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Vol. 47, 2011


bullet 4'2011

Erysipelas -- tendencies in treatment and prophylaxis - 47, 2011, №  4, 5-10.
K. Semkova, I. Yungareva and S. Marina
Clinic of Dermatology and Venereology, “Aleksandrovska” Hospital -- Sofia
Summary: Erysipelas is a superficial infection of the dermis and hypodermis. The main etiological agent are group A streptococci, but other bacterial species could also be involved, albeit rarely. The standard therapeutic approach is empirical application of penicillins, but macrolides, quinolones and glycopeptides could be used as well in case of resistance or hypersensitivity. The current tendencies include reduction of antibiotic treatment duration and out-patient management of the disease. Erysipelas recurs in one third of all patients and every new episode results in local damage of tissues and lymph vessels. Antibiotic prophylaxis with intramuscular penicillin is effective and safe method to reduce the number and frequency of recurrences in patients with known underlying risk factors.
Key words:  erysipelas, penicillins, prophylaxis of erysipelas
Address for correspondence: Kristina Semkova, M. D., Clinic of Dermatology and Venereology, “Aleksandrovska” Hospital, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: kristina_semkova@yahoo.com



Medically unexplained symptoms in medical practice: limitations of the concept of somatoform disorders - 47, 2011, №  4, 11-14.
I. Natsov
Psychiatrist -- Cherven Briag
Summary: Many epidemiological investigations demonstrate prevalence of approximately 33% of medically unexplained symptoms in general and specialized medical practice. Medically unexplained symptoms is a term used in the concept of somatoform disorders but not replacing them. The latter are a heterogeneous group of psychic disorders in ICD-10 and DSM-IV connected by their tendency to present somatic symptoms. The price of their treatment is higher than the price of the treatment of general population. The group of somatoform disorders is one of the most controversial domains in modern psychiatry, a supporting keystone of the integrity between psychiatry and somatic medicine.
Key words:  medically unexplained symptoms; somatoform disorders
Address for correspondence: Ivo Natsov, M. D., Psychiatrist, 61, Yane Sandanski Str., Bg -- 5980 Cherven Briag, e-mail: ivo_nacov@abv.bg



Fabry disease - 47, 2011, №  4, 15-21.
E. Paskalev(1), S. Zelenski(2), N. Boyanova(2), S. Todorov(2) and T. Haralampieva(2)
(1)Department of Nephrology and Kidney Transplantation, Alexandrovska University Hospital -- Sofia, (2)Genzyme, Bulgaria
Summary:  Fabry disease is a progressive X-linked recessive storage disorder caused by deficient activity of alpha-galactosidase A (аlfa-Gal A, also known as trihexosidase), with the resultant accumulation of globotriaosylceramide and other glycosphingolipids. Severely affected patients have either no or very small amounts of detectable enzyme activity. Milder variant phenotypes have been described in which detectable though markedly decreased enzyme activity is present. Recent advances in direct enzyme replacement therapy for Fabry disease require the establishment of diagnostic and management guidelines for this rare genetic disease. The heterogeneity and complexity of this disorder and the expense of enzyme replacement regimes call for national guidelines for its management. Physicians in our country have limited experience with diagnosis, management and clinical follow up of Fabry patients thus Bulgarian consensus recommendations are needed to ensure the highest standard of care for Bulgarian patients and their families. The goal of this review is to make a general conclusion of the data from clinical trials and published materials about treatment of Fabry disease in order to establish consensus principles for diagnosis, clinical follow up and treatment of these patients in our country.
Key words:  Fabry disease, diagnosis, treatment, clinical follow up
Address for correspondence: Assoc. Prof. Emil Palkalev, 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



