitinib, sorafenib, sunitinib, vemurafenib), are embraced. In 2014 the National Health Insurance Fund paid 80 mln Levas for reimbursement of these medicinal products. Three of the analyzed TKIs therapies are expected to be included in the PML -- bosutinib, regorafenib, ponatinib. The summarized results of a metaanalysis of pharmacoeconomic assessments of the TKIs therapies by diagnoses, their cost effective alternatives and adopted public expenses from budget of the National Health Insurance Fund are presented. Adaptation and update of the data on pharmacoeconomic assessments can raise cost effectiveness of medicinal therapies.
Key words: oncological therapies, tyrosine kinase inhibitors, pharmacoeconomic assessments, therapeutical alternatives, cost effectiveness
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg



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bullet 2'2015

Steroid hormones in acute coronary syndrome - Medical Review (Medicinski pregled), 51, 2015, № 2, 26-33.
N. Semerdzhieva(1), St. Denchev(2), A. Tzakova(3) and M. Stoycheva(4)

(1)Clinic of Cardiology, University Hospital “Alexandrovska“, Medical University --  Sofia, (2)Clinic of Cardiology, Medical Institute of Ministry of Interior --  Sofia, (3)Central Clinical Laboratory, University Hospital “Alexandrovska“, Medical University --  Sofia, (4)Department of Occupational Medicine, Faculty of Public Health, Medical University --  Sofia
Summary: Previous studies failed to directly demonstrate and thoroughly characterize an association of sex steroid hormones and acute coronary syndrome.
Aim: The aim of the present study was an assessment of the significance of sex steroids: 17 beta-estradiol (E2), testosterone (T) and dehydroepiandrosterone-sulphate (DHEA-S) for the risk of occurrence of acute coronary syndrome (ACS) and the severity of myocardial damage in acute coronary artery disease.
Material and methods: A hundred and sixty six persons: 136 having acute coronary syndrome (59 women and 77 men) and 30 individuals (17 women and 13 men) without ischemic heart disease were included in the study.
Results: The studied sex steroids were not associated with the incidence of acute coronary syndrome (ACS). In ACS a specific for male gender correlation of the plasma concentrations of E2 close to the upper level of the normal range with markers of myocardial necrosis, the severity of the coronary arteriosclerosis and with worse left ventricular systolic function was observed.
Conclusions: 17 beta-estradiol, testosterone and dehydroepiandrosterone-sulphate in acute phase of coronary syndrome are not associated with the risk of its occurrence in both genders. Estradiol contributes to the severity of myocardial damage in male patients with acute coronary artery disease.
Key words: acute coronary syndrome, 17 beta-estradiol, testosterone, dehydroepiandrosterone-sulphate, gender, myocardial damage
Address for correspondence: Nia Semerdhzieva, M.D., Clinic of Cardiology, University Hospital “Alexandrov­ska”, 1 “Sv. G. Sofiyski” St., Bg --  1431 Sofia, e-mail: niaemilova@yahoo.com

 

 

Wilson disease -- histomorphological aspects - Medical Review (Medicinski pregled), 51, 2015, № 2, 34-38.
D. Gancheva and I. Kotzev
Clinic of Gastroenterology, Hepatology and Nutrition, Sv. Marina University Hospital, Medical University --  Varna
Summary: Introduction. Wilson disease (WD) is an inherited disease associated with copper accumulation and leading to liver cirrhosis and neuropsychotic disorders. The cases of subclinical course, unclear liver disease, elements of hemolysis, or unspecified neuropsychotic disease represent a serious challenge. The purpose of the study was to evaluate the diagnostic relevance of the morphological examination of liver disease in WD patients.
Material and methods. Sixty-five WD patients were followed-up during the period from 2003 till 2013. Twenty-three patients (35.4%) underwent percutaneous aspiration liver biopsy by Menghini technique. Hematoxylin-eosin and PAS staining for visualization of nuclear glycogen were used. A histochemical examination with Rhodanine for copper detection was carried out in 21 patients.
Results. Most commonly, a steatosis (in 16 out of 23 patients) was described followed by fibrosis (12/23), inflammatory infiltration (11/23), and vacuolated hepatocytic nuclei (11/23). Rhodanine staining showed a positive result in 10 out of 21 cases. In 10 of the biopsied patients, a non-alcoholic steatohepatitis, but in 6 ones either a coexisting chronic viral hepatitis B, or chronic viral hepatitis C were established.
Conclusions. Despite the small number of biopsied patients our observation showed the most frequent histological findings in the liver tissue in patients with WD. Our results prove that in combination with clinical and laboratory data, the histomorphological study confirms the diagnosis in difficult and unclear cases.
Key words: Wilson disease, liver biopsy, morphological findings
Address for correspondence: Diana Gancheva, M. D., Clinic of Gastroenterology, Hepatology and Nutrition, Sv. Marina University Hospital, Medical University, 1, Hristo Smirnenski St., Bg --  9010 Varna, e-mail: gancheva_vn@abv.bg