Diagnostic value of anti-neutrophil cytoplasmic antibodies - 47, 2011, №  4, 22-30.
M. Hristova and M. Baleva
Department of Clinical Laboratory and Clinical Immunology, Medical University -- Sofia
Summary: The interpretation of anti-neutrophil cytoplasmic antibodies is often not an easy task and it requires profound knowledge about the discrepancy of the detection methods with consequent false positive and false negative results. In the last years, there are many attempts for a standardization of those methods in order to allow them to play a role not only as an useful serological assay but also as diagnostic criteria in the classification of ANCA associated vasculitis (AAV). The clinical interpretation of the results is complicated also because of the fact that ANCA are a heterogenous group and some of the types can be found in different chronic-inflammatory and autoimmune diseases, after the use of some drugs, and in infectious and malignant processes. That is why in this review we discuss the current immunological characteristics of the above-mentioned states and present the new understanding and trends about the diagnostic significance which ANCAs contribute to clinical practice.
Key words:  cANCA, pANCA, anti-PR3 ANCA, anti-MPO ANCA, minor specificities, antibo­dies against the lysosomal-associated membrane protein 2, neutrophil extracellular traps, ANCA-associated vasculitis
Address for correspondence:  Maria Hristova Hristova, Department of Clinical Laboratory and Clinical Immunology, MU, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, e-mail: maria_hr@dir.bg



HLA and hepatitis B infection - 47, 2011, №  4, 31-33.
M. Baleva(1), E. Naumova(1), A. Mihaylova(1), D. Petrova(2) and K. Tchernev(2)
(1)Department of Clinical Immunology, (2)Clinic of Gastroenterology, University Hospital Alexandrovska – Sofia
Summary:  Investigations upon the relationship between some HLA alleles and the persistence of hepatitis B infection have been evaluated. The significance of the determination of HLA system in different ethnic populations is pointed out. The data about association between some HLA antigens and the immune response after vaccination have been discussed.
Key words:  hepatitis B virus, HLA
Address for correspondence:  Prof. Marta Baleva, University Hospital Alexandrovska, 1. Sv. G. Sofiiski Str, Bg -- 1431 Sofia, e-mail: marta_baleva@yahoo.com



Alzheimer’s disease -- what is new in the pharmacotherapy? - 47, 2011, № 4, 34-40.
P. Gateva(1, 2), S.-G. Panagis Moshonas(2)
(1)Pharmacology and Toxicology Department, Medical University -- Sofia, (2)Medical Faculty, Sofia University “Kl. Ohridski”
Summary:  Alzheimer’s disease is the most prevalent cause for dementia worldwide. The treatment of this disease is an important and unresolved problem up to now. The modern treatment is based on proved pathogenetic mechanisms and thus favorably influences symptoms. Acetylcholinesterase in mild and moderate cases and memantine in severe cases are used. Important investigational candidate drugs for treatment of Alzheimer’s disease are also discussed in the paper.
Key words:  Alzheimer’s disease, memantine, acetylcholinesterase inhibitors
Address for correspondence: Pavlina Gateva, M. D., Pharmacology and Toxicology Department, Medical University, 2, Zdrave Str., Bg -- 1431 Sofia, е-mail: pandreeva_gateva@yahoo.com