 

 

Self-management of hypertension in patients with chronic kidney disease 3 stage or higher - Medical Review (Medicinski pregled), 51, 2015, № 2, 39-43.
M. Lyubomirova and B. Bogov
Department of Nephrology, University Hospital "Alexandrovska" --  Sofia
Summary: The key to reduce incidence of chronic kidney disease (CKD) is the early identification of patients at high risk for CKD and systematic follow-up and compliance with the rules of good clinical practice in the conservative treatment of already proven CKD. One possible mechanism is self-management of the factors responsible for the progression and particularly hypertension. The aim of the study was to analyze the ability of patients with CKD > 3 stage to exercise self-control of hypertension. We analyzed answers of 30 patients. The patients average age was 65.5 +/- 22.34, they were admitted to the hospital and were treated in Clinic of Nephrology between 1 January 2013 and 1 July 2014, with CKD and impaired kidney function, corresponding to CKD >= 3 stage, with persistently elevated serum creatinine levels > 200 mcmol/l. Only 10% of patients have understanding of the implementation of self-management technique. 16% exercises self-control of their hypertension. 40% of patients are willing to practice this technique and 60% do not want to control their own disease by themselves. The results lead to the conclusion that self-management of hypertension is not known and applicable technique in our practice.
Key words: chronic kidney disease, progression of CKD, hypertension, self-management
Address for correspondence: Mila Lyubomirova, M. D., Department of Nephrology, University Hospital "Alexandrovska", 1 Sv. G. Sofiyski St., Bg --  1431 Sofia, е-mail: MLjubomirova@yahoo.com

 

 

Development of stable pharmaceutical formulation of an oral drop solution containing metamizole sodium monohydrate - Medical Review (Medicinski pregled), 51, 2015, № 2, 44-48.
K. Kafedjyiski(1) and St. Kafedjyiski(2)
(1)CTG Bulgaria SPLtd --  Sofia, (2)Chemax Pharma EOOD --  Sofia
Summary: The main problem during the development of a formulation based on metamizole sodium --  stability in relation with the degradation products of the active substance, is defined. The effects of the buffer type, its capacity and pH of the solution on the stability of metamizole sodium in aqueous solution are investigated. As a result, the optimal conditions and the composition of solution for oral drops are defined: citrate buffer, capacity of 125 mM and pH 7.7.
Key words: metamizole sodium, aqueous solution, oral drops
Address for correspondence: Krum Kafedjiiski, e-mail: k_kafedjiiski@yahoo.com


 

MANAGEMENT IN HEALTHCARE

Health politics decisions without economic assessment of budgetary impact --  an analysis of consequences - Medical Review (Medicinski pregled), 51, 2015, № 2, 57-61.
T. Vekov(1) and S. Dzhambazov(2)