bullet 3'2011

Simplified dermatoscopic criteria for diagnosing benign and dysplastic melanocytic lesions and melanoma of the skin: indications for surgical removal - 47, 2011, № 3, 5-18.47, 2011, 3, 5-18.
G. Tchernev(1), J. W. Patterson(2), P. Penev(1), G. Vashina(1), N. Kiriyak(1), V. Todeva(1), D. Gancheva(1), J. Ananiev(3), M. Galabova(3), D. Karshakova(1), S. Kurteva(1), M. Penev(4), G. Kupcova(5), J. C. Cardoso(6) and C. Salaro(7)
(1)Department of Dermatology and Venereology, Medical Faculty, Trakian University -- Stara Zagora, (2)Division of Surgical Pathology and Cytopathology, University of Virginia Hospital -- Charlottesville, VA, USA, (3)Department of General and Clinical Pathology, Medical Faculty, Trakian University -- Stara Zagora, (4)Department of II-nd Internal Clinic, Medical Faculty, Trakian University -- Stara Zagora, (5)Department of Dermatology and Venereology -- Kezmarok, Slovak Republic, (6)Dermatology and Venereology Department, University Hospital of Coimbra Praceta Mota Pinto -- Coimbra, Portugal, (7)Instituto de Dermatologia Professor Rubem David Azulay/ Santa Casa de Misericórdia do Rio de Janeiro, Brasilia
Summary: Dermatoscopy is a modern methodology for non-invasive examination of the epidermis, the dermal-epidermal zone and the papillary dermis. It is carried out with the aid of a special device, the so-called dermatoscope, using variable light produced at a sharp angle. The microscopic or rather the dermatoscopic study of the skin layers is coupled with an optical phenomenon only after the application of oil immersion. This makes the epidermis more transparent, and the tissue beneath the skin -- more accessible for observation and analysis. Using this diagnostic method increases the ability to accurately differentiate between melanocytic and non-melanocytic, as well as between benign and malignant cutaneous lesions. Dermatoscopy has become a method without which the everyday dermatological and dermatosurgical practice would be unthinkable. It is a bridge between conservative and invasive dermatology. Proper application of the above methods often has life-saving importance, especially in cases which pertain to a refinement of the diagnostics in patients with malignant melanoma. For example, over the years, there has been ongoing controversy concerning the effect of hormones on melanoma and dysplastic nevi. Some researchers have speculated that melanomas and dysplastic nevi may grow rapidly and spread due to the hormones associated with pregnancy. There has been also some concern that hormonal and immunological alterations occurring during pregnancy might activate melanocytic nevi (MN) and favour the development and progression of melanoma. The ability to recognize the early transformation of such lesions to melanoma is greatly aided by routine use of dermatoscopy in clinical practice. The present article is focused on the development of dermatoscopy over the centuries. It presents frequently used and easily applicable dermatoscopic criteria for easy and quick identification of the origin of lesions in clinical practice. The simplified dermatoscopic criteria presented here, as well as the clinical algorithms that can be used in determining the origin of benign melanocytic lesions and melanomas, should prove useful to a wide range of professionals, such as surgeons, dermatosurgeons, gynecologists and general practicioners.
Key words: dermatoscopy, malignant melanoma, surgery, melanocytic lesions
Address for correspondence: Assoc. Prof. Georgi Tchernev, M.D., Ph. D., Department of Dermatology and Venerеology, Faculty of Medicine, Trakian University, 11, Armeyska Str., Bg -- 6000 Stara Zagora, tel. + 359 885 588424, e-mail: georgi_tchernev@yahoo.de



Psoriasis and cardiovascular risk - 47, 2011, № 3, 19-21.
I. Gruev and A. Toncheva
Clinic of Internal Diseases, NMTH ”Tsar Boris III” -- Sofia
Summary: An increasing amount of scientific information proves that psoriasis is not only a skin disease, but a systemic inflammatory process. Cardiovascular diseases are the most common cause of mortality and morbidity among the patients with psoriasis. Recently the chronic inflammation is found to be the “missing link” between psoriasis and atherosclerosis. There are great expectations that therapy with statins and modern anti-inflammatory agents could block the common pathogenic pathways of both psoriasis and atherosclerosis.
Key words: psoriasis, inflammation, atherosclerosis, cardiovascular diseases
Address for correspondence: Ivan Gruev, M. D., Clinic of Internal Diseases, NMTH “Tsar Boris III”, 108, Maria Luiza Blvd., Bg -- 1233 Sofia, e-mail: ivangruev@yahoo.com



Methods for selective respiratory muscle training in COPD rehabilitation - 47, 2011, 3, 22-26.
St. Kemerov.
Department of Physical Medicine and Rehabilitation, University Hospital “Lozenets” -- Sofia
Summary: Chronic obstructive pulmonary disease (COPD) is a chronic progressive condition with rapidly increasing frequency. The main symptom of COPD is dyspnea. In accordance with pathogenesis of dyspnea, many studies towards effects of selective respiratory muscle training have beеn conducted. Because some unresolved rehabilitation problems of patients with COPD still persist some questions about strength and endurance of respiratory muscles are topics of interest. In the present study, some important investigations on selective respiratory muscle training are discussed and the basic methods in use are described.
Key words: chronic obstructive pulmonary disease, pulmonary rehabilitation, respiratory muscle training
Address for correspondence: Stoyan Kemerov, M. D., Department of Physical Medicine and Rehabilitation, University Hospital “Lozenets”, 1, Kozyak Str., Bg -- 1407 Sofia, e-mail: kemerov_stoyan@yahoo.com




bullet 2'2011

Investigating predictive markers for the development of radiation normal tissue adverse events -- an approach to personalized radiotherapy - 47, 2011, 2, 5-12.
EE. Encheva and T. Hadjieva
Radiotherapy Department, University Hospital “Tsaritsa Ioanna -- ISUL” -- Sofia
Summary: Radiotherapy is one of the three cancer treatment modalities and applies the fastest developing technologies. Despite the advanced technologies cancer radiotherapy inevitably exposes part of normal tissue and organs to irradiation. This leads to development of symptoms, associated with early and late adverse events occurring during the radiotherapy course or weeks, months and years after irradiation or complex treatment. The authors review the types of radiotherapy adverse events and the known factors, related to its development. The technology advance had solved а part of the problem by minimizing the volume of normal tissue irradiated. But there is a further need of methods, investigating probable predictive markers for the development of normal tissue adverse events. The international initiatives for revealing the genetic factors responsible for their development are outlined. The prospective of patient gene profiling for predicting normal tissue morbidity and the future application of personalized radiotherapy with regard to radiotherapy adverse events are discussed.
Key words: radiotherapy, adverse events, predictive markers, genetic profiles, personalized radiotherapy
Address for correspondence: Elitsa Encheva, M. D., Radiotherapy Department, University Hospital “Tsaritsa Ioanna -- ISUL”, 8, Bjalo more str., Bg -- 1527 Sofia, tel. +359 2 9432351, e-mail: dr.encheva@gmail.com



Intracellular renin-angiotensin system -- a new target for pharmacotherapy - 47, 2011, № 2, 13-19.
G. Krasteva(1) and E. Lakova(2)

(1)Division of Experimental and Clinical Pharmacology, (2)Division of Pathophysiology, Medical University -- Pleven
Summary: The renin-angiotensin system (RAS) has traditionally been accepted as a circulatory system with short-term regulatory effects оn volume and blood pressure homeostasis. Recently, the local RASs have been described as regulator of chronic tissue effects. Tissue RAS has been further categorized into extracellular (autocrine/paracrine) and intracellular (intracrine) RAS (iRAS). The iRAS has been reported to be significantly upregulated in certain pathological conditions (hyperglycemia, sympathetic stimulation). iAT-II actions are not completely blocked by the ACE inhibitors and AT1-receptor blockers, due to inability to enter the cell or to block the alternative pathways of iAT-II synthesis and action. The clearest example of “intracrine” pharmacology in the RAS is provided by the renin inhibitor aliskiren with its ability to block both extracellular and intracellular generation of AT-II. Advancement of the knowledge of the iRAS may assist more comprehensive understanding and effective treatment of cardiovascular and metabolic disorders.
Key words: intracellular RAS, intracellular AT-II, chymase, hyperglycemia, renin inhibitors
Address for correspondence: Genka Krasteva, M. D., Division of Experimental and Clinical Pharmacology, Medical University, 1, Kl. Ohridski Str., Bg -- 5800 Pleven, +359 64 884 282, e-mail: krusteva_med@abv.bg