(1)Faculty of Public Health, Medical University --  Pleven, (2)Faculty of Public Health, Medical University --  Sofia
Summary: The study is aimed at an analysis of budgetary impact from changed and complemented regulative acts based on data from annual reports for fulfillment of the budget of National Health Insurance Fund for the period 2010 --  2013 and prognostic results for 2014. The study encompasses major trends related with health insurance payments --  inpatient care and reimbursed medicinal products. The lack of preliminary design of budgetary expenses and ineffective control on implementation and accounting of performed medical activities cause the annual expenditure of 420 million Leva in the direction of inpatient care and 70 million Leva in the direction of fully reimbursed medicinal products, for which no additional funds are predesigned. Conclusions: Any decision related with inclusion or exclusion of health technology or medicinal therapy, which are paid by public funds such as National Health Insurance Fund, must be reckoned with therapeutic efficacy, comparative cost effectiveness in relation to available alternatives and real opportunities of budget.
Key words: public funds, budgetary overspending, health economic assessment
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg --  5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

HELPING PRACTICE

Forensic toxicology testing in case of death. II. The basic mistakes - Medical Review (Medicinski pregled), 51, 2015, № 2, 62-66.
V. N. Atanasov

Analytical Toxicology Laboratory, Military Medical Academy -- Sofia
Summary: The work aims to identify the main sources of mistakes associated with forensic postmortem toxicological testing. Different factors leading to an error of analysis and their explanation are discussed. Attention is paid to the interpretation of obtained results and some peculiarities of forensic toxicology data. The main analytical limitations are commented as well as their influence to the final result of the forensic report.
Key words: mistakes, postmortem toxicology
Address for correspondence: Assoc. Prof. Vasil N. Atanasov, PhD, Analytical Toxicology Laboratory, Military Medical Academy, 3, G. Sofiyski St., Bg -- 1606 Sofia, e-mail: vatanasov@vma.bg

 

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bullet 1'2015

Iron-deficiency anemia and anemia in chronic diseases -- new tools in differential diagnosis - Medical Review (Meditsinski pregled), 51, 2015, №1, 31-35.
V. Manolov(1), V. Paskaleva-Peycheva(2), B. Bogov(3), D. Yonova(4), E. Vazelov(4), E. Hadjiev(5), M. Velizarova(1), B. Atanasova(6), S. Hadjidekova(1), V. Vasilev(6) and K. Tzatchev(6)
(1)Department of Medical Genetics, (2)Clinic of Rheumatology, “Sv. Ivan Rilski” Hospital, (3) Clinic of Nephrology, Department of Internal Diseases, (4)Dialysis Center, (5) Clinic of Hematology, Department of Internal Diseases, (6)Department of Clinical Laboratory and Clinical Immunology, Medical University -- Sofia
Summary: Hepcidin is shown to be very low in patients with iron-deficiency anemia (IDA), as well as in those with a low serum ferritin in the latent and pre-latent forms of deficit without accompanying anemia. Anemia of chronic disease (ACD) is an acquired disorder of iron homeostasis. This condition is associated with infection, malignancy, organ failure, severe trauma, or other causes of inflammation. Differentiation between the two conditions is important for the correct choice of therapeutic approach. We determined serum hepcidin levels, a key iron homeostasis regulator using a Sandwich ELISA method in 90 patients with: chronic kidney disease, stages II to V (n = 30), iron-deficiency anemia (IDA) (n = 30) and rheumatoid arthritis (n = 30) for a period of two years. To calculate the indexes for differentiation of iron deficiency anemia from anemia of chronic diseases we determined serum iron, total iron-binding capacity (TIBC), ferritin and soluble transferrin receptors. We established significant higher levels of hepcidin in patients with ACD 90.7-770.2 mcg/L (P < 0.001); serum concentration of hepcidin in patients with IDA were significantly lower 0.45-2.1 mcg/L (P < 0.001); the reference ranges for hepcidin were 3.052-37.750 mcg/L. Using а) index of soluble transferrin receptors to ferritin [(i)sTfr], b) index of hepcidin to ferritin (Hepc/Fer) and c) index of transferrin saturation to hepcidin (TSAT/Hepc) we determined cut-off levels for differentiation between IDA and ACD -- а) 0.108; b) 0.363; c) 2.272. Our results show the main role of serum hepcidin quantification in differentiation between IDA and ACD and help clinicians to make the right therapeutic choice.
Key words: hepcidin, iron-deficiency anemia, anemia in chronic diseases, rheumatoid arthritis, chronic kidney diseases, dialysis
Address for correspondence: Victor Manolov, M.D., Department of Medical Genetics, Medical University, 1 “Sv. G. Sofiyski” Blvd., Bg -- 1431 Sofia, tel. +359 2 9230 928, e-mail: victhedoc2@yahoo.com