Clinical, epidemiologic and socioeconomic aspects of osteoarthrosis - 47, 2011, № 2, 20-23.
Zl. Kolarov and R. Rashkov
Clinic of Rheumatology, Medical University -- Sofia
Summary: Viewed are the main clinical manifestations and morphological changes in osteoarthrosis. Presented are epidemiological data about spread, prevalence, socioeconomic and therapeutic aspects of the most frequent rheumatic disease. Analysed are the recommendations of the American College of Rheumatology on management in patients with osteoarthrosis, including pharmacologic and non-pharmacologic means to overcome the pain and establish appropriate movement regime and comfort for the patients.
Key words: osteoarthrosis, joint cartilage, epidemiology, treatment
Address for correspondence: Prof. Zlatimir Kolarov, M. D., Clinic of Rheumatology, University Hospital “Sv. Iv. Rilski”, 13, Urvich Str., Bg -- 1612 Sofia, tel. +359 2 958-23-71




bullet 1'2011

Infectious balanitis - 47, 2011, № 1, 5-10.
A. Mitev and G. Mateev
Department of Dermatology and Venereology, Medical University -- Sofia
Summary: Balanitis and balanoposthitis are diseases of man that are conventionally divided into acute and chronic, infectious and non-infectious. The purpose of this review is to present the infectious causes of these diseases. Infectious balanitis creates a broad social problem with its trend towards chronification, caused by limited access to laboratory diagnostics and therapy resistance.
Key words: infectious balanitis, balanoposthitis, candidal balanitis, Streptococcal balanoposthitis, аmoebic balanitis
Address for correspondence: Angel Mitev, M. D., Department of Dermatology and Venereology, Medical University, 1, Sv. G. Sofiiski Str., Bg -- 1431 Sofia, tel. +359 886 320374, +359 2 9230464, e-mail: mitev_angel@abv.bg



Hyperuricemia as a cardiovascular risk factor - 47, 2011, № 1, 11-14.
I. Gruev and A. Toncheva
Clinic of Internal Diseases, NMTH “Tsar Boris III” -- Sofia
Summary: The correlation between gout and hypertension, diabetes and renal diseases was established in19-th century. Since then, many epidemiological trials have shown the association of serum uric acid with cardiovascular diseases. Nevertheless the role of uric acid as an independent risk factor is still questioned, and there are no evidence based recommendations for treatment of the asymptomatic hyperuricemia.
Key words: uric acid, hyperuricemia, cardiovascular risk
Address for correspondence: Ivan Gruev, M. D., Clinic of Internal Diseases, NMTH „Tsar Boris ІІІ”, 104, Maria Luiza Blvd., Bg -- 1233 Sofia, e-mail: ivangruev@yahoo.com



Fibromyalgia and overlap with other diseases - 47, 2011, № 1, 15-18.
M. Panchovska-Mocheva
Clinic of Internal Diseases, MMA, MHAT, Medical University -- Plovdiv
Summary: Fibromyalgia is an illness which is characterized by diffuse muscle pain. Phy­sical examination findings include pressure pain in certain diagnostic points. Fibromyalgia is either an independent nosological unit or a part of an overlap syndrome with other rheumatic or non-rheumatic diseases. The differential diagnosis of fibromyalgia may prove to be a hard task even for experienced clinicians. In the differential diagnosis algorithm, immunological tests, biopsy, serology in search of an infection, hormone levels, imaging diagnostic methods are very important. It is essential to call other specialists -- gastroenterologist, neurologist, specialist in infections, psychiatrist, for a consultation. Treatment of fibromyalgia includes pharmacological and also non-pharmacological methods. The complex pathogenesis of the disease, including impaired neuroendocrine reactions, influences the attempts to fight pain.
Keу words: fibromyalgia, rheumatic diseases, nonrheumatic diseases, overlap, differential diagnosis
Аddress for correspondence: Assoc. Prof. Maria Panchovska-Mocheva, M. D., Clinic of Internal Diseases, MMA -- MHAT, 81, Hr. Botev Blvd., Bg -- 4000 Plovdiv, e-mail: panchovska@abv.bg



Achalasia: surgical and social aspects of diagnostics and therapy - - 47, 2011, № 1, 19-29.
S. Sopotenski(1), G. Petrova(2) and А. Chervenyakov(1)

(1)First Surgical Clinic -- UMHATEM “N. I. Pirogov” -- Sofia, (2)Faculty of Pharmacy, Medical University -- Sofia
Summary: The current review aims at analyzing the main publications in the area of surgical and social aspects of achalasia diagnostics and therapy. A literature database search has been performed through PubMed, Scopus, Cochrane library with key words achalasia, video assisted laparoscopic surgery, video assisted thoracoscopic surgery (VATS). A total of 150 publications have been identified, which had been systematized according to the area of analysis -- pathophysiology, epidemiology, diagnostics, therapy, and quality of life. Achalasia is a rare disease and studies on its therapy are relatively limited. There are still not well clarified mechanisms for the development of this disease that will probably improve its treatment or decrease the risk of its development. Therapeutic methods are developing permanently and main scientific questions discussed in the publications are related to the choice of most effective and safe methods for the patients, which will provide better long-term results. The surgical methods especially the minimal invasive techniques satisfy those tree requirements. The development of surgical techniques is in direction of improvement of both used approaches (thoracoscopic and laparoscopic), with the main aim to decrease the risk for patients, to increase symptom-free period, and to improve the efficacy of miotomy. Among the surgical methods, publications on different variants of Heller miotomy prevail. Most of the publications present results of the application of laparoscopic techniques. Тhe publications for thoracoscopic techniques are limited by number and authors, probably due to lots of reasons. In the first place this could be due to the well developed laparoscopic techniques or the smaller number of thoracal surgeons. The thoracoscopic methods are as safe, and efficacious as the laparoscopic ones. Besides thoracoscopic methods provide additional benefits as is the possibility to re-operate patients with previous abdominal surgery.
Key words: achalasia, surgery, VATS, quality of life
Address for correspondence: Stoyan Sopotenski, M. D., First Surgical Clinic, UMHATEM “N. I. Pirogov”, 21, Totleben Blvd., Bg -- 1606 Sofia



Principle systems for preparation and delivery of dialysate solution to the patients during hemodialysis - 47, 2011, № 1, 30-33.
A. Osichenko
Hemodialysis Department, Tokuda Hospital -- Sofia
Summary: Hemodialysis is a routine method of renal replacement therapy in nephrology. A high quality dialysate is of great importance for the realization of an adequate dialysis therapy. In the world, there are two main systems of preparing and delivering of dialysate to the patient: 1) Individual -- the dialysate solution is prepared in a separate dialysis machine and after that is delivered to the patient and 2) CDDS (Central Dialysis Fluid Delivery System) -- the dialysate solution is prepared centrally and after that is delivered to the dialysis machines and the patients. We estimate the advantages and the disadvantages of the two systems, as well as some technical characteristics of their implementation and utilization in the world and in Bulgaria.
Key words: hemodialysis, individual dialysis machine, Central Dialysis Fluid Delivery System
Address for correspondence: Alexander Osichenko, M. D., Hemodialysis Department, Tokuda Hospital, 51B, Nikola Vaptsarov Str., Bg 1407 Sofia, tel. +359 2 4034300, GSM: +359 884933100, e-mail: alosichenko@abv.bg




Pharmacogenetics and pharmacogenomics: genetic polymorphisms of drug-metabolizing enzymes and drug transporters - 47, 2011, № 1, 34-40.
S. Valcheva-Kuzmanova
Department of Preclinical and Clinical Pharmacology and Toxicology, Medical University -- Varna
Summary: Pharmacogenetics is the study of the genetic basis for variation in drug response. Genetic polymorphisms can influence the pharmacokinetics of drugs, the target molecules of drug action or the manifestation of a disease. In this review, there are considered some of the genetic polymorphisms of drug-metabolizing enzymes and drug transporters which determine variations in drug pharmacokinetics, and respectively, variations in drug effects (therapeutic and adverse effects).
Key words: genetic polymorphisms, drug-metabolizing enzymes, drug transporters
Address for correspondence: Assoc. Рrof. Stefka Valcheva-Kuzmanova, MD, PhD, Department of Preclinical and Clinical Pharmacology and Toxicology, Medical University, 55 Marin Drinov Str., Bg -- 9002 Varna, tel. +359 52 677 078, e-mail: stefkavk@yahoo.com


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