 

 

Index of consumption of health and social services of premature children from birth to 3 years of age - Medical Review (Meditsinski pregled), 51, 2015, №1, 36-40.
M. Kambourova, P. Hristova and I. Hristova
Medical University -- Pleven
Summary: Needs for health and social services for premature children in early childhood are higher than those of term infants. The aim of the study was to determine the index of consumption of health and social services of the preterm children by analyzing the given health care from birth to 3 years of age. The study covered 298 infants including 154 premature and 144 full-term infants born at University Hospital in Pleven in 2007 and followed the consumption of health and social services to 3 years of age for children living permanently in the city of Pleven. It was found a statistically significant difference between the studied groups of children in terms of number of used health and social services in the period of early childhood. The findings for consumption of health and social services of the preterm children confirm the hypothesis that premature children living in urban areas are a risk group with a high demand for health and social support to 3 years.
Key words: prematurity, health and social services, index of consumption
Address for correspondence: Mariela Kamburova, M.D., PhD, Faculty of Public Health, Medical University, 1, Sv. Kliment Ochridscy St., Bg -- 5800 Pleven, e-mail: mariela_kamburova@yahoo.com

 

 

 

MANAGEMENT IN HEALTHCARE

Control of pricing and reimbursement via positive drug list: analysis of the results in Bulgaria for the period 2013-2014 year - Medical Review (Meditsinski pregled), 51, 2015, №1,  52-58.
T. Vekov
Faculty of Public Health, Medical University -- Pleven
Summary: The study represents an analysis of the innovative medicines included in the Positive Drug List (PDL) in Bulgaria for the period 2013-2014 year. The analysis focused on prices of therapy, data from clinical trials of medicinal products’ efficacy and safety, sales value, etc. The results show that some changes in the Ordinance on the conditions, rules and procedures for regulation and registration of pharmaceutical prices in Bulgaria are needed, such as: 1. Reference pricing based on pharmacoeconomic evidence should be applied at the level of therapeutic alternatives and not at the level of INN; 2. Expert reports on efficacy, safety and pharmacoeconomic evaluation of innovative drug therapies should be published to allow for transparency and objectivity of the decisions; 3. In the absence of therapeutic alternatives, it is necessary to determine the maximum expense on won QALY, over which the medicinal product will not be paid with public funds.
Key words: Positive Drug List, innovative drug therapies, pharmacoeconomic evaluation
Address for correspondence: Prof. Toni Vekov, Faculty of Public Health, Medical University, 1, Sv. Kl. Ohridski St., Bg -- 5800 Pleven, e-mail: t.vekov.mu.pleven@abv.bg

 

 

 

HELPING PRACTICE

Forensic toxicology testing in case of death. I. Samples Samples - Medical Review (Meditsinski pregled), 51, 2015, №1,  59-67.
V. N. Atanasov
Analytical Toxicology Laboratory, Military Medical Academy -- Sofia
Summary: A summarized protocol based on the recent standards in the field of Forensic toxicology is presented. The main preliminary stages of forensic toxicology investigation are described -- crime scene investigation, external and internal examination of the corpse, sampling and storage of the samples as well as the preliminary information needed. The basic properties of the postmortem samples are discussed.
Key words: samples, postmortem toxicology
Address for correspondence: Assoc. Prof. Vasil N. Atanasov, PhD, Analytical Toxicology Laboratory, Military Medical Academy, 3, G. Sofiyski St., Bg -- 1606 Sofia, e-mail: vatanasov@vma.bg

 

Last update of the page: 18.12.2015.

 

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